The Knee Joint

Springer
Paris
Berlin
Heidelberg
New York
Hong Kong
Londres
Milan
Tokyo
The Knee Joint
Surgical Techniques and Strategies

Michel Bonnin
Annunziato Amendola
Johan Bellemans
Steven MacDonald
Jacques Ménétrey
Michel Bonnin Steven MacDonald
Centre Orthopédique Santy London Health Sciences Centre
24, avenue Paul Santy University Campus
69008 Lyon University of Western Ontario
France 339 Windermere Road
London, ON, N6A 5A5
Annunziato Amendola
Canada
University of Iowa
Hospitals and Clinics Jacques Ménétrey
200 Hawkins Drive Clinique et polyclinique
01018 JPP Iowa Cit d’orthopédie de l’appareil moteur
IA, 52242-1088 Hôpital universitaire de Genève
USA 24, rue Micheli-du-Crest
Johan Bellemans 1211 Genève 14
Weligerveld 1 Suisse
3212 Pellenberg
Belgique

ISBN : 978-2-287-99352-7 Springer Paris Berlin Heidelberg New York

© Springer-Verlag France, Paris, 2012

Springer is member of Springer Science + Business Media

springer.com

This work is subject to copyright. All rights are reserved, Whether the whole or part of the material is concerned, specifi
fi-
cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or
in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the
provisions of the German Copyright Law of September 9, 1965, in its current version, and permissions for use must
always be obtained from Springer. Violations are liable for prosecution under the German Copyright Law.
The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in
the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and
therefore free for general use.
Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained
in this book. In every individual case the user must check such information by consulting the relevant literature.

Illustration of cover: Marc Donon

Cover design: Jean-François Montmarché
Layout: Nord-Compo - Villeneuve d’Ascq
List of Contributors

M. Aboelnour 745-9 Dunstable Road

Department of Orthopaedics, MA Mansoura Luton
University, Mansoura, Egypt, Germany Beds LU4 0HL

J. D. Agneskirchner Jean-Manuel Aubaniac

DK Henriettenstiftung Hannover,
D-30171 Hannover, Marienstrasse 72-90,
Germany
T. Ait Si Selmi
Centre Orthopédique Santy
24, avenue Paul Santy
69008 Lyon France
Sam Akhavan
Orthopaedic Sports Research and Clinical,
Cleveland Clinic Sports Health, Cleveland
Clinic Foundation, Cleveland, Ohio USA
Karl Fredrik Almqvist
Department of Traumatology and Orthopaedic
Surgery, Ghent University,
Belgium
Annunziato Amendola
University of Iowa Sports Medicine Center,
University of Iowa Hospitals and Clinics,
200 Hawkins Dr., Iowa city, Iowa, 52242 USA
Andrew A. Amis
Biomechanics Section, Mechanical Engineering
Department, Imperial College London,
London SW7 2AZ, UK
Elizabeth A. Arendt
Department of Orthopaedic Surgery,
University of Minnesota, Minneapolis, MN 55454
Jean-Noel A. Argenson
Department of Orthopedic Surgery
Aix-Marseille University
Hospital Sainte-Marguerite, Marseille, France
Abdullah Ashour
Department of Orthopedic Surgery,
Aix-Marseille University,
Hospital Sainte-Marguerite, Marseille, France
Sunil Apsingi
24 The Drummonds
Department of Orthopedic Surgery,
Aix-Marseille University,
Hopital Sainte-Marguerite,
Marseille, France
Xavier Ayral
Service de Rhumatologie B
Hôpital Cochin
27, rue du faubourg Saint Jacques
75014 Paris, France
Roger Badet
Pôle ostéo-articulaire santé et sport
60, avenue du Médipôle
38300 Bourgoin Jallieu, France
Roald Bahr
Oslo Sports Trauma Research Center,
Norwegian School of Sport Sciences,
PB 4014 Ullevål Stadion, 0806 Oslo, Norway
C. Lowry Barnes
Arkansas Specialty Orthopaedics,
600 South McKinley, Suite 405,
Little Rock, Arkansas, 72205, USA
Philippe Beaufils
fi
Orthopaedic Department
Versailles Hospital
F-78150 Le Chesnay, France
Johan Bellemans
Department of Orthopaedic Surgery,
University Hospitals Leuven, Belgium
Universitaire Ziekenhuizen KU Leuven,
campus Pellenberg, Weligerveld 1,
3212 Pellenberg, Belgium
Department of Orthopaedics,
University hospitals Leuven,
Herestraat 49 B-3000 Leuven, Belgium
Guy Bellier
Orthopaedic Surgery
23, avenue Niel
75017 Paris, France
VI The Knee Joint

Timothy H. Bell Stephen J. Burnett

London Health Sciences Center,
University Campus, Room ADD
Jim’s room, 339 Windermere Road,
London, Ontario, Canada
Jérôme Bérard
Paediatric Orthopaedic Department,
CHU Lyon, Hôpital universitaire
Femme-Mère-Enfant de Lyon,
Université Claude Bernard Lyon 1
59, boulevard Pinel, 69677 Bron, France
Daniel J. Berry
Department of Orthopeadic Surgery
Mayo Clinic, 200 First Street SW
Rochester, Minnesota, USA
Aaron J. Bigham
Division of Orthopaedic Surgery,
London Health Sciences Centre,
339 Windermere Road,
London, ON, Canada
Davide Edoardo Bonasia
University of Iowa Sports Medicine,
Via Lamarmora 26,
Torino, 10128, Italy
Jean-Paul Bonvarlet
Institut Nollet, 23 rue Brochant,
75017 Paris, France
M. Bonnin
Centre Orthopédique Santy,
24, avenue Paul Santy,
69008 Lyon, France
Division of Orthopaedic Surgery,
Royal Jubilee Victoria Hospital,
Victoria, BC, Canada
Christophe Bussière
Centre Orthopédique Médico-Chirurgical
71640 Dracy-le-Fort
Pieter Byn
AZ Maria Middelares Gent,
Kortrijksesteenweg 1028,
9000 Gent, Belgium
James R Carmichael
Consultant orthopaedic surgeon
Peterborough and Stamford Hospitals
NHS Foundation Trust UK
David Carmody
Level 2/445 Victoria Ave,
Chatswood 2067 NSW Australia
Yannick Carrillon
Centre Orthopédique Santy,
24, avenue Paul Santy, 69008 Lyon, France
Yves Catonné
Orthopaedic Department
Hôpital de la Pitié-Salpétrière
47-83 boulevard de l’Hôpital
75651 Paris, France
P. Chambat
Centre Orthopédique Santy,
24 Av Paul Santy, 69008, Lyon, France

Robert Barry Bourne Le Roy Chong

London Health Sciences Centre,
University Hospital, London, Ontario, Canada
Jean Brilhault
Université François Rabelais Tours,
CHRU Tours, France
Robert H. Brophy
Department of Orthopaedic Surgery,
14532 South Outer Forty Drive,
Chesterfi
field, MO 63017
Department of Diagnostic Radiology,
Changi General Hospital, No 2,
Simei Street 3, 529889, Singapore
Franck Chotel
Paediatric Orthopaedic Department,
CHU Lyon, Hôpital universitaire Femme-Mère-
Enfant de Lyon,
Université Claude Bernard Lyon 1,
59, boulevard Pinel,
69677 Bron, France

Robert T. Burks Mark Clatworthy

University of Utah Orthopaedic Center, Middlemore Hospital
590 Wakara Way, Auckland, New Zealand
Salt Lake City Utah 84108
Neil Clerk
Philippe Burdin Fowler Kennedy Sport Medicine Centre,
Université François Rabelais Tours, 3M Centre, University Of Western Ontario,
CHRU Tours, France London, Ontario, Canada N6A 3K7
 List of Contributors VII

Brian J. Cole Natasa Devic

Departments of Orthopedics & Anatomy Imperial College London, Biomechanics
and Cell Biology Section, Mechanical Engineering Department,
Division of Sports Medicine South Kensington Campus, Exhibition Road,
Section Head, Cartilage Restoration Center at London SW7 2AZ
Rush Rush University Medical Center,
Department of Orthopedic Surgery, Karolien Didden
1611 W Harrison, Suite 300 Chicago, Universitaire Ziekenhuizen KU Leuven,
IL 60612, USA Weligerveld 1, 3212 Pellenberg, Belgium
Kristoff
ff Corten Patrick Djian
Department of Orthopaedics, Educational Secretary of the European Society
University hospitals Leuven, of Sports Traumatology, Knee surgery and
Herestraat 49 B-3000 Leuven Arthroscopy (ESSKA)
23, avenue Niel
Angela Deakin 75017 Paris, France
Golden Jubilee National Hospital,
Beardmore Street, Clydebank,
G81 4HX Glasgow UK Simon Donell
Institute of Orthopaedics,
Michael J. DeFranco Norfolk & Norwich University Hospital, UK
Rush University Medical Center,
Department of Orthopedic Surgery, Michael Dunbar
1725 West Harrison Street, Division of Orthopaedic Surgery, Dalhousie
Suite 1063, Chicago, IL 60612 University, 1796 Summer Street Suite# 4822,
QEII Health Sciences Centre,
David Dejour Halifax NS, Canada
Lyon-Ortho-Clinic
8 Avenue Ben Gourion, Craig J. Edson
Lyon 69009, France GHS Orthopaedics Woodbine
Danville, PA, USA
Marco Delcogliano
Department of Orthopedic and Sports Andrew Edwards
Trauma, Rizzoli Orthopaedic Institute, 39 New Road
Bologna, Italy Wonersh Guildford
Surrey GU5 0SF
Craig J. Della Valle
Associate Professor of Orthopaedic Surgery, Evan D. Ellis
Rush University Medical Center, Department of Orthopaedic Surgery,
Chicago, IL 60612 Washington University, St. Louis, MO
Douglas A. Dennis Lars Engebretsen
Department of Biomedical Engineering, Department of Orthopaedic Surgery
University of Tennessee, Rocky Mountain Oslo University Hospital and Faculty
Musculoskeletal Research Laboratory, of Medicine University of Oslo, Norway
Denver, Colorado
Patrick Deprez Gregory C. Fanelli
Orthopaedic Department, A.Z. St-Lucas, 115 Woodbine Lane, Danville,
St-Lucaslaan 29, 8310 Brugge, Belgium PA 17822-5212, USA

Jacques Desnoyer Lutul D. Farrow

Orthopaedic Clinic Charles LeMoyne
126, rue Saint-Louis LeMoyne,
QC Canada
Gérard Deschamps
Centre Orthopédique Médico-Chirurgical
71640 Dracy-le-Fort
Department of Orthopaedic Surgery,
Cleveland Clinic, Cleveland, Ohio, USA
Giuseppe Filardo
Department of Orthopedic and Sports
Trauma, Rizzoli Orthopaedic Institute,
Bologna, Italy
VIII The Knee Joint
P. Filippini
University Paris XII APHP-Hôpital
Henri Mondor, 94010 Créteil, France
Donald C. Fithian
Department of Surgical Outcomes
and Analysis, 3033 Bunker Hill Street,
San Diego, CA 92109
Brian Forsythe
Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center,
Pittsburgh
Peter J. Fowler
Schulich School of Medicine & Dentistry,
University Of Western Ontario, Fowler
Kennedy Sport Medicine Centre,
3M Centre, London, Ontario,
Canada N6A 3K7
Freddie H. Fu
Department of Orthopaedic Surgery
University of Pittsburgh
3471 Fifth Avenue
Kaufman Building, Suite 1011
Pittsburgh, PA 15213, USA
Donald S. Garbuz
Department of Orthopaedics, University
of British Columbia, 3114-910 West 10th
Avenue, Vancouver, BC V5Z 4E3,
Canada
J Robert Giffin
ffi
Schulich School of Medicine & Dentistry,
University Of Western Ontario,
Fowler Kennedy Sports Medicine Centre,
London, Ontario, Canada N6A 3K7
Giovanni Giordano
Department of Orthopedic and Sports
Trauma, Rizzoli Orthopaedic Institute,
Bologna, Italy
Jason Gould
Department of Orthopedic Surgery,
The Mount Sinai Medical Center,
New York
Edward James Graham
London Health Sciences Centre,
University Hospital, London, Ontario
Alberto Gregori
Hairmyres Eaglesham Road,
G75 8RG Glasgow, UK
Ronald P. Grelsamer
Department of Orthopedic Surgery,
The Mount Sinai Medical Center,
New York
Chad J. Griffith
ffi
Department of Orthopaedic Surgery,
University of Minnesota, 2450 Riverside
Avenue, R200, Minneapolis, MN 55454
Allan Gross
Mt Sinai Hospital
Toronto, Canada
Arlen D. Hanssen
Mayo Clinic,
Rochester, Minnesota
Christopher D. Harner
Department of Orthopaedic Surgery,
University of Pittsburgh School of Medicine,
Pittsburgh
Yves Hémon
Department of Orthopedic Surgery
Aix-Marseille University
Hopital Sainte-Marguerite
Marseille, France
Julien Henry
Orthopaedic traumatology and Sport
Medecine Department
Hôpital Jules Courmont, CHU Lyon
69495 Pierre Bénite
France
Philippe Hernigou
University Paris XII APHP-Hôpital
Henri Mondor – 94010 Créteil- France
Timothy E. Hewett, FACSM
Departments of Physiology and Cell Biology,
Orthopaedic Surgery, Family Medicine,
Biomedical Engineering & Allied Medicine
The Ohio State University
2050 Kenny Road, Suite 3100
Columbus, OH 43221-3502
Departments of Pediatrics and Orthopaedic
Surgery, University of Cincinnati College
of Medicine, 3333 Burnet Avenue, MLC
10001, Cincinnati, OH 45229-3039
Benton E. Heyworth
Orthopaedic Surgery Resident, Hospital
for Special Surgery, 535 East 70th Street,
New York, NY 10021
Jürgen Höher
Clinic for Sports Medicine und Arthroscopy
 List of Contributors IX

at Cologne Merheim Medical Center Tim Kostamo

University of Witten-Herdecke
Cologne, Germany
James L. Howard
Division of Orthopaedic Surgery,
London Health Sciences Centre,
339 Windermere Road, London, ON, Canada
William J. Hozack
Rothman Institute at Thomas Jefffferson
University, 925 Chestnut Street, 5th Floor,
Philadelphia, PA 19107, USA
Junji Iwasa
Orthopaedic Center, Ullevaal University
Hospital and Medical School, Oslo, Norway
Jeff
ffrey D. Jackson
Department of Orthopedic Surgery,
Mayo Clinic, 200 First Street,
SW, Rochester, MN 55905
Redouane Jalil
University Paris XII APHP-Hôpital
Henri Mondor, 94010 Créteil- France
Bret T. Kean
University of Utah Orthopaedic Center,
590 Wakara Way,
Salt Lake City Utah 84108
Frédéric Khiami
Orthopaedic Department
Hôpital de la Pitié-Salpétrière
47- 83, boulevard de l’Hôpital
75651 Paris, France
Sung-Jae Kim
Department of Orthopaedic Surgery
and the Arthroscopy & Joint Research
Institute, Yonsei University Health System,
Seoul, Korea
Raymond H. Kim
Colorado Joint Replacement, Denver, Colorado
Richard Kjar
42 Green St, Wangaratta, VIC 3677, Australia
Dieter Kohn
Department of Orthopaedic Surgery,
University Hospital, Saarland University,
Homburg/Saar, Germany
Elizaveta Kon
Department of Orthopedic and Sports Trauma,
Rizzoli Orthopaedic Institute, Bologna, Italy
Department of Orthopaedics
3825 Sunset Street
Burnaby, BC V5G 1T4
Canada
Tron Krosshaug
Oslo Sports Trauma Research Center,
Norwegian School of Sport Sciences,
PB 4014 Ullevål Stadion, 0806 Oslo, Norway
Matthias Kusma
Department of Orthopaedic Surgery,
University Hospital, Saarland University,
Homburg/Saar, Germany
Robert F. LaPrade
The Steadman Clinic
Biomechanics Research Department - Steadman
Philippon Research Institute
181 W. Meadow Drive
Suite 1000 Vail,
Colorado 81657, USA
Leonard C. Latt
Duke University Medical Center, Box 3000,
Durham, NC 27710
Thomas Laumonier
Unité d’orthopédie et traumatologie du sport,
Service de chirurgie orthopédique
et traumatologie de l’appareil moteur,
Hôpitaux Universitaires de Genève,
24, rue Micheli-du-Crest,
CH-1211 Genève 14, Suisse
Jean Raphael Laurent
Orthopaedic Surgery
10A, rue du Bourdeau
7542 Mont-Saint-Aubert, France
Frédéric Lavoie
Service de Chirurgie Orthopédique,
Hôpital Notre-Dame, Centre Hospitalier
Universitaire de Montréal, 1560 Sherbrooke
Est, local DR 1118-16, Montréal, Canada
Vincent Leclercq
Prosthesis design and manufacturing
Symbios Orthopaedic SA
Pierre-François Leyvraz
Département appareil locomoteur
Hôpital orthopédique CHUV
CH-1011 Lausanne, Suisse
Philipp Lobenhoffer
ff
DK Henriettenstiftung Hannover,
D-30171 Hannover, Marienstrasse 72-90
X The Knee Joint
David Longino
Fowler Kennedy Sport Medicine Centre,
3M Centre, University Of Western Ontario,
London, Ontario, Canada N6A 3K7
Sébastien Lustig
Service de Chirurgie Orthopédique
Centre Albert-Trillat, Hospital
de la Croix-Rousse,
8, rue de Margnolles
69300 Caluire, Lyon, France
Tad M. Mabry
Mayo Clinic, Rochester, Minnesota
Steven J. MacDonald
University Hospital, London, Ontario,
Canada
Maurilio Marcacci
Department of Orthopedic and Sports
Trauma, Rizzoli Orthopaedic Institute,
Bologna, Italy
Giulio M. Marcheggiani Muccioli
Department of Orthopedic and Sports
Trauma, Rizzoli Orthopaedic Institute,
Bologna, Italy
Fabrizio Margheritini
Department of Health Science, Unit of Sports
Traumatology, Piazza Lauro de Bosis 6,
00199, Rome, Italy
Pier Paulo Mariani
Department of Health Science, Unit of Sports
Traumatology, Piazza Lauro de Bosis 6,
00199, Rome,
Italy
Robert G. Marx
Foster Center for Clinical Outcome Research,
Hospital for Special Surgery, 535 East
70th Street, New York, NY 10021
Weill Medical College of Cornell University,
New York, NY
Randy Mascarenhas
Department of Orthopaedic Surgery,
University of Pittsburgh School of Medicine,
Pittsburgh
Bassam A. Masri
Department of Orthopaedics,
University of British Columbia,
3114-910 West 10th Avenue,
Vancouver, BC V5Z 4E3, Canada
Matthew. J. Matava
Washington University Department
of Orthopaedic Surgery, St. Louis, MO
David R. McAllister
Sports Medicine Service
David Geff
ffen School of Medicine at UCLA
Department of Orthopaedic Surgery
Los Angeles, CA 90095-6902
James McAuley
London Health Sciences Center, University
Campus, Room ADD, 339 Windermere Road,
London, Ontario, Canada
Richard W. McCalden
University of Western Ontario,
Division of Orthopaedic Surgery,
London Health Science Centre,
London, Ontario, Canada
Allison G. McNickle
Rush University Medical Center,
Department of Orthopedic Surgery,
1725 West Harrison Street, Suite 1063,
Chicago, IL 60612
Jacques Ménétrey
Unité d’orthopédie et traumatologie du sport
(UOTS), Service de chirurgie orthopédique
et traumatologie de l’appareil moteur,
University Hospital of Geneva, Rue Gabrielle-
Perret-Gentil 4, 1211 Geneva 14
Guy Messerli
Unité d’orthopédie et traumatologie du sport
(UOTS), Service de chirurgie orthopédique
et traumatologie de l’appareil moteur,
University Hospital of Geneva,
Rue Gabrielle-Perret-Gentil 4,
1211 Geneva 14
Anthony Miniaci
CCLCM
Cleveland Clinic
5555 Transportation Blvd.
Garfi
field Heights, OH 44125, USA
Bernard Moyen
Orthopaedic Surgery
Centre Hospitalier Lyon-Sud
Chemin du Grand Revoyet
69495 Pierre-Bénite
France
M. Mukisi Mukasa
University Paris XII APHP-Hôpital
Henri Mondor, 94010 Créteil, France
 List of Contributors XI

Douglas D. R. Naudie Sebastien Parratte

London Health Sciences Center,
University Campus, Room A9-028,
339 Windermere Road, London,
Ontario, Canada
John H. Newman
Avon Orthopaedic Centre, Bristol, UK
Philippe Neyret
Service de Chirurgie Orthopédique,
Centre Albert-Trillat, Hôpital de la Croix-
Rousse, 8, rue de Margnolles,
69300 Caluire, Lyon,
France
Jean-Yves Nordin
Orthopaedic Surgery
Hôpital Bicêtre
78, rue du Général Leclerc
94270 Le Kremlin Bicêtre
France
Fabio R. Orozco
Orthopedic Surgery
2500 English Creek Avenue Building 1300
Egg Harbor Township, NJ 08234
S. Ostermeier
Orthopaedic Department
Hannover Medical School
Anna-von-Borries-Str. 1-7
30625 Hannover, Germany
Mark W. Pagnano
Department of Orthopedic Surgery,
Mayo Clinic, 200 First Street, SW,
Rochester, MN 55905
Ludovico Panarella
Clinica Valle Giulia, Via De Notaris 2b,
00197 Roma, Italy
Jean Claude Panisset
College of Orthopaedics, Clinique
des Cédres-Grenoble
48, avenue de Grugliasco
38130 Echirolles, France
Dietrich Pape
Department of Orthopaedic and Trauma
Surgery, Centre for Sports and Preventive
Medicine, Centre Hospitalier de Luxembourg-
Clinique d’Eich, 78, rte. d’Eich,
L-1460 Luxembourg
Richard D. Parker
Cleveland Clinic Sports Health,
Cleveland Clinic Foundation, Cleveland, Ohio
Department of Orthopedic Surgery
Aix-Marseille University, Hopital
Sainte-Marguerite, Marseille, France
Frédéric Picard
Golden Jubilee National Hospital, Beardmore
Street, Clydebank, G81 4HX Glasgow UK
Sergio R. Piedade
Professor, Department of Orthopedics
and Traumatology, School of Medical Sciences,
Exercise and Sport Medicine Group,
State University of Campinas / UNICAMP
Rua Tessália Vieira de Camargo n° 126
Cidade Universitaria Zeferino Vaz,
13083-887, Campinas/SP
Alexandre Poignard
University Paris XII APHP-Hôpital
Henri Mondor, 94010 Créteil, France
Mathew W. Pombo
Department of Orthopaedic Surgery, University
of Pittsburgh Medical Center, Pittsburgh
Hollis G. Potter
Weil Medical College of Cornell University,
535 East 70th Street, New York, NY 10021
Jean Louis Prudhon
College of Orthopaedics,
Clinique des Cedres-Echirolles
48, avenue de Grugliasco
38130 Echirolles, France
Giancarlo Puddu
Clinica Valle Giulia, Via De Notaris 2b,
00197 Roma, Italy
Bénédicte Quelard
Centre Orthopédique Santy, 24, avenue Paul
Santy, 69008, Lyon, France
Olivier Rachet
Centre Hospitalier Publique d’Hauteville,
01 110 Hauteville, France
Kian Raiszadeh
400 Craven Road, San Marcos, CA 92078,
USA
Amar S. Ranawat
Hospital for Special Surgery
535 East 70th St, 6th Floor
New York, NY 10021, USA
Anil. S. Ranawat
Hospital for Special Surgery
XII The Knee Joint

535 East 70th St, 6th Floor
New York, NY 10021, USA
Chitranjan S. Ranawat
Hospital for Special Surgery
535 East 70th St, 6th Floor
New York, NY 10021, USA
Corey J. Richards
Department of Orthopaedics,
University of British Columbia,
3114-910 West 10th Avenue,
Vancouver, BC V5Z 4E3, Canada
James R. Robinson
Avon Orthopaedic Centre,
Southmead Hospital,
Westbury-on-Trym, Bristol.
BS10 5NB, UK
Samuel P. Robinson
Department of Orthopaedics,
University of Pittsburgh,
3200 South Water Street,
Pittsburgh, PA 15213
Sérgio Rocha Piedade
Department of Orthopedics and Traumatology,
School of Medical Sciences, Exercise and Sport
Medicine Group, State University of Campinas,
CEP 13081-970 Campinas, Sao Paulo, Brasil
James R. Robinson
Orthopaedic Surgery
Nuffiffield Health Bristol Hospital
Upper Byron Place
Clifton Bristol BS8 1JU UK
Aaron G. Rosenberg
Rush University Medical Center, 1725 West
Harrison Street, Suite 1063, Chicago, IL 60612
Alexander P. Sah
Rush University Medical Center, 1725 West
Harrison Street, Suite 1063,
Chicago, IL 60612
Elhadi Sariali
Orthopaedic Department
Hôpital de la Pitié-Salpétrière
47-83 boulevard de l’Hôpital
75651 Paris, France
Sven Scheffl
ffler
Center for Musculoskeletal Surgery, Charité,
University Medicine Berlin, Germany
Richard D. Scott
New England Baptist Hospital
125 Parker Hill Ave Ste 560
Boston, MA
Romain Seil
Department of Orthopaedic and Trauma
Surgery, Centre for Sports and Preventive
Medicine, Centre Hospitalier de Luxembourg-
Clinique d’Eich, 78, rte. d’Eich,
L-1460 Luxembourg
Elvire Servien
Service de Chirurgie Orthopédique,
Centre Albert-Trillat, Hôpital de la Croix-
Rousse, 8, rue de Margnolles,
69300 Caluire, Lyon, France
Michael A. Shaff ffer
Department of Rehabilitation Therapies,
0733 JPP, University of Iowa Hospitals
and Clinics, Iowa City, IA 52242
Sven Shafifizadeh
Department for Orthopedics
and Trauma Surgery
Cologne Merheim Medical Center
University of Witten-Herdecke Cologne,
Germany
Wei Shen
Department of Orthopaedics, University
of Pittsburgh, 3200 South Water Street,
Pittsburgh, PA 15213
Yosuke Shima
Orthopaedic Center, Ullevaal University
Hospital and Medical School, Oslo, Norway
Darryl B. Sneag,
Fourth-year Medical Student
Albert Einstein College of Medicine,
Yeshiva University
Bertrand Sonnery-Cottet
Centre Orthopédique Santy,
24 Av Paul Santy, 69008 Lyon, France
Sankar Sripada
Trauma and Orthopaedics, Ninewells Hospital
and Medical School, Dundee DD1 9SY,
Scotland, UK
Christina Stukenborg-Colsman
Orthopaedic Department
Hannover Medical School
Anna-von-Borries-Str. 1-7
30625 Hannover Germany
Michael Tanzer
Division of Orthopaedic Surgery, McGill
University, Montreal, Quebec, Canada

Neil Thomas
Consultant Orthopaedic Surgeon
BMI The Hampshire Clinic UK
Bruno Tillie
Orthopaedic Surgery
Clinique Bon Secours
2, rue du Docteur Forgeois
62000 Arras
Harukazu Tohyama
Department of Sports Medicine and Joint
Reconstruction Surgery Hokkaido
University School of Medicine, Sapporo, Japan
Geert Van Damme
Department of Orthopaedic Surgery
AZ Sint Lucas, Sint Lucaslaan 29
8310, Brugge, Belgium
Pieter Vansintjan
Department of Orthopaedic Surgery,
Ghent University Hospital,
Ghent, Belgium
Ronald J van Heerwaarden
Limb Deformity Reconstruction Unit, Depart-
ment of Orthopaedics Sint Maartenskliniek
Woerden, Polanerbaan 2, 3447 GN Woerden,
The Netherlands
Johan Vanlauwe
Department of Orthopaedics, University
hospitals Leuven, Herestraat 49 B-3000
Leuven
Hilde Vandenneucker
Department of Orthopaedics,
University hospitals Leuven,
Herestraat 49 B-3000 Leuven, Belgium
Chris M. van den Broek
Department of Orthopaedics, Sint Maartensk-
liniek, PO Box 9011 6500 GM Nijmegen,
The Netherlands
Gijs G. van Hellemondt
Department of Orthopaedics, Sint Maartensk-
liniek, PO Box 9011 6500 GM Nijmegen,
The Netherlands
Ramiro Vargas
Centre Orthopédique Santy,
24 Av Paul Santy, 69008 Lyon, France
Florence Unno-Veith
Clinique et polyclinique
d’orthopédie de l’appareil moteur
List of Contributors XIII
Hôpital universitaire de Genève
24, rue Micheli-du-Crest
1211 Genève 14
Suisse
Rene Verdonk
Knee Surgery & Sports Traumatology
Department of Orthopaedic Surgery
Ghent University Hospital
Belgium
Peter Verdonk
Knee Surgery & Sports Traumatology
Department of Orthopaedic Surgery
Ghent University Hospital and Stedelijk
Ziekenhuis Roeselare Belgium
Jan Victor
Orthopaedic Department, A.Z. St-Lucas,
St-Lucaslaan 29, 8310 Brugge, Belgium
Coen A. Wijdicks
Biomechanics Research Department
Steadman Philippon Resarch Institute
181 West Weadow Drive,
Suite 1000 Vail, CO 81657, USA
Philippe Wilmes
Department of Orthopaedic and Trauma Sur-
gery, Centre for Sports
and Preventive Medicine,
Centre Hospitalier de Luxembourg-Clinique
d’Eich, 78, rte. d’Eich,
L-1460 Luxembourg
H. Windhagen
Orthopaedic Department
Hannover Medical School
Anna-von-Borries-Str. 1-7
30625 Hannover
Germany
Andy Williams
Department of Orthopaedic Surgery,
Chelsea and Westminster Hospital,
369 Fulham Road,
London SW10 9NH
Glenn N. Williams
Graduate Program in Physical Therapy
and Rehabilitation Science,
Medical Education Building,
University of Iowa, Iowa
Rick W. Wright
Washington University Department
of Orthopaedic Surgery,
St. Louis, MO
XIV The Knee Joint
Thomas Y. Wu
Department of Orthopaedic Surgery,
Ventura County Medical Center,
Ventura, California, USA
Ate B. Wymenga
Department of Orthopaedics, Sint Maartensk-
liniek, PO Box 9011 6500 GM Nijmegen,
The Netherlands
Kazunori Yasuda
Department of Sports Medicine and Joint
Reconstruction Surgery, Hokkaido
University School of Medicine, Sapporo,
Japan
Stefano Zaffffagnini
Department of Orthopedic and Sports Trauma,
Rizzoli Orthopaedic Institute, Bologna,
Italy
Rachad Zayni
Centre Orthopédique Santy
24 Av Paul Santy
69008 Lyon, France
Bohdanna T. Zazulak
DPT, MS, OCS
Yale New Haven Hospital
Department of Orthopaedics
and Rehabilitation
20 York Street
New Haven, Connecticut 06510, USA
Yale University School of Medicine
Department of Orthopaedics
Yale Physician’s Building
800 Howard Avenue
New Haven, Connecticut 06510, USA
Sébastien Zilber
University Paris XII APHP-Hôpital
Henri Mondor, 94010 Créteil, France
Table of Contents

Foreword ........................................................................................ XXI

I The Traumatic Knee ..................................................................... 1

Basic Sciences ............................................................................................ 3
1. The menisci: anatomy, healing response, and biomechanics
A. Amendola, D. E. Bonasia....................................................................................... 5
2. The cruciate ligaments: anatomy, biology, and biomechanics
S. Scheffl
ffler .............................................................................................................. 11
3. The anatomy and biomechanics of the medial collateral ligament
and posteromedial corner of the knee
A. A. Amis, J. R. Robinson ........................................................................................ 23
4. The lateral collateral ligament and posterolateral corner
C. J. Griffi
ffith, C. A. Wijdicks, R. F. LaPrade ............................................................... 31
5. Basic science of ligament healing
H. Tohyama, K. Yasuda ............................................................................................. 43
Clinical Basis ............................................................................................. 51
6. Clinical basis: epidemiology, risk factors,
mechanisms of injury, and prevention
of ligament injuries of the knee
T. E. Hewett, B. T. Zazulak, T. Krosshaug, R. Bahr ................................................... 53
7. MRI evaluation of knee ligaments
H. G. Potter, D. B. Sneag, L. R. Chong ....................................................................... 71
8. Classifi
fication of knee laxities
S. R. Piedade, E. Servien, F. Lavoie, P. Neyret ........................................................... 85
9. Scoring the knee
B. E. Heyworth, R. H. Brophy, R. G. Marx ................................................................ 95
The Menisci ............................................................................................... 107
10. Arthroscopic meniscectomy
J. C. Panisset, J. L. Prudhon...................................................................................... 109
11. Meniscal sutures
P. Wilmes, D. Pape, R. Seil ......................................................................................... 125
12. Meniscal allograft transplantation
P. Verdonk, P. Vansintjan, R. Verdonk ....................................................................... 139
The ACL ..................................................................................................... 149
13. Diagnostic and surgical decision ACL tears
B. T. Kean, R. T. Burks .............................................................................................. 151
14. Natural history of ACL tears: from rupture to osteoarthritis
M. J. Matava, R. W. Wright, E. D. Ellis ..................................................................... 163
XVI The Knee Joint

15. Graft choice in ACL reconstruction

D. E. Bonasia, A. Amendola....................................................................................... 173
16. Tunnels, graft positioning, and isometry in ACL reconstruction
A. Williams, N. Devic ................................................................................................ 183
17. Technique in ACL reconstruction: hamstring reconstruction
D. Longino, N. Clerk, P. J. Fowler, J. R. Giffin
ffi ........................................................... 195
18. Technique in ACL reconstruction: patellar tendon
D. R. McAllister, T. Y. Wu .......................................................................................... 203
19. Place of navigation in anterior cruciate ligament reconstruction
G. Messerli, J. Ménétrey ........................................................................................... 217
20. Single or double bundle?
B. Sonnery-Cottet ..................................................................................................... 227
21. Anatomic double-bundle ACL reconstruction: how I do it?
K. Yasuda .................................................................................................................. 235
22. Results of ACL reconstruction
J. Iwasa, Y. Shima, L. Engebretsen ............................................................................ 245
23. Arthrofi
fibrosis after anterior cruciate ligament reconstruction
P. Chambat, R. Vargas, J. Desnoyer........................................................................... 263
24. ACL rehabilitation
M. A. Shaffer,
ff G. N. Williams .................................................................................... 269
25. ACL rupture in children: anatomical and biological bases, outcome
of ACL defificient knee in childhood: strategy, operative technique, results,
and complications.
F. Chotel, J. Henry, J. Bérard .................................................................................... 291
26. Combined injuries of the anterior cruciate ligament
and posterolateral corner
S. P. Robinson, W. Shen, F. H. Fu ............................................................................... 325
27. Failure in ACL reconstruction: etiology, treatment, and results
N. Thomas, J. Carmichael ......................................................................................... 343
The PCL...................................................................................................... 355
28. Defi
finition and diagnosis of posterior cruciate ligament injury
and algorithm of treatment
J. Ménétrey ............................................................................................................... 357
29. Natural history of PCL ruptures
S. Akhavan, R. D. Parker ........................................................................................... 369
30. The PCL: difffferent options in PCL reconstruction:
choice of the graft? One or two bundles?
J. Höher, S. Shafizadeh
fi ............................................................................................. 377
31. Graft tunnel positioning during PCL reconstruction
A. A. Amis, A. Edwards, S. Apsingi ........................................................................... 387
32. Techniques in posterior cruciate ligament reconstruction:
an arthroscopic approach
B. Forsythe, R. Mascarenhas, M. W. Pombo, C. D. Harner ........................................ 395
33. Arthroscopic reconstruction of the posterior cruciate ligament
using double-bundle and tibial-inlay technique
S.- J. Kim .................................................................................................................. 405
34. Technique in PCL reconstruction: mini posterior approach
R. Badet, P. Verdonk, S. Rocha Piedade ..................................................................... 411
 Table of Contents XVII

35. Results of PCL reconstruction

F. Margheritini, M. Aboelnour, P.P. Mariani .............................................................. 417
36. Combined injuries to the posterior cruciate ligament
and medial collateral ligament of the knee
B. Forsythe, R. Mascarenhas, M. W. Pombo, C. D. Harner ........................................ 421
37. PCL injury associated with a posterolateral tear
K. Corten, J. Bellemans ............................................................................................. 427
Bicruciate injuries and dislocations .......................................................... 441
38. The multiple-ligament injured knee
G. C. Fanelli, C. J. Edson .......................................................................................... 443
39. Surgical treatment of cartilage tear: principles and results
F. U. Veith, J. Ménétrey ............................................................................................ 457
40. Technique of mosaicplasty
A. Miniaci, L. D. Farrow ........................................................................................... 483
41. Allograft osteoarticular resurfacing
M. J. DeFranco, A. G. McNickle, B. J. Cole................................................................ 497
42. Technique of chondrocytes implantation
S. Zaff
ffagnini, E. Kon, G. Filardo, G. Giordano, M. Delcogliano,
G. M. Marcheggiani Muccioli, M. Marcacci ............................................................... 505
43. Regenerative medicine for cartilage
T. Laumonier, J. Ménétrey ........................................................................................ 511
Patello-femoral joint ................................................................................. 517
44. The biomechanics of the patella
R. P. Grelsamer, J. Gould ........................................................................................... 519
45. Imaging of patellofemoral joint
Y. Carrillon ................................................................................................................ 525
46. Anterior knee pain and patellar instability: diagnosis and treatment
K. F. Almqvist, E. A. Arendt ...................................................................................... 533
47. Patellar stabilization for episodic patellar instability
K. Raiszadeh, D. C. Fithian, L. D. Latt ...................................................................... 539
48. Deepening trochleoplasty for patellofemoral instability
D. Dejour, P. Byn ....................................................................................................... 549

II The Degenerative Knee ............................................................... 559

Osteoarthritis of the patello-femoral joint ............................................... 561
49. Patellofemoral osteoarthritis: pathophysiologie, treatment,
and results
H. Vandenneucker, K. Didden, J. Bellemans ............................................................. 563
50. Patellofemoral replacement
J. H. Newman ........................................................................................................... 573
Indications in osteoarthritis of the femoro-tibial joint ............................ 583
51. Is there a place for arthroscopy in the degenerative knee?
P. Djian, G. Bellier, B. Moyen, X. Ayral, J. P. Bonvarlet .............................................. 585
52. Surgical indications in medial knee osteoarthritis
F. Lavoie, S. Lustig, E. Servien, S. R. Piedade, P. Neyret............................................ 591
XVIII The Knee Joint

Osteotomy around the knee ...................................................................... 601

53. Biomechanics, basis, and indications of osteotomies around the knee
P. Hernigou, S. Zilber, A. Poignard, R. Jalil, P. Filippini, M. Mukisi Mukasa ............. 603
54. Technique of closing wedge HTO
D. Kohn, D. Pape ....................................................................................................... 611
55. Technique of open wedge HTO
P. Lobenhoff
ffer, J. D. Agneskirchner ........................................................................... 621
56. Results of HTO in medial OA of the knee
A. Amendola, D. E. Bonasia....................................................................................... 633
57. Osteotomies in the valgus knee
G. Puddu, L. Panarella .............................................................................................. 643
58. Medial closing wedge varus osteotomy of the distal femur
R. J. van Heerwaarden ............................................................................................. 653
Unicondylar knee arthroplasty ................................................................. 661
59. Technical considerations, results,
and complications of mobile-bearing UKA
R. W. McCalden ........................................................................................................ 663
60. Fixed bearing unicompartmental knee prosthesis:
results, complications, and technical considerations
G. Deschamps, C. Bussière, S. Donell ........................................................................ 669
61. Indications of unicompartmental knee arthroplasty
C. L. Barnes, R. D. Scott ............................................................................................ 685
62. Lateral Unicompartmental Knee Replacement
J. H. Newman ........................................................................................................... 689

III Primary Total Knee Arthroplasty............................................... 695

Design and concept in TKA ....................................................................... 697
63. The history of total knee arthroplasty
A. S. Ranawat, A, S. Ranawat, C. S. Ranawat .......................................................... 699
64. Posterostabilized TKA: advantages and disadvantages
S. Parratte, J.-M. Aubaniac, J.-N. A. Argenson ......................................................... 709
65. Conservation of posterior cruciate ligament
in fixed-bearing total knee replacement
J.Y. Nordin, Guepar Group ....................................................................................... 721
66. Deep dish TKA: advantages and disadvantages
P.-F. Leyvraz, V. Leclercq ........................................................................................... 729
67. Bicruciate retaining TKA: the future?
J. Bellemans, K. Corten, J. Vanlauwe, H. Vandenneucker ......................................... 735
68. Mobile-bearing total knee arthroplasty:
advantages and disadvantages
R. H. Kim, D. A. Dennis ............................................................................................ 741
69. Fixed-bearing total knee arthoplasty:
advantages and disadvantages
D. Kohn, M. Kusma ................................................................................................... 755
70. Cement fixation for total knee arthroplasty
J. D. Jackson, M. W. Pagnano.................................................................................... 759
 Table of Contents XIX

Surgical techniques ................................................................................... 765

71. Pre-operative imaging techniques
in primary total knee replacement: role for computed tomography
P. Beaufi
fils.................................................................................................................. 767
72. The mini-subvastus approach for total knee arthroplasty
J. D. Jackson, M. W. Pagnano.................................................................................... 775
73. The degenerative knee – surgical techniques: “gap balancing”
C. Stukenborg-Colsman, S. Ostermeier, H. Windhagen ............................................ 783
74. Component orientation and total knee arthroplasty
F. R. Orozco, W. J. Hozack ......................................................................................... 791
75. Rotation of components in total knee arthroplasty
M. Bonnin ................................................................................................................. 797
76. Improving mobility
S. Parratte, A. Ashour, Y. Hémon, J.-M. Aubaniac, J.-N. Argenson ........................... 809
77. Medical management before and after TKA
E. J. Graham, R. B. Bourne ....................................................................................... 815
78. Rehabilitation protocol following total knee arthroplasty
B. Quelard, O. Rachet ............................................................................................... 823
The Patella in TKA ..................................................................................... 839
79. Why I always resurface the patella in TKA
K. Corten, S. J. MacDonald ....................................................................................... 841
80. Why I do not routinely resurface the patella in TKA
A. J. Bigham, J. L. Howard........................................................................................ 857
Navigation in TKA ..................................................................................... 865
81. Total knee replacement navigation: the different ff techniques
F. Picard, A. Gregori, A. Deakin................................................................................. 867
82. Why using navigation in total knee arthroplasty?
P. Deprez, J. Victor .................................................................................................... 879
Results in Primary TKA ............................................................................. 885
83. Results and function of total knee arthroplasty
M. Dunbar, S. Sripada, R. Kjar ................................................................................. 887
Diffi
fficulties in Primary TKA ....................................................................... 895
84. TKA in the stiff
ff knee
J. Vanlauwe, H. Vandenneucker, J. Bellemans........................................................... 897
85. The lateral approach in the valgus knee
R. Zayni, M. Bonnin .................................................................................................. 901
86. TKA in the severe valgus knee: lateral epicondyle sliding osteotomy technique
J. Brilhault, P. Burdin................................................................................................ 907
87. Total knee replacement in patients with severe varus deformity
Y. Catonné, E. Sariali, F. Khiami, B. Tillie ................................................................. 915
88. Total knee arthroplasty after failed high tibial osteotomy
M. Bonnin, R. Zayni .................................................................................................. 923
89. Total knee arthroplasty after malunion
T. Ait Si Selmi, D. Carmody, Ph. Neyret .................................................................... 933
XX The Knee Joint

90. Revision total knee arthroplasty after failed unicompartmental knee replacement
J. R. Laurent ............................................................................................................. 941
Failures and Revision in TKA .................................................................... 953
91. Causes of failures in TKA
M. Bonnin ................................................................................................................. 955
92. The painful total knee arthroplasty
G. Van Damme, J. Victor ........................................................................................... 969
93. Pre-operative planning for revision TKA
E. J. Graham, S. J. MacDonald.................................................................................. 983
94. Technique of revision: surgical approach
M. Tanzer, S. Burnett................................................................................................ 989
95. Revision TKA: component removal
K. Corten, S. J. MacDonald ....................................................................................... 1003
96. Management of bony defects in revision TKR
M. Clatworthy .......................................................................................................... 1009
97. Stems in revision TKA
D. J. Berry ................................................................................................................. 1021
98. Technique of revision in TKA: joint line level
C. M. van den Broek, G. G. van Hellemondt, A. B. Wymenga .................................... 1029
99. Technique of revision in total knee arthroplasty: the patella
D. D. R. Naudie, T. H. Bell, J. McAuley...................................................................... 1039
100. Extensor mechanism allograft – surgical technique
A. P. Sah, C. J. Della Valle, A. G. Rosenberg .............................................................. 1049
101. Infection in total knee arthroplasty – prevention
T. Kostamo, S. J. MacDonald .................................................................................... 1057
102. Diagnosis of infection after total knee arthroplasty
C. J. Richards, D. S. Garbuz, B. A. Masri ................................................................... 1063
103. Infection in total knee arthroplasty: treatment
T. M. Mabry, A. D. Hanssen ...................................................................................... 1071
Foreword

E
verything began when Johan Bellemans, Michel Bonnin, Jacques Ménétrey and I concluded the
1999 ISAKOS Congress in Washington, to anxiously begin our ESSKA-AOSSM Travelling Fellow-
ship. We travelled together visiting each of our host centers around the United States for almost a
month, where I enjoyed every day with my three fellows in my role as the “godfather”. During the next
part of our trip when guests of Peter Fowler, one of my best friends, at the University of Western Ontario
in London, Canada, we met Annunziato Amendola, a young “Italian” surgeon. More recently I met Steven
McDonald, a brilliant young Canadian surgeon.
Since normal locomotion is impossible without proper knee function and since numerous abnormalities
can interfere with normal function, the knee joint is our most frequently operated joint in the human
body. The expansion in knee treatment options and approaches introduce challenging problems to the
practicing surgeon and to the orthopaedic residents in training. Most important, this knowledge provides
the basis upon which an orthopaedist counsels a patient regarding the risks and benefi fits of every opera-
tive treatment. Actually many patients before or after the physician visit go into the internet to try to
understand if the suggestions of the treating surgeon are the same suggested by the “opinion leaders”.
They often get confused and frightened by the very diff fferent suggestions and proposals from diff fferent
orthopaedic surgeons. These patients have high expectations for overcoming their knee complaints and
ability to return to their previous activity level.
The text of this book is comprehensive and covers all surgical aspects of the knee pathology. Basic science,
epidemiology, imaging and surgical techniques are clearly reported and illustrated in a didactic fashion.
Despite the huge number of textbooks, journals and instructional courses dedicated to the knee, there
are still enormous areas of controversies within the orthopaedic community. This is why a multicontinen-
tal team of experts have been invited to defi fine and present their own vision and hands-on experience.
The book is divided in three parts: meniscal and ligamentous injuries, patello-femoral pathology and the
degenerative knee.
One lesson that can be drawn from this book is that none of us can accomplish much by ourselves and
that only through cooperation in groups and across national boundaries we can achieve real progress in
term of improved patient care.
For the future much remains to be improved and basic research needs to be further refined.
fi With its com-
prehensive, up-to-date summary of our knowledge of the knee, this book, thanks to the organization and
knowledge of the editors, will be a very valuable aid in furthering our understanding and management of
the “knee patient”.
Wishing a great success to the editors, I would like to report three quotations. TheTh first is from William
Harvey (1578-1657): “I would say with Fabricius, let all reasoning be silent when experience gainsays its
conclusion. The too familiar vice of the present age is to obtrude as manifest truths, mere fancies, born of
conjecture and superfi ficial reasoning, altogether unsupported by the testimony of sense.”
The second is from Robert Leach: “Enjoy the book, absorb the material so assiduously collected by the
editors and use that material to the benefi fit of your patients”. The third quotation is from my teacher
Jack C. Hughston: “To readers I would say, let the experience presented by this book speak for itself.”

Giancarlo Puddu, MD
Internationally Renowned Orthopaedic Surgeon
Inducted into Sports Medicine Hall of Fame
I The Traumatic Knee
Basic Sciences

A. Amendola, D.E. Bonasia The menisci: anatomy, healing
response, and biomechanics
Introduction
I
njury to the meniscus from both sports inju-
ries and daily living activities is common. As
a result, arthroscopic treatment of menis-
cal lesions has become one of the most common
orthopaedic surgical procedures, with arthroscopic
partial meniscectomy as one of the top 10 ortho-
paedic surgical procedures performed in the United
States (1). Occurring isolated or associated with
ligamentous injuries, meniscal tears can result in
abnormal joint function and mechanics, leading to
subsequent degeneration of the joint.
In past years, there has been a significant
fi improve-
ment in the management of meniscal tears and
defi
ficiency, with the acquired knowledge of the
biomechanical importance of these structures in
preserving articular cartilage and joint stability.
In 1887, Sutton described the meniscus as “the
functionless remains of a leg muscle” (2). In 1948
Fairbanks stated that “meniscectomy is not wholly
innocuous,” in his report of post-meniscectomy
radiographic changes (3).
With respect to meniscal repair and healing, in
1883, Thomas Annandale (4) was the first to suture
a meniscal tear. In 1936, King (5) showed that
degenerative changes appeared in a canine model
after meniscectomy and that peripheral menis-
cal tears could heal. In the 1950s and 1960s, the
menisci were considered as unnecessary develop-
mental remnants and total meniscectomy was per-
formed for almost any meniscal tear suspected on
clinical examination. It took almost a century from
Annandale’s report until a conservative approach
to the management of meniscal tears was applied
clinically. In the last two decades, understand-
ing meniscal importance and the development of
arthroscopic techniques have improved meniscal
preservation and the healing response.
Currently, the main functions attributed to the
menisci are (1) shock absorbing by dispersing
loads (6,7); (2) increasing congruity and contact
area between femur and tibia (8); (3) providing
joint stability (9); (4) protecting an anterior cru-
ciate ligament (ACL)-deficient
fi knee from arthritic
changes (10); (5) proprioception (11); (6) limita-
Chapter 1
tion of extreme flexion and extension (8); (7) artic-
ular cartilage nutrition (12).
Anatomy
Gross features
In terms of gross anatomy, the menisci are
C-shaped or semicircular fibrocartilaginous struc-
tures with bony attachments at the anterior and
posterior aspects of the tibial plateau (Fig. 1).
The medial meniscus (MM) is C-shaped, with the
posterior horn larger than the anterior one. The Th
anterior horn attachment is variable, and this should
be considered with meniscal transplantation and
anterior horn avulsions’reattachment (Fig. 2). Berlet
and Fowler (13), in their anatomic study, described
four types of anterior horn MM attachments. Th The
type IV variant has no firm bony attachment and is
connected with the intermeniscal ligament or the
soft tissues at the ACL insertion (Fig. 1). Nelson and
LaPrade (14) described similar type of attachment
in 14% of the cadavers examined; however, in the
majority of them, a firm anterior bony attachment
was observed. The posterior root of the MM attaches
anterior to the insertion of the posterior cruciate
ligament (PCL) and behind the medial tibial spine.
Johnson et al. (15) mapped the bony insertion sites
of the menisci, describing their location and surface
area. The anterior horn of the MM has the largest
insertion area (61.4 mm2) and the posterior horn of
the lateral meniscus (LM), the smallest (28.5 mm2).
The remainder of the MM is firmly attached to the
joint capsule and the surface of the deep medial cap-
sular ligament. Th
The capsular attachment of the MM
on the tibial side is referred to as the coronary liga-
ment. A thickening of the capsular attachment in the
midportion spans from the tibia to the femur and is
referred to as the deep medial collateral ligament.
The LM has an almost circular shape. It covers a
larger portion of the tibial articular surface than
does the MM (Fig. 1). Discoid LMs have been
reported with an incidence of 3.5–5% (16). The
6 The Traumatic Knee

Fig. 2 – Medial (M) compartment, showing the concave shape of the medial tibial condyle
and the anterior and posterior horns of the medial meniscus. A: anterior aspect of the tibia,
P: posterior. The MRI picture demonstrates the concavity of the medial tibial plateau (white
Fig. 1 – Anatomical specimen of the tibial plateau with arrow).
the menisci. A: anterior aspect of the tibia, P: posterior, M:
medial meniscus, L: lateral meniscus compartment, ACL:
anterior cruciate ligament: note the anterior and posterior
horn attachments of the lateral meniscus adjacent to the
anterior cruciate ligament. The arrow shows the anterior
horn attachment of the medial meniscus may or may not
be attached to bone.

Fig. 3 – Lateral (L) compartment. Note that the anterior and

posterior horn attachments always attach to bone very close
together on either side of the tibial spine. The MRI picture
demonstrated the convex nature of the lateral tibial plateau.

anterior and posterior horns attach much closer to
each other than do those of the MM, making this
anatomical area very consistent and therefore easy
to maintain during meniscal transplantation. Th The
anterior horn of the LM and the ACL attach adja-
cent to each other and can be used as landmarks
for ACL reconstruction and meniscal transplanta-
tion (Fig. 3). Th
The posterior root is posterior to the
lateral tibial eminence. In Wrisberg’s variation of
discoid LM, the posterior horn bony attachment
is absent, and the posterior meniscofemoral liga-
ment (of Wrisberg) is the only stabilizing structure.
This type of insertion can result in posterior horn
instability, although a hypermobile meniscus may
occur with a normal bony attachment. Th The anterior
meniscofemoral ligament (of Humphrey) runs from
the posterior horn of the LM anterior to the PCL
and inserts on the femur. The popliteus tendon lies
posterior and lateral to the posterior root insertion
of the LM. The popliteal hiatus consists in a portion
of the LM, where there is no firm peripheral attach-
ment to the femur and tibia. TheTh meniscal tears in
this area are less likely to heal. Simonian et al. (17)
investigated the role of the two popliteomeniscal
fasciculi and showed that the disruption of both of
them may increase meniscal motion at the hiatus
and cause hypermobility of the posterior horn of
the LM. Furthermore, Thompson et al. (18), with a
3D MRI, demonstrated the greater mobility of the
LM compared to the MM, through the knee range of
motion. The excursion of the LM averaged 11.2 mm,
compared to 5.2 mm of the MM. This phenomenon
can be explained by the less rigorous attachments
that the LM has to the articular capsule.
Microscopic Features
Ultrastructurally, the meniscus is composed of
fibrochondrocytes that reside within and maintain

the extracellular matrix, which is composed of col-
lagen and various proteoglycans. This Th extracellular
matrix gives the meniscus its biologic and material
properties that allow it to perform its load-bear-
ing function. The collagen fibers (three layers) lie
mostly along the longitudinal axis, with oblique
and radial fibers to enhance the structural integ-
rity (19). This orientation allows compressive loads
to be dispersed by the circumferential fi fibers, while
the radial fibers act as tie fibers to resist longitudi-
nal tearing. Th
The surface fiber orientation is more of
a mesh network or random confi figuration, thought
to be important in the distribution of shear stress.
The majority of collagen (90%) is type I, and
the remainder are types II, III, V, and VI. Elastin
accounts for approximately 0.6% of the dry weight
of the meniscus, and non-collagenous proteins, for
8–13% (20).
The fibrochondrocytes synthesize the fibrocar-
tilaginous matrix and appear to be of two types,
with the more superfi ficial cells being oval or fusi-
form and the deeper cells being more rounded.
Both types contain abundant endoplasmic reticula
and Golgi complexes and few mitochondria.
Vascularity
At birth, the entire meniscus is vascular, but at 9
months, the inner one-third has become avascular.
This decrease in blood supply continues to age 10
years, when the meniscus closely resembles the
adult meniscus. Arnoczky and Warren (21) stud-
ied the adult vascularity of the menisci and dem-
onstrated that only the outer 10–25% of the LM
and the outer 10–30% of the MM are vascular. Th The
blood supply to the meniscus comes from the peri-
meniscal capillary plexus, which arises from the
superior and inferior branches of the medial and
lateral genicular arteries. A thin layer of synovium
extends a short distance over both the superior
and inferior surfaces of the menisci, without, how-
ever, contributing to the meniscal vascularity. At
the popliteal hiatus, the LM is relatively avascular.
Because of the avascular nature of the inner por-
tion of the meniscus, cell nutrition is believed to
occur mainly through diff ffusion of synovial fluid
(22). The menisci are historically divided in three
zones (red-red, red-white, and white-white). The Th
red-red zone consists of the outer third of the
meniscus and is vascular; the red-white zone rep-
resents the mid-third and receives nourishment
from both blood supply and synovial fluid;
fl and the
white-white zone is considered totally avascular
and nourished by synovial fluid only.
The neuroanatomy of the meniscus is not totally
clear, but the distribution of neural elements has
The menisci: anatomy, healing response, and biomechanics 7
been demonstrated to be similar to the vascular
supply. The meniscal roots are the most richly
innervated, while the body’s innervation is mainly
peripheral. Although not entirely clear, sensory
feedback and proprioception functions were
hypothesized for these nerve endings. It seems
that the greatest feedback occurs at the extremes
of flexion and extension, when the horns are com-
pressed and neural cells stimulated. Dye et al. (23),
who did neurosensory mapping of the internal
structures of the knee, confi firmed that probing
peripheral tissues is more painful than central.
Meniscal healing response
The key factor in the process of tissue repair is
accessibility of cells and infl
flammatory mediators to
the site of injury. Th
The formation of a clot is an ini-
tial phase that provides a scaffold
ff for matrix forma-
tion and is a chemotactic stimulus for the cellular
elements that are involved in wound healing (24).
Therefore, tears in the vascular zone (red-red) tend
to form a clot and heal, whereas tears in the avas-
cular central region (white-white) do not. But the
most common tears and the dilemma occur when
the lesion is in the red-white zone. Furthermore,
in this zone a significant
fi portion of the meniscus
is usually involved. Th Therefore, in an attempt to
get these tears to heal every aspect of the process
is important: (1) technical suturing to provide a
stable repair; (2) post-operative cautious rehabili-
tation and return to activity; and (3) stimulation
of the repair site by hematoma. Webber et al. (25)
showed in tissue culture that meniscal cells can pro-
liferate and synthesize an extracellular matrix when
exposed to factors that normally present in wound
hematoma. In order to promote healing, many
authors investigated the use of a fibrin
fi clot, fibrin
glue, cell growth factors, creating traumatic vascu-
lar access channels, and adjacent synovial bleeding
by various methods. Currently, abrading the syn-
ovium adjacent to the tear, and “freshening up” the
tear by rasps or shavers, is the common method of
allowing hematoma’s formation (24). Although the
real effi
fficacy of these procedures is unknown, we do
know clinically the healing rate of meniscal tears is
higher in knees with concurrent ACL reconstruc-
tion. This may indicate that hematoma formation
and bone marrow stimulation can promote menis-
cal healing. In addition to stability of the joint and
the location of the tear, other factors that seem to
positively aff
ffect healing include the acuity of the
lesion, the young age of the patient, and a non-de-
generative pattern of the tear (26,27).
In terms of rehabilitation, immobilization of the
knee seems to ultrastructurally decrease collagen
8 The Traumatic Knee
content in the meniscus, while knee motion tends
to prevent collagen loss (28). Nevertheless, besides
biology, the rehabilitation program should be
defined
fi according to multiple factors: (1) tear pat-
tern; (2) stability of the tear and fixation;
fi (3) asso-
ciated procedures; (4) age and activity level of the
patient.
Biomechanics
As previously mentioned, the menisci are impor-
tant in many aspects of knee function, including
load sharing, shock absorption, reduction in joint
contact stresses, passive stabilization, increasing
congruity and contact area, limitation of extremes
of flexion and extension, and proprioception. The
findings of joint space narrowing, osteophyte for-
mation, and squaring of the femoral condyles after
total meniscectomy suggested that the meniscus is
important in joint protection and led to investiga-
tions of the role of the meniscus in joint function.
The MM and the LM transmit respectively about
50% and 70% of the load with the knee extended,
and this increases to 85% with the knee flexed
fl 90°
(6). Radin et al. (29) demonstrated that the loads
across the joint are well distributed with intact
menisci. Removal of the MM results in a 50–70%
reduction in femoral condyle contact area and in
a 100% increase in contact stress (30,31). Total
lateral meniscectomy causes a 40–50% decrease
in contact area and increases contact stress in
the lateral compartment to 200–300% of normal.
In addition, partial removal of the meniscus will
alter load characteristics, particularly when two-
thirds of the posterior horn are removed (32).
Because of these biomechanical considerations
and anatomy (less congruent articular surfaces),
lateral compartment is more meniscus dependent
than medial one (Figs. 2 and 3) (12). Lee et al. (33)
demonstrated that the increase of contact stresses
through the joint is proportional to the amount of
MM removed, especially when the more peripheral
portions of the MM are excised. Furthermore, they
showed that the loss of hoop tension (i.e., segmen-
tal meniscectomy) is equivalent to total meniscec-
tomy in load-bearing terms.
Along with the biomechanical changes that can
occur with meniscectomy, the results of some
studies (22) suggest that biochemical activity of
cartilage is also affected.
ff The improved joint con-
gruity, which occurs through meniscus contact,
is thought to play a role in joint lubrication and
cell nutrition. As mentioned, the meniscus, being
one-half as stiff
ff as articular cartilage, also plays
a role in shock absorption. In one study (34), the
shock absorption capacity of the normal knee was
reduced by 20% after meniscectomy. Th The menisci
also showed an important function in providing
joint stability (9). Medial meniscectomy in the
stable knee has little effffect on anteroposterior
motion, but in the ACL-defi ficient knee, it results
in increased anterior tibial translation of up to
58% at 90° of flexion. Shoemaker and Markolf
(10) demonstrated that the posterior horn of the
MM is the most important structure resisting an
applied anterior tibial force in an ACL-deficient
fi
knee. Allen et al. (35) showed that the resul-
tant force in the MM of the ACL-defi ficient knee
increased by 52% in full extension and by 197%
at 60° of flexion under a 134-N load. Although
the inner two-thirds of the meniscus is important
in maximizing joint contact area and increasing
shock absorption, the integrity of the peripheral
one-third is essential for both load transmission
and stability.
In summary, the menisci are important structures
with significant
fi joint-protective properties. A clear
understanding of the function, biology, and heal-
ing capacity of the meniscus is important to allow
proper decision making in the clinical setting.
References
1. Harner CD (2004) The use of allografts in sports medicine.
AOSSM Annual Meeting, Quebec City, Canada
2. Bland-Sutton J (1897) Ligaments: their nature and mor-
phology. 2nd ed. London, UK: JK Lewis
3. Fairbank, TJ (1948) Knee joint changes after meniscec-
tomy. J Bone Joint Surg 30B (4):664–670
4. Annandale T (1885) An operation for displaced semilunar
cartilage. Clin Orthop 260:3–5
5. King D (1936) The healing of semilunar cartilages. J Bone
Joint Surg 18(2):333–342
6. Ahmed AM, Burke DL (1983) In-vitro measurement of
static pressure distribution in synovial joints. Part I: Tibial
surface of the knee. J Biomech Eng 105(3):216–225
7. Kurosawa H, Fukubayashi T, Nakajima H (1980) Load-
bearing mode of the knee joint: physical behavior of the
knee joint with or without menisci. Clin Orthop Relat Res
149:283–290
8. Greis PE, Bardana DD, Holmstrom MC, Burks RT (2002)
Meniscal injury: I. Basic science and evaluation. J Am Acad
Orthop Surg 10(3):168–176
9. Levy IM, Torzilli PA, Warren RF (1982) TheTh eff
ffect of medial
meniscectomy on anterior-posterior motion of the knee. J
Bone Joint Surg Am 64(6):883–888
10. Shoemaker SC, Markolf KL (1986) The Th role of the menis-
cus in the anterior-posterior stability of the loaded ante-
rior cruciate-defi
ficient knee. Eff
ffects of partial versus total
excision. J Bone Joint Surg Am 68(1):71–79
11. Baratz ME, Fu FH, Mengato R (1986) Meniscal tears: the
eff
ffect of meniscectomy and of repair on intraarticular
contact areas and stress in the human knee. A preliminary
report. Am J Sports Med 14(4):270–275
12. McCarty EC, Marx RG, DeHaven KE (2002) Meniscus
repair: considerations in treatment and update of clinical
results. Clin Orthop Relat Res 402:122–134
13. Berlet GC, Fowler PJ (1998) Th The anterior horn of the
medial meniscus: an anatomic study of its insertion. Am
J Sports Med 26:540–543

14. Nelson EW, LaPrade RF (2000) The Th anterior intermenis-
cal ligament of the knee: an anatomic study. Am J Sports
Med 28:74–76
15. Johnson DL, Swenson TM, Livesay GA, et al. (1995)
Insertion-site anatomy of the human menisci: gross,
arthroscopic, and topo-graphical anatomy as a basis for
meniscal transplantation. Arthroscopy 11:386–394
16. Vandermeer RD, Cunningham FK. (1989) Arthroscopic
treatment of the discoid lateral meniscus: results of long-
term follow-up. Arthroscopy 5:101–109
17. Simonian PT, Sussmann PS, van Trommel M, et al. (1997)
Popliteomeniscal fasciculi and lateral meniscal stability.
Am J Sports Med 25:849–853
18. Thompson WO, Thaete FL, Fu FH, Dye SF (1991) Tibial
meniscal dynamics using three-dimensional reconstruc-
tion of magnetic resonance images. Am J Sports Med
19:210–216
19. Beaupre A, Choukroun R, Guidouin R, et al. (1986) Knee
menisci: correlation between microstructure and biome-
chanics. Clin Orthop 208:72–75
20. McDevitt CA, Webber RJ (1990) Th The ultra-structure and
biochemistry of meniscal cartilage. Clin Orthop 252:8–18
21. Arnoczky SP, Warren RF (1982) Microvasculature of the
human meniscus. Am J Sports Med 10:90–95
22. Mow VC, Fithian DC, Kelly MA (1990) Fundamentals of
articular cartilage and meniscus biomechanics. In: Ewing
JW, editor. Articular cartilage and knee joint function: basic
science and arthroscopy. New York: Raven Press: 1–18
23. Dye SF, Vaupel GL, Dye CC (1998) Conscious neurosen-
sory mapping of the internal structures of the human
knee without intraarticular anesthesia. Am J Sports Med
26:773–777
24. Ritchie JR, Miller MD, Bents RT, Smith DK (1998) Meniscal
repair in the goat model. The use of healing adjuncts on cen-
tral tears and the role of magnetic resonance arthrography
in repair evaluation. Am J Sports Med 26(2):278–284
The menisci: anatomy, healing response, and biomechanics 9
25. Webber RJ, Harris MG, Hough AJ (1985) Cell culture of
rabbit meniscal fibrochondrocytes: proliferative synthetic
response to growth factors and ascorbate. J Orthop Res
3(1):36–42
26. Belzer JP, Cannon WD Jr (1993) Meniscus tears: treat-
ment in the stable and unstable knee. J Am Acad Orthop
Surg 1(1):41–47
27. Eggli S, Wegmuller H, Kosina J, et al. (1995) Long-term
results of arthroscopic meniscal repair. An analysis of iso-
lated tears. Am J Sports Med 23(6):715–720
28. Dowdy PA, Miniaci A, Arnoczky SP, et al. (1995) The
Th effffect
of cast immobilization on meniscal healing. An experi-
mental study in the dog. Am J Sports Med 23(6):721–728
29. Radin EL, de Lamotte F, Maquet P (1984) Role of the
menisci in the distribution of stress in the knee. Clin
Orthop 185:290–294
30. Fukubayashi T, Kurosawa H (1980) Th The contact area and
pressure distribution pattern of the knee: a study of nor-
mal and osteoarthrotic knee joints. Acta Orthop Scand
51:871–879
31. Kettelkamp DB, Jacobs AW (1972) Tibiofemoral contact
area: determination and implications. J Bone Joint Surg
Am 54:349–356
32. Watanabe Y, Scyoc AV, Tsuda E, et al. (2004) Biomechani-
cal function of the posterior horn of the medial meniscus:
a human cadaveric study. J Orthop Sci 9(3):280–284
33. Lee SJ, Aadalen KJ, Malaviya P, et al. (2006) Tibiofemoral
contact mechanics after serial medial meniscectomies in
the human cadaveric knee. Am J Sports Med 34(8):1334–
1344
34. Voloshin AS, Wosk J (1983) Shock absorption of menis-
cectomized and painful knees: a comparative in-vivo
study. J Biomed Eng 5:157–161
35. Allen CR, Wong EK, Livesay GA, et al. (2000) Importance
of the medial meniscus in the anterior cruciate ligament-
defi
ficient knee. J Orthop Res 18:109–115

S. Scheffler The cruciate ligaments: anatomy,
biology, and biomechanics
Anatomy
T
he first mentioning of the cruciate liga-
ments originates from an Egyptian papyrus
role dated around 3000 BC. Hippocrates
described the typical subluxation of the knee joint
caused by cruciate ligament defi ficiency around
460–370 BC. It is believed that Claudius Galen
von Pergamen (129–199 BC) is responsible for the
naming of the cruciate ligaments, calling them “lig-
ament genu cruciata.” In 1836, the Weber brothers
from Goettingen, Germany, published a detailed
analysis of the effffect of cruciate ligament insuf-
ficiency on knee kinematics (1). The first English
detailed description of cruciate ligament anatomy,
biomechancis, and injury pattern was presented
by I. Palmer (2) in his thesis work and defined
fi the
positive anterior drawer phenomenon after ante-
rior cruciate ligament (ACL) injury.
Embryology
Th knee starts to develop in the 4th week of gesta-
The
tion with a recognizable structure around the 6th
week in utero (3). The formation of the cruciate lig-
aments has been observed as early as 6–8 weeks in
fetal development (4,5). First, the posterior cruci-
ate ligament (PCL) can be distinguished before the
initial development of the ACL (5). It is assumed
that the cruciate ligaments originate from either
the fetal blastoma as a ventral condensation (6)
or as derivatives from the posterior portion of the
joint capsule (7). They develop from a concentra-
tion of synovial mesenchyme between the femoral
and tibial origins (8) and can be clearly separated
from their surrounding tissue of the intermittent
joint zone (3). The ACL gradually moves into a more
posterior location from the initial anterior location
in the knee joint as the intercondylar space forms
(6). The PCL does not change its location during
further fetal development (5). Both cruciate liga-
ments remain coated by the synovial membrane,
therefore being extrasynovial in the intra-articular
environment (3). The organization of diff fferent
functional bundles of the ACL is clearly present at
Chapter 2
16 weeks of gestation, and the organization of the
various ligamentous structures of the knee joint is
completed shortly thereafter (5).
During fetal development, both cruciate liga-
ments are highly cellular with fibroblasts dis-
playing a distinct longitudinal orientation along
the axis of tension. It is assumed that knee joint
motion is guided from the beginning by both cru-
ciate ligaments and that they are a prerequisite
for proper development and maturation of the
femoral condyles and the tibial plateau. It was
observed that both cruciate ligaments already
have the capability of adapting their structural
composition and orientation to the mechanical
loading environment during fetal development.
This allows for the development of the complex
structure of the cruciate ligaments with their
significant impact on knee joint kinematics.
Macroscopic anatomy
The ACL and the PCL are located at the center of the
human knee joint in the intercondylar fossa. Th The
ACL extends from the anteromedial (AM) aspect
of the tibia toward the posterolateral (PL) area of
the lateral femoral condyle (Fig. 1). The
Th PCL arises
from the posterior tibia and moves anteromedially
behind the ACL to the lateral surface of the medial
femoral condyle (Fig. 2). Due to their anatomical
location, both cruciate ligaments allow for a com-
plex functional interaction, providing translational
and rotational stability to the human knee joint.
Functional anatomy
ACL
The ACL is a non-isometric structure that shows
signifi
ficant variations in its tension behavior
throughout the cross section. Several authors
described the ACL to be composed of differ- ff
ent functional bands (Fig. 3). First Palmer (2)
and later Girgis et al. (9) divided the ACL into a
smaller AM bundle and a larger PL bundle (10),
while Amis (11) and Hollis et al. (12) found three
12 The Traumatic Knee

A B
Fig. 1 – (A, B) Illustration of ACL anatomy. Note the change in orientation of the anteromedial (straight line) and posterolateral bundle (dotted
line) at extension (1A) and flexion (1B). (Courtesy of Dr. Thore Zantop.)

Fig. 2 – View of the posteromedial aspect of the PCL outlining the artificially separated AL and
PM bundles. The tibial footprint in the facet between the medial and lateral posterior horns of
the menisci can be identified. (Courtesy of Andrew Amis, PhD)

Fig. 3 – Variations in the tibial attachment areas of the AM and PL bundle of the ACL. (Colom-
bet et al., Arthroscopyy 2006.)

diff
fferent functional structures (AM, intermediate
band, PL). The simplifi fied two-bundle model has
become the most accepted model and a blueprint
for anatomic ACL reconstruction. Both bundles
are non-isometric during the fl flexion-extension
path of the knee joint. In knee extension, the
AM and PL bundles are parallel to each other,
with the AM bundle being signifi ficantly longer
(34 mm) than the PL bundle (22.5 mm) (12; Fig.
1B). In extension the PL bundle is tight, while
the AM bundle is moderately loose. The highest
loads in the ACL were observed during anterior
tibial loading near extension, which indicates the
necessity of a stronger PL bundle. Th The AM bundle
lengthens and becomes tight in fl flexion, while the
PL bundle slackens toward flexion (12; Fig. 1A).
With increasing flflexion, the parallel fiber orienta-
tion is lost and the femoral insertion site of the
ACL becomes more horizontal, causing the AM to
wrap around the PL bundle (Fig. 1B). Amis and
Dawkins showed that in flexion beyond 90°, the
PL bundle retightens toward full flexion (11).
PCL
Similarly to the ACL, the PCL does not consist
of a single functional unit but of two main fi fiber
bundles, the anterolateral (AL) and posteromedial
(PM) (9,13,14; Fig. 2). However, other authors have
suggested that the PCL’s fiber anatomy and behav-
ior are more complex, describing the PCL as a fiber
fi
continuum composed of up to four consistent geo-
graphical fiber regions (15). Amis et al. described
this more a functional than an anatomical division
due to the difffferent tensioning behavior of the

respective bundles during the arc of knee motion.
The AL bundle has been found to be substantially
stronger and having a larger cross-sectional area
than the PM bundle (16). TheTh AL bundle is slack
and curved in the extended knee joint. With
increasing flexion, the PCL lengthens and tight-
ens, providing the dominating constraint to tibial
posterior translation. The PM bundle is tight in
extension but, due to its proximodistal alignment,
resists hyperextension rather than posterior tibial
loading (13). During mid-flexion,
fl it moves past
the AL bundle anteriorly along the medial side of
the notch and becomes loose. In deep flexion,
fl PM
fibers are taut again and contribute to posterior
drawer stabilization (13,17).
Insertion site anatomy
ACL
The ACL is a dense collagenous structure with an
irregular cross-sectional area that increases from
the femur to the tibia and changes with flexion
fl
and extension (18). At the attachment areas on the
femoral and tibial bone, the ACL fans out to 3.5
times the size of its mid-substance (19).
The femoral attachment has been depicted on
the inner surface of the lateral femoral condyle
at its posterior part (9,20). Girgis et al. described
the femoral insertion site as a vertically disposed
semicircle (9), while Odensten (21) and Harner et
al. (19) found it to be more of an oval than a round
shape. The
Th actual diameter of the insertion site
shows significant
fi variation with the overall diam-
eter measuring from 11 to 24 mm (3,20). In a more
recent study by Colombet at al. (22), the proxim-
odistal diameter of the femoral attachment of the
ACL was measured to be 13.9 ± 9.5 mm, and the
anteroposterior diameter 9.3 ± 7.1 mm. In exten-
sion, the fibers
fi of the AM bundle are located at the
most anterior and proximal aspect of the femoral
insertion site, while the PL bundle fascicles origi-
nate at the posterodistal area of the femoral ACL
The cruciate ligaments: anatomy, biology, and biomechanics 13
attachment (11). As the ACL moves from its proxi-
mal insertion, its diameter increases and reaches
its maximum as it inserts tibially (3,6). Th
The tibial
attachment of the ACL is located in front of and
lateral to the medial intercondylar tubercle. Its
lateral border is adjacent to the anterior horn and
can extend to the posterior horn of the lateral
meniscus. The width of the tibial attachment site
has been determined to range from 8 to 12 mm
and the anteroposterior length between 14 and
21 mm (3,9,20,22). TheTh nomenclature AM and PL
bundle derives from their anatomical insertion
in the tibial footprint of the ACL: the AM bundle
inserts anteromedially and the PL bundle poste-
rolaterally. Colombet et al. (22) found large varia-
tions among the relative locations of the AM and
PL bundles in the tibial footprint. Even though
the centers of the two fiber bundles lay antero-
posterior, the individual attachment areas of the
AM and PL bundles were mediolaterally parallel to
each other and showed a large variation (Fig. 3)
compared to the very consistent femoral footprint
of the ACL.
PCL
The PCL is longer and stronger than the ACL (23).
PCL footprints on the femur and the tibia are three
times larger than its mid-substance cross-sectional
area (24).
The femoral insertion site of the PCL is located
at the medial femoral condyle and extends to the
medial side of the femoral intercondylar notch.
In knee extension, the PCL forms a “half-moon”
shape against the articular cartilage of the medial
femoral condyle (Fig. 4). The
Th area of the femoral
attachment varies, sometimes extending poste-
riorly all the way to the posterior margin of the
articular cartilage and proximally fanning out to
the roof of the intercondylar notch (13). In knee
flexion, the much stronger AL bundle (16) covers
the area from the 12 to 3 o’clock position (right
knee) and shows only little variations in its loca-
tion. The morphology of the PM bundle is more
Fig. 4 – Outline of the femoral footprint of the PCL.
(Courtesy of Dr. Freddie Fu)
14 The Traumatic Knee
variable, extending from the 3 o’clock position
toward variable locations on the posterior aspect
of the medial femoral condyle. Often, menis-
cofemoral ligaments (MFLs) can be identified fi
in human knee joints (Fig. 5). Th The anterior MFL
of Humphrey attaches distal to the PCL on the
femur and becomes superfi ficial in deep flexion of
the knee joint (13). Care has to be taken not to
mistake this structure as part of the PCL when
performing PCL reconstruction and locating the
position of the femoral tunnel. Th The PCL fibers
move posterodistally toward the posterior edge
of the tibia in between the posterior horns of the
medial and lateral menisci. This area of attachment
is called the PCL facet (9) and is distinct from the
vertical posterior cortex. Its location is most con-
sistent among the insertion sites of the cruciate
ligaments, showing a predominately rectangular
shape (25). It was found that the posterior fibers
fi
blend with the periosteum and expand down the
posterior surface of the tibia for about 1.5–2 cm,
with some fibers blending into the posterior cap-
sule (24). The
Th AL fibers insert in the anteroproxi-
mal area of the tibial PCL footprint, covering the
entire flat intercondylar surface of the PCL facet
(Fig. 2). They border the posterior edge of the
root of the posterior horn of the medial meniscus
(13,26) becoming more trapezoidal in shape. The Th
PM fibers attach centrally at the posterior sur-
face of the tibia below the AL fibers. They extend
past the rim of the tibial plateau about 1.5 cm
postero-lateral-distally close to the attachment
area of the popliteus muscle. Some anatomical
studies revealed posterior oblique fibers
fi of the
PCL that might be confused with the posterior
MFL of Wrisberg (27). Th These fibers are situated
posteriorly on the PCL moving from the medial
femoral condyle to the lateral facet of the tibia,
where they insert to the bone below the posterior
horn of the lateral meniscus.
Fig. 5 – Posterior view of PCL anatomy and the posterior meniscofemoral
ligament of Wrisberg. (Courtesy of Dr. Thore Zantop.)
Biology
Microanatomy
The ACL and PCL microstructures follow the typi-
cal organization of connective tissues found in
human joints, even though characteristic differ- ff
ences between both cruciate ligaments exist.
Both cruciate ligaments are covered by a vascular
layer, termed “epiligament” (28,29), which is more
cellular and richer in sensory and proprioceptive
nerves than the ligaments themselves. Below the
epiligament the typical fibrous
fi architecture of the
cruciate ligaments appears. These ligaments are
hierarchically organized into groups of parallel
fibers, fascicles, which are surrounded by a connec-
tive tissue called the paratenon. In the ACL, these
fascicles have a size of 250 m to several millime-
ters. The fascicles interdigitate and branch out to
connect superfi ficially with deeper layers of fascicles
in the ligament (28). This is typically found at the
femoral and tibial insertion sites. In the PCL, such
interdigitation is much more sparse with a homog-
enous strictly parallel orientation of the PCL fiber
fi
bundles (28). The
Th fascicles can be further divided
into subfasciculi (100–250 m in diameter), which
are covered by an epitenon. Th The subfascicular units
(1–20 m) are composed of collagen fibrils, rang-
ing between 20 and 155 nm in diameter for the
ACL and 20 and 180 nm for the PCL (28,30). The Th
collagen fibrils
fi are part of a complex three-dimen-
sional network of cellular components, such as
fibroblasts and myofi fibroblasts that are submerged
in an extracellular matrix, providing the environ-
ment for a sound mechanical and biological func-
tion of the cruciate ligaments. Furthermore, both
cruciate ligaments display a characteristic direct
type of insertion to the femoral and tibial bone.
This direct insertion consists of a transition from
ligamentous tissue via a zone of fibrocartilage and
mineralized cartilage to bone (31).
Cellular components
Most of the current knowledge on cellular compo-
sition of cruciate ligaments is based on analyses of
the ACL, with little information available on the
PCL. The local cells found in both cruciate ligaments
are fibroblasts. In the ACL, a typical distribution
from proximal to distal can be found (32,33). In
both ligaments, a subform of fibroblasts
fi has been
identifi
fied that exhibits contractile properties, the
so-called myofibroblasts.
fi Their specifi
fic function in
cruciate ligaments is not fully understood, but it is
assumed that they play a role in the regular crimp
formation and in the healing ligament (33,34).

Murray et al. described the fibroblast distribution
in the AM bundle of the ACL (33). They depicted
a proximal part about one-fourth of the overall
length that was highly cellular with round and
ovoid cells next to parallel-oriented fusiform cells.
The distal three-fourths of ACL were dominated
by spheroid cell at a much lower cell density and
a shorter crimp formation. Duthon et al. (32) also
observed signifi
ficant histological diff
fferences along
the ACL, but distinguished a middle part from a
proximal and distal part. The middle part was less
cellular than the proximal and contained fusiform
and spindle-shaped fibroblasts and a special zone
of cartilage and fibrocartilage, especially in the
anterior part where the ligament is in close prox-
imity to the intercondylar notch. Some authors
postulated that the presence of this zone is caused
by a physiological impingement against the ante-
rior part of the intercondylar roof due to the ana-
tomical orientation of the AM bundle (35). The Th
cytoplasm of the fusiform cells is attached to the
extracellular collagen and seems to play a role in
the typical crimp formation (32,33). In the distal
part, Duthon et al. (32) found chondroblasts and
ovoid fibroblasts, which resembled the cells of
articular cartilage. They have abundant cellular
organelles indicating high cellular activity. In the
area of the distal ACL insertion, chondrocyte cells
can be seen typically in the zone of fibrocartilage
and mineralized fibrocartilage that anchors the
ligament to the bone.
Extracellular components
All cellular components are suspended in a com-
plex three-dimensional matrix of extracellular
structures. Most of the extracellular volume is
composed of collagen fi fibrils. Strocchi et al. (29)
observed two types of fibrils
fi in the ACL: the first
type was of variable diameter between 35 and 75
nm and had an irregular outline. They accounted
for around half of the entire ACL and were secreted
by fibroblasts. It is believed that these large fibrils
are designed to resist high tensile stress. Th The sec-
ond type had a uniform diameter around 45 nm
and comprised around 44% of the entire ACL.
This type was secreted by fibro-condroblasts and
was mainly responsible for maintaining the three-
dimensional organization of the ligament. Baek et
al. (30) found that the distribution of these two
types of collagen fibrils varied signifi ficantly along
the length of the ligament and between the ACL
and the PCL. While the ACL had an increase of
average fibril diameter from proximal (66 nm)
to middle (75 nm) to distal (78 nm), the trend
for the PCL was opposite with deceasing average
fibril diameter (proximal 90 nm; middle 75 nm;
The cruciate ligaments: anatomy, biology, and biomechanics 15
distal 60 nm). Similarily, Neurath et al. also found
that the average fibril diameter of the ACL (74 nm)
was below that of the PCL (82 nm) (28). In both
ligaments, fibrils are organized into parallel and
dense structures that follow a regular wave pat-
tern, the so-called crimp, which is planar centrally
and helical at the periphery of the ligaments. TheTh
crimp pattern represents the unique ability of the
cruciate ligaments to allow for continuous recruit-
ment of load-carrying collagen fi fibrils, therefore
functioning as a buffer
ff or shock absorber, so that
longitudinal stretch of the ligament does not lead
to immediate, irreversible fibrous damage.
The matrix of the cruciate ligaments demonstrates
the following four diff
fferent systems:
Collagen
Diff
fferent types of collagen have been identifi fied in
the ACL and PCL.
Type I collagen is the dominating collagen in liga-
ments and tendons. Its fibers are oriented in a
parallel fashion and are responsible for the tensile
strength of the ligament.
Type II collagen can be found at the femoral and tib-
ial insertion sites in the fibrocartilaginous regions
of the ACL. The presence of collagen type II is an
indicator of applied pressure or shear as at the
femoral and tibial attachment sites.
Type III collagen has been identified
fi in the ACL in
the loose connective tissue that separates the type
I collagen bundles. It can be found along the whole
length of both cruciate ligaments with a concen-
tration near the insertion sites (36). This type of
collagen is usually increasingly generated during
the ligamentization process of the remodeling
replacement graft.
Type IV collagen is found in the basal lamina of the
intra- and periligamentous vessels. Signifi ficantly
more type IV collagen was found in the PCL than
in the ACL. Both cruciate ligaments showed signif-
icantly lower type IV collagen density in their less
vascularized mid-portion (36).
Type VI collagen can be found in both cruciates along
the complete length of the ligament with concen-
tration in the distal zones and higher expression in
the ACL than the PCL (36). Type VI collagen serves
as a gliding component between functional fi fibrillar
units, and its concentration near the attachment
sites can be explained by the higher strains found
in these compared to the mid-substance regions.
Glycosaminoglycans
These ground substances allow, in combination
with proteoglycans, for homogenous distribution
of water throughout the ligaments that accounts
for 60–80% of the total wet-weight of the ACL and
PCL. This leads to modifi
fications of the viscoelastic
16 The Traumatic Knee
properties of the cruciate ligaments and functions
as a protection mechanism against repetitive load-
ing.
Glyco-conjugates
These play an important role in intra- and extra-
cellular matrix morphology, cellular adhesion, and
cell migration. In the cruciate ligaments, laminin,
entactin, tenascin, and fi fibronectin are found.
Duthon et al. reported upregulated concentrations
in the proximal part of the ACL (32).
Elastic components
These components are essential for facilitating
the large length changes of the ligaments during
motion (29,36) and therefore can be found pre-
dominantly along the mid-substance of the liga-
ments. Matrix components identified
fi in the ACL
are oxytalan, elaunin, mature elastic fi
fibers, and
elastic membranes.
Vascularity
Both cruciate ligaments receive their vascularity
from the middle genicular artery (MGA) that origi-
nates from the popliteal artery and enters the knee
joint through the dorsal capsule (37,38). From the
intra-articular part of the MGA, several branches
connect to the various soft tissues of the intrac-
ondylar fossa, such as the cruciate ligaments. Th The
synovial membrane of the ACL becomes vascular-
ized at the junction of the joint capsule distal to the
infrapatellar fat pad, mainly by a large, posteriorly
descending branch of the MGA and small nutrient
arteries (20,38; Fig. 6). The larger vessels of the
MGA descend toward the PCL (37). The Th vascular
density of the ACL decreases from proximal to dis-
tal, while the PCL shows a more homogenous and
higher vascular density along its length than the
ACL (28). Petersen et al. (37) found three avascular
zones in the PCL: the fibrocartilage of the respec-
Fig. 6 – Sagittal (A) and coronal (B) views of the vascular anatomy of
the ACL. On the sagittal section, the middle genicular artery leaves the
popliteal artery at a right angle (arrows) crossing the posterior capsule. FP
refers to infrapatellar fat pad. (Reproduced with permission and copyright
© of Wiley-Liss (38).)
tive insertions sites was devoid of vessels as well as
the central part of the middle third of the PCL.
The various branches of the MGA build a synovial
plexus in the epiligament that ensheathes the cru-
ciate ligaments along their entire length. Smaller
vessels penetrate the ligament transversely to anas-
tomose with endoligamentous vessels that are lon-
gitudinally aligned to the collagen bundles in a par-
allel fashion (6). Interestingly, both attachment sites
of either cruciate ligament do not contribute to the
endoligamentous supply with no crossing of intralig-
amentous vessels to the tibia or femur (20,32,39).
Besides the MGA, small arterioles from the Hoffa ff
fat pad penetrate the ligamentum mucosum (38),
while infrapatellar branches of the inferior genicular
arteries supply the distal portion of the ACL.
Innervation
The ACL possesses most of its neural structures in
its subsynovial layer and near the insertion sites
(3). These neural structures originate from the
posterior articular branches of the tibial nerve (40)
and penetrate the posterior joint capsule to follow
the synovial and periligamentous vessels of the
ACL. The majority of the nerve fibers are associated
with endoligamentous vasculature, having a vaso-
motor function. Autonomous smaller myelinated
nerve fibers (2–10 m in diameter) and unmyeli-
nated nerve fibers (1 m in diameter) were identi-
fied in the ACL that lied among the fascicles of the
ligament (40). Similar findings were made for the
PCL (41). Schultz et al. (42) also found unmyeli-
nated axons at the PCL surface, which Solomonow
(43) and Raunest et al. (44) located predominantly
at the insertion sites. The receptors of the nerve
fibers found in both cruciate ligaments (45) have
been identified
fi as:
– Ruffi
ffini receptors, which are located on the surface
of the entire ligament with concentrations at its
respective attachment sites (46) and are espe-
cially sensitive to stretch;
– Vater-Pacini receptors, which are also located at
the femoral and tibial insertion sites of the cru-
ciate ligaments (41,46,47) and are sensitive to
rapid movements;
– Golgi-like tension receptor, which can be found
throughout the surface, beneath the synovial
membrane, and near the attachment sites of the
cruciate ligaments (41,42,46).
– free-nerve endings, which were recognized as noci-
ceptors as well as local effectors
ff that release neu-
ropeptides with vasoactive function, facilitating
a modulatory effect
ff in normal tissue homeosta-
sis (45).
All these neural receptors serve the purpose of
proprioception, providing afferent
ff feedback of

ligamentous tension, which affects
ff muscular activ-
ity and impacts on overall knee stability. Changes
in ligament tension initiate the output of muscle
spindles through the fusimotor system. Such acti-
vation of aff
fferent nerve fibers in the proximal part
of the ACL has been shown to result into motor
activity of the knee flexors
fl and was termed the
“ACL reflflex.” Due to the long latency of this refl
flex
arc, an automatic protective mechanism cannot be
assumed. However, this neural feedback mecha-
nism seems to play an important role in normal
knee function and is involved in the updating of
muscle programs (48). A disruption of the ACL and
the aff
fferent feedback of its mechanoreceptors has
been determined to be responsible for the loss of
accuracy of joint position sense (48).
Biomechanics
The ACL and the PCL facilitate an elaborate inter-
action with the medial and lateral structures, the
menisci and bony anatomy of the patella, and
tibiofemoral joint. This enables the knee joint to
move in six degrees of freedom (three translational
motions: anteroposterior, mediolateral, proxim-
odistal; three rotational motions: fl flexion-exten-
sion, internal-external, abduction-adduction).
The ACL is the primary constraint for anterior
tibial translation (49). It limits internal rotation as
a secondary stabilizer, mainly in conjunction with
the medial collateral ligament and posteromedial
structures of the knee joint (17).
The PCL is the primary constraint to posterior
tibial translation in flexion (9,17,50). At 90° the
PCL carries 95% of a posterior directed load (49),
which is reduced to 83% or below with increasing
extension (51). Secondary function of the PCL is
to constrain external rotation as well as adduction
and abduction of the knee joint.
Structural and viscoelastic properties
The tensile strength of young human ACL’s has been
determined by Woo et al. to be around 2160 N (52),
while Amis et al. measured forces of 1620 N for
the AL bundle and 258 N for the PM bundle of the
PCL of elder people (75 years) (16). It was shown
that with increasing age the tensile strength of the
ACL was reduced by a factor of 2.5 (52). Based on
these calculations, Amis et al. (17) estimated the
overall PCL strength in young human individuals
to be around 4500 N. Similar difffferences have been
reported for stiff
ffness of the cruciate ligaments with
the PCL being substantially stronger (347 N/mm)
(16) than the ACL (242 N/mm) (52).
The cruciate ligaments: anatomy, biology, and biomechanics 17
Both cruciate ligaments exhibit a typical pattern
of elongation during loading (Fig. 7). Initially,
only small loads are required to elongate the liga-
ment, which is called the “toe region” of their load-
elongation behavior. At these loads, successive
recruitment and straightening of ligament fibersfi
can be observed. This results into increasing stiff ff-
ness until all ligament fibers are fully load bear-
ing and maximum ligament stiffnessff is obtained.
At this point, a linear relationship exists between
increasing loads and elongation. When the cruci-
ate ligaments are unloaded, a full return to initial
ligament length is observed; therefore, no struc-
tural damage results from loads of the linear load-
elongation relationship. However, when the yield
load is reached, non-reversible structural damage
occurs in the ligament, changing the linear rela-
tionship to a non-linear load-elongation behav-
ior, which peaks at maximum (failure) loads,
indicating complete destruction of ligamentous
integrity.
Another important biomechanical function of
cruciate ligaments is their viscoelastic behavior
(10,53). It describes the history- and time-depen-
dent changes in ligament loading and elongation.
When the ligaments are kept at a constant stretch
for a continuous time, the load required to main-
tain elongation decreases and reaches a steady state
after a certain time period (53). This phenomenon
is called the stress-relaxation behavior. When liga-
ments are exposed to a constant load over a period
of time, the ligaments lengthen until a steady
state is obtained, which is called creep (53). ThThese
properties are facilitated by a complex interaction
of cross-links, collagen fibers,
fi and cellular compo-
nents, such as myofifibroblasts of the ligaments, and
Fig. 7 – A load-elongation curve can be seen, characteristic for cruciate
ligaments. Initial loads in the toe region result in non-linear increase of
elongation due to successive fiber recruitment. The linear region deter-
mines maximum ligament stiffness. At these loads, all ligament fibers are
recruited and no structural damage can be observed. The load-elongation
curve changes to a non-linear relationship after the yield load is reached.
This is due to increasing structural, non-reversible damage of ligament
fibers until complete failure takes place at maximal sustained loads.
18 The Traumatic Knee
function to avoid excessive loading of the ligaments
during repetitive or continuous exercises.
Kinematics
Th fibers of the ACL undergo non-isometric length
The
changes during the arc of knee motion, providing
varying degrees of restraint to anterior tibial trans-
lation, which is the primary function of the ACL.
Takai (54) and Hollis et al. (12) observed that the
length of the AM bundle of the ACL increased by
around 10% (3.3–3.6 mm) during passive flexion fl
from 0° to 90°, while the length of the PL bundle
decreased between 6% and 32%. This Th underlines
the more dominant function of the AM bundle at
higher flexion
fl and of the PL bundle near extension
in restraining anterior tibial translation. Amis and
Dawkins (11) found that in internal rotation the
length increase of ACL fi fibers was more profound
than during external rotation, highlighting the
secondary function of the ACL to restrain internal
rotation.
The primary function of the PCL is to limit poste-
Th
rior tibial translation. It was shown that isolated
cutting of the PCL resulted in only small increases
in posterior tibial drawer near extension, but in
much greater posterior instability toward flexion
fl of
the knee joint (9,17). Similar to the ACL, the PCL
is also a non-isometric structure. The AL bundle
is the primary restraint to posterior tibial drawer
from 30° to 120° of flexion with the PM bundle car-
rying only about 50% of the load of the AL bundle
during this range of motion (16). Toward fl flexion
greater than 120°, the PM bundle becomes the
dominant structure in the PCL. Near extension,
the PM bundle also carries larger loads than the AL
bundle. It still does not contribute greatly to resist
posterior tibial translation. This might be explained
by its anatomical orientation, which does not allow
adequate fiber recruitment following a posterior-
directed force. Therefore, toward full extension,
other structures than the PCL, especially the PL
structures, are the primary posterior stabilizer of
the knee joint (17). It was shown that isolated PCL
defi
ficiency only resulted in small increases in inter-
nal-external rotation (55). This can be explained by
the location of the PCL near the rotational center
of the knee and its small moment arm that can
act against internal and external rotation as well
as abduction and adduction. Therefore, the PCL is
only a secondary constraint, with posteromedial
and posterolateral structures being the primary
stabilizers for rotation and abduction/adduction
of the knee joint. This
Th was confi firmed by the obser-
vation that only combined injuries of the PCL and
PL structures caused significant
fi increases in exter-
nal rotation (50).
The varying function of the ACL and PCL during
flexion and extension substantially infl fluences the
relative motion of the femur and tibia, respectively.
The coordinated passive action of the cruciates is
responsible, in part, for the sliding movement of
the femur during knee flexion beyond 20°. As a
portion of the ACL becomes taut with the continu-
ing rollback of the knee, it causes a sliding motion
between the femur and the tibia around 20° of fl flex-
ion. The PCL, on the other hand, becomes respon-
sible for the posterior sliding movement of the
condyle during full extension (56).
It has also been shown that muscle activity has a
considerable impact on knee kinematics, which
substantially changes loads and strains of both
cruciate ligaments compared to passive motion of
the knee joint (10). The
Th strain behavior, i.e., the
change of ligament length under a certain load,
has been analyzed for the ACL in vitro and in vivo
(57,58). Beynnon et al. found in in vivo analyses
in human trials that quadriceps activation, extend-
ing the knee joint against a 45-N load, resulted in
ACL strains of up to 4% near extension (57). He
also found that loads and strains of the ACL were
substantially reduced toward higher flexion angles
with and without quadriceps contraction (59).
With the knee in 90° of flexion, no changes in
ACL strain were observed with quadriceps activa-
tion, underlining the dominating function of the
ACL near extension (59). Therefore, care should
be taken during exercises with quadriceps muscles
activation during the early rehabilitation phase
following ACL reconstructions to avoid excessive
loading of the graft and its fixation. Hamstrings
activation was shown to have a protective effect
ff on
the ACL. Bach et al. observed that a simultaneous
activation of hamstring and quadriceps muscles
led to signifi
ficantly decreased strains of the ACL
compared to quadriceps activation alone (60).
Other authors discovered signifi ficantly reduced
anterior tibial translation and internal rotation as
well as substantially reduced forces in the ACL with
hamstring contraction, especially at higher fl flexion
angles (58,61). Therefore,
Th it seems reasonable to
assume that closed-chain exercises with hamstring
co-contraction might be benefi ficial during early
rehabilitation following ACL reconstruction.
The PCL is protected by quadriceps activity. Covey
et al. found that a quadriceps force led to signifi- fi
cant loosening of PCL fibers
fi at flexion angles less
than 75° compared to the unloaded passive motion
of the knee joint from 0° to 120° (15). Tibial inter-
nal rotation signifificantly slackened the anterior
and central fiber regions near extension and sig-
nifi
ficantly tightened the central and posterior
fiber regions with progressive flexion. External
rotation had an eff ffect similar to internal rota-
tion on the anterior and central fiber regions but

caused signifi
ficant slackening of the posterior fiber
regions from 0° to 45°. Markolf et al. (58) found a
substantial increase in PCL forces with hamstring
activation under a 100-N posterior load between
30° and 105° and a maximum at 90° of flexion.
They also found that a posterior load of 100 N did
not elicit any force changes in the PCL at exten-
sion, indicating that structures other than the PCL
take over posterior stabilization of the knee joint.
The application of either external or internal rota-
tion resulted in growing PCL forces only at fl
flexion
angles beyond 60°, which were further increased
by hamstring activity. This
Th information must be
considered during rehabilitation after PCL recon-
struction with quadriceps activity stress-shielding
and hamstring activity straining the PCL graft.
In situu forces
Little is known about the in vivo forces that work
upon the cruciate ligaments during active motion
due to the lack of accurate, non-invasive assess-
ment methods. In vivo strain measurements of
quadrupeds and humans suggest that activities of
daily living only cause small loads of about 20% of
the ACL’s failure capacity (59).
In vitro measurements of cadaveric knee joints
revealed that the ACL experienced signifi ficantly
higher in situ forces at or near extension than in
flexion (62). Under a 110-N anterior tibial load, in
situ forces of the ACL were 103 N at 15° of flexion,
which decreased to 59 N at 90° of flexion, indicating
the importance of the ACL near extension. Gabriel
et al. (63) demonstrated that under a 134-N ante-
rior tibial load, the PL bundle carried the highest
in situ forces at extension (67 N), while the AM
bundle was under signifi ficantly higher loads from
15° to 120° of flexion with a maximum of 90 N at
60° of flexion. These findings emphasize the non-
isometric function of the ACL and bears important
implications for tensioning the respective bundles
in ACL double-bundle reconstruction at different
ff
flexion angles. Passive knee flexion between 10° and
fl
110° without application of external loads produced
no or a very small strain increase of the AM and PL
bundles (59). This implies that free range of motion
between 0° and 110° of flexion
fl should not have a
damaging effect
ff on a reconstructed ACL. However,
if the knee is hyperextended or hyperflexed,
fl a sub-
stantial surge in in situ forces between 100 and
240 N and strains up to 8% can be experienced in
the ACL (60,64). Therefore, such extreme motions
of the knee joint must be avoided during the early
phases of rehabilitation following ACL surgery.
Markolf et al. used an in vitro cadaveric model to
measure in situ forces of the PCL under various
loading conditions. They found that a posterior
The cruciate ligaments: anatomy, biology, and biomechanics 19
load of 100 N resulted in PCL in situ forces of 125 N
and with additional hamstring activity, an increase
up to 160 N at flexion angles beyond 80° (58).
Quadriceps activation did not allow for substantial
reduction of PCL in situ forces. Li et al. made simi-
lar observations, with the PCL experiencing in situ
forces up to 100 N at 90° of flexion under hamstring
contraction without a posterior directed load. Inter-
estingly, they found a substantial decrease in PCL
loading (35 N) at deep flexion
fl of 150° (65). These
studies imply that active hamstring contraction
must be avoided, especially toward mid-flexion
fl at
90° during the early phase of rehabilitation follow-
ing PCL reconstruction. Quadriceps co-contraction
does not provide suffifficient protection of the PCL
throughout the range of motion regarding the in
situ forces of the PCL.
The knowledge of the anatomy, the biology and
biomechanics of the ACL and PCL are the basic
elements for successful treatment of their respec-
tive injuries. When performing ACL and PCL
reconstruction, the anatomic landmarks must be
respected and reconstructed. The continuous gains
in knowledge of ACL and PCL biomechanics will
help to design new techniques that will restore
these properties to facilitate long-term stability
and knee function. This will aid to improved graft
healing and allow adaptation or even restoration
of the biological properties of the intact ACL. Only
then, we will be able to serve our patients in the
best possible way, so that full return to pre-injury
activity and function can be achieved and future
damage of the knee joint can be prevented.
References
1. Weber W, Weber E (1836) Mechanik der menschlichen
Gehwerkzeuge
2. Palmer I (1938) On the injuries to the ligaments of the
knee joint: a clinical study. Acta Chir Scand 91:1–282
3. Reiman PR, Jackson DW (1987) Anatomy of the anterior
cruciate ligament. In: Jackson DW, Drez D, editors. Th The
anterior cruciate defi ficient knee. St. Louis: CV Mosby &
Co: 17–26
4. Gardner E, O’Rahilly R (1968) The early development of
the knee joint in staged human embryos. J Anat 102(Pt
2):289–299
5. Merida-Velasco JA, Sanchez-Montesinos I, Espin-Ferra J,
et al. (1997) Development of the human knee joint liga-
ments. Anat Rec 248(2):259–268
6. Ellison AE, Berg EE (1985) Embryology, anatomy, and
function of the anterior cruciate ligament. Orthop Clin
North Am 16(1):3–14
7. Keith A, editor (1933) Human embryology and morphol-
ogy. Baltimore: Williams Wood and Co
8. Tilmann B (1974) Zur funktionellen Morphologie der
Gelenkentwicklung. Orthop Prax 12:328–342
9. Girgis FG, Marshall JL, Monajem A (1975) The Th cruciate
ligaments of the knee joint. Anatomical, functional and
experimental analysis. Clin Orthop Relat Res 106:216–
231
20 The Traumatic Knee
10. Smith BA, Livesay GA, Woo SL (1993) Biology and biome-
chanics of the anterior cruciate ligament. Clin Sports Med
12(4):637–670
11. Amis AA, Dawkins GP (1991) Functional anatomy of the
anterior cruciate ligament. Fibre bundle actions related to
ligament replacements and injuries. J Bone Joint Surg Br
73(2):260–267
12. Hollis JM, Takai S, Adams DJ, et al. (1991) TheTh effffects of
knee motion and external loading on the length of the
anterior cruciate ligament (ACL): a kinematic study. J Bio-
mech Eng 113(2):208–214
13. Amis AA, Gupte CM, Bull AM, Edwards A (2006) Anatomy
of the posterior cruciate ligament and the meniscofemo-
ral ligaments. Knee Surg Sports Traumatol Arthrosc
14(3):257–263
14. Van Dommelen BA, Fowler PJ (1989) Anatomy of the
posterior cruciate ligament. A review. Am J Sports Med
17(1):24–29
15. Covey DC, Sapega AA, Marshall RC (2004) Th The eff
ffects of
varied joint motion and loading conditions on posterior
cruciate ligament fiber length behavior. Am J Sports Med
32(8):1866–1872
16. Race A, Amis AA (1994) The mechanical properties of the
two bundles of the human posterior cruciate ligament. J
Biomech 27(1):13–24
17. Amis AA, Bull AM, Gupte CM, et al. (2003) Biomechanics
of the PCL and related structures: posterolateral, postero-
medial and meniscofemoral ligaments. Knee Surg Sports
Traumatol Arthrosc 11(5):271–281
18. Harner CD, Livesay GA, Kashiwaguchi S, et al. (1995)
Comparative study of the size and shape of human
anterior and posterior cruciate ligaments. J Orthop Res
13(3):429–434
19. Harner CD, Baek GH, Vogrin TM, et al. (1999) Quanti-
tative analysis of human cruciate ligament insertions.
Arthroscopy 15(7):741–749
20. Arnoczky SP (1983) Anatomy of the anterior cruciate liga-
ment. Clin Orthop Relat Res 172:19–25
21. Odensten M, Gillquist J (1985) Functional anatomy of the
anterior cruciate ligament and a rationale for reconstruc-
tion. J Bone Joint Surg Am 67(2):257–262
22. Colombet P, Robinson J, Christel P, et al. (2006) Morphol-
ogy of anterior cruciate ligament attachments for ana-
tomic reconstruction: a cadaveric dissection and radio-
graphic study. Arthroscopy 22(9):984–992
23. Hoher J, Scheffl
ffler S, Weiler A (2003) Graft choice and graft
fixation in PCL reconstruction. Knee Surg Sports Trauma-
tol Arthrosc 11(5):297–306
24. Harner CD, Xerogeanes JW, Livesay GA, et al. (1995) The Th
human posterior cruciate ligament complex: an interdis-
ciplinary study. Ligament morphology and biomechanical
evaluation. Am J Sports Med 23(6):736–745
25. Dargel J, Pohl P, Tzikaras P, Koebke J (2006) Morphomet-
ric side-to-side difffferences in human cruciate ligament
insertions. Surg Radiol Anat 28(4):398–402
26. Moorman CT, 3rd, Murphy Zane MS, Bansai S, et al. (2008)
Tibial insertion of the posterior cruciate ligament: a sagit-
tal plane analysis using gross, histologic, and radiographic
methods. Arthroscopy 24(3):269–275
27. Gupte CM, Bull AM, Thomas RD, Amis AA (2003) A review
of the function and biomechanics of the meniscofemoral
ligaments. Arthroscopy 19(2):161–171
28. Neurath M, Stoff fft E (1992) [Fascicular and sub-fascicular
architecture of the cruciate ligament]. Unfallchirurgie
18(3):125–132
29. Strocchi R, de Pasquale V, Gubellini P, et al. (1992) The Th
human anterior cruciate ligament: histological and ultra-
structural observations. J Anat 180 (Pt 3):515–519
30. Baek GH, Carlin GJ, Vogrin TM, et al. (1998) Quantitative
analysis of collagen fibrils
fi of human cruciate and menis-
cofemoral ligaments. Clin Orthop Relat Res 357:205–211
31. Woo SL, Maynard J, Butler D, et al. (1988) Ligament, ten-
don, and joint capsule insertion to bone. In: Woo SL-Y BJ,
editor. Injury and repair of the musculoskeletal soft tis-
sues. Park Ridge: American Academy of Orthopaedic Sur-
geons: 133–166
32. Duthon VB, Barea C, Abrassart S, et al. (2006) Anatomy of
the anterior cruciate ligament. Knee Surg Sports Trauma-
tol Arthrosc 14(3):204–213
33. Murray MM, Spector M (1999) Fibroblast distribution in
the anteromedial bundle of the human anterior cruciate
ligament: the presence of alpha-smooth muscle actin-pos-
itive cells. J Orthop Res 17(1):18–27
34. Scheffl
ffler SU, Schmidt T, Gangey I, et al. (2008) Fresh-
frozen free-tendon allografts versus autografts in anterior
cruciate ligament reconstruction: delayed remodeling and
inferior mechanical function during long-term healing in
sheep. Arthroscopy 24(4):448–458
35. Petersen W, Zantop T (2007) Anatomy of the anterior cru-
ciate ligament with regard to its two bundles. Clin Orthop
Relat Res 454:35–47
36. Neurath MF, Stoff fft E (1992) Structure and function of
matrix components in the cruciate ligaments. An immu-
nohistochemical, electron-microscopic, and immunoelec-
tron-microscopic study. Acta Anat (Basel) 145(4):387–
394
37. Petersen W, Tillmann B (1999) Blood and lymph supply
of the posterior cruciate ligament: a cadaver study. Knee
Surg Sports Traumatol Arthrosc 7(1):42–50
38. Scapinelli R (1997) Vascular anatomy of the human cru-
ciate ligaments and surrounding structures. Clin Anat
10(3):151–162
39. Petersen W, Tillmann B (1999) Structure and vasculariza-
tion of the cruciate ligaments of the human knee joint.
Anat Embryol (Berl) 200(3):325–334
40. Kennedy JC, Alexander IJ, Hayes KC (1982) Nerve supply
of the human knee and its functional importance. Am J
Sports Med 10(6):329–335
41. Katonis P, Papoutsidakis A, Aligizakis A, et al. (2008)
Mechanoreceptors of the posterior cruciate ligament. J
Int Med Res 36(3):387–393
42. Schultz RA, Miller DC, Kerr CS, Micheli L (1984) Mecha-
noreceptors in human cruciate ligaments. A histological
study. J Bone Joint Surg Am 66(7):1072–1076
43. Solomonow M, Krogsgaard M (2001) Sensorimotor con-
trol of knee stability. A review. Scand J Med Sci Sports
11(2):64–80
44. Raunest J, Sager M, Burgener E (1996) Proprioceptive
mechanisms in the cruciate ligaments: an electromyo-
graphic study on refl flex activity in the thigh muscles. J
Trauma 41(3):488–493
45. Franchi A, Zaccherotti G, Aglietti P (1995) Neural system
of the human posterior cruciate ligament in osteoarthri-
tis. J Arthroplasty 10(5):679–682
46. Katonis PG, Assimakopoulos AP, Agapitos MV, Exarchou
EI (1991) Mechanoreceptors in the posterior cruciate
ligament. Histologic study on cadaver knees. Acta Orthop
Scand 62(3):276–278
47. Zimny ML, Schutte M, Dabezies E (1986) Mechanorecep-
tors in the human anterior cruciate ligament. Anat Rec
214(2):204–209
48. Krogsgaard MR, Dyhre-Poulsen P, Fischer-Rasmussen T
(2002) Cruciate ligament refl flexes. J Electromyogr Kine-
siol 12(3):177–182
49. Butler DL, Noyes FR, Grood ES (1980) Ligamentous
restraints to anterior-posterior drawer in the human knee.
A biomechanical study. J Bone Joint Surg Am 62(2):259–
270
50. Vogrin TM, Hoher J, Aroen A, et al. (2000) Effects
ff of sec-
tioning the posterolateral structures on knee kinematics
and in situ forces in the posterior cruciate ligament. Knee
Surg Sports Traumatol Arthrosc 8(2):93–98

51. Piziali RL, Seering WP, Nagel DA, Schurman DJ (1980)
The function of the primary ligaments of the knee in
anterior-posterior and medial-lateral motions. J Biomech
13(9):777–784
52. Woo SL, Hollis JM, Adams DJ, et al. (1991) Tensile proper-
ties of the human femur-anterior cruciate ligament-tibia
complex. The
Th effffects of specimen age and orientation. Am
J Sports Med 19(3):217–225
53. Woo SL (1982) Mechanical properties of tendons and liga-
ments. I. Quasi-static and nonlinear viscoelastic proper-
ties. Biorheology 19(3):385–396
54. Takai S, Woo SL, Livesay GA, et al. (1993) Determination
of the in situ loads on the human anterior cruciate liga-
ment. J Orthop Res 11(5):686–695
55. Grood ES, Stowers SF, Noyes FR (1988) Limits of move-
ment in the human knee. Eff ffect of sectioning the pos-
terior cruciate ligament and posterolateral structures.
J Bone Joint Surg Am 70(1):88–97
56. Kapandji IA, editor (1970) The physiology of the joints.
Edinburgh: Churchill Livingstone
57. Beynnon BD, Fleming BC, Johnson RJ, et al. (1995)
Anterior cruciate ligament strain behavior during
rehabilitation exercises in vivo. Am J Sports Med
23(1):24–34
58. Markolf KL, O’Neill G, Jackson SR, McAllister DR (2004)
Eff
ffects of applied quadriceps and hamstrings muscle loads
The cruciate ligaments: anatomy, biology, and biomechanics 21
on forces in the anterior and posterior cruciate ligaments.
Am J Sports Med 32(5):1144–1149
59. Beynnon B, Howe JG, Pope MH, et al. (1992) The Th mea-
surement of anterior cruciate ligament strain in vivo. Int
Orthop 16(1):1–12
60. Bach JM, Hull ML (1998) Strain inhomogeneity in the
anterior cruciate ligament under application of external
and muscular loads. J Biomech Eng 120(4):497–503
61. More RC, Karras BT, Neiman R, Fritschy D, et al. (1993)
Hamstrings – an anterior cruciate ligament protagonist.
An in vitro study. Am J Sports Med 21(2):231–237
62. Sakane M, Livesay GA, Fox RJ, et al. (1999) Relative con-
tribution of the ACL, MCL, and bony contact to the ante-
rior stability of the knee. Knee Surg Sports Traumatol
Arthrosc 7(2):93–97
63. Gabriel MT, Wong EK, Woo SL, et al. (2004) Distribu-
tion of in situ forces in the anterior cruciate ligament in
response to rotatory loads. J Orthop Res 22(1):85–89
64. Markolf KL, Gorek JF, Kabo JM, Shapiro MS (1990) Direct
measurement of resultant forces in the anterior cruciate
ligament. An in vitro study performed with a new experi-
mental technique. J Bone Joint Surg Am 72(4):557–567
65. Li G, Zayontz S, Most E, DeFrate LE, et al. (2004) In situ
forces of the anterior and posterior cruciate ligaments in
high knee flexion: an in vitro investigation. J Orthop Res
22(2):293–297

A.A. Amis, J.R. Robinson The anatomy and biomechanics
of the medial collateral ligament
and posteromedial corner of the knee
Introduction
T
he medial and posteromedial aspect of the
knee has been studied much less than the
posterolateral aspect. The underling reason
for that relates to the greater healing potential of
the medial collateral ligament (MCL), which means
that medial injuries are often treated conserva-
tively, so there has been less pressure to develop
sophisticated methods to treat these structures
surgically. A further contributor to this situation
is the diff
fference in the mechanical environment,
which means that injuries may have diff ffering
impacts on function. However, because the clini-
cian is always alert to the possibility of damage to
the posterolateral structures, it may be the case
that medial side injuries are not looked for, or that
changes in rotational laxity are misdiagnosed. ThThis
chapter aims to provide some basic anatomical and
biomechanical data that should alert the reader
to the altered laxity of the knee that results from
damage to the medial and posteromedial struc-
tures and the relative importance of those struc-
tures in the function of the knee.
Anatomy
There have been a number of anatomical descrip-
tions of the ligamentous and capsular structures
that restrain tibiofemoral motion on the medial
and posteromedial aspect of the knee (1–7). A
review of these shows that many different
ff inter-
pretations of the anatomy have been published.
That has arisen partly because of the complex-
ity of the overlapping arrangement of thin tissue
layers around the medial aspect of the knee. The Th
key paper to understanding the anatomy was by
Warren and Marshall (7), who proposed a system
of three layers of tissue (Fig. 1). The
Th more super-
ficial layer of fascial tissue does not contain obvi-
ous structural bands linking the femur to the tibia,
as it wraps over the medial femoral condyle and
patella. However, although this is a thin layer, that
does not mean that it has a negligible functional
Chapter 3
role, just that there has not yet been serious study
of that. Experience suggests that a very wide yet
thin layer of tissue may actually be rather strong.
The intermediate and deep (capsular) layers of tis-
sue contain obvious thickenings or condensations
of collagenous fibers
fi on the medial and postero-
medial aspect of the knee. Some of these fibrous
fi
tissue bands have been named and their functions
examined, including the medial patellofemoral
ligament.
This chapter will deal with three principal struc-
tures: the MCL, which may be split into two lay-
ers: the deep MCL (dMCL) and the superficial
fi MCL
(sMCL), plus the posteromedial capsule (PMC).
These are the main units that stabilize the medial
aspect of the tibiofemoral joint and will each be
described below. There
Th are other structures that
make what are assumed to be relatively minor
contributions to stability of the medial aspect of
the knee, including the medial patellotibial liga-
ment and associated retinacular fibers, but their
contributions to tibiofemoral stability have not
been studied. This function may be discerned from
their alignment and attachments and also from
evidence that the retinacula at either side of the
patella contribute to the knee extension moment
(8), thus transmitting tensile forces across the joint
line, and therefore compressing and stabilizing
the knee. Because this action derives from muscle
actions, the quadriceps acting on the patella, this
may be termed a “dynamic” stabilizing action,
rather than the passive actions of ligaments that
result only from stretching and elastic tension.
Dynamic stabilization has other contributors at
the medial aspect of the knee, such as the medial
hamstrings muscle tensions. Th These act approxi-
mately parallel to the femur, so they impose an
adduction moment across the knee when it is at or
near extension and an increasing internal rotation
moment as the knee flexes. The semimembranosus
is the most interesting of these muscles because it
has extensive fibrous bands arising from its distal
tendon sheath that diverge in more proximal, ante-
rior, and lateral directions to attach to thickened
zones in the PMC. It is tempting to suggest roles
for these bands in stabilizing the knee (9); but they
24 The Traumatic Knee

Patellotemoral Patellotemoral
ligament ligament

Sarterius
Superficial
medicial Capsule Semimembranoosus
ligament
A Superficial
Disseection Point of split natal ligament
kine Dissection layer II
Popliteus
Gracillis

Sem
mitendinosus
Gracillis
Semitendinosus

Fig. 1 – The three tissue layers over the medial aspect of the knee according to Warren and Marshall (6). The dissection has proceeded via a longitudinal
incision along the easily palpated anterior edge of the superficial MCL. (Reproduced from Ref. 6 with permission from the J Bone Joint Surg.)

are slack when the knee is extended, because the

tendon is then pulling proximally, and the fibrous
fi
bands buckle in the closing gap between the ten-
don and the posterior condyle, so the tibiofemoral
stabilizing action then derives from the tendon
tension crossing the joint line and not from the
capsular attachments (Fig. 2). TheTh fibrous expan-
sions do tighten when the knee fl flexes, because the
semimembranosus swings with the femur, away
from the axis of the tibia. When the semitendino-
sus pulls posteriorly, it tenses the proximal fi
fibrous
expansions that link it to the PMC, particularly the
anterior band that attaches below the medial rim
of the tibial plateau, inducing tibial internal rota-
tion (Fig. 3). The
Th reason for this complex structure
is poorly understood.

Superficial
fi MCL
The superfi
ficial MCL (sMCL) is the most prominent
ligamentous structure of the medial aspect of the
knee. The sMCL is seen as a long and broad band
of tight collagen fibers
fi when the superfi
ficial fascial
layer (layer 1) is removed, so it is a part of War-
ren and Marshall’s (7) intermediate layer 2, which Fig. 2 – At 30° flexion, the semimembranosus tendon tension is acting to
control tibial valgus laxity, as it dissipates distally, at the medial ridge of
is extracapsular (Fig. 1). Th
The sMCL extends from the tibial diaphysis, adjacent to the distal attachment of the long fibers of
the area of the medial femoral epicondyle to the the superficial MCL. Just proximal to the joint line, the posteromedial cap-
anteromedial aspect of the tibia, typically extend- sule (PMC) has slackened and is buckling, revealing the fiber orientation
ing 6–8 cm below the joint line. Flexion-extension that goes distal/posterior from the femoral attachment that is distal to the
of the knee shows that the sMCL remains taut adductor tubercle to the posterior/medial rim of the tibial plateau.
 The anatomy and biomechanics of the medial collateral ligament and posteromedial corner of the knee
Fig. 3 – At 80° knee flexion, the posteromedial capsule has slackened fur-
ther and folded, while the anterior fibers of the superficial MCL are tight.
The semimembranosus is now acting as an internal rotator of the tibia, act-
ing via the anterior expansion that attaches on the medial edge of the tibia,
below the joint line.
across the range of knee motion, leading to the
expectation that it will act to stabilize the knee
against abduction moments at all angles of knee
flexion. The long, taut fibers of the sMCL are easily
identifi
fied, and have a defi
finite and easily palpatable
anterior edge, anterior to which there is no dense
intermediate tissue layer overlying the joint cap-
sule. A longitudinal incision along this boundary
allows the anterior fibers of the sMCL to be lifted
medially away from the deeper structures below;
there is an easily penetrated plane between the
sMCL and the dMCL and associated capsule below
(Figs. 1 and 4). This opening is limited by the fiber
tension, so a distal release is required for more
extensive exposure here.
The femoral attachment of the sMCL is a com-
Th
pact, approximately 15-mm-diameter ellipse and
concentrated into and over the prominence of
the medial femoral epicondyle and into the saddle
proximal/posterior to the epicondyle and so ante-
rior/distal to the adductor tubercle. Because the
deepest fibers run tangential to the bone surface,
they insert into the distal-facing slope of the epi-
condyle, while the more superficial
fi fibers pass over
and cover it and insert proximal-posterior to it.
Thus, although most published descriptions say
that the sMCL inserts into the epicondyle (2,10),
LaPrade et al. (3) found the center of this area
25
Fig. 4 – In this anterior-posterior view, the forceps has lifted the superficial
MCL away from the femoro-meniscal part of the deep MCL, opening the gap
between them anteriorly, showing their junction posteriorly. The deep MCL
attaches to the rim of the medial meniscus. (Reproduced from Ref. 5 with
permission from the J Bone Joint Surg.)
3 mm proximal and 5 mm posterior to the tip of
the epicondyle; Hughston and Eilers (2) described
this as 10 mm distal and anterior to the adductor
tubercle. As this attachment rotates with knee
flexion, so the anterior sMCL fibers are stretched
while the more posterior fibers slacken (4; Fig. 3).
The tibial attachment is approximately 6 cm distal
to the joint line and is approximately 2 cm long; it
extends distally and slightly posteriorly in a linear
attachment approximately 3 mm wide, close to the
medial ridge of the shaft of the tibia, where it is
associated with the terminal insertion of the semi-
membranosus and the descending fi fibers of the
PMC that approach proximally and slightly poste-
riorly. Although LaPrade et al. (3) described a pos-
terior proximal sMCL attachment close to the joint
line, we have interpreted that to be associated with
the PMC, while the more anterior sMCL passes
over the anterior arm of the semimembranosus
expansion, that attaches just below the joint line.
The length of the sMCL attachment gives a range
of fiber lengths, so it has been reported to range
from 10 to 12 cm overall fiber length.
Deep MCL
The deep MCL (dMCL) is a capsular ligament, so
it is in layer 3 of Warren and Marshall (7) and is
attached firmly to the medial rim of the medial
meniscus as it passes the joint line (Fig. 5). Th
Thus,
the dMCL is usually described as consisting of fem-
oro-meniscal and menisco-tibial parts. Th
This distinc-
tion is functionally important, because rupture of
26 The Traumatic Knee

has dense fibers arrayed in it that course from the

Fig. 5 – View of deep aspect of the deep MCL in a disarticulated right knee.
The probe is supporting the anterior edge of the superficial MCL. The deep
MCL is tensed, and the meniscus has lifted from the tibial plateau suffi- ffi
ciently for the menisco-tibial part of the deep MCL to be seen. If the menis-
cus lifts much more than this under a valgus moment, it suggests damage
of the menisco-tibial part of the deep MCL.
the more distal part is associated with pathological
mobility of the meniscus, and is identifi
fiable by the
lifting of the meniscus away from the tibial pla-
teau when the knee is subjected to an abduction
moment and the interior is viewed arthroscopi-
cally. Th
The dMCL is a ribbon of fibers that has linear
attachments to both the femur and tibia, oriented
antero-posteriorly (5). ThThe femoral attachment is
immediately distal to the epicondylar attachment
of the sMCL, while the tibial attachment is to the
medial rim of the tibial plateau and thus close to
the joint line and proximal to the attachment of
the anterior arm of the semimembranosus expan-
sion. The dMCL is overlaid by the sMCL, and their
anterior edges are parallel and close to each other.
The posterior edge of the dMCL is marked by its
Th
blending with the posterior edge of the sMCL
(Fig. 4) so that we may define
fi the structures poste-
rior to this junction as being the PMC. Thus,
Th at this
boundary, layers 2 and 3 blend together to become
a single capsular layer 3. Anteriorly, the joint cap-
sule is relatively thin, so the edge of the dMCL is
easily identified.
fi
femoral to the tibial attachments. Among those,
some have been labelled as a “posterior oblique
ligament” (POL) that is a thicker band that passes
in a posterior-distal direction from its attachment
immediately distal/posterior to the adductor tuber-
cle to the rim of the posterior/medial tibial plateau
(Fig. 6). Because the dMCL is capsular, it follows
that the femoral attachment of the PMC is a pos-
terior continuation of that linear attachment that
sweeps posteriorly and then proximally around the
distal and posterior aspect of the adductor tubercle,
before passing laterally, over the top of the medial
femoral condyle. ThThus, the femoral attachment of
the PMC is a long curved line that marks the lim-
its of the synovial capsule of the medial condyle.
Similarly, the tibial attachment is linear, around
the posteromedial rim of the plateau, but having
passed over the rim of the plateau, the fibers
fi also
continue in a distal-anterior direction to attach
at the medial ridge of the tibial diaphysis adja-
cent to the sMCL. This interpretation of the func-
tional anatomy here diffffers from that described by
LaPrade et al. (3), who did not show a tibial attach-
ment for the PMC or POL; rather, they interpreted
it as attaching to the sheath of semimembranosus.
Examination of our own dissections found that
the PMC was tensed by tibial internal rotation,
directly between the femoral attachment and the
rim of the tibial plateau (Fig. 6). Because the PMC
is attached posterior to the femoral axis of flexion,
fl

Posteromedial capsule
The posteromedial capsule (PMC) has a complex
anatomy, and the literature is not helpful; there are
diff
fferent interpretations. The functional concern is
to identify load-bearing tissue bands that might be
targeted during surgical reconstructions/repairs.
A complex arrangement of distinct and separate Fig. 6 – The posteromedial capsule is tensed by full extension of the knee:
fiber bundles was shown by Hughston and Eilers
fi the bulges of the posterior femoral condyle and the rim of the tibial plateau
(2), but that artist’s impression is not duplicated in are seen. The posterior-distal orientation of the capsular fibers are seen,
reality: the PMC is actually the joint capsule that among which is the band known as the posterior oblique ligament (POL).
 The anatomy and biomechanics of the medial collateral ligament and posteromedial corner of the knee
it slackens as soon as the knee starts to flex; with
deeper flexion, the slack capsule folds and is car-
ried anteriorly, beneath the posterior edge of the
sMCL that remains tight when the knee fl flexes
(Fig. 3). Th
The observation of this distinct pattern of
slackening when the knee flexes,
fl in contrast to the
isometry of the adjacent sMCL, led Fischer et al.
(11) to speculate that it has a different
ff functional
role.
If the dissection of the PMC is continued round to
the posterior aspect of the knee, it passes deep to
the medial head of the gastrocnemius and is inti-
mately attached to it. This
Th part of the capsule is
slack when the knee is flexed
fl and then tensed in
terminal knee extension by the outward bulge of
the posterior femoral condyle (Fig. 6).
Biomechanics
Strength of the ligaments
Several studies have tested the tensile strength of
the MCL (12–14), but those studies did not sepa-
rate the MCL complex into its three anatomical
structures. Those papers described their speci-
mens as having the length of the sMCL fi fibers, so
it is presumed that the dMCL and the PMC were
discounted in those studies. A more recent study
(15) examined the three principal structures using
a method of separating them via three tibial bone
blocks: anterior/proximal for the dMCL, posterior/
proximal for the PMC, and distal for the sMCL. That
Th
allowed each ligament to be tested along the line of
its fibers, with bone-ligament-bone specimens.
The tensile load-versus-extension graphs (Fig. 7)
Th
show several things:
(a) All three structures had functionally significant
fi
strength: the sMCL failed at 534 ± 85 N (mean
27
± SD), the dMCL at 194 ± 82 N, and the PMC at
425 ± 121 N.
(b) The sMCL was not signifi ficantly stronger than
the PMC, but both were signifi ficantly stronger
than the dMCL.
(c) The sMCL had signifi ficantly higher tensile stiff
ff-
ness than the other two structures; the implica-
tion of this is that it will take more of the load
when an abduction (valgus) moment is imposed
on the knee.
(d) The dMCL failed at signifi ficantly lower elonga-
tion than the other structures (7.1 ± 1.1 mm,
versus 10.2 ± 1.1 mm for sMCL, and 12.0 ±
3.0 mm for the PMC).
It is likely that the failure loads will be higher in
younger, more active people than represented by
these cadaveric specimens with a mean age of 77
years. That was suggested by six of eight sMCLs fail-
ing by avulsion of the femoral attachment; a re-test
of the ligament substance was 74% stronger. Bone-
ligament-bone preparations have been used to estab-
lish the eff
ffect of limb immobilization and age on the
ultimate strength of the MCL in animals (16,17).
They showed that immobilization caused resorption
and weakening of the ligament attachment sites.
The lower elongation to failure of the dMCL
explains the clinical finding of dMCL rupture while
the knee remains stable against abduction (valgus)
loading, when the sMCL has not ruptured. Most
of the specimens failed in the femoro-meniscal
region. The earlier failure of the dMCL relates to
its shorter fibers, so they are subjected to a higher
percent strain elongation, for a given tibiofemoral
angulation, than the sMCL and PMC fibers. fi
The PMC had both strength and elongation to fail-
ure that did not diff ffer signifi
ficantly from those of
the sMCL. Further, most of the specimens failed in
their mid-substance, proving that the attachment
of the PMC to the posteromedial rim of the tibial
plateau is structurally significant.
fi
Fig. 7 – Mean tensile force versus
extension graphs for the three
structures: the superficial MCL
(sMCL), the deep MCL (dMCL), and
the posteromedial capsule (PMC).
The crosses show ±1 SD on the
mean failure loads and extensions.
(Reproduced from Ref. 15 with per-
mission from the J Biomech.)
28 The Traumatic Knee
Stabilizing actions
Valgus-varus rotation
It has long been known that the MCL is the pri-
mary restraint to tibial valgus (abduction) rotation
and that it does not have a role in varus (18). A
more recent study (19) measured the contribu-
tions of each of the three main structures. When
the ligaments were intact, valgus laxity in response
to a 5-Nm bending moment was approximately
3°, from 0° to 90° knee flexion. Cutting the sMCL
allowed signifificant increases in valgus laxity, to
approximately 8°, from 15° to 90° knee flexionfl
(Fig. 8). Further cutting of the dMCL and PMC
allowed further small but statistically significant
fi
increases in valgus laxity, which then equalled
13° ± 3° at 30° flexion. However, when the cut-
ting sequence was reversed, isolated cutting of the
dMCL and PMC did not cause a significant
fi increase
in valgus laxity. These
Th diff
fferences show that the
sMCL is the primary restraint to valgus from 0° to
90° knee flexion, with the dMCL and PMC acting
as secondary restraints. The PMC is tight in the
extended knee, where it contributed 32% of the
restraint to a 5-Nm valgus moment and the sMCL
65%. However, the PMC slackened as soon as the
knee started to flex, so the sMCL resisted 96% of
the load at 30° knee flexion.
Tibial internal-external rotation
For the intact knee, both tibial internal rotation
laxity and external rotation laxity, in response to
an axial torque of 5 Nm, were smallest with the
knee extended (±12°); this increased progressively
as the knee flexed, to ±20° rotation at 90° flexion
(19). After all three medial structures had been
cut, the rotational laxity increased; it then ranged
from ±20° in extension to approximately ± 32° at
30–90° flexion.
Tibial internal rotation was controlled mostly
by the sMCL and PMC; cutting the dMCL had
no measurable effect.
ff The PMC was dominant at
0° and 15° knee flexion, where cutting the other
structures did not add to the pathological laxity.
The roles swapped over as the knee flexed, so that
cutting the sMCL caused the entire increase in
internal rotation laxity at 60° and 90° knee flflex-
ion (Fig. 9).
Tibial external rotation increased after cutting
either of the dMCL and sMCL, at all angles of flex-
fl
ion from 0° to 90°. The increase in tibial external
rotation after cutting the sMCL was significant
fi
overall, and was largest, 10°, at 60° and 90° knee
flexion. This effffect was less with dMCL cutting,
approximately 5° when the knee was flexed fl 30°
or more. Kennedy and Fowler (20) found that 45°
tibial external rotation ruptured the dMCL but left
the sMCL intact. Slocum and Larson (6) stated that
rupture of the capsular ligament (the dMCL) was
the basic lesion allowing abnormal tibial external
rotation. Cutting the PMC did not have a signifi- fi
cant eff
ffect on tibial external rotation.
Tibiofemoral anterior-posterior translation laxity
If the tibia is free to rotate during an anterior or
posterior (AP) drawer test, then the load is resisted
almost entirely by the cruciate ligaments (21); cut-
ting the three medial structures does not affect
ff the
AP laxity signifificantly at any angle of knee flex-
ion. However, if the tibia is held in a fixed
fi rotated
position during AP drawer testing, the situation
is diff
fferent. That is because the rotation can both
tighten the peripheral structures and also realign
them. For example, tibial external rotation moves
the distal attachment of the sMCL and dMCL ante-
riorly, so they will then be both tight and aligned to
resist anterior drawer. Conversely, tibial internal
rotation has a similar effffect on the PMC, so it then
Fig. 8 – Valgus laxity increases in response to 5-Nm moment,
with the knee intact and after sequential cutting of the sMCL,
dMCL, and then PMC. Note that most of the pathological lax-
ity increase occurred after cutting the sMCL while the dMCL
and the PMC were still intact. (Reproduced from Ref. 19 with
permission from the Am J Sports Med.)
 The anatomy and biomechanics of the medial collateral ligament and posteromedial corner of the knee
may resist tibial posterior drawer, particularly near
knee extension when it is tighter. ThThese observa-
tions were the basis of the Slocum and Larson tests
for knee stability (6), when the anterior drawer
test was done with the tibia held in neutral and
rotated positions, thus demonstrating the actions
of the peripheral structures. Robinson et al. (19)
found that these maneuvers approximately halved
the tibial anterior drawer test laxity with the tibia
held in fixed external rotation, and posterior laxity
with fixed internal rotation. During the anterior
drawer test in fixed external rotation, the dMCL
had resisted 32% of the drawer force and the sMCL
16%. The greater role of the dMCL arose because
its shorter fibers were realigned more by the tibial
external rotation. Similarly, Noyes et al. (22) found
that the MCL (combined sMCL and dMCL) resisted
40% and the ACL 52% of the anterior drawer force,
with the tibia held in external rotation. The Th role
of the dMCL is increased by its attachment to the
medial meniscus: a rupture of the distal menisco-
tibial part mobilizes the meniscus, resulting in
greater anterior laxity (23).
The medial structures are important secondary
restraints against tibial posterior drawer when the
knee is at or near extension because that is the
most important posture for weight-bearing stabil-
ity. It has been shown (24) that the PCL is only a
secondary restraint to tibial posterior drawer in
these postures, and there is widespread recogni-
tion of the stabilizing role of the posterolateral
corner structures (25). However, the posterome-
dial structures are also important. In a posterior
drawer test of the extended knee with free tibial
rotation, the sMCL resisted 8% of the force and
the PMC 28%. ThisTh effffect was magnifi fied by fixed
internal rotation: the sMCL then resisted 18% and
the PMC 42% of the load, so the combined actions
of the PCL plus posterolateral corner contributed
only 40% (19). Similarly, Ritchie et al. (26) found
that cutting the sMCL allowed increased tibial pos-
terior drawer when the tibia was flexed
fl 90° and
internally rotated 20°.
29
Fig. 9 – Tibial internal rotation laxity for the knee intact and
after cutting medial structures. Note how most of the patho-
logical increase in laxity near knee extension resulted from
cutting the PMC, whereas the sMCL was most important in
60° and 90° knee flexion. (Reproduced from Ref. 19 with per-
mission from the Am J Sports Med.)
Conclusions
– The most important structures for passive sta-
bility of the medial aspect of the knee are the
superfi
ficial (sMCL) and deep (dMCL) parts of the
medial collateral ligament and the PMC.
– The sMCL attaches over the area of the axis of
flexion of the femur, so it remains tight across
the range of knee flexion-extension.
fl Across its
width, the anterior fibers are tensed by knee flex-
ion, while the posterior fibers
fi slacken.
– The PMC attaches posterior to the axis of flexion
of the femur, so it slackens with knee fl flexion.
– The PMC is tightened by knee extension and tibial
internal rotation, when it is an important restraint
to both internal rotation and posterior drawer.
– The sMCL is the principal restraint to valgus
(abduction) angulation of the tibiofemoral joint.
The sMCL takes most of the load because it is
the stiff
ffest ligamentous structure on the medial
aspect of the knee.
– The dMCL is tightened rapidly by tibiofemoral
relative motion because its fibers are shorter
than those of the other ligaments; it has a role
in limiting tibial external rotation and anterior
drawer in external rotation.
References
1. Brantigan OC, Voshell AF (1943) The tibial collateral liga-
ment: its function, its bursae, and its relation to the medial
meniscus. J Bone Joint Surg Am 25:121–131
2. Hughston JC, Eilers AF (1973) The Th role of the posterior
oblique ligament in repairs of acute medial (collateral) lig-
ament tears of the knee. J Bone Joint Surg 55A:923–940
3. LaPrade RF, Engebretsen AH, Ly TV, et al. (2007) The Th anat-
omy of the medial part of the knee. J Bone Joint Surg Am
89:2000–2010
4. Palmer I. (1938) On the injuries to the ligaments of the
knee joint. Acta Chir Scand 81 Suppl, 53:3–282
5. Robinson JR, Sanchez-Ballester J, Bull AMJ, et al. (2004)
The posteromedial corner revisited – an anatomical
description of the restraining structures of the medial
aspect of the human knee. J Bone Joint Surg Br 86:674–
681
30 The Traumatic Knee
6. Slocum DB, Larson RL (1968) Rotatory instability of the
knee. Its pathogenesis and a clinical test to determine its
presence. J Bone Joint Surg 50A:211–225
7. Warren LF, Marshall JL. (1979) The supporting structures
and layers on the medial side of the knee: an anatomical
analysis. J Bone Joint Surg 61-A:56–62
8. Powers CM, Chen YJ, Farrokhi S, Lee TQ (2006) Role of
peripatellar retinaculum in transmission of forces in the
extensor mechanism. J Bone Joint Surg Am 88:2042–
2048
9. Strobel M, Stedfeld H-W (1990) Diagnostic evaluation of
the knee. Berlin: Springer-Verlag: 17–25
10. Wymenga AB, Kats JJ, Kooloos J, Hillen B (2006) Surgical
anatomy of the medial collateral ligament and the poster-
omedial capsule of the knee. Knee Surg Sports Traumatol
Arthrosc 14:229–234
11. Fischer RA, Arms SW, Johnson RJ, Pope MH (1985) Th The
functional relationship of the posterior oblique ligament
to the medial collateral ligament of the human knee. Am J
Sports Med 13:390–397
12. Kennedy JC, Hawkins RJ, Willis RB, Danylchuck KD. (1976)
Tension studies of human knee ligaments. Yield point, ulti-
mate failure, and disruption of the cruciate and tibial col-
lateral ligaments. J Bone Joint Surg 58-A:350–355
13. Marinozzi G, Pappalardo S, Steindler R. (1983) Human
knee ligaments: mechanical tests and ultrastructural
observations. Ital J Orthop Traumatol 9:231–240
14. Trent PS, Walker PS, Wolf B. (1976) Ligament length pat-
terns, strength, and rotational axes of the knee joint. Clin
Orthop 117:263–270
15. Robinson JR, Bull AMJ, Amis AA (2005) Structural prop-
erties of the medial collateral ligament complex of the
human knee. J Biomech 38:1067–1074
16. Laros GS, Tipton CM, Cooper RR. (1971) Influence fl of
physical activity on ligament insertions in the knees of
dogs. J Bone Joint Surg 53A:275–286
17. Woo SL, Orlando CA, Gomez MA, et al. (1986) Tensile
properties of the medial collateral ligament as a function
of age. J Orthop Res 4:133–141
18. Grood ES, Noyes FR, Butler DL, Suntay WJ (1981) Liga-
mentous and capsular restraints preventing straight
medial and lateral laxity in intact human cadaver knees. J
Bone Joint Surg 63A:1257–1269
19. Robinson JR, Bull AMJ, Thomas R deW, Amis AA (2006)
The role of the medial collateral ligament and posterome-
dial capsule in controlling knee laxity. Am J Sports Med
34:1815–1823
20. Kennedy JC, Fowler PJ (1971) Medial and Anterior insta-
bility of the knee. J Bone Joint Surg 53A:1257–1270
21. Butler DL, Noyes FR, Grood ES (1980) Ligamentous
restraints to anterior-posterior drawer in the human knee.
A biomechanical study. J Bone Joint Surg 62A:259–270
22. Noyes FR, Grood ES, Butler DL, Paulos LE (1980) Clini-
cal biomechanics of the knee-ligament restraints and
functional stability. In: A Funk (ed): AAOS Symposium on
the Athlete’s Knee. Surgical Repair and Reconstruction.
Mosby, St. Louis, Missouri, 1–35
23. Hughston JC, Barrett GR (1983) Acute anteromedial rota-
tory instability. Long-term results of surgical repair. J
Bone Joint Surg 65A:145–153
24. Race A, Amis AA (1996) Loading of the two bundles of the
posterior cruciate ligament: an analysis of bundle function
in A-P drawer. J Biomech 29:873–879
25. Apsingi S, Nguyen T, Deehan D, et al. (2008) The Th role of
PCL reconstruction in knees with combined PCL and pos-
terolateral corner defificiency. Knee Surg Sports Traumatol
Arthrosc in press Oct 16:104–111
26. Ritchie JR, Bergfeld JA, Kambic H, Manning T (1998) Iso-
lated sectioning of the medial and posteromedial capsu-
lar ligaments in the posterior cruciate ligament-deficient
fi
knee. Infl fluence on posterior tibial translation. Am J
Sports Med 26:389–394

C.J. Griffith, C.A. Wijdicks,
R.F. LaPrade
The lateral collateral ligament
and posterolateral corner
The lateral collateral ligament and
posterolateral corner
Anatomy of the posterolateral knee
T
he anatomy of the posterolateral corner of
the knee has been noted to be very complex
with 32 individual structures in addition
to 3 separate bones that articulate on the lateral
side of the knee (1). Evolutionary changes of lat-
eral knee structures have disposed it as a complex
structure. Originally, in lower animal species, the
fibula articulated directly with the femur (2–4).
In higher-order mammals, the fibula has migrated
distally and created the complex interactions of the
posterolateral knee (5). The most complex interac-
tions of the posterolateral knee primarily comprise
of the popliteus complex and its attachments to
the fibula and lateral meniscus. It remains recog-
nized that the arrangement of these structures is
complex and has the potential to be difficult
ffi to
A B
Chapitre 4
recognize in a severely acute injury. Recognition
of the main structures and their relationships
to each other, in addition to the important bony
landmarks of the posterolateral knee, can simplify
one’s understanding and treatment of injuries to
this unique part of the knee.
Fibular collateral ligament
The fibular (lateral) collateral ligament is described
as one of the three main structures of the poste-
rolateral corner of the knee (Fig. 1A and B) (6).
The fibular collateral ligament (FCL) is typically
4–5 mm in width and attaches proximally in a
fanlike manner on the femur (6). Its proximal
attachment on the femur is noted to be slightly
proximal (1.4 mm) and posterior (3.1 mm) to the
lateral epicondyle (6). While some of its fi fibers do
expand over a portion of the lateral epicondyle,
its main attachment site is in a small depression
just proximal and posterior to the lateral epicon-
dyle. From its proximal attachment site, it courses
extra-articularly under the superfi ficial layer of
Fig. 1 – (A) Cadaveric photograph dis-
playing course of the fibular collateral
ligament from its femoral attachment
posterosuperior relative to the lateral
epicondyle to its attachment on the
lateral fibular head. (B) Illustrative dem-
onstration of both the popliteofibular
ligament from the musculotendinous
junction of the popliteus muscle to the
fibular styloid tip and off the popliteus
tendon. (Reprinted with permission from
Am J Sports Med 31(6): 856, Fig. 1.)
32 The Traumatic Knee
the iliotibial band and the lateral aponeurosis of
the long head of the biceps femoris to attach to
the lateral aspect of the fibular
fi head. It has been
noted to attach to the fibular head in the small
indentation, which is approximately 40% of the
distance from the anterior aspect of the fi fibular
head to the posterior aspect (6). Its attachment
on the fibula is longer in a proximal-distal direc-
tion than its bony attachment on the femur, and
some of its attachment fibers on the fibula have
been noted to blend with the facial fibers of the
peroneus longus muscle (7). A simple method for
identifi
fication of the FCL attachment to the fibu-
lar head has been described as a horizontal inci-
sion through the biceps bursa, 1 cm proximal to
the fibular head, where the FCL can be identifi fied
in all but the most severe posterolateral corner
injuries (8).
Iliotibial band
The iliotibial band, also referred to as the iliotibial
tract, is an important landmark over the postero-
lateral corner of the knee due to the fact that it is
rarely injured, and in most surgical approaches to
posterolateral knee structures start with an inci-
sion directly over the superfi ficial layer of the ili-
otibial band. The iliotibial band comprises of four
main components over the lateral side of the knee
(9,10). These consist of the superfi ficial layer, the
iliopatellar band, the deep fibers, and the capsu-
lo-osseous layer (9). TheTh superfi ficial layer of the
iliotibial band covers the more posterior aspect
of the vastus lateralis muscle and courses down
to attach distally on Gerdy’s tubercle (Fig. 2). A
portion of the iliotibial band, called the iliopatel-
lar band, courses up to attach to the lateral border
of the patella. Along its more posterior aspects of
the knee, it blends with the fascial fifibers offff of the
short-headed biceps femoris.
In the region of the lateral intermuscular septum,
the iliotibial band is attached to the femur by the
deep fibers, also called Kaplan’s fibers, and the cap-
sulo-osseous layer of the iliotibial band (11). The Th
capsulo-osseous layer of the iliotibial band consists
of a fine fascial sling, which attaches to the iliotib-
ial band in this area, and then courses around the
anterolateral aspect of the lateral femoral condyle
to attach distally on the tibia in the same region as
the meniscotibial attachment site of the mid-third
lateral capsular ligament (10). ThThe capsulo-osseous
layer, also called the retrograde tract fibers by Lob-
benhaufer, has been noted to form an anterolateral
sling over the posterolateral corner of the knee and
theorized to contribute to a reduction in the pivot
shift maneuver in the face of an anterior cruciate
ligament (ACL) tear. ThisTh portion of the iliotibial
band was historically reconstructed in extra-artic-
ular ACL reconstructions.
Fig. 2 – Superficial band of iliotibial tract anatomy displaying the superfi-
cial band of the iliotibial band, which lies superficial to the more posterior
aspect of the vastus lateralis muscle and courses down to attach distally on
Gerdy’s tubercle.
As mentioned previously, the superfi ficial layer of
the iliotibial band serves as an important land-
mark to identify other posterolateral corner
structures intraoperatively because it has been
noted to be only injured in about 3% of postero-
lateral corner injuries (8). Thus,
Th the iliotibial band
can be utilized as an important landmark to iden-
tify all but the most severe posterolateral corner
injuries.
Mid-third lateral capsular ligament
The mid-third lateral capsular ligament is a
thickening of the lateral capsule, which courses
from the femur to the tibia and is effectively
comparable to the deep medial collateral liga-
ment on the medial side of the knee (10). The
mid-third lateral capsular ligament femoral
attachment site is just anterior to the popliteus
tendon attachment on the femur, and its poste-
rior femoral attachment site is just anterior to
the lateral gastrocnemius tendon attachment
site (10). It then courses down to attach to the
lateral meniscus and then more distally to its
attachment site on the tibia. Its tibial attach-
ment site, which is more frequently injured,
has been known to share a common attachment
with the anterior arm of the short head of the
biceps femoris and the capsulo-osseous layer of
the iliotibial band. Because the two portions, on
each side of the meniscus, have different attach-
ments and appear to be of different thicknesses,
they are often referred to as two different struc-
tures. The portion that attaches to the femur
is called the meniscofemoral portion, while the
portion that attaches to the tibia is called the
meniscotibial portion. As mentioned previously,
it is the meniscotibial portion that is most com-
monly injured. The meniscotibial portion can be

injured with an avulsion of the portion of the
tibia, diagnosed as a Segond fracture or with a
soft-tissue avulsion of the structures that attach
to the tibia at this location, called a soft-tissue
Segond avulsion (12).
Long head of the biceps femoris
Th long head of the biceps femoris has six diff
The ffer-
ent anatomic components at the knee. There Th are
two tendinous components. Th These are the direct
and anterior arms of the long head of the biceps,
which attach to the fibular head. The direct arm
attaches on the lateral aspect of the fibular styloid,
while the anterior arm crosses lateral to the fibular
head and has a fascial attachment to the aponeu-
rosis that covers the anterior compartment of the
knee. The anterior arm of the long head of the
biceps femoris forms a bursa where it crosses the
distal quarter of the FCL (13). The average length
of this bursa is 18 mm, and the bursa surrounds
the FCL by approximately 270° (13). An incision
through the biceps bursa is one of the primary
incisions utilized to perform repairs or reconstruc-
tions of the posterolateral corner structures. Th This
technique is valuable in the scenario of an acute
repair of the FCL and a reconstruction procedure
(Fig. 3).
The other components of the long head of the
Th
biceps femoris are fascial attachments. Proximally,
there is a refl
flected arm that courses up to attach to
the posterior border of the iliotibial band. In addi-
tion, there is a lateral aponeurosis that attaches to
the more posterior and lateral aspect of the FCL.
It is believed that, through this attachment, there
is some dynamic control of the FCL by the biceps
femoris complex. Finally, there is a distal aponeu-
rosis off
ff the long head of the biceps femoris, which
courses distally and attaches to the lateral gastroc-
nemius complex.
Fig. 3 – Photograph displaying the biceps bursa, which lies just superficial
to the fibular collateral ligament and serves as the primary incision site for
reconstructions of posterolateral corner structures.
The lateral collateral ligament and posterolateral corner 33
Short head of the biceps femoris
The short head of the biceps femoris has five major
components at the knee. Th The first component con-
sists of the main muscle body, which courses off ff
the posterolateral aspect of the distal femur and
attaches to the medial aspect of the long head of
the biceps femoris main common tendon (10). It
then has a tendinous attachment with the main
common tendon, which becomes the direct arm
of the short head of the biceps. This Th tendinous
attachment from the short head of the biceps fem-
oris attaches just lateral to the tip of the fibular
fi
styloid (10). Just proximal to its tendinous attach-
ment, there is a very thick and stout capsular arm
that courses to the posterolateral joint capsule
and the lateral gastrocnemius tendon. This Th com-
ponent is called the capsular arm. Th The more distal
aspect of the capsular arm attaches to the tip of
the fibular styloid and attaches proximally to the
region of the fabella on the lateral gastrocnemius
tendon. Thus, the more distal aspect of the capsu-
lar arm of the short head of the biceps femoris is
the fabellofi
fibular ligament (6,10). The fabellofi fibu-
lar ligament is noted to be very tight in extension
and very loose in flexion.
fl It has been described to
have the greatest variability among the posterolat-
eral corner structures; however, other studies have
found that its variability is primarily in the overall
thickness of the tendon and not in its actual pres-
ence (6). Since by defi
finition it is the distal edge of
the capsular arm of the short head of the biceps
femoris, we have found it always to be present in
over 300 fresh frozen cadaveric dissections that we
have performed.
Just distal to the capsular arm of the short biceps
femoris is a fine aponeurosis that courses from
the short-head biceps tendon up to the posterolat-
eral aspect of the FCL. This
Th structure is the short
biceps lateral aponeurosis. And finally, an anterior
arm of the short biceps femoris is present, which
courses medial to the FCL and attaches to the
posterior aspect of the meniscotibial portion of
the mid-third lateral capsular ligament, sharing a
common attachment site with the capsulo-osseous
layer of the iliotibial band (10). We have noted
that the short head of the biceps femoris is com-
monly found to be torn off ff with bony or soft-tissue
Segond avulsions of the tibia both clinically and on
MRI scans (12).
Lateral gastrocnemius tendon
The lateral gastrocnemius tendon is a tendinous
thickening at the far lateral aspect of the lateral
gastrocnemius musculature. It blends impercep-
tively into the meniscofemoral portion of the
posterolateral capsule at the level of the fabella or
cartilaginous fabella (10). In our experience, we
34 The Traumatic Knee

have found that there is always a bony or cartilagi-

nous fabella present, and we have performed his-
tological studies on cadavers to verify this. Once
the lateral gastrocnemius tendon attaches to the
fabella, it cannot be separated either surgically or
histologically from the lateral capsule in this area.
The lateral gastrocnemius tendon is rarely injured
in the face of posterolateral corner injuries, and
its femoral attachment site, which is close to the
supracondylar process on the lateral femoral con-
dyle, is a good reference point for treatment of
acute posterolateral corner injuries for repairs or
in the case of acute or chronic posterolateral cor-
ner reconstructions (6).

Popliteus complex
The popliteus complex, which is a very important
posterolateral rotatory stabilizer to the knee, has
both a static and a dynamic function. TheTh main ten-
dinous attachment of the popliteus muscle is at the
top fifth of the popliteal sulcus. At this location,
the center of the popliteus tendon attachment is
18.5 mm anterior to the center of the FCL attach-
ment on the femur (6). As one courses distally, the
popliteus has three popliteomeniscal fascicles that
attach the lateral meniscus to the popliteus ten-
don (6,10,14). These occur in the popliteal hiatus.
These include the anteroinferior, posterosuperior,
and posteroinferior popliteomeniscal fascicles.
The anteroinferior popliteomeniscal fascicle is the
strongest and provides the most stability to lateral
meniscal motion (15). As one courses further dis-
tal, at the level of the popliteus musculotendinous
junction, the popliteofi fibular ligament courses from
the popliteus tendon down to the posteromedial
aspect of the fibular styloid (Figs. 1B and 4). There
are two divisions to the popliteofi fibular ligament.
These include the anterior and posterior divisions.
The posterior division is larger and is believed to be
stronger. Anatomically, the more proximal aspect of
the popliteofifibular ligament blends with the more
distal aspect of the popliteomeniscal fascicles.
In addition to these attachment sites, there is also
a stout attachment that courses from the more
proximal aspect of the popliteus muscle up to the
posterior aspect of the posterior horn of the lat-
eral meniscus. This structure is called the popliteal
aponeurosis. In some of the older literature, this
structure was referred to as part of the arcuate
ligament (16).
Coronary ligament to the lateral meniscus
The coronary ligament to the lateral meniscus is
the meniscotibial portion of the posterior capsule,
which extends laterally from the popliteomenis-
cal fascicles back medially to the root attachment
of the lateral meniscus (10). It originates medi-
Fig. 4 – Photograph displaying the courses of both the anterior and poste-
rior (pointer) attachment sites of the popliteofibular ligament (PFL) from
the musculotendinous junction of the popliteus muscle to the fibular sty-
loid tip and off the popliteus tendon (posterior view, right knee). FCL, fibu-
lar collateral ligament; PLT, popliteus tendon. (Reprinted with permission
from Am J Sports Med 31(6): 858, Fig. 4.)
ally just lateral to the posterior cruciate ligament
(PCL), and its lateral border is at the edge of the
popliteal hiatus. This structure is thought to pro-
vide some stability to the posterior horn of the
lateral meniscus and possibly some function in
preventing hyperextension. However, its specific fi
function has not been identifi fied through biome-
chanical testing to this point in time.
Biology of posterolateral knee injuries
The bony architecture of the posterolateral corner of
the knee difffferentiates it signifi
ficantly from that of
the medial side of the knee. The two convex oppos-
ing surfaces of the lateral femoral condyle and lateral
tibial plateau have an inherent bony incongruity that
requires the native ligaments to be intact to make it
stable. This bony architecture is diff fferent than the
medial side of the knee, which has a convex shape of
the medial femoral condyle and the concave surface
of the medial tibial plateau to provide bony stabil-
ity. Thus, this bony architecture incongruity, com-
bined with the dependence upon the attachments
to the fibular head and styloid of several structures
to provide bony stability, indicates that posterolat-
 The lateral collateral ligament and posterolateral corner 35

eral knee injuries are at a much higher risk of not

healing when treated non-operatively, compared
to medial-sided knee injuries. A study by Kannus
reported that patients with grade 3 posterolateral
corner injuries do not heal and that these patients
often go on to develop signifi ficant instability and
osteoarthritis over time (17).
The clinical observation in humans that the poste-
rolateral structures do not heal when injured has
also been proven in the animal model. Th There have
been three animal model studies that have had
the anatomy of the posterolateral corner studied
in detail and then went on to in vitro or in vivo
cutting studies. The
Th rabbit model was first studied
(18–20). The rabbit anatomy was found to be simi-
lar to the human knee for the popliteus tendon and
the FCL, but no distinct popliteofi fibular ligament
was observed. The bony architecture of the rabbit
was found to be similar to the human except that
the tibia and the fibula were fused. In both 3- and
6-month cutting studies, it was found that there
was gross instability produced in the rabbit knees Fig. 5 – Photograph demonstrating preoperative examination under anes-
after posterolateral corner sectioning and that the thesia during surgical procedure to section posterolateral knee structures
posterolateral corner structures did not heal over in a goat model.
time. While there was a trend noted to the devel-
opment of medial compartment osteoarthritis,
the number of rabbits utilized in the study was not of the FCL, popliteus tendon, and popliteofibular
fi
suffi
fficient to find signifi
ficant amounts of osteoar- ligament were similar to the human knee. Biome-
thritis. chanical testing on a canine knee model also found
The second posterolateral injury model that was that there was a signifificant amount of instability
studied utilized the goat (Fig. 5). The goat model produced by sectioning the FCL, popliteus tendon,
was chosen because of its larger size and its ability and popliteofifibular ligament. While the canine
to potentially perform both cruciate ligament and knee is currently being investigated as to a poten-
posterolateral corner reconstructions on it. How- tial model to determine the outcomes of untreated
ever, the bony architecture of the goat knee is sig- posterolateral corner injuries and to determine if
nificantly
fi diff
fferent from that of the human. There possible interventional studies can prevent the
is no distinct fibula in the goat, and the fibular head secondary instability and development of osteoar-
is fused to the lateral tibial plateau and positioned thritis, these in vivo studies are still ongoing at
more proximally than in humans. After in vivo this point in time.
studies were completed, it was recognized that this
fused fibular head creates a more concave shape of
the lateral tibial plateau and provides more bony Biomechanics of the fibular (lateral) collateral ligament
congruity in the goat knee than either in the human and posterolateral structures
or in the rabbit knee. While both 3- and 6-month
studies found that there were significant
fi amounts Almost all of the biomechanical studies on the
of posterolateral instability on biomechanical test- posterolateral knee have been evaluated largely
ing, these were not felt to be clinically significant,
fi through cadaveric sequential sectioning studies.
and there was no trend toward the development of In these studies, motion changes are assessed
osteoarthritis in the goat knee model. and utilized to determine the contribution of the
Finally, a canine model was studied in which both sectioned structure for overall knee stability for
anatomic and biomechanical evaluations were per- certain applied loads. It is unfortunate that many
formed on the posterolateral corner of the knee of of the biomechanical studies performed between
cadaveric specimens (21). In the study by Griffith ffi diff
fferent study groups across the world are diffiffi-
et al., they found a similar bony architecture in the cult to compare to each other because of the dif-
canine knee to the human knee. The fibula was not ferences in nomenclature and the fact that many
fused to the tibia, and there were two opposing of the cutting studies grouped and sectioned sev-
convex surfaces present on the lateral side of the eral posterolateral structures together. The
Th follow-
knee. In addition, the attachment sites and courses ing sections examine the different
ff applied forces
36 The Traumatic Knee
and which structures have been determined to be
the primary and secondary stabilizers to resisting
abnormal increases in these joint motions.
Role of the posterolateral structures in preventing varus
and valgus rotation
All published biomechanical studies have dem-
onstrated that the fibular (lateral) collateral liga-
ment is the primary restraint to varus motion in
all degrees of knee flexion (22–26). In fact, while
isolated sectioning of the FCL has been noted to
cause a significant
fi increase in varus rotation at
any knee flexion angle, varus rotation has not
been found to be increased with any other poste-
rolateral structure sectioning as long as the FCL is
intact (23,24).
Many of the different
ff structures have been found
to be important in providing secondary varus
stability in FCL-deficient
fi knees. Nielson and Hel-
mig reported that the popliteus tendon had an
important secondary stabilizing role to preventing
abnormal varus rotation of the knee after fibular
collateral sectioning (27). Gollehon et al. found
that sectioning the popliteus tendon and postero-
lateral capsular structures signifi ficantly increased
varus opening, while Grood et al. found that sec-
tioning the popliteus tendon and posterolateral
capsule, along with any structures attached to the
fibular head, resulted in further signifi ficant varus
opening of the knee compared to isolated fibularfi
collateral sectioning alone (23,25).
In addition to the posterolateral structures, both
cruciate ligaments have been noted to resist varus
rotation when the FCL and other posterolateral
structures have been sectioned. Gollehon et al.
reported that after the FCL and posterolateral
structures were sectioned, sectioning of the PCL
resulted in a large increase of varus rotation, which
was signifificantly increased to isolated cutting of
the FCL (25). Grood et al. also found that after cut-
ting the FCL, popliteus tendon, and posterolateral
structures, there was a significant
fi further increase
in varus opening of the knee when the PCL was
sectioned (23). Nielsen and Wroble both reported
that sectioning the ACL after the posterolateral
corner structures and FCL have been sectioned
resulted in a signifificant increase in varus opening
of the knee (27,28).
No studies to date have found any role of poste-
rolateral structures in preventing increased valgus
rotation after posterolateral corner structure sec-
tioning (25,27,28).
Role of the posterolateral structures in preventing anterior
tibial translation
It has been demonstrated that isolated section-
ing of the posterolateral structures results in no
signifi
ficant increase in anterior tibial translation
(23,25,27). However, it has been demonstrated
that when the ACL has been sectioned, further
sectioning of the posterolateral corner structures
results in a significant
fi increase in anterior tibial
translation (27,29,30).
Thus, while it has been found that the posterolat-
eral corner structures have very little primary role
in preventing anterior tibial translation, they do
have an important secondary role to preventing
anterior tibial translation in the face of a concur-
rent ACL tear. This observation is clinically very
important because a patient who demonstrates
a 3+ or 4+ Lachman test has a high probability
of having a concurrent loss of an important sec-
ondary restraint. In a large number of cases, this
defi
ficiency would be the posterolateral corner
structures. Thus, any patient who is found to have
a signifi
ficant increase in anterior tibial translation
on their Lachman’s test clinically should be evalu-
ated to be sure that there is no concurrent postero-
lateral corner structure injury.
Role of the posterolateral corner structures in preventing
posterior translation of the tibia
The posterolateral knee structures have been noted
to play a statistically significant
fi but minor clini-
cally important primary role in restricting poste-
rior tibial translation. Studies have demonstrated
that isolated sectioning of the posterolateral struc-
tures can result in a slight, but significant,
fi increase
in posterior tibial translation at all angles of knee
flexion (23,25,30). However, in the majority of
patients with defi ficiencies of the posterolateral cor-
ner structures, the largest increase in posterior tib-
ial translation was close to extension. In addition
to this minor primary role of the posterolateral cor-
ner structures in restricting increases in posterior
tibial translation, these structures have also been
found to have a very important secondary role in
providing posterior stability to the knee when the
PCL is sectioned. Both isolated popliteus tendon
sectioning and combined popliteus tendon and
posterolateral corner structure sectioning in PCL-
defificient knees resulted in a rather dramatic and
signifificant posterior tibial translation (23,25,27).
To summarize, posterolateral corner structures
have both a primary and a secondary role to pro-
viding posterior stability to the knee. The primary
role in preventing abnormal posterior tibial trans-
lation is minor, and most of this function occurs
near extension. However, there is also a rather sig-
nifi
ficant secondary role to preventing posterior tib-
ial translation in PCL-defi ficient knees. The clinical
importance of this observation is that in patients
with PCL tears, a 3+ posterior drawer test or
increases of posterior tibial translation more then

12 mm on bilateral PCL stress x-rays would have a
high chance of having a concurrent posterolateral
corner injury in addition to the PCL tear.
Role of the posterolateral corner structures in preventing
internal rotation at the knee
Several studies have demonstrated that isolated or
combined sectioning of the FCL and other poste-
rolateral corner structures results in a significant
fi
increase of internal rotation at the knee (23,24,31).
In addition, Wroble demonstrated that in the ACL-
deficient
fi knee, sectioning the posterolateral cor-
ner structures resulted in a significant
fi increase in
internal tibial rotation (28). Most of the significant
fi
increase in internal tibial rotation was found near
extension.
In summarizing the role of the posterolateral cor-
ner structures in preventing internal rotation of
the tibia on the femur, the posterolateral corner
structures do have a small role in preventing pri-
mary internal rotation. In addition, they have been
found to be important as a secondary restraint to
internal rotation in the ACL-defi ficient knee, espe-
cially with a knee that is close to full extension.
However, the clinical usefulness of determining
increased internal rotation has not been deter-
mined to date because of the large variability
and the amount of internal rotation that occurs
between different
ff knees.
Role of the posterolateral corner structures in preventing
external rotation at the knee
It has been well demonstrated that the posterolat-
eral corner structures have a very important role
to preventing external rotation of the knee. ThereTh
have been many studies that have demonstrated
that the greatest amount of external rotation is at
30° of knee flexion and averages between 13° and
17° of external rotation (23–25). In addition, in
all of these studies, it was found that as the knee
was flexed further, the amount of external rota-
tion decreased only when the posterolateral corner
structures were sectioned. ThThe amount of increased
external rotation of the knee with isolated poste-
rolateral corner structure sectioning is between 5°
and 7° at 90° of knee flexion (23–25). The clinical
signifi
ficance of these findings is that the dial test at
both 30° and 90° of knee flexion is based upon the
results of these biomechanical studies (23–25). In
addition to isolated posterolateral corner structure
sectioning, it has been found that sectioning both
the ACL and the PCL has been found to result in
increased external rotation of the knee at 90° of
knee flexion when the posterolateral corner struc-
tures are sectioned first (23,25,28). In fact, the
amount of external rotation seen at 90° of knee
flexion with either an ACL or a PCL injury will be
fl
The lateral collateral ligament and posterolateral corner 37
Fig. 6 – Photograph demonstration positive dial test of the left knee during
preoperative examination under anesthesia.
similar to the amount of external rotation seen at
30° of knee flexion with isolated posterolateral cor-
ner structure sectioning.
The clinical implication of this observation is that
for isolated posterolateral corner injuries, there
should be a decrease in the amount of external
rotation of the tibia on the femur when the dial
test is performed at 90° compared to 30° of knee
flexion (Fig. 6). If there is a PCL or ACL injury con-
current with this posterolateral corner injury, the
amount of external rotation found at 90° of knee
flexion should be similar to the amount of external
rotation seen at 30° of knee flexion. Thus, if the
dial test is found to be signifi ficantly increased at
both 30° and 90° of knee flexion, there is a high
likelihood of a combined cruciate ligament injury.
Role of the popliteomeniscal fascicles to lateral meniscal
stability
Simonian et al. found that sectioning the poplit-
eomeniscal fascicles resulted in a significant
fi increase
of anterior motion of the lateral meniscus when
loaded (15). They also found that the anteroinferior
popliteomeniscal fascicle was larger and provided a
greater amount of stability to the lateral meniscus
than the thinner posterosuperior popliteomeniscal
fascicle. They theorized that with loads seen during
normal daily activities, it might be expected that
mechanical symptoms would develop in patients
when the popliteomeniscal fascicles were torn
because of the increased meniscal motion.
Eff
ffects of a posterolateral corner injury on joint contact
forces in the knee
Skyhar et al. reported on alterations in joint contact
pressure in the knee for PCL- and posterolateral
corner structures-defificient knees (32). The study
found that there was a significant
fi increase in joint
contact pressures in both the patellofemoral joint
38 The Traumatic Knee
and the medial compartment of the tibiofemo-
ral joint when the PCL is sectioned. The highest
increase in joint contact pressures were seen with
additional combined sectioning of the posterolat-
eral structures. From the study, the authors con-
cluded that patients with combined PCLs and
posterolateral knee injuries should be counseled
about the increased risk of osteoarthritis of these
compartments if these injuries are not treated sur-
gically.
Biomechanical failure properties of the posterolateral
structures of the knee
The individual failure characteristics of the FCL,
popliteofifibular ligament, and popliteus tendon
have been more recently defined.
fi Previous studies
found that the mean ultimate tensile strength of
the FCL was 295 N, the popliteofi fibular ligament
was 298 N, and the popliteus tendon was 700 N
(1). Another study by Sugita and Amis found that
the individual tensile strength of the FCL was 309
N and that of the popliteofi fibular ligament was 180
N (33). Maynard et al. tested the combined tensile
strength of the lateral (fi
fibular) collateral ligament,
popliteofifibular ligament, and popliteus tendon
and simultaneously stretched all three structures
along the axis of the FCL (34). Their
Th mean tensile
strengths under these testing conditions were 750
N for the FCL and 425 N for the popliteofibular fi
ligament. Thus,
Th it is clear that the failure proper-
ties of these three structures can resist fairly large
loads prior to failure, but they are not as strong
as the native ACL or PCL. In analyzing the failure
properties for these three important posterolateral
knee structures, it has been recommended that the
minimum possible graft replacements for these
structures consist of a semitendinosus tendon
(maximum failure load, 1216 N), a central quad-
riceps tendon graft (maximum failure load, 1075
N), or a portion of an Achilles tendon allograft
(maximum failure load, 3055 N) (1,31,35). Due to
the lower overall ultimate tensile strengths of the
gracilis tendon and a tubularized superfi ficial layer
of the iliotibial band, it is not recommended that
these grafts be utilized to reconstruct these poste-
rolateral knee structures.
Force measurements to applied loads on posterolateral
corner structures
In additional to information gained from biome-
chanical cutting studies, the primary and second-
ary stabilizing functions of the posterolateral cor-
ner structures have also been studied directly by
measuring the force of these structures to applied
loads. This information helps in analyzing the total
eff
ffect and importance of these individual struc-
tures on knee stability during functional loads.
One study found that with application of a varus
load to the knee, there was a fairly constant load
response on the FCL at 0°, 30°, and 60° with a
decrease in the overall load response at 90° of knee
flexion (36). With the FCL intact, there was very
little force on the popliteus tendon and popliteo-
fibular ligament. With external rotation loads, the
highest amount of force on the FCL was at 0° of
knee flexion. The popliteus tendon and the popli-
teofi
fibular ligament exhibited similar loading pat-
terns with external rotation moments. The Th mean
load response on both the popliteus tendon and
the popliteofi fibular ligament was highest at 60°
in knee flexion. Overall, there was a signifificantly
decreased load on the popliteus tendon and the
popliteofifibular ligament at 0° compared to the
other degrees of knee flexion.
fl Overall, there was
found to be a reciprocal relationship of load shar-
ing in external rotation between the FCL and the
popliteus complex depending upon the knee flex- fl
ion angle that was tested. Overall, the force on
the FCL with external rotation loads was higher
than the popliteus complex loads at lower flexion
fl
angles, with the popliteus complex having higher
load sharing against external rotation at 60° and
90° of knee flexion.
These direct force measurements have determined
that the FCL is an important load-sharing structure
against external rotation force near extension. In
fact, it was more highly loaded than the popliteus
complex, which would imply that the FCL has an
important role in preventing external rotation in
early knee flexion that was not recognized in previ-
ous posterolateral knee cutting studies.
The eff
ffects of deficient posterolateral corner structures
on cruciate ligament reconstruction grafts
There have been several studies that demonstrated
that if the posterolateral corner structures were
not present, there was a significant
fi increase in
force on both ACL and PCL reconstruction grafts,
which could lead to their failure. Based on these
studies, it has been recommended to concurrently
reconstruct the posterolateral corner structures at
the same time as cruciate ligament reconstructions
to minimize the chance of the graft stretching out
and failing over time.
Early on in our evaluation of posterolateral cor-
ner knee injuries, we found a high rate of ACL
reconstruction graft failures that were referred
to us for treatment that had concurrent postero-
lateral corner injuries which had not been treated
which lead to the ACL graft failure. This
Th observa-
tion prompted biomechanical testing of the force
seen on an ACL graft in the face of deficient
fi poste-
rolateral corner structures. Tests were performed
on cadaveric knees with the posterolateral corner

structures first intact and then following section-
ing of the FCL, popliteofifibular ligament, and popli-
teus tendon (Fig. 7). Overall, we found a significant
fi
increase in graft force after FCL sectioning during
varus loading at both 0° and 30° of knee fl flexion,
as well as for coupled loading of varus and inter-
nal rotation moments at 0° and 30° of knee flexion
(Fig. 8). The increase in graft force that was found
remained signifificant with additional sectioning of
the popliteofi
fibular ligament and the popliteus ten-
don. In comparing the forces seen on the graft, for
a patient with a typical body weight and height, and
a 6% adduction moment to the knee, we calculated
that there could potentially be 444 N of force on
the ACL reconstruction graft (37). Since Rowden
Fig. 7 – ACL graft force-measuring
testing apparatus for loading and
force measurement on the ACL
graft during testing. (Reprinted
with permission from Am J Sports
Med 27(4): 470, Fig. 1.)
Fig. 8 – Graph depicting the absolute tensile forces on ACL grafts to applied loads with posterolateral corner structures in the intact, transected, and recon-
structed states. (Reprinted with permission from Am J Sports Med 27(4): 472, Fig. 3.)
The lateral collateral ligament and posterolateral corner 39
et al. reported that the failure strength of a patellar
tendon ACL graft was 416 N immediately follow-
ing reconstruction, one can see that this adduction
moment force on an ACL reconstruction graft in
the face of concurrent posterolateral corner inju-
ries can be signifi
ficant (38). Based on this informa-
tion, we recommended that strong consideration
be given to either repairing or reconstructing pos-
terolateral corner injuries, especially in those knees
with evidence of injury to the FCL and concurrent
varus instability, at the time of ACL reconstruc-
tion. This combined procedure would signifi ficantly
reduce the risk of ACL graft failure.
A subsequent study was performed to assess the
risk of absent posterolateral corner structures on
a PCL graft (Fig. 9) (39). In this study, section-
ing of the popliteus tendon, popliteofi fibular liga-
ment, and FCL signifi ficantly increased the force
on a PCL graft over the intact state. The largest
increases in force on the PCL graft occurred both
with a varus moment and with a coupled posterior
drawer force and external rotation torque. These Th
loading states independently caused a significant fi
increase in graft forces at 30°, 60°, and 90° of knee
flexion when a posterolateral knee injury was pres-
ent (Fig. 10). Thus, this study verifified the clinical
observation that untreated posterolateral knee
injuries contributed to PCL graft failure by signifi- fi
cantly increasing forces on the PCL graft. Th Thus, we
recommended the repair or reconstruction of the
posterolateral corner structures at the same time
as PCL reconstruction in combined posterolateral
corner and PCL injuries with evidence of either
increased varus or coupled posterior drawer and
external rotation instability. Th This simultaneous
repair or reconstruction will decrease the chance
of PCL graft failure after the reconstruction.
40 The Traumatic Knee
Fig. 9 – Tensioning apparatus on the
proximal posterior tibia to measure
force on the PCL graft. (Reprinted
with permission from Am J Sports
Med 30(2): 234, Fig. 1.)
Influence of the integrity of the posterolateral structures
on tibiofemoral orientation when an anterior cruciate
ligament graft is Tensioned
A specifi
fic study was initiated to attempt to answer
the question on whether either the posterolateral
corner structures or the ACL graft should be tight-
ened first at the time of a repair or reconstruc-
tive procedure (40). In this study, an ACL graft
was tensioned at increasing graft forces both with
and without the posterolateral corner structures
being intact. It was found that in a knee deficient
fi
of posterolateral corner structures, increasing the
traction force on an ACL graft while tensioning on
the tibia with greater than a 60-N distal traction
Fig. 10 – Graph depicting the absolute tensile forces on PCL grafts to applied loads with posterolateral corner structures in the intact, transected, and
reconstructed states. (Reprinted with permission from Am J Sports Med 30(2): 236, Fig. 3.)
force caused the tibia to rotate externally (Fig. 11).
Thus, it was found that if the ACL graft was tight-
ened before the posterolateral corner structures
were repaired, there was a significant
fi increase of
external rotation of the tibia on the femur. Thus,
we recommended that injured posterolateral cor-
ner structures be repaired or reconstructed prior
to fixation of ACL grafts to minimize the risk of
developing an external rotation deformity of the
knee.
Biomechanical analysis of posterolateral corner
reconstruction procedures
There is a paucity of studies in the literature that
have analyzed whether posterolateral corner recon-
struction procedures restore normal joint motion.
More recently, two studies have analyzed anatomic
reconstructions of the fibular (lateral) collateral
ligament as well as the FCL, popliteus tendon, and
popliteofi
fibular ligament in an attempt to restore
stability to the knee with fibular (lateral) collateral
ligament injuries or complete grade 3 posterolat-
eral corner injuries.
A study by Coobs et al. examined an anatomic
reconstruction of the FCL using an autogenous
semitendinosus graft (Fig. 12A and B) (41). In
this reconstructive procedure, 7-mm tunnels were
drilled at the attachment site of the FCL on the
femur and a 6-mm tunnel was drilled from lateral
to posteromedial through the fibularfi head. The
tunnel entered the fibula at the anatomic attach-
ment site of the FCL. Comparisons were made
to varus rotation, external rotation, and internal
rotation at 0°, 15°, 30°, 60°, and 90° of knee flexion.
fl
This study validated that an anatomic FCL recon-
struction using an autogenous semitendinosus

Fig. 11 – Graph depicting the change in relative position of the tibia with
respect to the femur resulting from sectioning all of the posterolateral cor-
ner structures.
A B
Fig. 12 – Illustration depicting the anatomic reconstruction of an isolated
FCL injury using a semitendinosus graft. The intact popliteus tendon and
popliteofibular ligament are also shown. (A) Posterior view, right knee. (B)
Lateral view, right knee. FCL graft, fibular collateral ligament reconstruc-
tion with an autogenous semitendinosus graft; PLT, popliteus tendon; PFL,
popliteofibular ligament. (Reprinted with permission from Am J Sports Med
35(9): 1523, Fig. 2.)
graft restored near-normal stability to knees with
isolated FCL injuries. Th
Thus, it was demonstrated
that an anatomic reconstruction of the FCL with
an autogenous semitendinosus graft was a viable
option to treat non-repairable acute or chronic FCL
tears in patients with varus instability.
We also developed an anatomic posterolateral cor-
ner reconstruction technique concurrently with
the University of Oslo (36). This
Th reconstructive
technique anatomically reconstructed the FCL,
popliteus tendon, and popliteofi fibular ligament
(Fig. 13A and B). This
Th technique was based upon
our previous anatomic studies that demonstrated
that the popliteus tendon and FCL attachment
sites on the femur were separated by an average
of 18.5 mm. We felt that one graft on the femur
The lateral collateral ligament and posterolateral corner 41
A B
Fig. 13 – Illustration depicting the anatomic reconstruction of the fibular
collateral ligament, popliteus tendon, and popliteofibular ligament. FCL,
fibular collateral ligament; PLT, popliteus tendon; PFL, popliteofibular liga-
ment. (A) Posterior view, right knee. (B) Lateral view, right knee. (Reprinted
with permission from Am J Sports Med 32(6): 1410, Fig. 3.)
could not adequately restore the normal motion
of the knee with such a large difference
ff in posi-
tion between these two attachment sites. Thus,
we worked concurrently with our colleagues at the
University of Oslo on a surgical approach and, after
several diff
fferent techniques were trialed, arrived at
our current technique, as we felt it was the most
reproducible. It was then tested biomechanically
to determine if it could restore static stability to
varus translation, as well as internal and external
rotation. This study found that an anatomic pos-
terolateral corner reconstruction technique that
reconstructs the FCL, popliteus tendon, and popli-
teofi
fibular ligament restored varus and external
rotation stability in knees with grade 3 posterolat-
eral corner injuries.
References
1. LaPrade RF, Bollom TS, Wentorf FA, et al. (2005) Mechani-
cal properties of the posterolateral structures of the knee.
Am J Sports Med 33:1386–1391
2. Herzmark MH (1938) The evolution of the knee joint. J
Bone Joint Surg Am 20:77–84
3. Haines RW (1942) The tetrapod knee joint. J Anat 76:270–
301
4. Kaplan EB (1961) ThThe fabellofi
fibular and short lateral liga-
ments of the knee joint. J Bone Joint Surg Am 43-A:169–
179
5. Fürst CM (1903) Der musculus popliteus und seine Sehne.
Ueber ihre Entwicklung und uber einige damit zusammen-
hangende Bildungen. Lunds Universitets Arsskrift Band
39. Lund, Sweden: E. Malstroms Buchdruckerei
6. LaPrade RF, Ly TV, Wentorf FA, Engebretsen L (2003) The Th
posterolateral attachments of the knee: a qualitative and
quantitative morphologic analysis of the fibular
fi collateral
42 The Traumatic Knee
ligament, popliteus tendon, popliteofi fibular ligament, and
lateral gastrocnemius tendon. Am J Sports Med 31:854–860
7. Terry GC, LaPrade RF (1996) The Th biceps femoris muscle
complex at the knee. Its anatomy and injury patterns
associated with acute anterolateral-anteromedial rotatory
instability. Am J Sports Med 24:2–8
8. LaPrade RF, Terry GC (1997) Injuries to the posterolateral
aspect of the knee. Association of anatomic injury patterns
with clinical instability. Am J Sports Med 25:433–438
9. Terry GC, Hughston JC, Norwood LA (1986) The anatomy
of the iliopatellar band and iliotibial tract. Am J Sports
Med 14:39–45
10. Terry GC, LaPrade RF (1996) The Th posterolateral aspect of
the knee. Anatomy and surgical approach. Am J Sports
Med 24:732–739
11. Kaplan EB (1962) Some aspects of functional anatomy of
the human knee joint. Clin Orthop 23:18–29
12. LaPrade RF, Gilbert TJ, Bollom TS, et al. (2000) The mag-
netic resonance imaging appearance of individual struc-
tures of the posterolateral knee. A prospective study of
normal knees and knees with surgically verifi fied grade III
injuries. Am J Sports Med 28:191–199
13. LaPrade RF, Hamilton CD (1997) The Th fibular collateral
ligament-biceps femoris bursa. An anatomic study. Am J
Sports Med 25:439–443
14. Staubli HU, Birrer S (1990) The popliteus tendon and its
fascicles at the popliteal hiatus: gross anatomy and func-
tional arthroscopic evaluation with and without anterior
cruciate ligament defificiency. Arthroscopy 6:209–220
15. Simonian PT, Sussmann PS, van Trommel M, et al. (1997)
Popliteomeniscal fasciculi and lateral meniscal stability.
Am J Sports Med 25:849–853
16. Last RJ (1948) Some anatomical details of the knee joint.
J Bone Joint Surg Br 30-B:683–688
17. Kannus P (1989) Nonoperative treatment of Grade II and
III sprains of the lateral ligament compartment of the
knee. Am J Sports Med 17:83–88
18. Crum JA, LaPrade RF, Wentorf FA (2003) The anatomy of
the posterolateral aspect of the rabbit knee. J Orthop Res
21:723–729
19. LaPrade RF, Wentorf FA, Crum JA (2004) Assessment of
healing of grade III posterolateral corner injuries: an in
vivo model. J Orthop Res 22:970–975
20. Laprade RF, Wentorf FA, Olson EJ, Carlson CS (2006) An
in vivo injury model of posterolateral knee instability. Am
J Sports Med 34:1313–1321
21. Griffi
ffith CJ, Laprade RF, Coobs BR, Olson EJ (2007) Anat-
omy and biomechanics of the posterolateral aspect of the
canine knee. J Orthop Res 25:1231–1242
22. Grood ES, Noyes FR, Butler DL, Suntay WJ (1981) Liga-
mentous and capsular restraints preventing straight
medial and lateral laxity in intact human cadaver knees. J
Bone Joint Surg Am 63:1257–1269
23. Grood ES, Stowers SF, Noyes FR (1988) Limits of move-
ment in the human knee. Eff ffect of sectioning the poste-
rior cruciate ligament and posterolateral structures. J
Bone Joint Surg Am 70:88–97
24. Nielsen S, Rasmussen O, Ovesen J, Andersen K (1984)
Rotatory instability of cadaver knees after transection
of collateral ligaments and capsule. Arch Orthop Trauma
Surg 103:165–169
25. Gollehon DL, Torzilli PA, Warren RF (1987) The Th role of
the posterolateral and cruciate ligaments in the stability
of the human knee. A biomechanical study. J Bone Joint
Surg Am 69:233–242
26. Markolf KL, Mensch JS, Amstutz HC (1976) Stiffness ff and
laxity of the knee – the contributions of the supporting
structures. A quantitative in vitro study. J Bone Joint Surg
Am 58:583–594
27. Nielsen S, Helmig P (1986) Posterior instability of the
knee joint. An experimental study. Arch Orthop Trauma
Surg 105:121–125
28. Wroble RR, Grood ES, Cummings JS, et al. (1993) The Th role
of the lateral extraarticular restraints in the anterior cru-
ciate ligament-deficient
fi knee. Am J Sports Med 21:257–
262; discussion 263
29. Veltri DM, Deng XH, Torzilli PA, et al. (1996) The Th role of
the popliteofi fibular ligament in stability of the human
knee. A biomechanical study. Am J Sports Med 1996;
24:19–27
30. Veltri DM, Deng XH, Torzilli PA, et al. (1995) The Th role
of the cruciate and posterolateral ligaments in stability
of the knee. A biomechanical study. Am J Sports Med
23:436–443
31. Noyes FR, Stowers SF, Grood ES, et al. (1993) Posterior
subluxations of the medial and lateral tibiofemoral com-
partments. An in vitro ligament sectioning study in cadav-
eric knees. Am J Sports Med 21:407–414
32. Skyhar MJ, Warren RF, Ortiz GJ, et al. (1993) The Th effffects
of sectioning of the posterior cruciate ligament and the
posterolateral complex on the articular contact pressures
within the knee. J Bone Joint Surg Am 75:694–699
33. Sugita T, Amis AA (2001) Anatomic and biomechanical
study of the lateral collateral and popliteofi fibular liga-
ments. Am J Sports Med 29:466–472
34. Maynard MJ, Deng X, Wickiewicz TL, Warren RF (1996)
The popliteofifibular ligament. Rediscovery of a key element
in posterolateral stability. Am J Sports Med 24:311–316
35. Harris NL, Smith DA, Lamoreaux L, Purnell M (1997)
Central quadriceps tendon for anterior cruciate ligament
reconstruction. Part I: Morphometric and biomechanical
evaluation. Am J Sports Med 25:23–28
36. LaPrade RF, Johansen S, Wentorf FA, et al. (2004) An
analysis of an anatomical posterolateral knee reconstruc-
tion: an in vitro biomechanical study and development of
a surgical technique. Am J Sports Med 32:1405–1414
37. LaPrade RF, Resig S, Wentorf F, Lewis JL (1999) The Th
eff
ffects of grade III posterolateral knee complex injuries
on anterior cruciate ligament graft force. A biomechanical
analysis. Am J Sports Med 27:469–475
38. Rowden NJ, Sher D, Rogers GJ, Schindhelm K (1997) Ante-
rior cruciate ligament graft fixation.
fi Initial comparison of
patellar tendon and semitendinosus autografts in young
fresh cadavers. Am J Sports Med 25:472–478
39. LaPrade RF, Muench C, Wentorf F, Lewis JL (2002) The Th
eff
ffect of injury to the posterolateral structures of the knee
on force in a posterior cruciate ligament graft: a biome-
chanical study. Am J Sports Med 30:233–238
40. Wentorf FA, LaPrade RF, Lewis JL, Resig S (2002) The Th
infl
fluence of the integrity of posterolateral structures on
tibiofemoral orientation when an anterior cruciate liga-
ment graft is tensioned. Am J Sports Med 30:796–799
41. Coobs BR, LaPrade RF, Griffi ffith CJ, Nelson BJ (2007) Bio-
mechanical analysis of an isolated fibular (lateral) collat-
eral ligament reconstruction using an autogenous semi-
tendinosus graft. Am J Sports Med
 Chapter 5

H. Tohyama, K. Yasuda Basic science of ligament healing

Structure of ligaments with periosteal collagen fibers,

fi which in turn are
anchored to the adjacent bone without a fibrocar-
fi

L
igaments function as short bands of fibrous
fi tilage layer. Indirect insertions contain Sharpey’s
connective tissue that connect bone or sup- fibers, which are collagen fibers that are continu-
porting soft tissue structures. The organiza- ous from ligament to bone and have an important
tion of the ligament is hierarchical. Ligaments are role in securing the ligament to bone. An example
composed of bundles of type I collagen fi fiber, which is the insertion of the medial collateral ligament
make approximately 70% of the dry weight of the (MCL) into the tibia.
tissue (1). Small amounts of elastin are present, A complex blood supply with a fairly uniform
with rows of fibroblasts within parallel bundles of microvascular pattern runs throughout the liga-
extracellular matrix. In the hierarchical structure ment substance, originating from the insertion
of the ligament, the collagen matrix comprises a sites and passing through the ligament in a longi-
series of fibrils, which are then grouped into fibers tudinal fashion. The vessels are small but appear
forming a subfascicular unit (Fig. 1) (2). ThThe sub- critical in nutrition of the central portion of the
fascicular units are surrounded by a thin layer of ligament (4). Although diff ffusion from the syn-
connective tissue. Multiple subfascicular units are ovium or extracellular space is also important for
bound together to form a fasciculus that can range the nutrition of the ligament, a vascular supply
from microns to millimeters in diameter.
At ligament insertion into bone, the ligament
material changes from rigid to more flexible. fl
Insertions are classifified as direct or indirect (3).
Direct insertions are typically associated with
long ligaments inserting into small areas of bone,
while indirect insertions are usually short liga-
ments inserting into a large area. Direct insertion
shows four distinct zones: ligament, unmineral-
ized fibrocartilage, mineralized fibrocartilage, and
bone (Fig. 2). The femoral origin of the anterior
cruciate ligament (ACL) is a direct insertion. Indi-
rect insertions contain collagen fi fibers that blend

Fig. 1 – A schematic diagram of the structural hierarchy of ligament. There

are six distinctive structural levels in a ligament or a tendon. The first level is
the collagen molecule described below; the sixth level is the tendon itself. Fig. 2 – Direct insertion of the ligament shows four distinct zones: liga-
In between, in ascending order are the microfibrils, the subfibrils, the fibrils, ment (I), unmineralized fibrocartilage (II), mineralized fibrocartilage (III),
and the fascicles. (From Ref. 2.) and bone (IV).
44 The Traumatic Knee
is necessary for adequate nutrition of the central
portion of the ligament (5). Th
Therefore, disruption
of the blood supply may adversely affect
ff viabil-
ity of intraligamentous cells and the remodeling
of the extracellular matrix, resulting in possible
increased risk for rupture of the ligament. Various
nerve endings have been found in ligament tissue.
Histolochemical studies have shown nerve endings
involved in proprioception and nociception in knee
ligaments (6,7).
Mechanical properties of ligaments
Tensile testing of ligaments is widely used to
evaluate mechanical properties of ligaments
(8,9). The force-elongation curve of the liga-
ment tissue follows a pattern consistent with
collagenous tissues (Fig. 3). The ligament ini-
tially has a non-linear structural response to an
applied tensile force. This “toe” region has been
attributed to straightening of the crimp pattern
and to non-uniform recruitment of individual
nonparallel fiber in the ligament tissue. If we
apply a tensile force to the ligament, a small
force induces elongation of the ligament tissue
as some crimps are straightened. Additional
applied load elongates the fibril of the ligament
tissue. As the ligament tissue has varying crimp
and fibril orientation in contrast to the tendon
tissue, ligaments may resist stretch at different
levels of elongation. With increase in the elonga-
tion of the ligament tissue, more fibrils become
uncrimped and oriented parallel to the direction
of the applied load. This recruitment of fibrils
gradually stiffens the ligament tissue.
Fig. 3 – A force-elongation curve. There are three regions that are com-
monly used to describe a force-elongation or stress-strain curve. The first
region is termed the “toe region” and elicits a non-linear increase in load
as the tissue elongates. The second region represents the linear region of
the curve. In the third region, isolated collagen fibers are disrupted and
begin to fail.
General wound healing
Healing of an injury to a connective tissue struc-
ture including a ligament requires complex inter-
actions between cells, extracellular matrix, growth
factors, and mediators of the infl flammatory
response (10–12). An optimal sequence and timing
of the stages of soft tissue repair are necessary for
successful healing. Th
The alteration of the sequence
or the timing after an injury of connective tissue
structure may induce scar formation and dysfunc-
tion of the healing tissue rather than recovery of
normal structure-function relationship. Wound
healing can be basically divided into infl
flammatory,
proliferative, and maturation phases as described
below, although these phases can be modifi fied by
the size and location of the injury, vascular supply,
and local mechanical environments (13).
The inflflammatory phase of wound healing begins
immediately after injury with influx
fl of blood into
the wound site and subsequent formation of a
fibrin clot. The binding fibrin and fibronectin in
the clot initially stabilize the injury site in spite
of its low mechanical strength. Platelets, neutro-
phils, and macrophages migrate into the injury
site, and these cells release chemotactic factors for
fibroblasts and proteolytic enzymes such as matrix
metalloproteinases (MMPs).
During the proliferative phase of the wound heal-
ing, endothelial cells and fibroblasts, including
myofifibroblasts, accumulate at the injury site. Typi-
fied by vascular endothelial growth factor (VEGF),
angiogenic factors mediate capillary formation
at the injury site. Platelet-derived growth fac-
tor (PDGF) and transforming growth factor-beta
(TGF-beta) also stimulate migration, differentia-
ff
tion, and matrix synthesis of endothelial cells and
fibroblasts, including myofifibroblasts.
In the maturation phase of the wound healing,
fibroblasts secrete extracellular matrix including
type I and type III collagen. During the early matu-
ration phase, disorganized collagen deposition is
observed with numerous fibroblasts. As the scar
matures, type I collagen production and deposi-
tion predominates. Remodeling of the scar occurs
by continuous degradation and synthesis of extra-
cellular matrix.
Biomechanical evaluation
after acute ligament injuries
The healing of extra-articular ligament injuries has
been extensively studied over the decade using
the MCL of the knee (8,14–18). The healing of the
MCL after sharp transaction and mop-end inju-
ries has been studied. These experimental stud-

ies indicate that injuries to the MCL heal well in a
variety of animal models. Outcomes after surgical
and non-surgical treatment of mop-end tears have
not been signifificantly diff
fferent. An experimental
study using a rabbit model shows that the ulti-
mate failure load of the femur-MCL-tibia complex
reaches approximately 70% of the normal complex
at 12 weeks after either surgical or non-surgical
treatment of mop-end tears (18). These Th findings
have been supported by a clinical study of isolated
MCL injury, wherein conservative treatment was
preferable to operative intervention (20–22).
In contrast to the case in the MCL, it is well known
that ACL injuries poorly heal (23). The periliga-
ment environment and local mechanical factors
may be responsible for the poor healing potential
of the ACL. In the ACL, vascular response is pro-
fuse after its injury, but a stable fibrin
fi clot at the
injury site is not maintained (4). Dilution of the
hematoma by synovial fluid fl inhibits clot forma-
tion, which initiates the healing response. Intrin-
sic diff
fference in cell populations in the ACL and
MCL may also aff ffect their healing potentials after
their injuries. Cells isolated from the ACL demon-
strate lower rates of proliferation and migration
in culture, in comparison with cells from the MCL
Fig. 4 – (A) A schematic diagram of the operative procedure to create the
incomplete ACL tear. The distance between the two lines was measured at 90°
of knee flexion under anterior drawer force of 10 N (a).<Comp: Make changes
in figure label in the artwork as well.> It was approximately 5 mm. The anter-
omedial and posterolateral half of the right ACL was transected with a scalpel
at the proximal and distal one-third levels, respectively (b and c). An anterior
drawer force is applied for 5 min, so that the ACL was elongated 2 mm (d). The
ACL becomes slack after the anterior drawer force is removed (E).
Fig. 4 –(B) Averaged load-elongation curves for the femur-ACL-tibia com-
plexes after the incomplete ACL injury. Ultimate failure load of the femur-
ACL-tibia complex is less than 50% of the normal complex 12 weeks even
after incomplete tears. (From Ref. 27.)
Basic science of ligament healing 45
(24–27). A biomechanical study using a rabbit
model showed that ultimate failure load of the
femur-ACL-tibia complex is less than 50% of the
normal complex even 12 weeks after incomplete
tears (Fig. 4) (28).
ACL graft healing in animal models
The histologic structure of tendon grafts after ACL
reconstruction has been extensively evaluated
using animal models. Arnoczky et al. observed a
synovial membrane with an abundant blood supply
at 4 weeks and central avascular necrosis around
the patellar tendon (PT) graft at 6 weeks after ACL
reconstruction in the canine model (29). They also
found that the central area was revascularized at
5 months, and their grafts appeared similar to an
ACL at 1 year. Amiel et al. showed central PT graft
acellularity at 2 weeks, with cellular repopulation
from 3 to 6 weeks in a rabbit ACL reconstruction
model (5). At 30 weeks after ACL reconstruction
with a PT graft, the cell size and shape and the ori-
entation of the collagen bundles in the graft were
similar to those in a normal ACL. In a separate
report, Amiel et al. showed that the PT fibroblast
could not survive in a synovial environment and
that the PT graft was repopulated with fi fibroblasts
of a synovial origin (30). Ballock et al. reconstructed
rabbit ACLs with a PT graft and found an irregular
crimp pattern as late as 52 weeks after surgery,
with a cellular appearance similar to that of an ACL
(31). Concerning hamstring tendon graft, Grana
et al. described the histologic changes within the
intra-articular segment of a hamstring tendon
autograft during the initial 52 weeks after surgery
(32). While the grafts remained viable at all time
periods, they found relative central acellularity at 4
weeks, with repopulation of this region with spin-
dle cells at 8 weeks, and that the number of cell
nuclei in the hamstring tendon graft was similar
to that of the normal ACL at 52 weeks in spite of
some variation in the size and shape of the fibro-fi
blast cell nuclei. The remodeling of autologous ten-
don grafts used for ACL reconstruction is essential
for the clinical outcome after ACL reconstruction,
but the first 7 weeks of remodeling are associated
with an extensive decrease of the tensile strength
of the graft (33).
After harvesting for ACL reconstruction, autolo-
gous tendon grafts are separated from the circu-
lation, and the tissue becomes necrotic, followed
by ingrowth of a hypercellular and hypervas-
cular reparative tissue (29,30,34). Hypoxia is a
known potent stimulator for VEGF expression in
solid tumors (35), and thus it seems likely that
decreased oxygen tension at the transition to the
46 The Traumatic Knee

necrotic part may stimulate VEGF expression also VEGF mediates angiogenesis in the intra-articular
in tendon grafts after ACL reconstruction. We tendon graft in an early remodeling phase after
investigated temporal changes in the relationships the ACL reconstruction. This fact shows that VEGF
between VEGF expression, fibroblast proliferation, produced by the fibroblasts
fi induces revasculariza-
and angiogenesis in the PT graft at the early phase tion in the graft and implied that VEGF application
after ACL reconstruction in the rabbit model. We is a potential strategy to accelerate angiogenesis in
showed that VEGF was highly expressed in pro- the graft after ACL reconstruction.
liferating extrinsic fibroblasts
fi at 2 and 3 weeks
(Fig. 5A and B) (36). From 4 weeks, although the
ratio of VEGF-positive cells was reduced in the
graft, angiogenesis still continued to be enhanced Human studies on ACL graft healing
(Fig. 5A and C). In this period, vascular endothe-
lial cells mainly produced VEGF, which might con- All animal models have certain limitations, such as
tribute to promote localized angiogenesis. Con- the diffi
fficulty to replicate today’s refi
fined techniques
cerning VEGF expression in the grafted tendon at with optimized graft placement and sufficient
ffi fixa-
the long term after ACL reconstruction, Peterson tion, which might affect
ff the mechanical forces that
et al. (37) studied the expression of VEGF 6–104 are transmitted to the graft and its ensuing the
weeks after an ACL reconstruction model in sheep. remodeling and healing of the graft. Also, limita-
They showed there was strong immunostaining tions exist in the control of the weight bearing after
for VEGF in the synovial and subsynovial tissue in the surgery in the animal models. Th Therefore, it is
the periphery of the graft and within the invading important to understand that differences
ff between
reparative tissue at 6 weeks. At 24 weeks, how- the results of graft healing studies in animal mod-
ever, the intensity of VEGF immunostaining was els cannot be directly applied to the human ACL
decreased. At 52 and 104 weeks, grafts were largely patients. Several human biopsy studies found that
VEGF negative. These findings have suggested that the remodeling activity of human ACL grafts dur-

Fig. 5 – Temporal changes in the relationships between vascular endothelial growth factor (VEGF) expression, fibroblast proliferation, and angiogenesis in
the patellar tendon (PT) graft at the early phase after ACL reconstruction in the rabbit model. (A) Expression of VEGF in the PT graft at 2 and 8 weeks (×25);
(B) expression of proliferating cell nuclear antigen (PCNA) as a marker of cell proliferation in the PT graft at 2 and 8 weeks (×25); (C) expression of CD31 as a
marker of the vascular endothelial cell in the PT graft at 3 and 8 weeks (×25). (From Ref. 34.)

ing the first
fi 3 months is diff fferent from the healing
graft in animal models (38,39). Although the previ-
ously described healing process of animal models,
i.e., graft necrosis, recellularization, revascular-
ization, and matrix remodeling, are also found in
human ACL graft biopsies, the remodeling activity
of human ACL graft is not so drastic. Rougraff ff and
Shelbourne found viable intrinsic cells in human
biopsy specimens from the graft at all time points
between 3 and 8 weeks after ACL reconstruction
(39). Large areas of the human ACL graft seem to
stay unchanged, displaying tendinous structure
with normal collagen alignment and crimp pattern.
Neovasucularization was also found but did not
seem to be excessive as in the animal model.
Since free tendon grafts are separated from their
vascular supply during harvesting, ingrowth of new
blood vessels is an essential step for the process of
tendon graft remodeling (29). Yamagishi et al. (40)
measured surface blood fl flow in ACLs reconstructed
with a bone-PT-bone autograft using laser Doppler
flowmetry in clinical cases. They found signifi ficantly
high blood flow
fl values for the reconstructed ACL
at 6 and 12 months, and a gradual return to near
normal values for the reconstructed ACL 18 months
after surgery. Shino et al. (41) also measured surface
blood flow in allografts after ACL reconstruction
and examined their histology through biopsy speci-
mens procured during second-look arthroscopy.
They found signifi ficantly high blood flow values for
the reconstructed ACL at 6 months, and a gradual
return to near-normal values for the reconstructed
ACL 12 months after surgery.
Although human biopsy studies showed substan-
tial diff
fferences from animal models for the prolif-
eration phase, the matrix remodeling phases seem
to be similar in both models in terms of biological
progression. Analysis of the biopsies of human PT
graft by Rougraff ff et al. (39) found that degenera-
tion of the graft increases until 6–10 months and
only slowly disappears between 1 and 3 years post-
operatively. Several biopsy studies confirmed
fi that
ACL grafts show a replacement of large-diameter
fibrils by large-diameter fibrils, which does not
change even after more than 2 years after ACL
reconstruction. Recently, Delay et al. (42) reported
a human ACL reconstruction case in which the core
portion of the PT graft still remained necrotic at
18 months after surgery.
Graft-tunnel healing after ligament
reconstruction in animal models
Tendon graft healing within the bone tunnel is one
of the most important factors affffecting success of
ligament reconstruction, as it contributes to deter-
Basic science of ligament healing 47
mine the mechanical characteristics of the bone-
graft-bone complex. Several animal experimental
and clinical studies have shown that tendon graft
heals within the bone tunnel by formation of a
bone-graft interface. Animal experimental studies
on tendon-bone healing are based on two differ- ff
ent models: an extra-articular model and an intra-
articular model. In the extra-articular model, the
tendon is detached from one of its insertions and
fixed within a drilled tunnel of an adjacent bone. In
the intra-articular model, an ACL reconstruction is
performed using a free or pedicle tendon graft. The
Th
extra-articular model does not consider the biolog-
ical stimuli of the intra-articular environment that
may affffect graft healing within the bone tunnel.
Recent studies using the extra-articular model
showed that tendon graft heals within a bone
tunnel by formation of an indirect-type interface
with fibrous tissue containing perpendicular col-
lagen fibers resembling Sharpey fibers penetrat-
ing into the bone. In a biomechanical study, the
healing tissue at the bone-tendon interface was
not mechanically competent until 8 weeks after
surgery (43).
Animal experimental studies using intra-articular
models of ACL reconstruction with single or double
strands of tendon graft showed that an ACL graft
heals within the bone tunnel by formation of an
indirect-type junction with collagen fibers
fi resem-
bling Sharpey fibers
fi perpendicular to the tunnel
wall (Fig. 6). Goradia et al. (44) reported that in a
sheep ACL reconstruction model using a doubled
semitendinous tendon graft, graft failure occurred
by pullout from the bone tunnel up to 12 weeks
after surgery and stated that a semitendinosus
tendon graft has not completely healed within the
Fig. 6 – Histological appearance of the tendon graft at 12 weeks after ACL
reconstruction in the dog. A tendon graft heals within the bone tunnel
by formation of an indirect-type junction with collagen fibers resembling
Sharpey fibers to the bonny tunnel wall (B) (H&E, original magnification
×100). (From Ref. 43.)
48 The Traumatic Knee
bone tunnel for as long as 3 months after the ACL
reconstruction surgery. Concerning the healing
process of ACL grafts with bone plugs within bone
tunnels, the healing process of the tendinous por-
tion of the graft within the bone tunnel is consid-
ered to be diff
fferent from the healing process of the
bone plug (45). TheTh intraosseous tendinous por-
tion of the graft heals by forming collagen fi fibers
that resemble Sharpey fi fibers perpendicular to the
tunnel wall and appear well organized by 3 months
after surgery. On the other hand, the bone plug of
the bone-tendon-bone graft incorporation at the
tunnel wall occurs through a progression of necro-
sis, resorption, and remodeling. However, the
native insertion site of the bone-tendon-bone graft
shows degeneration of the fibrocartilaginous layer
by several weeks during the bone plug remodeling.
Concerning biomechanical comparison between
tendon-bone and bone-bone healing, animal
experimental studies using the intra-articular ACL
reconstruction model show that bone-bone healing
occurs more rapidly than tendon-bone healing. Up
to a few weeks, both soft tissue tendon and bone
plug tendon grafts fail by pullout from the tunnel.
During several weeks after surgery, the bonding
between the bone plug and the tunnel wall appears
mechanically stronger than that between the soft
tissue tendon and the tunnel wall, although the
mechanical superiority of bone-bone healing is no
more signifificant by 3 months after surgery (45).
Therefore, the fixation method for soft tissue ten-
Th
don graft is considered to be more important than
that for the bone-tendon graft during the first
fi sev-
eral weeks after ACL reconstruction.
Graft-tunnel healing after ligament
reconstruction in human biopsy studies
Although a certain number of animal studies were
reported on graft-tunnel healing, investigation of
graft-tunnel healing in human ACL reconstruc-
tion is very limited. A two-case study reported on
biopsy at the graft-bone interface in the patients
who underwent revision surgery for graft failure
by trauma at 6 and 10 months after ACL recon-
struction using doubled hamstring tendon graft
with metal interference screws (46). The study
showed graft integration by collagen fibers
fi resem-
bling Sharpey’s fibers
fi between the tendon and the
bone wall. Another study reported the histological
findings of 12 biopsies from the patients under-
going arthroscopy with various sorts of reasons
between 3 and 20 months after ACL reconstruc-
tion using doubled hamstring tendon graft with
a suspension fixation device (TransFix) (47). At
5–6 months after surgery, some collagen fi fibers
resembling Sharpey’s fibers
fi and immature woven
bone were seen between the tendon and the bone
wall. The tendon-bone interface was composed of
a continuous layer of Sharpey-like fibersfi after 1
year, although no contact was seen at the tendon-
bone interface in three cases. Concerning the com-
parison between the interference screw fi fixation
and the suspension fixation for hamstring tendon
graft, Nebelung et al. (48) evaluated biopsies from
the femoral tunnel in four patients at 6–14 months
after ACL reconstruction with a suspension device
(Endobutton or TransFix) and one with an inter-
ference screw. In patients with a suspension device,
granulation tissue without continuity of collagen
fibers was observed at the tendon-bone interface.
In contrast, a metaplastic fibrocartilage was noted
at the tendon-bone interface in patients with no
suspension device.
Regarding bone-PT-bone graft healing, Petersen
and Laprell (49) examined histological findings of
biopsies at ACL revision surgery and reported that
bone-PT-bone graft healed within bone tunnel by
bone plug incorporation and a direct-type insertion
of the native bone plug-tendon junction was main-
tained. However, Ishibashi et al. (50) showed that
the original insertion of the native bone plug-ten-
don junction was not observed in biopsies that were
obtained at the revision surgery more than one year
after the initial ACL reconstruction surgery.
All above-mentioned studies on graft-tunnel heal-
ing after human ACL reconstruction are based on
histological examination of biopsy from cases that
underwent revision surgery due to an ACL graft
failure. There are high possibilities that failure of
the ACL graft might aff ffect their histological find-
ings and that a poor healing process of the graft
within the bone tunnel might induce the ACL graft
failure. Therefore, we should take these possibili-
ties into account for the interpretation of the find-
fi
ings of these biopsy studies on graft-tunnel heal-
ing in human ACL reconstruction.
Summary
Healing of an injury to ligament tissues requires
complex interactions between cells, extracellular
matrix, growth factors, and mediators of the inflam-
fl
matory response. Wound healing can be basically
divided into infl
flammatory, proliferative, and mat-
uration phases. Animal experimental studies indi-
cate that injuries to the extra-articular ligament,
such as an MCL of the knee, heal well. In contrast
to the case in the MCL, the periligament environ-
ment and local mechanical factors may be respon-
sible for the poor healing potential of the ACL.
After harvesting for ACL reconstruction, autolo-

gous tendon grafts are separated from the circula-
tion, and the tissue becomes necrotic. Therefore,
the remodeling of autologous tendon grafts used
for ACL reconstruction is essential for the clinical
outcome after ACL reconstruction, but the firstfi
several weeks of remodeling are associated with
an extensive decrease of the mechanical strength
of the graft. VEGF mediates angiogenesis in the
intra-articular tendon graft in an early remodeling
phase after the ACL reconstruction. Tendon graft
healing within the bone tunnel is one of the most
important factors affffecting success of ligament
reconstruction. Tendon graft heals within a bone
tunnel by formation of an indirect-type interface
with fibrous tissue containing perpendicular col-
lagen fibers resembling Sharpey fibers penetrating
into the bone. The bone plug of the bone-tendon-
bone graft incorporation at the tunnel wall occurs
through a progression of necrosis, resorption, and
remodeling, although the native insertion site of
the bone-tendon-bone graft shows degeneration
of the fibrocartilaginous layer by several weeks
during the bone plug remodeling.
Reference
1. Amiel D, Frank C, Harwood F, et al. (1984) Tendons and
ligaments: a morphological and biochemical comparison.
J Orthop Res 1(3):257–265
2. Kastelic J, Galeski A, Baer E (1978) The multicomposite
structure of tendon. Connect Tissue Res6(1):11–23
3. Cooper RR, Misol S (1970) Tendon and ligament inser-
tion. A light and electron microscopic study. J Bone Joint
Surg Am 52(1):1–20
4. Arnoczky SP, Rubin RM, Marshall JL (1979) Microvascu-
lature of the cruciate ligaments and its response to injury.
An experimental study in dogs. J Bone Joint Surg Am
61(8):1221–1229
5. Amiel D, Abel MF, Kleiner JB, et al. (1986) Synovial fluid
fl
nutrient delivery in the diathrial joint: an analysis of rab-
bit knee ligaments. J Orthop Res 4(1):90–95
6. Schultz RA, Miller DC, Kerr CS, Micheli L (1984) Mecha-
noreceptors in human cruciate ligaments. A histological
study. J Bone Joint Surg Am 66(7):1072–1076
7. Zimny ML (1988) Mechanoreceptors in articular tissues.
Am J Anat 182(1):16–32
8. Woo SL, Gomez MA, Seguchi Y, et al. (1983) Measure-
ment of mechanical properties of ligament substance
from a bone-ligament-bone preparation. J Orthop Res
1(1):22–29
9. Woo SL, Newton PO, MacKenna DA, Lyon RM (1992) A
comparative evaluation of the mechanical properties of
the rabbit medial collateral and anterior cruciate liga-
ments. J Biomech 25(4):377–386
10. Murphy PG, Loitz BJ, Frank CB, Hart DA (1993) Influence
fl
of exogenous growth factors on the expression of plasmi-
nogen activators by explants of normal and healing rabbit
ligaments. Biochem Cell Biol 71:522–529
11. Murphy PG, Loitz BJ, Frank CB, Hart DA (1994) Influ- fl
ence of exogenous growth factors on the synthesis and
secretion of collagen types I and III by explants of normal
and healing rabbit ligaments. Biochem Cell Biol 72:403–
409
Basic science of ligament healing 49
12. Woo SL-Y, Suh JK, Parsons IM, et al. (1998) Biological
intervention in ligament healing eff ffect of growth factors.
Sports Med Arthrosc Rev 6:74–82
13. Frank CB, Bray RC, Hart DA, et al. (1994) Soft Tissue Heal-
ing. In: Fu F, Harner CD, Vince KG. editors. Knee surgery. 1
ed. Baltimore: Williams and Wilkins: 189–229
14. Abramowitch SD, Papageorgiou CD, Debski RE, et al.
(2003) A biomechanical and histological evaluation of the
structure and function of the healing medial collateral
ligament in a goat model. Knee Surg Sports Traumatol
Arthrosc 11(3):155–162
15. Woo SL, Gomez MA, Inoue M, Akeson WH (1987) New
experimental procedures to evaluate the biomechanical
properties of healing canine medial collateral ligaments. J
Orthop Res 5(3):425–432
16. Gomez MA, Woo SL, Inoue M, et al. (1989) Medical col-
lateral ligament healing subsequent to different
ff treatment
regimens. J Appl Physiol 66(1):245–252
17. Inoue M, Woo SL, Gomez MA, et al. (1990) Effects ff of sur-
gical treatment and immobilization on the healing of the
medial collateral ligament: a long-term multidisciplinary
study. Connect Tissue Res25(1):13–26
18. Weiss JA, Woo SL, Ohland KJ, et al. (1991) Evaluation of
a new injury model to study medial collateral ligament
healing: primary repair versus nonoperative treatment. J
Orthop Res 9(4):516–528
19. Woo SL, Inoue M, McGurk-Burleson E, Gomez MA (1987)
Treatment of the medial collateral ligament injury. II: Struc-
ture and function of canine knees in response to diff ffering
treatment regimens. Am J Sports Med 15(1):22–29
20. Derscheid GL, Garrick JG (1981) Medial collateral ligament
injuries in football. Nonoperative management of grade I
and grade II sprains. Am J Sports Med 9(6):365–368
21. Indelicato PA, Hermansdorfer J, Huegel M (1990) Non-
operative management of complete tears of the medial
collateral ligament of the knee in intercollegiate football
players. Clin Orthop Relat Res 256:174–177
22. Jones RE, Henley MB, Francis P (1986) Nonoperative
management of isolated grade III collateral ligament
injury in high school football players. Clin Orthop Relat
Res 213:137–140
23. O’Donoghue DH, Rockwood CA Jr, Frank GR, et al. (1966)
Repair of the anterior cruciate ligament in dogs. J Bone
Joint Surg Am48(3):503–519
24. Amiel D, Nagineni CN, Choi SH, Lee J (1995) Intrinsic
properties of ACL and MCL cells and their responses to
growth factors. Med Sci Sports Exerc 27(6):844–851
25. Geiger MH, Green MH, Monosov A, et al. (1994) An in
vitro assay of anterior cruciate ligament (ACL) and medial
collateral ligament (MCL) cell migration. Connect Tissue
Res 30(3):215–224
26. Kobayashi K, Healey RM, Sah RL, et al. (2000) Novel method
for the quantitative assessment of cell migration: a study
on the motility of rabbit anterior cruciate (ACL) and medial
collateral ligament (MCL) cells. Tissue Eng 6(1):29–38
27. Nagineni CN, Amiel D, Green MH, et al. (1992) Character-
ization of the intrinsic properties of the anterior cruciate
and medial collateral ligament cells: an in vitro cell culture
study. J Orthop Res10(4):465–475
28. Kondo E, Yasuda K, Yamanaka M, et al. (2003) Biome-
chanical evaluation of a newly devised model for the elon-
gation-type anterior cruciate ligament injury with partial
laceration and permanent elongation. Clin Biomech (Bris-
tol, Avon) 18(10):942–949
29. Arnoczky SP, Tarvin GB, Marshall JL (1982) Anterior cru-
ciate ligament replacement using patellar tendon. An eval-
uation of graft revascularization in the dog. J Bone Joint
Surg Am 64(2):217–224
30. Amiel D, Kleiner JB, Akeson WH (1986) Th The natural his-
tory of the anterior cruciate ligament autograft of patellar
tendon origin. Am J Sports Med 14(6):449–462
50 The Traumatic Knee
31. Ballock RT, Woo SL, Lyon RM, et al. (1989) Use of patel-
lar tendon autograft for anterior cruciate ligament recon-
struction in the rabbit: a long-term histologic and biome-
chanical study. J Orthop Res 7(4):474–485
32. Grana WA, Egle DM, Mahnken R, Goodhart CW (1994) An
analysis of autograft fixation after anterior cruciate liga-
ment reconstruction in a rabbit model. Am J Sports Med
22(3):344–351
33. Butler DL, Grood ES, Noyes FR, et al. (1989) Mechanical prop-
erties of primate vascularized vs. nonvascularized patellar
tendon grafts; changes over time. J Orthop Res 7(1):68–79
34. Amiel D, Kleiner JB, Roux RD, et al. (1986) The phenom-
enon of “ligamentization”: anterior cruciate ligament
reconstruction with autogenous patellar tendon. J Orthop
Res 4(2):162–172
35. Ben-Av P, Crofffford LJ, Wilder RL, Hla T (1995) Induction
of vascular endothelial growth factor expression in syn-
ovial fibroblasts by prostaglandin E and interleukin-1:
a potential mechanism for infl flammatory angiogenesis.
FEBS Lett 372(1):83–87
36. Yoshikawa T, Tohyama H, Enomoto H, et al. (2006)
Expression of vascular endothelial growth factor and
angiogenesis in patellar tendon grafts in the early phase
after anterior cruciate ligament reconstruction. Knee Surg
Sports Traumatol Arthrosc 14(9):804–810
37. Petersen W, Unterhauser F, Pufe T, et al. (2003) The angio-
genic peptide vascular endothelial growth factor (VEGF) is
expressed during the remodeling of free tendon grafts in
sheep. Arch Orthop Trauma Surg123(4):168–174
38. Johnson LL (1993) The outcome of a free autogenous
semitendinosus tendon graft in human anterior cruciate
reconstructive surgery: a histological study. Arthroscopy
9(2):131–142
39. Rougraffff BT, Shelbourne KD (1999) Early histologic
appearance of human patellar tendon autografts used
for anterior cruciate ligament reconstruction. Knee Surg
Sports Traumatol Arthrosc 7(1):9–14
40. Yamagishi T, Fujii K, Roppongi S, Hatsuumi H (1998)
Blood flow measurement in reconstructed anterior cruci-
ate ligaments using laser Doppler flowmetry. Knee Surg
Sports Traumatol Arthrosc 6(3):160–164
41. Shino K, Inoue M, Horibe S, et al. (1991) Surface blood
flow and histology of human anterior cruciate ligament
allografts. Arthroscopy7(2):171–176
42. Delay BS, McGrath BE, Mindell ER (2002) Observations
on a retrieved patellar tendon autograft used to recon-
struct the anterior cruciate ligament. A case report. J
Bone Joint Surg Am 84-A(8):1433–1438
43. Rodeo SA, Arnoczky SP, Torzilli PA, et al. (1993) Tendon-
healing in a bone tunnel. A biomechanical and histologi-
cal study in the dog. J Bone Joint Surg Am 75(12):1795–
1803
44. Goradia VK, Rochat MC, Grana WA, et al. (2000) Tendon-
to-bone healing of a semitendinosus tendon autograft
used for ACL reconstruction in a sheep model. Am J Knee
Surg 13(3):143–151
45. Tomita F, Yasuda K, Mikami S, et al. (2001) Comparisons
of intraosseous graft healing between the doubled flexor
fl
tendon graft and the bone-patellar tendon-bone graft in
anterior cruciate ligament reconstruction. Arthroscopy
17(5):461–476
46. Pinczewski LA, Clingeleffer
ff AJ, Otto DD, et al. (1997)
Integration of hamstring tendon graft with bone in recon-
struction of the anterior cruciate ligament.Arthroscopy
13(5):641–643
47. Robert H, Es-Sayeh J, Heymann D, et al. (2003) Hamstring
insertion site healing after anterior cruciate ligament
reconstruction in patients with symptomatic hardware or
repeat rupture: a histologic study in 12 patients. Arthros-
copy 19(9):948–954
48. Nebelung W, Becker R, Urbach D, et al. (2003) Histological
findings of tendon-bone healing following anterior cruci-
ate ligament reconstruction with hamstring grafts. Arch
Orthop Trauma Surg 123(4):158–163
49. Petersen W, Laprell H (2000) Insertion of autologous
tendon grafts to the bone: a histological and immunohis-
tochemical study of hamstring and patellar tendon grafts.
Knee Surg Sports Traumatol Arthrosc8(1):26–31
50. Ishibashi Y, Toh S, Okamura Y, et al. (2001) Graft incorpo-
ration within the tibial bone tunnel after anterior cruciate
ligament reconstruction with bone-patellar tendon-bone
autograft. Am J Sports Med 29(4):473–479
Clinical Basis
 Chapter 6

T.E. Hewett, B.T. Zazulak,

T. Krosshaug, R. Bahr
Clinical basis: epidemiology,
risk factors, mechanisms of injury,
and prevention of ligament injuries
of the knee

Introduction romuscular control about the knee takes place with

maturation in female athletes. In sports, the high-

K
nee ligament injuries can be devastating to an est ACL injury incidences occur during participation
athlete’s career and pose long-lasting deleteri- in basketball, soccer, and team handball, especially
ous eff
ffects in the form of knee osteoarthritis among top-level female athletes that compete in
(1). We will begin with a review of the epidemiology these sports (Table 1). Th
This trend is similar for knee
of athletic knee ligament injury in general. Further- injuries, in general, as well (Table 2). Another sport
more, we will review the mechanisms of injury and with a high risk of knee injuries (and ACL injuries)
relative risk factors for these common athletic inju- is skiing. However, since the incidence is typically
ries. This chapter will also review the epidemiology,
mechanism, risk factors, and prevention of knee Table 1 – Risk of ACL injury by sport. The numbers reported are average
joint injuries in general; however, it will focus on estimates based on published studies.
one of the most serious knee injuries experienced
during participation in sports: disruption of the Sport Competition Training Comments
anterior cruciate ligament (ACL). This injury may incidencea incidencea
not be the most common ligament injury experi- Basketball 0.28–0.40 Ɋ b
0.14 Ɋ NBA & WNBA
enced in sports; however, it is one of the most seri- 0.08–0.16b ɉ b
0.04 ɉ (6–8)
ous in terms of absence from sport, pain, disability, *NCAA data 2006
and increased risk of development of osteoarthritis (6,7)
about the knee joint (2). We will therefore discuss Soccer 0.33–2.2 Ɋ b
0.10 Ɋ *NCAA data 2006
methods for prevention of knee ligament injuries, 0.12 ɉ b
0.04 ɉ (6,9)
which currently is the only 100% efficacious
ffi inter- Team 1.3–2.8 Ɋ 0.03Ɋ Elite level (1)
vention for long-term health of the knee joint. handball 0.23 ɉ –
Volleyball 0.19 Ɋ 0.05 Ɋ NCAA data 2006
(Agel J, personal
communication)
Epidemiology of knee ligament injury in sports Alpine 4.4Ɋ c – ** per 100,000
skiing 4.0 ɉ c – skier days (10),
The objective of this section is to review the published Ɋ twice of ɉ in
literature regarding knee ligament injuries in sports, some studies
addressing the following questions: what is the inci- Field 0.15 Ɋ 0.05 Ɋ NCAA data 2006
dence of knee ligament injury in the athletic popula- Hockey (Agel J, personal
tion? How does knee ligament injury incidence vary communication)
by gender, age, and sport? Of all knee ligaments, the Ice hockey 0.14 Ɋ – NCAA data 2006
ACL is the ligament that has been most investigated. 0.21 ɉ 0.02 ɉ (Agel J, personal
There is evidence in the literature that ACL injuries communication)
vary by gender, by age, and by sport. A sex difference
ff Wrestling 0.70 ɉ 0.06 ɉ NCAA data 2006
in knee injury risk is apparent in high-risk landing (Agel J, personal
and cutting sports, where female athletes sufferff ACL communication)
injuries more often than their male counterparts a
Incidence is reported for adult, competitive athletes as the number of
taking part in the same sports at the same level of injuries per 1000 h of training and competition or per 100,000 skiing days
competition (3,4). Evidence also suggests that, with in alpine skiing.
growth and development, the incidence of knee liga- b
Explanation for asterisk needed.
ment injury increases in females (5). Decrease in neu- c
Explanation for double asterisk needed.
54 The Traumatic Knee

Table 2 – Risk of knee injury by sport, age, and sex. The numbers reported are average estimates based on published studies.
Sport Age group Incidence in femalesa Incidence in malesa References
Basketball 14–18 years 0.71 AH 0.31 AH (11)
Collegiate 0.37 AE 0.25 AE (12)
Adult 4.4 AE 2.5 AE (7)
Soccer Collegiate 0.40 AE 0.33 AE (13)
Collegiate 1.6 AE 1.3 AE (3)
7–50+ 0.13 AH 0.094 AH (14)
Field hockey Collegiate 0.30 AE NA (15)
Lacrosse Collegiate 0.20 AE 0.20 AE (16,17)
Gymnastics Collegiate 0.53 AE NA (18)
Volleyball Collegiate 0.22 AE NA (19)
Football Collegiate NA 1.58 AE (20)
a
Incidence is reported as the number of injuries per 1000 athlete hours (AH) of training and competition or 1000 athlete exposures (AE). NA: data not
available.

reported as the number of injuries per 100,000 skier
days in studies on skiing injuries, it is not possible to
compare these figures to those from team sports.
Key risk factors for knee injuries
A large number of studies have investigated poten-
tial risk factors for severe knee injuries, and a major-
ity of this work has focused on ACL injuries. When
considering athletes that compete at the elite or
collegiate level, the risk of suffffering an ACL injury
ranges between 2 and 8 times greater for women
compared to men for similar sports at similar levels
of competition, and consequently, there appears to
be a consensus across sports that gender is a risk fac-
tor for ACL disruption (21). However, there remains
a signifi
ficant knowledge gap concerning the risk fac-
tors for serious knee injuries such as an ACL disrup-
tion. This is because only a few well-designed pro-
spective studies are available, and most studies have
assessed only one factor in isolation. Considering
that the risk factors for ACL injury are multifacto-
rial (e.g., multiple risk factors act in combination to
increase an athletes risk of suffffering an ACL injury)
(22), this approach is not appropriate to assess
how risk factors act in combination to increase an
individuals risk of suffffering a severe knee ligament
injury. Further, a large majority of these studies
have identifi fied sex diff
fferences in anatomy as well
as hormonal and neuromuscular function; however,
they fail to relate these differences
ff to the risk of suf-
fering a severe knee ligament injury.
External risk factors
Surface
The shoe-surface interaction has been studied
as an ACL injury risk factor in different
ff sports.
A study of Australian football athletes reported
that the risk of sustaining non-contact ACL inju-
ries increased during high-evaporation and low-
rainfall periods (23). Studies of soccer athletes
reported that competing on artificial
fi turf does not
increase the risk of knee injuries compared with
natural grass (24). In contrast, recent studies of
professional American football athletes suggest
that the incidence of ACL injuries may be greater
on the new artifi ficial turf designs in comparison to
the older turf designs (25). In the sport of Euro-
pean team handball, it was shown that the risk of
ACL injury was 2.4 times greater when competing
ficial floors (with an increased coeffi
on artifi fficient
of friction) compared with wooden floors (26).
Earlier studies of American football athletes have
shown that the use of longer cleat lengths and an
associated higher torsional resistance at the foot-
turf interface places these athletes at increased
risk of suff
ffering knee injuries (24). There is little
doubt the shoe-playing surface interface is impor-
tant to consider when developing intervention
strategies to reduce the incidence rate of serious
knee injuries.
Knee bracing
Two investigations have studied the effect ff of pro-
phylactic knee bracing on American football ath-
letes. The first study found signifi
ficantly fewer medial
collateral ligament (MCL) injuries occurred in ath-
letes who used prophylactic bracing in comparison
to those who did not use braces (27); however, the
ffect of prophylactic bracing on ACL injuries could
eff
not be determined because of the small sample size.
In contrast, the second study did not find fi statisti-
cally significant
fi diff
fferences between braced and
unbraced athletes in terms of the risk of sustaining
MCL injuries (27). Additional research is needed in
this area to establish the eff ffect that prophylactic
braces have on knee injuries.
 Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee
Ski bindings
Although alpine ski bindings have been devel-
oped to eff ffectively protect skiers from tibia and
ankle fractures, the present-day alpine ski binding
designs are inadequate for preventing ACL disrup-
tions, even when the bindings function as designed
and are properly adjusted (28). In a large prospec-
tive study of ACL-deficient
fi professional alpine ski-
ers, the risk of sustaining a subsequent knee injury
(e.g., injury to other structures about the knee
such as articular cartilage and the menisci) was 6.4
times greater for non-braced skiers in comparison
to braced skiers (29).
Competition vs. training
Participating in a game appears to be a strong risk
factor for knee injury. Studies of European team
handball athletes have shown that the relative
risk of sustaining an ACL injury is approximately
30 times greater during competition than during
training (30). As can be seen from Table 1, the dif-
ference in injury risk between training and compe-
tition is a consistent finding across sports. At this
point in time, the explanation for this large differ-
ff
ence has not been determined, but the most likely
explanation is that the intensity of play is much
higher during competition and that during train-
ing much time is spent on basic training activities
with a low risk of injury.
Internal risk factors
Previous injury
Recent studies have suggested that having a pre-
vious injury may be a risk factor for subsequent
injury – either a rupture of the ACL graft, an ACL
rupture to the contralateral knee, or another type
of acute or overuse knee injury (31–33).
Age
Although there appears to be a consensus that
the risk of suffffering an ACL injury increases for
female athletes during their growth spurt, there
are no investigations that have included age as a
potential risk factor in the analysis of serious knee
injuries in skeletally mature athletes. Similarly, no
investigations of the eff
ffect of age on the likelihood
of suff
ffering a knee injury in skeletally immature
athletes exist.
Body composition
An increased body mass index (BMI) has been
found to be associated with an increased risk of
suff
ffering ACL injuries in female cadets attending
the US Military Academy (34). However, other
55
studies have not found such a relationship (35,36).
The data on BMI appear to be inconsistent, making
it diffi
fficult to establish reliable conclusions.
Genetics
Two case-control studies reported that familial
tendency is a risk factor for ACL injury (37,38).
Athletes who suffffer an ACL tear are twice as likely
to have a relative with an ACL tear compared with
age-, sex-, and sport-matched controls.
Race
In a recent 4-year cohort study, it was found that
white European American athletes were 6.6 times
more likely to suffer
ff an ACL tear compared with
other ethnic groups (39).
Knee alignment
The Q angle of the knee has been studied as a pos-
sible explanation for the gender difference
ff in ACL
injury rates, with the rationale that high Q angles
may be associated with excessive valgus loading of
the knee. These studies consistently report higher
Q angles in females (40–42). A case-control study
reported that the mean Q angles of athletes sus-
taining knee injuries were signifi ficantly larger
than the mean Q angles for athletes who were not
injured (14° vs. 10°) (43). In contrast, others have
reported that the risk of suff ffering a knee injury
was not related to anatomical alignment differ- ff
ences such as Q angles (44). One study reported
that pelvic width to thigh length ratio, and not Q
angle, predicts dynamic valgus angulation about
the knee during the single leg squat (45). It has
also been shown that a long femur to tibia ratio
may be a risk factor for ACL injuries in competitive
alpine skiers (46).
Intercondylar notch width
One of the most studied factors in relation to ACL
injury is the femoral intercondylar notch width.
Several investigators have hypothesized that a nar-
row intercondylar notch or notch width index (e.g.,
the ratio of the width of the femoral notch to the
width of femoral condyles when observed via x-ray
in a coronal plane view) may predispose athletes to
an increased risk of ACL injury (47–50). One cause
could be that a narrower femoral notch is associ-
ated with a smaller, weaker ACL. Another possi-
bility is that impingement of the ACL against the
femoral intercondylar notch may be more predom-
inant when the notch is narrow. This may induce
micro tears of the ligament during participation
in athletics that subsequently progress to macro
tears that weaken the ligament and predispose it
to an increased risk of a complete tear. Research is
56 The Traumatic Knee
needed to delineate the role of notch impingement
as an ACL injury risk factor. One review study (51)
and two prospective cohort studies (48,50), as well
as several other lesser quality studies (52,53), have
found that athletes with a decreased femoral notch
width are at increased risk of suff ffering an ACL
injury. There are, however, also several studies that
do not show such an association (47,49,54), and
as a consequence, it remains unclear how notch
width geometry, or notch width index, is related to
increased risk of suff
ffering an ACL injury.
ACL properties
Th size and material properties of the ACL are fac-
The
tors that may infl fluence the risk of this ligament
tearing. It has been shown that ACLs, in females
are smaller than in males when normalized for
body weight (47). In addition, it has been reported
that female ligaments have lower strain and strain
energy density at failure as well as 22.5% lower
modulus of elasticity (55). However, at the current
point in time, no risk factor studies have consid-
ered these variables. On the other hand, there are
studies that have established increased anterior
knee laxity as a risk factor for females (56), and this
may be a result of differences
ff in the size and mate-
rial properties of the ACL. It is important for us
to point out that these studies are relatively small,
and such factors can only explain a relatively small
proportion of the variance in ACL injury risk. Gen-
eralized joint and ligament laxity have also been
proposed as risk factors for knee ligament injuries;
however, most of these studies have evaluated the
eff
ffect on these variables on all lower extremity
injuries as a group and not knee ligament injuries
in isolation. A few exceptions exist, and these stud-
ies suggest that increased generalized joint laxity
and increased hyperextension of the knee may be
associated with increased risk of suff ffering an ACL
injury (34,57).
Foot pronation
It has been suggested that foot pronation may lead
to anterior tibial translation, and subsequently
sprain the ACL; however, the results are conflict-
fl
ing. Three case-control studies found a relation-
ship between foot pronation/navicular drop and
ACL injuries, whereas one found no such relation-
ship (56,58,59).
Hormone levels
To determine how diff fferent phases of the men-
strual cycle aff
ffect ACL injury risk, it appears neces-
sary to accurately describe the hormone milieu with
serum or urine-based measures of hormone con-
centrations and then use these data to accurately
identify the phase of the cycle when injury occurs.
The use of an athlete’s self-report of menstrual his-
tory is inadequate to determine the phase of cycle
at the time of injury (60), and findings from such
studies reveal conflflicting results (21,60). Review
of studies that have used hormone measurements
reveals that the risk of suff
ffering a non-contact ACL
injury is greater during the pre-ovulatory phase of
the menstrual cycle in comparison to the post-ovu-
latory phase (61).
Patella tendon-tibia shaft angle
One of the most investigated hypotheses in recent
years is whether a quadriceps contraction per-
formed with the knee near extension can create a
force of suffi
fficient magnitude on the patellar ten-
don such that it produces an anterior translation
of the tibia relative to the femur and ruptures the
ACL (63,64). The patella tendon-tibia shaft angle
(PTTSA) is the sagittal plane angle between the
tibia (ankle to knee joint) and the line of action
of the patellar tendon. When the knee is near full
extension, an increased PTTSA produces a larger
magnitude of anterior-directed force on the tibia
and increases the loads transmitted to the ACL. It
has been shown that females have greater PTTSA
throughout the range of knee flexion
fl compared to
males, and that this angle is greater when the knee
is close to full knee extension. However, no risk
factor studies have included PTTSA in the analy-
ses. The same is true for the slope of the tibial
plateau in the sagittal plane. An increased slope
of the plateau will generate an increased anteri-
or-directed force on the tibia when compression
forces, such as that produced during landing or
plant and cut maneuvers, are produced across the
knee (65).
Landing mechanics
Another explanation for the gender difference
ff in
ACL injury rate is that females may land with the
knees in a more extended position compared with
men, creating a higher PTTSA and possibly gen-
erating an increased anterior-directed shear force
on the tibia (66,67). Although several studies have
investigated this knee flexion hypothesis, there
is no consensus in the literature. In a recent pro-
spective risk factor study of 205 female athletes in
soccer, basketball, and volleyball, where knee flex-
fl
ion angles produced during jump landings were
assessed, no significant
fi diff
fferences were found
between injured and uninjured subjects (31). The Th
same study showed that valgus motion and valgus
moments predicted ACL injuries with a sensitivity
of 78% and a specifi ficity of 73%. Also, leg domi-
nance was studied, but this factor was not found to
be associated with risk of suffffering an ACL injury.
It should be mentioned that only nine ACL injuries
 Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee 57

were included in this study, so new studies should
be conducted to confirm
fi these findings.
Other neuromuscular factors
Several neuromuscular measures have been pro-
posed as possible risk factors for ACL injury.
Quadriceps dominance, ligament dominance, limb
dominance, muscle reaction time, time to peak
force, muscle stiff
ffness, muscle strength, poor neu-
romuscular control of the trunk, and fatigue are all
factors that may have an influence
fl on an athlete’s
risk of suff
ffering an ACL injury (22,68). It has been
shown that females exhibit greater quadriceps
dominance and that they have less muscle stiffness
ff
and muscle strength compared to males. However,
none of these factors have been studied as ACL
injury risk factors, and consequently, it is not pos-
sible to determine the relative importance of these
factors at this point in time.
It should be noted that factors such as anatomic
alignment and ligament properties are not easily
modififiable, and therefore, direct intervention on
such factors may be difficult.
ffi Nevertheless, if we
can identify individuals at risk (e.g., athletes who
anatomically are prone to ACL injury), it may be
possible to initiate individualized injury preven-
tion measures. It has been shown that combining
two or more risk factors such as notch width and
BMI results in a dramatic increase in the risk of
ACL injury (relative risk 26.2) compared to having
only one of the two factors in isolation (relative
risks of 3.5 and 4.0, respectively) (34).

Table 3 – Internal and external factors for knee ligament sprains in different sports. The numbers reported are average estimates based
on the studies available.
Risk factor Relative risk Evidence Comments
External risk factors
Surface 2–2.4×* + Few studies. Greater risk of injury when competing on higher friction
floors, but only for women.
Meteorological conditions 1.9–2.8× + Only one study. Non-contact ACL injuries more frequent during high
evaporation and low-rainfall periods.
Footwear NA + Only two studies. Shoes with longer cleats produced significantly
greater ACL injury rates.
Game vs. Practice 29.9× +(+) Higher ACL injury rate during competition.
Internal risk factors
Gender 2–8× ++ Risk of ACL injury is greater in women compared to men when
participating in the same sport at the same level of competition.
Previous injury 3.1–11.3× + Risk for new knee injuries in general as well as new ACL injuries, both in
the reconstructed and the contralateral knee.
Age NA - No studies were found that included age as a potential risk factor for
ACL injury
BMI 3.5× + Few studies. Higher risk of ACL injury for women with high BMI.
Conflicting results.
Familial tendency 2.0×* + Only two studies. Athletes with an ACL tear are 2 times more likely to
have a relative with an ACL tear.
Race 6.6×* + Only one study. White European American players more susceptible to
ACL tears compared with other ethnic groups.
Q-angle NA + Higher Q-angle in females. Conflicting results.
Leg length NA + Long femur relative to tibia may be a risk factor in skiers. Wide pelvis
relative to femur predicts dynamic valgus in one-legged squats
Intercondylar notch width index 3.7–6.0× + Small notch width index may lead to increased risk of suffering an ACL injury.
Several positive studies, but also some studies with conflicting results
Ligament cross-sectional area NA - No risk factor studies. Relative larger cross-sectional area in males after
adjusting for body weight
Ligament material properties NA - No risk factor studies. Female ligaments have lower strain and strain
energy density at failure, as well as lower modulus of elasticity
compared to males
Anterior knee laxity 2.7× + Only two studies. The larger, prospective study found a 2.7 fold
increased risk for ACL injury in females with A-P knee laxity values
greater than 1 SD of the mean. A-P knee laxity had no effect on risk of
ACL injury in males.
58 The Traumatic Knee

Risk factor Relative risk Evidence Comments

General joint laxity 2.8× + Few studies. Females exhibit greater joint laxity than males. Skiers with
increased hyperextension of the knee are in significantly increased risk
of suffering ACL injury.
Patella tendon – tibia shaft NA - No risk factor studies. PTTSA is greater in females compared to males
angle (PTTSA)
Foot pronation/navicular drop NA + Three studies found a relationship, whereas one study found no
relationship.
Phase of menstrual cycle 3.2×* + Studies that have accurately measured phase of cycle with serum or
urine based assays of estradiole and progesterone have observed a
greater proportion of ACL injuries in the preovulatory phase of the
menstrual cycle in comparison to the post-ovulatory phase. One
study of recreational alpine skiers found the odds ratio of suffering an
ACL disruption was 3.2 times greater during the preovulatory phase
compared to the postovulatory phase of the menstrual cycle.
Knee flexion during landing NA - Only one risk factor study that showed no relationship. Conflicting
results among studies looking at gender differences.
Valgus motion and valgus NA + Only one risk factor study. Valgus moments have a sensitivity of 78%
moment during landing and a specificity of 73% for predicting ACL injury status.
Leg dominance during landing NA - Only one risk factor study, but no significant effect of this variable on
ACL injury risk. Females have greater side-to-side (leg dominance)
differences in knee loads
Quadriceps dominance NA - No risk factor studies. Females exhibit greater quadriceps dominance
than males.
Muscle stiffness NA - No risk factor studies. Females have lower muscle stiffness than males.
Muscle strength NA - No risk factor studies. Females have lower muscle strength than males.
Muscle reaction time NA - No risk factor studies.
Time to peak force NA - No risk factor studies.
Fatigue NA - No risk factor studies. No gender differences. Fatigue may alter the
neuromuscular control of knee biomechanics
a
Relative risk indicates the increased risk of injury to an individual with this risk factor relative to an individual who does not have this characteristic. A
relative risk of 1.2× means that the risk of injury is 20% higher for an individual with this characteristic.
b
Evidence indicates the level of scientific evidence for this factor being a risk factor for ligament sprains: ++, convincing evidence from high-quality
studies with consistent results; +, evidence from lesser quality studies or mixed results; ?, expert opinion without scientific evidence.
*Odds ratio and not relative risk.
NA, not available.

Injury mechanisms for knee injuries
Much attention has been given to treatment of
serious knee injuries, ACL and MCL disruptions
in particular; however, very little is known about
the risk factors that predispose an athlete to these
ligament tears and the injury mechanisms that
produce these debilitating injuries. During most
Olympic sports, ACL injuries are commonly non-
contact in nature and can occur during plant and
cut maneuvers (Fig. 1), but a high proportion of
these injuries also occurs during landings (Fig. 2).
In basketball, landings are the most frequently
reported mechanism for ACL injuries (69).
It is important to realize that while an athlete
may appear to land on both feet with body weight
equally distributed between legs, at the point
of impact the entire ground reaction force may
be supported by the leg that suff ffers an injury.
Previous studies have suggested that the knee
is near extension at the time of ligament injury
(i.e., less than 30°) (26,57); however, recent stud-
ies that have included a validation of the visual
inspection method indicate that the knee is likely
injured when it is in a position of greater fl
flexion
(69,70). Although the majority of ACL injuries
are non-contact by definition,
fi the movement pat-
terns often involve perturbation by an opponent,
e.g., body contact prior to the injury (69). Even if
a few details are known, we still lack vital knowl-
edge about the injury mechanisms. A complete
biomechanical description should quantify whole
body and knee kinematics, loading directions and
magnitudes, and the rate of application of exter-
nal and internal forces about the lower extremity
(71).
 Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee
Fig. 1 – Frame sequence of a plant and cut team handball injury showing
the athlete at initial ground contact (A), at 40 ms (B), and at 100 ms (C),
respectively.
Skiing injury mechanisms
Knee ligament injury mechanisms in traditional
alpine skiing have been investigated for some time,
and various injury mechanisms have been pro-
posed, both for ACL injuries and other ligament
injuries (72,73). Some knee injury mechanisms
are equipment related, such as when the back por-
tion of the ski boot acts to produce a “boot-induced
anterior drawer” (e.g., an anterior-directed force
on the tibia that tears the ACL) or when the edge
of the ski is caught in the snow.
Some injury mechanisms are associated with cer-
tain circumstances, such as backward fall, with the
weight of the skier on the inner edge of the tail of
the ski resulting in a sharp uncontrolled inward
twist of the lower leg (Fig. 3). Th This scenario is
termed the “phantom foot mechanism” and is con-
sidered the most common ACL injury mechanism
in alpine skiing (74).
Fig. 3 – Drawing of the body position in the “phantom foot” injury mecha-
nism. The weight of the skier is on the inner edge of the tail of the ski result-
ing in a sharp uncontrolled inward twist of the lower leg. From [74].
59
Fig. 2 – Landing injury in basketball. The injured player is seen in white
shorts in the middle of the images at initial ground contact (A); 33 ms after
initial contact, corresponding to the approximate estimated time of rupture
(B); and 133 ms after initial contact (C).
Previous studies on knee ligament injury mecha-
nisms produced during alpine skiing have mainly
used approaches such as athlete interview and
visual inspection of injuries captured on video.
These approaches have methodological limitations,
and there is need for improvements of the existing
injury mechanism descriptions (75).
Hypotheses for non-contact ACL injuries
Although gross biomechanical information about
serious knee injuries exists, detailed biomechani-
cal information (i.e., joint loading) is not known.
For injuries that are caused by a direct blow to the
knee, which is the case for many MCL injuries, the
loading patterns are more obvious. However, for
non-contact ACL injuries, difffferent hypotheses are
heavily debated in the scientifi
fic community.
Studies have shown that external tibial rotation
combined with valgus rotation with the knee in an
extended or partially fl
flexed position initiates ACL
strain as the ligament contacts and then impinges
against the medial aspect of the lateral femoral
condyle (Fig. 4) (76).
The ligament impingement theory
The ligament impingement theory has also been
suggested based on observations from video analy-
sis studies (26). Although it remains unknown how
60 The Traumatic Knee
Fig. 4 – A sidestep cutting maneuver may lead to valgus and external
tibial rotation. The solid arrow indicates a possible impingement of the ACL
against the intercondylar notch.
the ligament impinges against the medial aspect
of the lateral femoral condyle and strains the ACL,
there is evidence that valgus loading of the tibia rel-
ative to the femur is likely an important aspect of
the loads applied to the knee during an ACL injury
(77). A recent prospective risk factor study showed
that increased valgus loading when landing from a
jump was associated with increased risk of suffer-ff
ing an ACL injury amongst soccer, basketball, and
volleyball athletes (31). Several studies also report
that MCL injuries are frequently seen in combi-
nation with non-contact ACL injuries, indicating
that valgus loading was present (78). Interestingly,
laboratory-based motion analysis studies have dem-
onstrated that females develop larger magnitudes
of valgus and external torques about the knee when
landing from a jump in comparison to males (79),
suggesting that knee valgus loading may explain, at
least in part, the larger incidence rate of ACL inju-
ries seen in females compared to males taking part
in the same sport at the same level of competition.
A recent video-based analysis study of actual ACL
injury situations reported a large number of valgus
collapses about the knee for female athletes (69).
This evidence suggests that valgus loading plays
an important role in many of the non-contact ACL
injury situations, at least amongst female athletes.
However, there are likely to be other forces and
torques applied to the knee during injury, since it
has been shown that pure valgus loading will rup-
ture the MCL first, then the ACL, and second, only
a limited number of MCL ruptures are found in
conjunction with non-contact ACL injuries.
Quadriceps loading
Several cadaver studies have shown that quadri-
ceps loading strains the ACL when the knee is near
extension. It has been hypothesized that a vigor-
ous quadriceps contraction when landing on an
extended knee can produce high ACL strain values
(63,64). In this theory, contraction of the quadri-
ceps muscle group and subsequent engagement
of the patellofemoral joint produces a load on the
patellar tendon, which has an anterior-directed
angulation relative to the tibia when the knee is
near extension, and this generates a force on the
tibia with an anterior-directed component. As the
knee is moved from an extended to a flexed posi-
tion, the orientation of the patellar tendon relative
to the tibia moves from an anterior to a posterior
direction as does the corresponding direction of the
force produced by the quadriceps extensor mecha-
nism. Understanding this biomechanical relation-
ship, studies have investigated if the gender differ-ff
ence in ACL injury incidence can be explained by
the fact that females appear to land with their knee
and hip in a more extended position. The Th find-
ings from these studies confl flict. In actual injury
situations, females are found to be at signifi ficantly
greater knee and hip flexion angles at initial con-
tact with the playing surface and at the assumed
point of injury in comparison to males (69). Th This
finding suggests that landing on straighter knees
may not be an important reason for the observed
diff
fference in ACL injury incidence rates between
males and females. Although a novel cadaver study
demonstrated that the quadriceps-induced ante-
rior drawer mechanism is capable of producing
ACL rupture (63), this approach was criticized for
not including ground reaction forces, which may
act posteriorly on the tibia and help restrain ante-
rior translation of the tibia. Three
Th mathematical
model simulation studies of landing and plant and
cut maneuvers, which included the eff ffect of ground
reaction and hamstrings forces, all concluded that
the anterior-directed shear force that acts on the
tibia cannot generate the suffi fficient magnitude to
rupture the ACL, even in extreme cases where ham-
strings forces are non-existent (65,79,80). Still,
the results of these studies were quite different,
ff
possibly due to the fact that realistic modeling and
simulation of the knee joint is challenging. In con-
trast to the findings from mathematical modeling
studies, a recently published cadaver study dem-
onstrated that anterior tibial translation and ACL
strain proportional to the applied quadriceps force
were generated when the ground contact forces
were also included. However, since the loading
was far from injury level, it is not possible to make
firm conclusions regarding the quadriceps-induced
anterior drawer mechanism from this study. Fur-
 Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee
ther investigations are required to delineate the
role of quadriceps-induced anterior drawer loading
of the tibia in producing ACL injuries.
Internal rotation
There are several factors that suggest internal rota-
tion of the tibia relative to the femur on a relatively
extended knee could be a potential mechanism of
non-contact ACL injuries. First, cadaver and human
studies have shown that the ACL is strained when
torques are applied to internally rotate the tibia rel-
ative to the femur (81). Second, internal rotation is
frequently reported to be the mechanism of injury
in athlete interview studies (30), in video analysis
(26), as well as suggested from the associated clini-
cal findings. Motion analysis studies of side step cut-
ting maneuvers usually show a dominance of inter-
nal tibial rotation during the stance phase. However,
males are reported to exhibit this pattern to a larger
degree than females, indicating that other loading
scenarios are likely associated with many female
non-contact ACL injuries. Hyperextension has also
been proposed as a possible mechanism, but this
seems unlikely considering that such injuries have
not been reported in any video analysis studies.
Conclusions
There is a need to develop better research meth-
ods to investigate the mechanisms of serious knee
injuries, particularly ACL injuries. Mathematical
simulation models have the potential to include all
important aspects of an injury (e.g., ground reac-
tion forces, tibiofemoral contact mechanics, and
neuromuscular control patterns) in a computer
environment, thus avoiding any hazard to athletes.
However, considerable challenges exist in generat-
ing valid models that replicate joint biomechanics
at the time of injury. Therefore,
Th such model-based
analysis should be accompanied by video analysis
as well as clinical studies looking at the associated
joint damage (arthroscopy, radiology, CT, MRI),
cadaver testing, motion analysis of similar “close-
to-injury situations,” and in-vivo studies where
ligament strain and forces are measured.
Preventing knee injuries among athletes
Developing “optimal
“ l” neuromuscular training
interventions for decreasing ACL injury
Neuromuscular training appears to be effective
ff at
reducing knee injury risk, particularly for female
61
athletes. For the optimal design of knee interven-
tion programs, we can learn much from a system-
atic analysis of the common components of the
published interventions, successful and unsuccess-
ful, designed to reduce knee injury risk in athletes.
Analyzing the common components of the most
eff
ffective and least effffective programs is useful for
the development of eff ffective intervention proto-
cols. Hewett et al. performed a systematic review
of intervention studies designed to reduce knee
injury risk in female athletes and revealed that
several programs appear to reduce ACL injury risk
(82). In contrast, other studies have failed to show
an effffect of neuromuscular training on the reduc-
tion of knee injury rates or establish that they can
alter lower extremity biomechanics (83,84). Most
of what is known has come from studies of female
athletes, as they are at increased risk of knee injury.
The mechanism of ACL injury may diff ffer between
females and males, particularly with respect to
the dynamic positioning and control of the knee,
as females demonstrate greater valgus collapse of
the lower extremity, primarily in the coronal plane.
However, female athletes may serve as a working
model for any athlete at increased risk of suff ffering
a knee injury. In this section, we will describe many
of the prevention methods and neuromuscular
training programs and provide broad instructions
and guidelines for the exercises. In addition, we will
review as many components of the successful, and
unsuccessful, programs as possible within the spe-
cifi
fic purview of knee injury prevention in athletes.
There appears to be a measurable eff ffect of neuro-
muscular training interventions on the reduction
of severe knee and ACL injuries. A comprehensive
review of the literature revealed that fi five of six
studies demonstrated that neuromuscular train-
ing reduced lower extremity injury risk, four of six
studies found that neuromuscular training reduced
serious knee injury risk, and three of six reported
decreased knee and ACL injury risk (82). Below we
summarize the components of the most successful
programs. Plyometric training and biomechanical
analysis of landing, cutting, and jumping tech-
niques were common components of the studies
that were effffective at reducing the risk of knee and
ACL injury in athletes.
Plyometrics is an important component for reduction
of ACL injury risk in athletes
The evidence for including a plyometric component
as a portion of a knee and ACL injury prevention
program is relatively strong. The systematic review
of the literature reported by Hewett et al. found that
reduced ACL injury risk occurred in those inter-
ventions that included plyometrics as part of the
62 The Traumatic Knee

training program, while those that did not include
plyometrics did not reduce knee or ACL injury risk
(85,86). The focus of plyometrics should be on
proper landing, cutting, and jumping techniques
and body mechanics during these movements.
Training programs that incorporate plyometrics
result in safe levels of varus or valgus stress about
the knee, and may increase “muscle-dominant” neu-
romuscular control patterns and reduce “ligament-
dominant” neuromuscular control patterns.
Studies by Hewett et al. (85,86), Myklebust et
al. (1) and Mandelbaum et al. (87) all incorpo-
rated high-intensity plyometric movements
into the design of their intervention programs
(Figs. 5–9). The studies by Heidt et al. (88) and
Soderman et al. (89), did not reduce ACL injury
risk. This can be explained, at least in part, by
the fact that the studies by Soderman et al. (89)

Fig. 5 – Athletic position: The athletic position is a functionally stable

position with the knees comfortably flexed, shoulders back, eyes up, feet
approximately shoulder-width apart, the body mass balanced over the balls
of the feet. The knees should be over the balls of the feet and chest should
be over the knees. This is the athlete-ready position and is the starting and
finishing position for most of the training exercises. During some of the
exercises the finishing position is exaggerated with deeper knee flexion in
order to emphasize the correction of certain biomechanical deficiencies.
Fig. 6 – Wall jump: The athlete stands erect with her arms semi-extended
overhead. This vertical jump requires minimal knee flexion. The gastrocne-
mius muscles should create the vertical height. The arms should extend fully
at the top of the jump. Use this jump as a warm-up and coaching exercise as
this relatively low intensity movement can reveal abnormal knee motion in
athletes with poor side-to-side knee control.

Fig. 7 – Tuck jump: The athlete starts in the athletic position with her feet shoulder-width apart. She initiates the jump with a slight crouch downward while
she extends her arms behind her. She then swings her arms forward as she simultaneously jumps straight up and pulls her knees up as high as possible. At the
highest point of the jump the athlete is in the air with her thighs parallel to the ground. When landing the athlete should immediately begin the next tuck jump.
Encourage the athlete to land softly, using a toe to mid-foot rocker landing. The athlete should not continue this jump if theyy cannot control the high landing force
or if they utilize a knock-knee landing.
 Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee 63

and Heidt et al. (88) had little chance of estab-
lishing if their intervention could reduce the risk
of injury because the sample size was likely too
small, and from this perspective, these should be
considered preliminary studies. With this caveat,
the studies that incorporated high-intensity ply-
ometrics reported reduced ACL injury risk, while
the studies that did not incorporate high-inten-
sity plyometrics did not report reductions in ACL
injury risk. Hence, the plyometric component of
a pre-season intervention program appears to
reduce serious ligamentous injuries, specifi fically
ACL injuries.
Plyometrics may be used as combined analysis and
training tools, with verbal or visual feedback, for
control of body motion, both during deceleration
and acceleration, and knee loading, especially with
respect to the reduction of abduction (or “valgus”)
torque about the knee. For example, Hewett et al.
have shown that plyometric jumps force control of
knee abduction torque (Fig. 7) (86). Th
The other exer-
cises that were included in the interventions that
reported decreased ACL injury risk were lateral
jumps over barriers (this forces trainees to stabilize
their trunk in the coronal plane while moving both
lower extremities side to side), landing and balanc-
ing on compliant surfaces and perturbed single-leg
balancing, and hop and holds for extended periods
(Figs. 12 and 13).

Movement biomechanics, technique, and education

Fig. 8 – Broad jump and hold: The athlete prepares for this jump in the
athletic position with her arms extended behind her at the shoulder. She
begins by swinging her arms forward and jumping horizontally and verti-
cally at approximately a 45° angle to achieve maximum horizontal distance.
The athlete must stick the landing with her knees flexed to approximately
90° in an exaggerated athletic position. The athlete may not be able to stick
the landing during a maximum effort jump in the early phases. In this situ-
ation, have the athlete perform a submaximal broad jump in which she can
stick the landing with her toes straight ahead and no inward motion of her
knees. As her technique improves, encourage her to add distance to her
jumps, but not at the expense of perfect technique.
components: coronal plane is key
The evidence in support of including movement
biomechanics; landing, cutting, and jumping tech-
nique; and education components of the effective
ff
interventions is also relatively strong. Olsen et al.
(90) have reported that in sports performed on
court and turf surfaces, most ACL injuries occur
by non-contact mechanisms during landing and
lateral pivoting. Th
The biomechanics of these land-
ing and cutting movements can be improved with

Fig. 9 – One hundred and eighty-degree jump: The starting position for this jump is standing erect with feet shoulder width apart. She initiates this two-footed
jump with a direct vertical motion combined with a 180° rotation in mid air, keeping her arms away from her sides to help maintain balance. When she lands she
immediately reverses this jump into the opposite direction. She repeats until perfect technique fails. The goal of this jump is to achieve maximum height with a
full 180° rotation. Encourage the athlete to maintain exact foot position on the floor, by jumping and landing in the same footprint.
64 The Traumatic Knee

neuromuscular training. Neuromuscular training programs. Of the non-effective

can increase coronal and sagittal plane control of
the lower extremity. For example, during a squat
jump (Fig. 10), a two-footed plyometric activity,
post-training results show that lower extremity
valgus alignment can be reduced at the knee and
hip. Conversely, during a single-leg task such as a
hop and hold maneuver (Figs. 12–16), the most
signifi
ficant changes may occur in the sagittal plane
of the knee.
There is strong evidence in support of landing, cut-
ting, and jumping technique training and its effect
ff
on reducing ACL injury risk. Hewett et al. reported
that technique and phase-oriented training, that
corrected jump and landing techniques in ath-
letes reduced ACL injuries in a female intervention
group compared to female controls and resulted in
injury levels similar to a male control group (85).
Myklebust et al. reported that the incidence of ACL
injury in elite handball was reduced with training
designed to improve awareness of lower extrem-
ity alignment and knee control during cutting and
landing activities (1). The studies by Hewett et al.
(85), Mandelbaum et al. (87), and Myklebust et al.
(1), which successfully reduced ACL injury risk,
all incorporated landing technique analysis and
feedback during training into their intervention
ff studies in our lit-
erature review, none incorporated landing/cutting
technique, and while only the Wedderkopp study
(91) found a decrease in traumatic lower extremity
injuries, none of these interventions reduced ACL
injury risk. Methods for altering biomechanical
technique include those of Hewett et al. (85,86),
which utilized a trainer to provide feedback and
awareness to an athlete during training, and of
Myklebust et al. (1), which utilized partner train-
ing to provide the critical feedback regarding lower
extremity alignment, particularly valgus (inward)
positioning of the knee.
Johnson et al. (92) reported that education and
public awareness of the high occurrence and
mechanisms of ACL injury can decrease injuries
in alpine skiers by greater than 50%. A reduction
of ACL injuries in ski instructors was achieved by
using “guided learning” techniques that educated
skiers to avoid “high-risk” skiing positions, such
as the skier positioned with a majority of the
weight on the downhill ski and their hips below
their knees. This approach is supported by Pra-
pavessis et al. (93), who reported that verbal or
visual or biofeedback regarding technique may
decrease reaction forces at the knee and reduce
ACL injuries.

Fig. 10 – Squat jump: The athlete begins in the athletic position with her feet flat on the mat pointing straight ahead. The athlete drops into deep knee, hip and
ankle flexion, touches the floor (or mat) as close to her heels as possible, then takes off into a maximum vertical jump. The athlete then jumps straight up verti-
cally and reaches as high as possible. On landing she immediately returns to starting position and repeats the initial jump. Repeat for the allotted time or until her
technique begins to deteriorate. Teach the athlete to jump straight up vertically, reaching as high overhead as possible. Encourage her to land in the same spot
on the floor, and maintain upright posture when regaining the deep squat position. Do not allow the athlete to bend forward at the waist to reach the floor. The
athlete should keep her eyes up, feet and knees pointed straight ahead, and have their arms to the outside of their legs.
 Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee
Fig. 11 – Broad jump to vertical jump: The athlete performs three succes-
sive broad jumps, and immediately progresses into a maximum effort verti-
cal jump. The three consecutive broad jumps should be performed as quickly
as possible and attain maximal horizontal distance. The third broad jump
should be used as a preparatory jump that will allow horizontal momentum
to be quickly and effi
fficiently transferred into vertical power. Encourage the
athlete to provide minimal braking on the third and final broad jump to
ensure that maximum energy is transferred to the vertical jump. Coach the
athlete to go directly vertical on the fourth jump and not move horizontally.
Utilize full arm extension to achieve maximum vertical height.
Fig. 13 – X-hops: The athlete begins faces a quadrant pattern stands, on a
single limb with their support knee slightly bent. She hops diagonally, lands
in the opposite quadrant, maintains forward stance and holds the deep
knee flexion landing for three seconds. She then hops laterally into the side
quadrant and again holds the landing. Next she hops diagonally backward
and holds the jump. Finally, she hops laterally into the initial quadrant and
holds the landing. She repeats this pattern for the required number of sets.
Encourage the athlete to maintain balance during each landing, keeping
her eyes up and visual focus away from their feet.
65
Fig. 12 – Hop and hold: The starting position for this jump is a semi-
crouched position on a single leg. Her arms should be fully extended behind
her at the shoulder. She initiates the jump by swinging the arms forward
while simultaneously extending at the hip and knee. The jump should carry
the athlete up at an approximately 45° angle and attain maximum distance
for a single-leg landing. Athletes are instructed to lands on the jumping
leg with deep knee flexion (to 90°). The landing should be held for a mini-
mum of three seconds. Coach this jump with care to protect the athlete from
injury. Start her with a submaximal effort on the single leg broad jump so
she can experience the level of diffi
fficulty. Continue to increase the distance
of the broad hop as the athlete improves her ability to stick and hold the
final landing. Have the athlete keep her visual focus away from her feet, to
help prevent too much forward lean at the waist.
Fig. 14 – Single leg balance: The balance drills are performed on a balance
device that provides an unstable surface. The athlete begins on the device
with a two-leg stance with feet shoulder width apart, in athletic position.
As the athlete improves the training drills can incorporate ball catches and
single leg balance drills. Encourage the athlete to maintain deep knee flex-
ion when performing all balance drills.
66 The Traumatic Knee
Fig. 15 – Bounding: The athlete begins this jump by bounding in place.
Once she attains proper rhythm and form encourage her to maintain the
vertical component of the bound while adding some horizontal distance
to each jump. The progression of jumps progresses the athlete across the
training area. When coaching this jump, encourage the athlete to maintain
maximum bounding height.
Single-leg balancing component and ACL injury risk
Though single-leg balance training alone may not be
eff
ffective for decreasing ACL injury rates in female
athletes, as the small studies that incorporated
single-leg balancing alone did not report decreased
knee or ACL injury risk in female athletes, it may be
an important component of neuromuscular train-
ing designed to decrease non-contact knee and ACL
injury. The studies by Hewett et al. (85,86) and Man-
delbaum et al. (87) incorporated single-leg stability
training, primarily utilizing hold positions from a
decelerated landing. Single-leg stability can be gained
with balance training on unstable surfaces. Mykle-
bust et al. (1) utilized partner training on Airex mats.
Again, however, the intervention programs that used
balance training in isolation were not effectiveff in
reducing knee injuries in females. Wedderkopp et al.
(91) reported a reduction in all soccer-related injuries,
although not knee or ACL injuries. Soderman et al.
(89) were not eff ffective in reducing injuries in female
soccer players. Wedderkopp et al. (91) and Soder-
man et al. (88) focused on balance training, primarily
utilizing unstable wobble boards. Therefore,
Th balance
training alone may not be as eff ffective for ACL injury
prevention as when it is combined with other types
of training. Interestingly, Caraffa ff et al. (94) studied
male soccer players and showed a significantfi eff
ffect of
balance board exercises on reducing ACL injury and
reported that balance training may be more effec- ff
tive in males than females. Alternatively, Beynnon et
al. (95), in a prospective study, reported that female
athletes who suffered
ff first-time ankle injuries had
greater body sway than female athletes who did not
go on to injury, while male athletes who went on to
ankle injury did not demonstrate increased trunk
sway compared to uninjured males.
Fig. 16 - Hop and hold.
A core component? Evidence for the effects
ff of “core
stability” training
There is not clear evidence whether “core stabil-
ity” exercises should be incorporated into an
intervention to reduce knee ligament injuries. It
is not clearly defi
fined what “core stability” exer-
cises actually represent and what their effectsff
are on the muscles that stabilize the trunk, hip
and pelvis. However, Zazulak et al. (68,96) dem-
onstrated that measures of “core” or trunk pro-
prioception and displacement predicted risk of
ACL injury in collegiate athletes with high sen-
sitivity and specifi
ficity. Interestingly, this eff
ffect
was observed in female, but not male, collegiate
athletes. This may indicate the need for including
trunk perturbation and strengthening in optimal
interventional training programs. The Th findings
support the integration of proprioceptive stability
training in ACL injury interventions, at least for
females. Krosshaug et al. (69) suggested that pre-
ventive programs to enhance knee control should
focus on avoiding valgus motion about this joint
and include distractions resembling those seen in
match situations.
Strength training eff
ffects on knee injury risk
Resistance training alone has not been shown to
reduce ACL injuries. However, inferential evidence
suggests that resistance training may reduce injury
based on benefi ficial adaptations that occur in
 Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee
bones, ligaments, and tendons after training. For
example, Lehnhard et al. (97) signifificantly reduced
injury rates with a strength training regimen in
men’s soccer. The studies by Hewett et al. (85,86)
and Mandelbaum et al. (87) incorporated strength
training in their intervention protocols. Myklebust
et al. (1), Heidt et al. (88), Soderman et al. (89),
and Petersen et al. (98) did not include strength
training in their interventions. The designs that
incorporated strength training were among the
most effffective at decreasing ACL injury rates. But
strength training in isolation may not be a prereq-
uisite for prevention, as the Myklebust et al. (1)
study was eff ffective in reducing ACL injury risk,
and it did not incorporate strength training. In the
final analysis, weight training alone has not been
reported to be eff ffective at decreasing ACL injury
rates and may not need to be incorporated into a
successful intervention. It is important for us to
point out that this may apply only to those sub-
jects who have adequate strength prior to entering
an injury prevention program.
Targeting participation in ACL injury interventions
to individuals or teams
Athletes at the greatest risk of ACL injury should
participate in neuromuscular training interven-
tions to decrease the risk of injuring this important
ligament. This
Th approach is specifi fic to the individual
athlete. The neuromuscular training protocol should
preferably be designed and instituted specifi fically for
and with athletes selected for neuromuscular training
based on identified
fi neuromuscular defi ficiencies and
imbalances. The
Th authors realize that the individual-
ized approach may not be tenable for team athletes
and their coaches. Although we do not know if the
generalizations from our review of the literature dis-
cussed above apply to all athletes or just those who
participate in jumping, landing, and cutting sports,
we can presume that there will be positive effectsff of
neuromuscular training programs designed around
these basic commonalities in effective
ff interventions.
These broad generalizations for the athlete in cutting
and landing sports, for “team training,” from the
studies discussed above, should be eff ffective if plyo-
metric training and landing, cutting, and jumping
technique training are included in the intervention.
The proper “training dose”:
e how much and how often
interventions should be performed
Neuromuscular power can increase within 6 weeks
of training and may result in decreases in peak
impact forces and knee abduction torques. Th The
evidence from the literature indicates that train-
67
ing sessions should be performed more than one
time per week, preferably at least two and up to
five times per week. The total pre-season training
duration of the intervention program should be
a minimum of 6, preferably 8 or more, weeks in
length. Pfeiffer
ff et al. (83) reported that 20 min of
“in-season” exercise 2 days per week was not suf-
ficient to decrease ACL injury risk in high school
age female basketball players. Gilchrist et al. (99)
also reported that an “in-season” program, with no
“pre-season” component, was only effective
ff in the
last half of the season.
The most effffective programs are progressive in nature.
Exercises should progress to techniques that initiate
perturbations that force the athlete to decelerate and
control the body in order to successfully perform the
landing, cutting, and jumping techniques. Th The inter-
vention should preferably be phasic in nature. Three
Th
exercise phases, such as technique, power, and per-
formance phases, are often utilized to facilitate pro-
gressions designed to improve the athletes’ability to
control body motion during dynamic activities. All
exercises in each phase should be progressed to exer-
cise techniques that incorporate perturbations that
force the athlete to decelerate and control the body
in multiple planes of motion, particularly the coronal
plane, in order to successfully perform each technique
with optimal form and safety level.
Conclusions
There is good evidence that neuromuscular train-
ing decreases knee and ACL injury incidence in ath-
letes. Plyometrics in combination with biomechan-
ics and technique (e.g., jumping/landing) training
appear to induce neuromuscular changes that
reduce ACL injury risk. Increased lower extrem-
ity muscle recruitment and strength likely have a
direct eff
ffect on the loading of the ACL during activ-
ities that involve cutting and landing. Although
ACL injuries likely occur too quickly (less than 70
ms) for refl
flexive muscular activation (greater than
100 ms), athletes can adopt preparatory muscle
recruitment and movement patterns that reduce
the incidence of injuries caused by unexpected
perturbations. The studies discussed above pro-
vide strong, but not unequivocal, evidence that
neuromuscular intervention training and educa-
tion programs are likely to be an effective
ff solution
to the problem of gender inequity in ACL injury.
Selective combination of neuromuscular training
components may provide additive effects, ff further
reducing the risk of ACL injuries.
It appears that plyometric power and biomechan-
ics technique training specifific to landing, cutting,
and jumping activities can induce neuromuscular
changes and prevent ACL injury, at least in female
68 The Traumatic Knee
athletes. Balance, core stability, and strength train-
ing may be useful adjuncts. However, we do not yet
know which of these components are most effec- ff
tive or whether their eff ffects are combinatorial.
Future research efffforts will assess the relative effi
ffi-
cacy of these interventions alone and in combina-
tion in order to achieve the optimal effectff in the
most effi
fficient manner possible. Selective combina-
tion of neuromuscular training components may
provide additive effffects, further reducing the risk
of knee and ACL injuries in female athletes.
Neuromuscular training interventions designed to
prevent injury should be based on the previously
published literature. Final conclusions are that
neuromuscular training and educational training
reduce ACL injury risk in female athletes if plyo-
metric exercises and biomechanical techniques are
incorporated into the protocol, training sessions
are performed more than one time per week, and
the duration of the training program is a minimum
of 6 weeks in length. The studies by Hewett et al.
(85,86), Myklebust et al. (1), and Mandelbaum et
al. (87) all incorporated plyometrics and biome-
chanical movement analysis and feedback into
their injury prevention programs and applied these
basic rules of proper intervention “dose.”
References
1. Myklebust G, et al. (2003) Prevention of anterior cruci-
ate ligament injuries in female team handball players: a
prospective intervention study over three seasons. Clin J
Sport Med 13(2):71–78
2. Lohmander LS, et al. (2004) High prevalence of knee
osteoarthritis, pain, and functional limitations in female
soccer players twelve years after anterior cruciate ligament
injury. Arthritis Rheum 50(10):3145–3152
3. Arendt E, Dick R (1995) Knee injury patterns among
men and women in collegiate basketball and soccer.
NCAA data and review of literature. Am J Sports Med
23(6):694–701
4. Malone TR, et al. (1993) Relationship of gender to ante-
rior cruciate ligament injuries in intercollegiate basketball
players. J South Orthop Assoc 2(1):36–39
5. Hewett TE, Myer GD, Ford KR (2004) Decrease in neuro-
muscular control about the knee with maturation in female
athletes. J Bone Joint Surg Am 86-A(8):1601–1608
6. Agel J, Arendt EA, Bershadsky B (2005) Anterior cruciate
ligament injury in national collegiate athletic association
basketball and soccer: a 13-year review. Am J Sports Med
33(4):524–530
7. Deitch JR, et al. (2006) Injury risk in professional basket-
ball players: a comparison of Women’s National Basketball
Association and National Basketball Association athletes.
Am J Sports Med 34(7):1077–1083
8. Mihata LC, Beutler AI, Boden BP (2006) Comparing the
incidence of anterior cruciate ligament injury in collegiate
lacrosse, soccer, and basketball players: implications for
anterior cruciate ligament mechanism and prevention.
Am J Sports Med 34(6):899–904
9. Faude O, et al. (2005) Injuries in female soccer players: a
prospective study in the German national league. Am J
Sports Med 33(11):1694–1700
10. Koehle MS, Lloyd-Smith R, Taunton JE (2002) Alpine ski
injuries and their prevention. Sports Med 32(12):785–793
11. Messina DF, Farney WC, DeLee JC (1999) The Th incidence
of injury in Texas high school basketball. A prospective
study among male and female athletes. Am J Sports Med
27(3):294–299
12. Agel J, et al. (2007) Descriptive epidemiology of collegiate
women’s basketball injuries: National Collegiate Ath-
letic Association Injury Surveillance System, 19881989
through 2003-2004. J Athl Train 42(2):202–210
13. Dick R, et al. (2007) Descriptive epidemiology of collegiate
women’s soccer injuries: National Collegiate Athletic Asso-
ciation Injury Surveillance System, 1988-1989 through
2002-2003. J Athl Train 42(2):278–285
14. Lindenfeld TN, et al. (1994) Incidence of injury in indoor
soccer. Am J Sports Med 22(3):364–371
15. Dick R, et al. (2007) Descriptive epidemiology of collegiate
women’s field hockey injuries: National Collegiate Ath-
letic Association Injury Surveillance System, 1988-1989
through 2002-2003. J Athl Train 42(2):211–220
16. Dick R, et al. (2007) Descriptive epidemiology of colle-
giate women’s lacrosse injuries: National Collegiate Ath-
letic Association Injury Surveillance System, 1988-1989
through 2003-2004. J Athl Train 42(2):262–269
17. Dick R, et al. (2007) Descriptive epidemiology of collegiate
men’s lacrosse injuries: National Collegiate Athletic Asso-
ciation Injury Surveillance System, 1988-1989 through
2003-2004. J Athl Train 42(2):255–261
18. Marshall SW, et al. (2007) Descriptive epidemiology of col-
legiate women’s gymnastics injuries: National Collegiate
Athletic Association Injury Surveillance System, 1988-
1989 through 2003-2004. J Athl Train 42(2):234–240
19. Agel J, et al. (2007) Descriptive epidemiology of collegiate
women's volleyball injuries: National Collegiate Ath-
letic Association Injury Surveillance System, 1988-1989
through 2003-2004. J Athl Train42(2):295–302
20. Dick R, et al. (2007) Descriptive epidemiology of collegiate
men’s football injuries: National Collegiate Athletic Asso-
ciation Injury Surveillance System, 1988-1989 through
2003-2004. J Athl Train 42(2):221–233
21. Griffi
ffin LY, et al. (2006) Understanding and preventing
noncontact anterior cruciate ligament injuries: a review of
the Hunt Valley II meeting, January 2005. Am J Sports
Med 34(9):1512–1532
22. Hewett TE, Myer GD, Ford KR (2006) Anterior Cruciate
Ligament Injuries in Female Athletes: Part 1, Mechanisms
and Risk Factors. Am J Sports Med 34(2):299–311
23. Orchard JW, Powell JW (2003) Risk of knee and ankle
sprains under various weather conditions in American
football. Med Sci Sports Exerc 35(7):1118–1123
24. Meyers MC, Barnhill BS (2004) Incidence, causes, and
severity of high school football injuries on FieldTurf ver-
sus natural grass: a 5-year prospective study. Am J Sports
Med 32(7):1626–1638
25. Ford KR, et al. (2006) Comparison of in-shoe foot load-
ing patterns on natural grass and synthetic turf. J Sci Med
Sport 9(6):433–440
26. Olsen OE, et al. (2004) Injury mechanisms for anterior
cruciate ligament injuries in team handball: a systematic
video analysis. Am J Sports Med 32(4):1002–1012
27. Albright JP, et al. (1994) Medial collateral ligament knee
sprains in college football. Effectiveness
ff of preventive
braces. Am J Sports Med 22(1):12–18
28. Natri A, et al. (1999) Alpine ski bindings and injuries. Cur-
rent findings. Sports Med 28(1):35–48
29. Kocher MS, et al. (2003) Eff ffect of functional bracing on
subsequent knee injury in ACL-deficient
fi professional ski-
ers. J Knee Surg 16(2):87–92
30. Myklebust G, et al. (1998) A prospective cohort study
of anterior cruciate ligament injuries in elite Norwegian
team handball. Scand J Med Sci Sports 8(3):149–153
 Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee
31. Hewett TE, et al. (2005) Biomechanical measures
of neuromuscular control and valgus loading of the
knee predict anterior cruciate ligament injury risk in
female athletes: a prospective study. Am J Sports Med
33(4):492–501
32. Orchard J, et al. (2001) Intrinsic and extrinsic risk factors
for anterior cruciate ligament injury in Australian foot-
ballers. Am J Sports Med 29(2):196–200
33. Shelbourne K, Davis T, Klootwyk T (1998) The Th relation-
ship between intercondylar notch width of the femur and
the incidence of anterior cruciate ligament tears. Am J
Sport Med 26:402–408
34. Uhorchak JM, et al. (2003) Risk factors associated with
noncontact injury of the anterior cruciate ligament: a pro-
spective four-year evaluation of 859 West Point cadets.
Am J Sports Med 31(6):831–842
35. Knapik JJ, et al. (2001) Risk factors for training-related
injuries among men and women in basic combat training.
Med Sci Sports Exerc 33(6):946–954
36. Ostenberg A, Roos H (2000) Injury risk factors in female
European football. A prospective study of 123 players dur-
ing one season. Scand J Med Sci Sports 10(5):279–285
37. Flynn RK, et al. (2005) The familial predisposition toward
tearing the anterior cruciate ligament: a case control
study. Am J Sports Med 33(1):23–28
38. Harner CD, et al. (1994) Detailed analysis of patients with
bilateral anterior cruciate ligament injuries. Am J Sports
Med 22(1):37–43
39. Trojian TH, Collins S (2006) The anterior cruciate liga-
ment tear rate varies by race in professional Women’s bas-
ketball. Am J Sports Med 34(6):895–898
40. Haycock CE, Gillette JV (1976) Susceptibility of women
athletes to injury: myth vs. reality. Journal of the Ameri-
can Medical Association 236(2):163–165
41. Livingston LA (1998) The quadriceps angle: a review of the
literature. J Orthop Sports Phys Ther 28(2):105–109
42. Zelisko JA, Noble HB, Porter M (1982) A comparison of
men’s and women’s professional basketball injuries. Amer-
ican Journal of Sports Medicine 10(5):297–299
43. Shambaugh JP, Klein A, Herbert JH (1991) Structural
measures as predictors of injury basketball players. Med
Sci Sports Exerc 23(5):522–527
44. Gray J, et al. (1985) A survey of injuries to the anterior
cruciate ligament of the knee in female basketball players.
Int J Sports Med 6(6):314–316
45. Pantano KJ, et al. (2005) Diff fferences in peak knee valgus
angles between individuals with high and low Q-angles
during a single limb squat. Clin Biomech (Bristol, Avon)
20(9):966–972
46. Beynnon BD, et al. (2003) The Th effffect of anterior cruciate
ligament defi ficiency and functional bracing on translation
of the tibia relative to the femur during nonweightbearing
and weightbearing. Am J Sports Med 31(1):99–105
47. Anderson AF, et al. (2001) Correlation of anthropometric
measurements, strength, anterior cruciate ligament size,
and intercondylar notch characteristics to sex differences
ff
in anterior cruciate ligament tear rates. Am J Sport Med
29(1):58–66
48. LaPrade RF, Burnett QM, 2nd (1994) Femoral intercon-
dylar notch stenosis and correlation to anterior cruciate
ligament injuries. A prospective study. Am J Sports Med
22(2):198–202; discussion 203
49. Schickendantz MS, Weiker GG (1993) The predictive value
of radiographs in the evaluation of unilateral and bilat-
eral anterior cruciate ligament injuries. Am J Sports Med
21(1):110–113
50. Souryal TO, Freeman TR (1993) Intercondylar notch size
and anterior cruciate ligament injuries in athletes. A pro-
spective study. Am J Sports Med 21(4):535–539
51. Hutchinson MR, Ireland ML (1995) Knee injuries in
female athletes. Sports Medicine 19(4):288–302
69
52. Anderson AF, et al. (1987) Analysis of the intercondy-
lar notch by computed tomography. Am J Sports Med
15(6):547–552
53. Lund-Hanssen H, et al. (1994) Intercondylar notch width
and the risk for anterior cruciate ligament rupture. A case-
control study in 46 female handball players. Acta Orthop
Scand 65(5):529–532
54. Lombardo S, Sethi PM, Starkey C (2005) Intercondylar
notch stenosis is not a risk factor for anterior cruciate
ligament tears in professional male basketball players: an
11-year prospective study. Am J Sports Med 33(1):29–34
55. Chandrashekar N, et al. (2006) Sex-based differences
ff in
the tensile properties of the human anterior cruciate liga-
ment. J Biomech 39(16):2943–2950
56. Woodford-Rogers B, Cyphert L, Denegar CR (1994) Risk
factors for anterior cruciate ligament injury in high school
and college athletes. J Athl Train 29(4):343–346
57. Boden BP, et al. (2000) Mechanisms of anterior cruciate
ligament injury. Orthopedics 23(6):573–578
58. Allen MK, Glasoe WM (2000) Metrecom Measurement of
Navicular Drop in Subjects with Anterior Cruciate Liga-
ment Injury. J Athl Train 35(4):403–406
59. Loudon JK, Jenkins W, Loudon KL (1996) The Th relation-
ship between static posture and ACL injury in female ath-
letes. J Orthop Sports Phys Ther 24(2):91–97
60. Hewett TE, Myer GD, Ford KR (2006) Anterior cruciate
ligament injury in female athletes: Part 1, mechanisms
and risk factors. Am J Sports Med 34(2):299–311
61. Beynnon BD, et al. (2006) A prospective, randomized
clinical investigation of the treatment of first-time
fi ankle
sprains. Am J Sports Med 34(9):1401–1412
62. Hewett TE, Zazulak BT, Myer GD (2007) Effects ff of the
menstrual cycle on anterior cruciate ligament injury risk:
a systematic review. Am J Sports Med 35(4):659–668
63. DeMorat G, et al. (2004) Aggressive quadriceps loading
can induce noncontact anterior cruciate ligament injury.
Am J Sports Med 32(2):477–483
64. Kirkendall DT, Garrett WE, Jr. (2000) The Th anterior cruci-
ate ligament enigma. Injury mechanisms and prevention.
Clin Orthop 372:64–68
65. Pfl
flum MA, et al. (2004) Model prediction of anterior cruci-
ate ligament force during drop-landings. Med Sci Sports
Exerc 36(11):1949–1958
66. Pollard CD, Davis IM, Hamill J (2004) Infl fluence of gender
on hip and knee mechanics during a randomly cued cut-
ting maneuver. Clin Biomech 19(10):1022–1031
67. Salci Y, et al. (2004) Comparison of landing maneuvers
between male and female college volleyball players. Clin
Biomech 2004:622–628
68. Zazulak BT, et al. (2007) The
Th effffects of core proprioception
on knee injury: a prospective biomechanical-epidemiolog-
ical study. Am J Sports Med 35(3):368–373
69. Krosshaug T, et al. (2007) Mechanisms of anterior cruciate
ligament injury in basketball: video analysis of 39 cases.
Am J Sports Med 35(3):359–367
70. Krosshaug T, et al. (2007) Estimating 3D joint kinematics
from video sequences of running and cutting maneuvers
– assessing the accuracy of simple visual inspection. Gait
Posture 26(3):378–385
71. Krosshaug T, Bahr R (2005) A model-based image-match-
ing technique for three-dimensional reconstruction of
human motion from uncalibrated video sequences. J Bio-
mech 38(4):919–929
72. Jarvinen M, et al. (1994) Mechanisms of anterior cruciate
ligament ruptures in skiing. Knee Surg Sports Traumatol
Arthrosc 2(4):224–228
73. Yu B, Garrett WE (2007) Mechanisms of non-contact ACL
injuries. Br J Sports Med 41(Suppl 1): i47–i51
74. Ettlinger CF, Johnson RJ, Shealy JE (1995) A method to
help reduce the risk of serious knee sprains incurred in
alpine skiing. Am J Sports Med 23(5):531–537
70 The Traumatic Knee
75. Krosshaug T, et al. (2007) Biomechanical analysis of
anterior cruciate ligament injury mechanisms: three-di-
mensional motion reconstruction from video sequences.
Scand J Med Sci Sports 17(5):508–519
76. Fung DT, Zhang LQ (2003) Modeling of ACL impingement
against the intercondylar notch. Clin Biomech (Bristol,
Avon) 18(10):933–941
77. McLean SG, Lipfert SW, van den Bogert AJ (2004) Effect ff
of gender and defensive opponent on the biomechanics
of sidestep cutting. Med Sci Sports Exerc. 36(6):1008–
1016
78. Speer KP, et al. (1992) Osseous injury associated with
acute tears of the anterior cruciate ligament. Am J Sports
Med 20(4):382–389
79. McLean SG, et al. (2005) Evaluation of a two dimensional
analysis method as a screening tool for anterior cruciate
ligament injury. Br J Sports Med 39(6):355–362
80. Simeonsson RJ, et al. (2000) Revision of the Interna-
tional Classifi
fication of Impairments, Disabilities, and
Handicaps: developmental issues. J Clin Epidemiol
53(2):113–124
81. Markolf KL, et al. (1995) Combined knee loading states
that generate high anterior cruciate ligament forces. J
Orthop Res 13(6):930–935
82. Hewett TE, Ford KR, Myer GD (2006) Anterior Cruciate
Ligament Injuries in Female Athletes: Part 2, A Meta-
analysis of Neuromuscular Interventions Aimed at Injury
Prevention. Am J Sports Med 34(3):490–498
83. Pfeiff
ffer RP, et al. (2006) Lack of eff
ffect of a knee ligament
injury prevention program on the incidence of noncontact
anterior cruciate ligament injury. J Bone Joint Surg Am
88(8):1769–1774
84. Soderman K, et al. (2001) Risk factors for leg injuries in
female soccer players: a prospective investigation dur-
ing one out-door season. Knee Surg Sports Traumatol
Arthrosc 9(5):313–321
85. Hewett TE, et al. (1999) The
Th eff
ffect of neuromuscular train-
ing on the incidence of knee injury in female athletes. A
prospective study. Am J Sports Med 27(6):699–706
86. Hewett TE, et al. (1996) Plyometric training in female ath-
letes. Decreased impact forces and increased hamstring
torques. Am J Sports Med 24(6):765–773
87. Mandelbaum BR, et al. (2005) Effectiveness
ff of a neuro-
muscular and proprioceptive training program in prevent-
ing the incidence of ACL injuries in female athletes: two-
year follow up. Am J Sport Med 33(6)<AQ: Please provide
page number in Reg. 87.>
88. Heidt RS, Jr., et al. (2000) Avoidance of soccer injuries with
preseason conditioning. Am J Sports Med 28(5):659–662
89.Soderman K, et al. (2000) Balance board training: prevention
of traumatic injuries of the lower extremities in female soc-
cer players? A prospective randomized intervention study.
Knee Surg Sports Traumatol Arthrosc 8(6):356–363
90. Olsen OE, et al. (2003) Relationship between floor type
and risk of ACL injury in team handball. Scand J Med Sci
Sports 13(5):299–304
91. Wedderkopp N, et al. (2003) Comparison of two interven-
tion programmes in young female players in European
handball – with and without ankle disc. Scand J Med Sci
Sports 13(6):371–375
92. Johnson RJ (2001) The ACL injury in female skiers. In:
prevention of noncontact ACL injuries. Griffi ffin LY, editor.
Rosemont, IL: American Academy of Orthopaedic Sur-
geons: 107–111
93. Prapavessis H, McNair PJ (1999) Effects ff of instruction in
jumping technique and experience jumping on ground reac-
tion forces. J Orthop Sports Phys Ther 29(6):352–356
94. Caraff
ffa A, et al. (1996) Prevention of anterior cruciate
ligament injuries in soccer. A prospective controlled study
of proprioceptive training. Knee Surg Sports Traumatol
Arthrosc 4(1):19–21
95. Beynnon B, et al. (2006) A Prospective Study of Risk Factors
for First Time Inversion Ankle Ligament Trauma. American
Academy of Orthopaedic Surgeons Annual Meeting
96. Zazulak BT, et al. (2007) Deficits
fi in neuromuscular con-
trol of the trunk predict knee injury risk: a prospective
biomechanical-epidemiological study. Am J Sports Med
35(7):1123–30
97. Lehnhard RA, et al. (1996) Monitoring injuries on a col-
lege soccer team: the effffect of strength training. J Strength
Cond Res 10(2):115–119
98. Petersen W, et al. (2006) A controlled prospective case con-
trol study of a prevention training program in female team
handball players: the German experience. Arch Orthop
Trauma Surg<AQ: Please provide volume, issue, and page
numbers for Ref. 97.>
99. Gilchrist JR, et al. (2004) A Randomized Controlled Trial
to Prevent Non-Contact ACL Injury in Female Collegiate
Soccer Players. Presented at the American Orthopaedic
Society for Sports Medicine in San Francisco, CA

H.G. Potter, D.B. Sneag,
L.R. Chong
MRI evaluation of knee ligaments
Introduction
D
ue to its superior soft tissue contrast, mul-
tiplanar capabilities and lack of ionizing
radiation, magnetic resonance (MR) imag-
ing (MRI) is a well-suited tool for evaluation of
knee ligaments. Strict attention to imaging tech-
nique is imperative, however, in order to provide
accurate and reproducible assessment of ligament
integrity, as well as to detect associated complica-
tions, including meniscal and chondral injuries.
Following ligament reconstruction, modification
fi
of pulse sequence parameters is essential to pre-
vent artifact from metallic fixation devices that
would preclude an accurate assessment of recon-
struction integrity. While the capabilities of MRI
in assessing the static and dynamic stabilizers of
the knee joint are well founded, it is important
for the referring clinician to correlate MRI find-
fi
ings with the clinical assessment of functional
ligament stability.
Imaging technique
Higher field strength MR units (1.5 or 3 T) gen-
erate increased signal to noise and permit higher
resolution imaging within acceptable scan times.
Protocols should include coronal, sagittal, and
axial images of the knee in order to fully evalu-
ate the ligaments and surrounding structures,
and appropriate slice resolution of 3–4 mm with
no interslice gap is imperative, particularly in the
coronal plane, to most eff ffectively evaluate the
posterolateral corner stabilizers. High in-plane
spatial resolution is important to depict the thin-
ner but important structures of the posterolateral
corner; this may be achieved by use of a higher
imaging matrix of 512 × 320–512. Fast spin echo
techniques are eff ffective in evaluating meniscal
injuries (1) as well as the integrity of the articular
cartilage (2,3). At least one plane obtained with
a fat suppression technique is also important in
order to “rescale” the contrast range and thereby
increase the conspicuity of translational or impac-
Chapter 7
tion injuries associated with ligament instability.
Cartilage-sensitive imaging is essential in order
to detect chondral shearing injuries associated
with ligament tears, which may alter both the
type of surgery performed as well as periopera-
tive management.
While standardized extremity coils are effective
ff
in evaluation of the ligaments, phased array coils
allow for increased signal to noise due to the pres-
ence of more coil elements that act in concert to
increase the signal received from the excited nuclei
in the tissue studied. A recommended imaging pro-
tocol for the assessment of knee ligaments is pro-
vided in Table 1 (1.5 and 3 T).
Table 1 – Recommended protocol for MRI of the knee (1.5- and 3-T mag-
nets).
A. 1.5-T magnet
Coil Phased array extremity knee coil
Position Feet first supine
Landmark Patellar apex
Series I Coronal fast spin echo (cartilage sensitive)
TR 4000-4500/TE 34 ms (effective); VBW 32
kHz; ETL 8-12; FOV 11–13 cm; SL 3.0 mm no
gap; matrix 512 × 256–320; NEX 2; phase
correct; NPW
Series II Sagittal fast spin echo with fat suppression
TR 3500-4000/TE 40 ms (effective); VBW
20.8 kHz; ETL 8-12; FOV 16 cm; SL 3.5–4 mm
with no gap; matrix 256 × 224; NEX 2; phase
correct; NPW
Series III Sagittal fast spin echo (cartilage sensitive)
TR 4000-4500/TE 34 ms (effective); VBW 32
kHz; ETL 8-12; FOV 16 cm; SL 3.5 mm with no
gap; matrix 512 × 384; NEX 2; phase correct;
NPW
Series IV Axial fast spin echo (below patellar apex to
base; cartilage sensitive)
TR 4500/TE 34-40 ms (effective); VBW 32
kHz; ETL 10; FOV 14 cm; SL 3.5 mm with no
gap; matrix 512 × 256–384; NEX 2; phase
correct; NPW
Series V Sagittal fast spin echo (meniscal windows)
TR 2300/TE 13 ms (effective); VBW 20.8; ETL
4-5; matrix 256 × 224; NEX 2
72 The Traumatic Knee

B. 3-T magnet (PCL) buckle (5) and “uncovering” of the posterior

Coil Phased array extremity knee coil horn of the lateral meniscus on sagittal images. In
Position Feet first supine addition, the ability to visualize the entire fi fibular
Landmark Patellar apex
(lateral) collateral ligament on one coronal image
should draw attention to the ACL, as it is typically
Series I Coronal fast spin echo (cartilage sensitive)
necessary to trace the former structure on multiple
TR 5100/TE 28 ms (effective); VBW 62.50 kHz;
coronal images in the setting of an intact ACL. Other
ETL 13; FOV 14 cm; SL 3.5 mm with no gap;
associated injuries in the setting of ACL may include
matrix 512 × 480; NEX 1; phase correct; NPW
O’Donoghue’s “unhappy triad,” which is described as
Series II Sagittal fast spin echo with fat suppression a medial collateral ligament (MCL) tear, an ACL tear,
TR 5000/TE 40 ms (effective); VBW 41.67 kHz;
and a medial meniscal tear (6). The Segond fracture
ETL 16; FOV 18 cm; SL 3.5 mm with no gap;
is an avulsion fracture of the lateral capsule from the
matrix 288 × 288; NEX 1; phase correct; NPW
tibia, which is noted as an often subtle, vertically ori-
Series III Sagittal fast spin echo (cartilage sensitive) ented cortical fragment on an anteroposterior (AP)
TR 5100/TE 28 ms (effective); VBW 62.50 kHz; radiograph, but more clearly delineated on MRI as a
ETL 13; FOV 16 cm; SL 3.5 mm with no gap; capsular avulsion on coronal images (Fig. 2) (7).
matrix 512 × 480; NEX 1; phase correct; NPW
Series IV Axial fast spin echo (below patellar apex to
base; cartilage sensitive)
TR 5300/TE 28 ms (effective); VBW 62.50 kHz;
ETL 17; FOV 14 cm; SL 3.5 mm with no gap;
matrix 512 × 480; NEX 1; phase correct; NPW
Series V Sagittal fast spin echo
TR 3200/TE 12 msec (effective); VBW 62.50
kHz; ETL 6; matrix 288 × 288; NEX 1
NPW, no phase wrap
VBW, variable bandwidth (reported over the entire frequency range);
ETL, echo train length;
SL,slice thickness;
NEX, number of excitations.

Cruciate ligaments
The anterior cruciate ligament (ACL) is composed of A
two main components: the anteromedial band and
the posterolateral bulk, the latter of which is the
primary stabilizer for preventing the pivot shift or
abnormal internal rotation of the tibia relative to the
femur. Increased signal intensity between these two
components may be encountered due to the signal
average of the adjacent intercondylar fat and should
not be misinterpreted as the presence of pathology.
Due to the inherent obliquity of the ACL fi
fibers, some
investigators have recommended oblique imaging
of the ACL, obtained from coronal or axial images
(4). This technique may be useful when imaging the
knee on low-fifield MRI systems (0.2–0.35 T), but this
is not part of standard practice and on higher field
fi
strength systems, the ACL can be eff ffectively evalu-
ated with standardized imaging planes.
The greatest predictive value in detecting complete
tears of the ACL is the presence of a complete dis- B
continuity in the ligament, often associated with
Fig. 1 – Sagittal (A) fat-suppressed and cartilage sensitive (B) fast spin echo
a characteristic transchondral fracture or “bone MR images in a 42-year-old man following acute ACL tear demonstrate the
bruise” pattern (Fig. 1). Due to the anterior transla- typical pattern of bone marrow edema (arrows) and effect on overlying
tion of the tibia relative to the femur in the setting cartilage (arrowheads) due to the transchondral fracture associated with
of an ACL tear, important secondary signs may also a pivot shift, located above the anterior horn of the lateral meniscus in the
be noted, including a posterior cruciate ligament lateral femoral condyle and at the posterolateral tibia.
 MRI evaluation of knee ligaments 73

A
Fig. 3 – Sagittal fast spin echo MR image in a 30-year-old man demon-
strates complete disruption of both fascicular attachments of the lateral
meniscus from the capsule (arrows).

B
Fig. 2 – Anteroposterior (A) radiograph and coronal (B) fast spin echo MR images
in a 15-year-old girl following acute ACL tear demonstrate a Segond fracture
(arrows), reflecting an avulsion of the tibial attachment of the lateral capsule.
A
Meniscal tears associated with ACL tears include
disruption of the fascicles (Fig. 3), peripheral, ver-
tically oriented tears of the posterior horn of the
medial meniscus, as well as a radial tear of the tib-
ial attachment of the posterior horn of the lateral
meniscus. The latter injury may be subtle on MRI,
yet be clinically relevant, and it is typically caused
by translation of the tibia anteriorly in the setting
of an ACL tear, where the posterior horn of the lat-
eral meniscus remains “tethered” posteriorly by the
meniscofemoral ligament attachments (Fig. 4) (8).
The “bone bruise” seen following ACL tears with
pivot shift is now recognized as a transchondral
fracture of varying severity. Bone marrow edema
pattern located above the anterior horn of the
lateral meniscus on sagittal images, as well as
over the far posterior margin of the lateral tibial B
plateau, is accompanied by a variety of chondral Fig. 4 – Sagittal fast spin echo MR images in a 15-year-old boy demon-
injuries ranging from compression to shear, the strate an acute ACL tear (A, arrow) and a radial tear of the tibial attachment
latter of which is more common over the convex of the posterior horn of the lateral meniscus (B, arrow).
74 The Traumatic Knee
surface of the tibial plateau and results in a more
severe magnitude of initial chondral injury (9).
Tiderius et al. studied 24 patients for an average of
3 weeks following ACL tear with delayed gadolini-
um-enhanced MRI and disclosed a generalized loss
of glycosaminoglycan index from both the lateral
and medial femoral condylar cartilages, suggesting
that the traumatic injury may affectff overall car-
tilage homeostasis, rather than just the cartilage
under the bone bruise (10).
While eminence avulsion at the ACL footprint is
typically diagnosed on routine radiographs, con-
comitant MRI in this setting may be useful in dis-
closing associated injury, as well as more accurately
assessing the degree of displacement (Fig. 5).
Clinical detection of ACL tears in acute rotational
injuries is diffi
fficult, and MRI may be useful in this
setting (11). The accuracy of MRI in diagnosing
complete ACL tears compared to surgery as the gold
standard is high, ranging between 95% and 96%
A A
B B
Fig. 5 – Sagittal (A) and coronal (B) fast spin echo MR images in a 49-year-
old woman demonstrate avulsion and displacement of the tibial eminence
at the ACL footprint (arrows).
(12). Accuracy is slightly lower when partial tears
are included, but it is still acceptable at 90–91%. Of
note, similar accuracy has been reported at both
middle (0.5-T) and higher (1.5-tesla) field strengths
(12). In addition to high diagnostic accuracy, MRI
can identify other injuries not easily assessed on
arthroscopy, particularly injuries to extracapsular
structures (13).
The diagnosis of partial ACL tears is made based on
partial discontinuity of the fibers. Careful scrutiny
of the orientation of the individual components of
the ACL is essential, where one may see preferen-
tial horizontal orientation of one component due
to partial ligament laxity (Fig. 6). Acute partial
ACL tears are typically associated with moderate
to large joint eff
ffusions. With chronicity, partial
ACL tears may remodel, and it may be challenging
to note the presence of a partial ligament injury
with apparent tissue continuity on sagittal images.
Careful evaluation to detect evidence of prior tran-
Fig. 6 – Sagittal fast spin echo MR images in a 54-year-old man with mod-
erate ACL laxity following prior partial ACL tear demonstrate preferential
horizontal orientation of the posterolateral bulk fibers.

schondral fracture may be helpful in disclosing a
previous high-grade ACL tear (Fig. 7).
Chronic, complete ACL tears are typically associ-
ated with horizontal orientation of the hypoin-
tense remnant, which often appears scarred to the
PCL (Fig. 8) or resorbed, leaving an empty, fat-filled
fi
intercondylar notch (Fig. 9).
Ganglion cyst formation of the cruciate ligaments
may be seen and refl flects mucinous degeneration
of connective tissue with or without synovial fluidfl
imbibition (14). A clue to this diagnosis is the pres-
ence of intraosseous ganglion cysts, which often
form on the roof of the intercondylar notch in the
distal femur, as well as in the central tibia (Fig. 10).
Large, soft tissue ganglia may cause intermittent
pain or restricted knee motion (typically in full
flexion), but do not necessarily refl
flect the presence
of functional ACL instability or partial tear (14).
A
B
Fig. 7 – Sagittal fast spin echo MR images in a 43-year-old man with a his-
tory of prior knee injury demonstrate apparent continuity of the ACL fibers
(A, arrow) but evidence of a prior transchondral fracture (B, arrow), indicat-
ing the patient sustained a previous high grade ACL tear.
MRI evaluation of knee ligaments 75
PCL tears are also noted by the presence of com-
plete or partial discontinuity of the thick bun-
dles of the ligament. Caution should be utilized
so as not to mistake the adjacent meniscofemo-
ral ligaments of Humphrey or Wrisberg as par-
tial tears of the ligament or displaced meniscal
fragments (Fig. 11). In the setting of a PCL tear,
these ligaments may remain stable and account
for foci of hypointensity seen in cross section on
MRI (Fig. 12).
Associated injuries of PCL tears include chondral
shearing injuries over the medial femoral condyle,
and careful follow-up of these lesions is important
in the setting of PCL insuffi
fficiency, as rapid degrada-
tion of articular cartilage may be seen, particularly
in the setting of a high-performance athlete, where
high loads are imparted to the PCL-deficient
fi knee
(Fig. 13).
Fig. 8 – Sagittal fast spin echo MR image in a 31-year-old man demonstrates
a chronic ACL tear with horizontal orientation of the scarred remnant (arrow).
Fig. 9 – Coronal fast spin echo MR image in a 31-year-old man demonstrates an
empty intercondylar notch, indicating partial resorption of the ACL (arrow).
76 The Traumatic Knee

A B
Fig. 10 – Sagittal (A) fat-suppressed and sagittal (B) fast spin echo MR images in a 48–year-old woman demonstrate an ACL ganglion extending posteriorly
(arrows). Note the incipient intraosseous ganglion formation in the anterior aspect of the tibia (arrowhead).

A B

C D
Fig. 11 – Coronal (A) and sagittal (B) fast spin echo MR images in a 67-year-old woman demonstrate an intact meniscofemoral ligament of Humphrey
(arrows). Coronal (C) and sagittal (D) fast spin echo MR images in a 42-year-old man demonstrate an intact meniscofemoral ligament of Wrisberg (arrows).
 MRI evaluation of knee ligaments 77

Fig. 12 – Sagittal fat-suppressed

(A) and fast spin echo (B) MR images
in a 27-year-old man following a
basketball injury that occurred 1½
weeks previously demonstrate a
high-grade partial PCL tear with an
intact meniscofemoral ligament of
A B
Humphrey (arrows).

Fig. 13 – Sagittal (A, B) and coronal (C) fast spin echo MR

images in a 26-year-old football player following a hyper-
extension injury 1 month previously reveal a complete
mid-substance PCL tear (A, arrow) and chondral shear
over the medial femoral condyle (B and C, arrows). Sagit-
tal (D, E) fast spin echo MR images in the same patient 9
months following the injury reveal remodeling of the PCL
(D, arrow) and progressive cartilage loss over the medial
A
femoral condyle (E, arrow).

B C

D E
78 The Traumatic Knee
Medial collateral ligament
Medial collateral ligaments have distinct deep
and superfificial components, separated by a tibial
collateral bursa. Injuries to the MCL are more
common on the femoral side. In a pure valgus
load, tears of the MCL may be associated with
compression of the lateral femorotibial compart-
ment with bone marrow edema pattern or true
osteochondral fractures. Avulsion of the deep
fibers from the medial femoral condyle may also
be associated with a focal edema pattern in the
central aspect of the medial femoral condyle, as
well as extracapsular soft tissue edema (Fig. 14).
A may also result in concomitant cruciate ligament
B corner injury is clinically relevant with regards
Fig. 14 – Sagittal (A) fat-suppressed MR image in a 23-year-old woman
1 month following a motor vehicle accident reveals a focal edema pattern
in the medial femoral condyle. Coronal (B) fast spin echo MR image in the
same patient reveals an avulsion injury of the medial collateral ligament
(arrow).
Fig. 15 – Axial fast spin echo MR image in a 17-year-old adolescent follow-
ing a recent flexion valgus injury demonstrates complete disruption of the
medial patellofemoral ligament and retinaculum (arrow).
If a tear of the MCL is isolated to the far anterior
fibers on coronal images, careful scrutiny of the
axial images should be performed, as the medial
patellofemoral ligament and retinaculum may
tear as an anterior extension of a primary val-
gus injury, particularly in knee flexion (Fig. 15).
Tears of the PCL often may be associated with a
reactive pes anserine bursa or injury to the semi-
membranosus attachment, particularly in the
setting of a higher force velocity injury, which
tear (Fig. 16). It is important to remember that
the assessment of MCL tears on MRI refl flects the
anatomic discontinuity of the fibers
fi but does not
necessarily correlate to the degree of functional
valgus instability, as assessed by clinical exami-
nation (15).
Posterolateral corner injuries
The posterolateral corner is a collection of soft
tissue constraints that act to stabilize against
varus stress and excessive external rotation of
the tibia relative to the femur. The structures
include the fibular (lateral) collateral ligament,
popliteus tendon, popliteofibular ligament, arc-
uate ligament, and the fabellofibular ligament
(Fig. 17). Failure to recognize posterolateral
to rotational instability, which may compro-
mise the functional integrity of subsequent ACL
reconstruction (16).
Evaluation of the posterolateral corner struc-
tures is best made on a combination of several

A
B
Fig. 16 – Sagittal (A) fat-suppressed MR image in a 19-year-old man
following a football injury that resulted in a complete PCL tear dem-
onstrates avulsion of the semimembranous tendon from its attach-
ment onto the femur with disruption of the posteromedial capsule.
Axial (B) fast spin echo MR image confirms the tendon detachment
(arrow).
planes of imaging, but the bulk is best visualized
on coronal images, requiring both high in-plane
and through-plane (slice) resolution. As a rota-
tory stabilizer, the popliteus tendon should be
carefully traced on consecutive coronal images
from the muscle tendon junction to the femo-
ral attachment. The popliteofibular ligament is
seen as a hypointense, obliquely oriented struc-
ture coursing from the popliteus tendon, often
on posterior coronal images at the level of the
muscle tendon junction, down to the fibular
head (Fig. 18). While subtle in its anatomic pro-
portions on MRI, this is an important stabilizer
of the posterolateral corner (17,18). It is not
MRI evaluation of knee ligaments 79
Fig. 17 – Coronal fast spin echo MR image in a 38-year-old woman dem-
onstrates an intact lateral collateral ligament (arrowheads) and intact
popliteus tendon at the hiatus (arrow).
Fig. 18 – Coronal fast spin echo MR image in a 38-year-old woman
demonstrates an intact popliteofibular ligament (arrow).
uncommonly torn during muscle tendon injury
of the popliteus (19).
In the setting of a chronic injury, the fifibular col-
lateral ligament may remodel with resultant thick-
ening. Proximal injury to the popliteus is not
uncommon, and careful evaluation of the coronal
and axial images is necessary in order to detect a
chronic proximal detachment, where the tendon
often appears scarred in the lateral gutter (Fig. 19).
Proximal fibular avulsion fractures may very likely
destabilize not only the conjoined tendon of the
biceps femoris muscle but also the fi fibular collat-
eral ligament and the popliteofi fibular ligament
(Fig. 20).
80 The Traumatic Knee
A A
B B
Fig. 19 – Sagittal (A) and axial (B) fast spin echo MR images in a 65-year-
old man demonstrate chronic proximal popliteus injury with formation of
intraosseous ganglion cysts (arrows).
Multiple-ligament-injured knee
Knee dislocation is a serious injury that results
in disruption of many of the primary and sec-
ondary stabilizers of the joint, often accompa-
nied by meniscal and cartilaginous disruption.
Careful review of all planes of imaging is nec-
essary to detect the magnitude of osseous and
soft tissue injury; this is essential in aiding sur-
gical planning and graft requirements for subse-
quent ligament reconstruction, meniscal repair,
and cartilage restoration procedures. In addi-
tion, injuries may further involve neurovascular
structures; the reported incidence of vascular
Fig. 20 – Coronal (A) fast spin echo and sagittal (B) inversion recovery MR
images in a 22-year-old professional football player show a small avulsion
fracture (arrows) from the tip of the fibular head, at the insertion of the
biceps femoris tendon, and the popliteofibular ligament, compatible with a
posterolateral corner injury.
injury ranges between 4.8% in low-velocity inju-
ries (20) and 45% in high-velocity injuries (21).
As a delay may exist between intimal injury
and clinical evidence of arterial insufficiency, a
negative initial examination with intact distal
pulses does not preclude a clinically relevant
arterial compromise. Conventional arteriog-
raphy via direct arterial puncture carries an
attendant morbidity of arterial injury, the use
of ionizing radiation, and the risks of iodinated
contrast agents. Contrast-enhanced MR angiog-
raphy performed via an intravenous injection is
an effective means by which to assess regional
vascular integrity, and requires an additional

Fig. 21 – Axial fast spin echo MR image in a 35-year-old man who sus-
tained a multiple ligament knee injury demonstrates partial disruption of
fascicles of the common peroneal nerve (arrow). (Reprinted with permis-
sion from Potter et al. (22).)
3–5 min of scanner time. MR angiography may
easily be performed at the end of the standard
examination to assess the ligaments and has
proven efficacious in detecting clinically occult
vascular injury (22).
Regional nerves may also be subject to injury,
with the common peroneal nerve sustaining the
highest incidence of injury, likely due to its close
approximation to the structures of the poste-
rolateral corner. While complete nerve transec-
tion is relatively uncommon, stretching injuries
may cause partial fascicle disruption resulting
in a foot drop. The nerve may also be encased
in hematoma, particularly in the setting of
associated fractures. Nerve architecture is best
assessed on consecutive axial images, where
focal alteration of fascicles and increased intra-
neural signal should raise strong suspicion for
injury (Fig. 21).
Imaging of the reconstructed ligaments
Following ligament reconstruction, it is necessary
to modify pulse sequence parameters to reduce
artifact generated by fi
fixation devices. In the pres-
ence of metallic instrumentation, susceptibility
artifact may be generated, creating large areas of
signal distortion adjacent to the reconstructed
ligament. Gradient echo techniques should be
avoided, as these are very susceptible to the arti-
fact induced by metallic instrumentation. The Th
MRI evaluation of knee ligaments 81
ability to perform frequency-selective fat sup-
pression may also be hampered; as such, a fast
inversion recovery or STIR (short tau inversion
recovery) sequence is recommended. Fast spin
echo techniques are very effi
fficacious in assessing
the integrity of soft tissue structures surround-
ing instrumentation.
The normal signal properties of ligament recon-
struction are those of a homogeneously hypoin-
tense signal intensity on moderate to long echo
time pulse sequences. Within the first 6 months
following knee construction, however, the graft
may show variable signal hyperintensity, par-
ticularly on a short echo time pulse sequence.
This has been attributed to periligamentous
vascularity and/or impingement (23), as well
as the process of “ligamentization” of the ten-
don graft (24,25). It is important to recall that
there is a slower rate of biologic incorporation
of allograft versus autograft tissue, particularly
in the first 6 months, which may account for
signal inhomogeneity encountered on MR pulse
sequencing. The mode of biologic fixation may
also affect the signal properties of the graft, as
bioabsorbable constructs may not only lead to
inhomogeneity in the intra-articular portion
of the graft but may also account for a regional
adverse synovial reaction that might simulate
that of infection. Osteolysis may occur follow-
ing bioabsorbable fixation, which may create
considerable increased signal intensity sur-
rounding the soft tissue within the osseous
tunnels.
Assessment of graft position is essential, as
malposition is included in the most common
causes of graft failure. The orientation of the
ACL reconstruction on sagittal images should be
parallel to the roof of the intercondylar notch,
with good bone ingrowth into both the femoral
and tibial tunnels (Fig. 22). If there is excessive
anterior placement of the femoral tunnel, the
graft may impinge on the roof of the intercondy-
lar notch, forming the so-called “cyclops” lesion,
indicative of focal hypertrophy of the synovium
due to abutment of the graft against the notch.
Similar findings may be seen following failure to
fully debride the native ACL stump at the time
of reconstruction (Fig. 23). Focal graft impinge-
ment against the roof of the intercondylar notch
should be distinguished from global arthrofibro-
sis, which is a cytokine-mediated, globalized cap-
sular contracture (26). Failure of fixation at the
bone graft or screw level is typically apparent on
radiographs; however, complications involving
plastic or biodegradable screws are best evalu-
ated on MRI (Fig. 24).
In the setting of an infection, inflammatory
synovitis, as well as the presence of bone mar-
82 The Traumatic Knee

A A

B B
Fig. 22 – Sagittal fast spin echo MR images in a 28-year-old man demon- Fig. 23 – Sagittal (A) and axial (B) fast spin echo MR images in a 39-year-
strate an intact, properly positioned ACL graft (arrows) using autologous old man demonstrate anterior position of the ACL graft at the entrance of the
patellar tendon performed with an endoscopic technique. femoral tunnel with a cyclops lesion (arrows) due to graft impingement.

row edema extending into the tibial tunnel, is Conclusion

noted, particularly in the initial perioperative
setting before bone graft incorporation into
the tunnels. The presence of pre-contrast bone
marrow edema followed by post-contrast mar-
row enhancement is strongly suggested with
the presence of concomitant osteomyelitis,
particularly in the setting of tunnel widening
and overt bone destruction (Fig. 25). Caution
should be utilized; however, to recall that in the
setting of bioabsorbable fixation, an inflamma-
tory synovitis may ensue that is not infectious
in etiology.
Magnetic resonance imaging is an accurate, non-
invasive modality in the diagnosis of both acute
and chronic ligament injuries of the knee, helping
to guide surgical planning and thereafter in the
assessment of the postoperative knee. Knowledge
of MR anatomy and imaging techniques, com-
bined with an understanding of injury mecha-
nism and expected postoperative changes, allows
the clinician to correlate clinical assessment with
corresponding MRI findings to ensure a compre-
hensive, accurate evaluation.
 MRI evaluation of knee ligaments 83

A B

Fig. 24 – Sagittal (A, B) and axial (C) fast spin echo MR images in a 45-year-
old man 6 months following bone-tendon-bone ACL reconstruction with
loss of terminal extension. While the sagittal images demonstrate anterior
placement of the femoral tunnel (A, arrow) and suspected cyclops lesion, a
displaced plastic screw (B and C, arrowheads) is noted against the anterior
C
synovial reflection.

A B
Fig. 25 – Sagittal (A) fast spin echo MR image in a 67-year-old woman following ACL reconstruction demonstrates widening of the tibial tunnel (arrow)
and synovitis. The sagittal (B) fat-suppressed image shows corresponding enhancement following gadolinium administration (arrowheads), indicative of
septic arthritis with concomitant tibial osteomyelitis.
84 The Traumatic Knee
References
1. Escobedo EM, Hunter JC, Zink-Brody GC, et al. (1996)
Usefulness of turbo spin-echo MR imaging in the evalu-
ation of meniscal tears: comparison with a conventional
spin-echo sequence. AJR Am J Roentgenol 167(5):1223–
1227
2. Bredella MA, Tirman PF, Peterfy CG, et al. (1999) Accuracy
of T2-weighted fast spin-echo MR imaging with fat satura-
tion in detecting cartilage defects in the knee: comparison
with arthroscopy in 130 patients. AJR Am J Roentgenol
172(4):1073-1080
3. Potter HG, Linklater JM, Allen AA, et al. (1998) Magnetic
resonance imaging of articular cartilage in the knee. An
evaluation with use of fast-spin-echo imaging. J Bone
Joint Surg Am 80(9):1276–1284
4. Hong SH, Choi JY, Lee GK, et al. (2003) Grading of ante-
rior cruciate ligament injury: diagnostic effi
fficacy of oblique
coronal magnetic resonance imaging of the knee. JCAT
27(5):814–819
5. Gentili A, Seeger LL, Yao L, et al. (1994) Anterior cruci-
ate ligament tear: indirect signs at MR imaging. Radiology
193(3):835–840
6. O’Donoghue DH (1964) The unhappy triad: etiology, diag-
nosis and treatment. Am J Orthop 6:242–247
7. Goldman AB, Pavlov H, Rubenstein D (1988) The Segond
fracture of the proximal tibia: a small avulsion that
refl
flects major ligamentous damage. AJR Am J Roentgenol
151(6):1163–1167
8. Brody JM, Lin HM, Hulstyn MJ, et al. (2006) Lateral
meniscus root tear and meniscus extrusion with anterior
cruciate ligament tear. Radiology 239(3):805-810
9. Potter HG, Foo LF (2006) Magnetic resonance imaging of
articular cartilage: trauma, degeneration and repair. Am J
Sports Med 34(4):661–677
10. Tiderius CJ, Olsson LE, Nyquist F, et al. (2005) Cartilage
glycosaminoglycan loss in the acute phase after an anterior
cruciate ligament injury: delayed gadolinium-enhanced
magnetic resonance imaging of cartilage and synovial
fluid analysis. Arthritis Rheum 52(1):120–127
11. Frobell RB, Lohmander LS, Roos HP (2007) Acute rota-
tional trauma to the knee: poor agreement between clini-
cal assessment and magnetic resonance imaging findings.
Scand J Med Sci Sports 17(2):109–114
12. Vellet AD, Lee DH, Munk PL, et al. (1995) Anterior cru-
ciate ligament tear: prospective evaluation of diagnostic
accuracy of middle- and high-fi field-strength MR imaging
at 1.5 and 0.5 T. Radiology 197(3):826–830
13. Munshi M, Davidson M, MacDonald PB, et al. (2000) The Th
effi
fficacy of magnetic resonance imaging in acute knee inju-
ries. Clin J Sport Med 10(1):34–39
14. Deutsch A, Veltri DM, Altchek DW, et al. (1994) Symptom-
atic intraarticular ganglia of the cruciate ligaments of the
knee. Arthroscopy 10(2):219–223
15. Schweitzer ME, Tran D, Deely DM, et al. (1995) Medial col-
lateral ligament injuries: evaluation of multiple signs, prev-
alence and location of associated bone bruises, and assess-
ment with MR imaging. Radiology 194(3):825–829
16. O’Brien SJ, Warren RF, Pavlov H, et al. (1991) Recon-
struction of the chronically insufficient
ffi anterior cruciate
ligament with the central third of the patellar ligament. J
Bone Joint Surg Am 73(2):278–286
17. Maynard MJ, Deng X, Wickiewicz TL, et al. (1996) The Th
popliteofifibular ligament. Rediscovery of a key element in
posterolateral stability. Am J Sports Med 24(3):311–316
18. Veltri DM, Deng XH, Torzilli PA, et al. (1996) The
Th role of the
popliteofifibular ligament in stability of the human knee. A
biomechanical study. Am J Sports Med 24(1):19–27
19. Potter HG (2000) Imaging of the multiple ligament
injured knee. In: Johnson DL. Clin Sports Med. WB Saun-
ders 19(3):425–441
20. Shelbourne KD, Porter DA, Clingman JA, et al. (1991) Low-
velocity knee dislocation. Orthop Rev 20(11):995–1004
21. Green NE, Allen BL (1977) Vascular injuries associ-
ated with dislocation of the knee. J Bone Joint Surg Am
59(2):236–239
22. Potter HG, Weinstein M, Allen AA, et al. (2002) Magnetic
resonance imaging of the multiple ligament injured knee.
J Orthop Trauma 16(5):330–339
23. Howell SM, Knox KE, Farley TE, et al. (1995) Revascular-
ization of a human anterior cruciate ligament graft dur-
ing the first two years of implantation. Am J Sports Med
23(1):42–49
24. Jackson DW, Coretti J, Simon TM (1996) Biologic incor-
poration of allograft anterior cruciate ligament replace-
ments. Clin Orthop Relat Res 324:126–133
25. Jackson DW, Grood ES, Arnoczky SP, et al. (1987) Freeze
dried anterior cruciate ligament allografts. Preliminary
studies in a goat model. Am J Sports Med 15(4):295–303
26. Kawamura S, Ying L, Kim HJ, et al. (2005) Macrophages
accumulate in the early phase of tendon-bone healing.
J Orthop Res 23(6):1425–1432
 Chapter 8

S.R. Piedade, E. Servien,

F. Lavoie, P. Neyret
Classification of knee laxities

Introduction plastic deformation. This

Ligament biomechanical behavior and function
Th mechanical behavior is a
characteristic of the viscoelastic materials that is
described as time and history dependence (Fig. 1)
(1,2). However, if ligament elongation exceeds the
physiological limit (yield point), a plastic deforma-

K
nee joint stability is determined by the tion occurs. In that context, knee joint kinemat-
ligament and capsular complex combined ics is compromised, potentially leading to clinical
with intact osteocartilaginous structures. knee joint instability.
The ligaments are described as dense connective In this chapter, we discuss the diff fferent types of
collagenous tissue bands that connect one bone ligament injury and classifi
fication of knee ligament
to another. Their purpose is to support loads of instabilities.
tension, particularly on their long axis, allow-
ing joint stability and guiding knee joint move-
ment.
In the physiologic limit, ligaments and joint cap- Types of ligament injuries (terminology)
sule can lengthen without arriving at irreversible Sprain is defifined by an injury of ligament that
stretches or tears ligamentous fi
fibers without com-
plete ligament rupture. It is classified
fi in three dif-
ferent levels (Table 1) (3).

First-degree sprain
Clinically, it presents a localized tenderness and it
is followed by no instability. It is characterized as a
tear of a minimum number of ligament fi fibers.

Second-degree sprain
Clinical examination shows a slight-to-moderate
abnormal motion. It happens as a result of a larger
number of ligament fibers
fi ruptured when com-
Fig. 1 – Ligament mechanical behavior submitted a uniaxial tensile test. pared to level I.

Table 1 – Correlation of sprain level with ligament fibers tear and clinical instability.
Sprain Tears of ligament fibers (amount) Clinical instability
First-degree Minimum No
Second-degree More ligamentous fibers Abnormal motion (slight-to-moderate)
Complete ligament tear (rupture) Demonstrable instability
Third-degree
Clinical examination (joint surfaces opening)
Grade I Less than 0.5 cm
Grade II 0.5–1.0 cm
Grade III More than 1.0 cm
86 The Traumatic Knee
Third-degree sprain
This level of injury is subdivided in three types,
according to joint surface opening:
1. Grade I = less than 0.5cm;
2. Grade II = 0.5 to 1.0cm;
3. Grade III= opening superior to 1.0 cm (complete
ligament rupture and obvious clinical laxity).
Table 1 summarizes the sprain classification
fi lev-
els and correlation with ligament fibers
fi tear and
clinical instability.
Laxity is defifined as looseness of a joint. It can be
reported as normal (patient’s collagenous char-
acteristic) or abnormal and can be measured by
radiological methods.
Instability is the result of ligament defi ficiency or
absence. It is secondary to a traumatic injury. Clin-
ically, it leads to increased or excessive displace-
ment between tibial and femoral surfaces.
Clinical examination (ligament tests)
During physical examination, the patient must be
relaxed, and clinical laxity tests must be performed
gently. All tests are performed with the patient in
dorsal decubitus unless specified fi otherwise. The
normal knee is examined first to establish the
patient’s normal laxity: this provides the exam-
iner with a baseline to determine pathologic lax-
ity (4–7).
Medial and lateral compartment integrity
assessment tests
Valgus stress test
The knee is flexed at 30° and a gentle valgus stress is
applied, with one hand placed on the lateral aspect
of the knee joint and the other hand grasping the
heel. This test evaluates the medial compartment
of the knee joint. However, when performed with
the knee fully extended, it is helpful to check the
posterior cruciate ligament (PCL) and posterome-
dial compartment’s status.
Varus stress test
Similarly, this test is performed with the knee
flexed at 30°; however, a varus stress is applied to
the knee joint. It helps the physician to evaluate
the ligament restrictors of the lateral compartment
of the knee. If this maneuver is performed with the
knee in full extension, the PCL and posterolateral
ligament restrictors’ status are checked. It must
be kept in mind that both knees are evaluated and
clinical findings compared.
ACL integrity assessment tests
Lachman-Trillat test
The examined knee is positioned at 20° of flexion,
and an anterior drawer is applied to the proximal
calf. Clinically, this test can be graded as a fi
firm or
soft endpoint (8).
Anterior drawer test
In this clinical test, the hip is flexed
fl to 45°, with
the knee flexed to 80–90°. The examiner places
his hands about the upper part of tibia and per-
forms anterior tibial displacement with the foot
in neutral, external, and medial rotations. Before
performing the test, it is important to check if
the hamstrings are relaxed to avoid false negative
test. It must be underscored that positive anterior
drawer test is absent in isolated anterior cruciate
ligament (ACL) lesion.
These two maneuvers (Lachman-Trillat and ante-
rior drawer tests) allow the examiner to analyze
the anterior tibial displacement and assess the
endpoint stiffness.
ff Anterior drawer test with inter-
nal and external rotations will assess medial and
lateral corners.
Pivot shift test
It reproduces the anterior tibial subluxation and
reduction, during the flexion-extension
fl of the
knee from 10° to 40°. A positive test confirms
fi an
ACL disruption (9–11).
PCL integrity assessment tests
Posterior drawer test
With the knee flexed to 90°, the examiner first
observes the relationship between the tibia and
femoral condyles. Normally, in the resting posi-
tion the medial tibial plateau lies 1 cm anterior to
the medial femoral condyle. It is considered the
most accurate clinical test to determine PCL insuf-
ficiency. Rubenstein et al. (12) have shown that
the posterior drawer test is the most sensitive test
(90%) and is highly specifi
fic (99%).Considering the
amount of subluxation, it is graded as I (1–5 mm),
II (5–10 mm), and III (more than 10 mm). Poste-
rior drawer test with internal and external rota-
tions will assess medial and lateral corners.
Reverse pivot shift
This clinical test helps the clinician to discern combi-
nation injuries from isolated PCL injuries. With the
patient in supine position, the examiner stands on
the side of the injured leg. One hand grasps the heel,
with the knee in full extension and neutral rotation.

Thereafter, a valgus stress is applied and the knee is
flexed. The test is considered positive when this test
induces a posterior subluxation of the lateral tibial
plateau between 20° and 30° of knee fl flexion and it
remains in this position with more flexion.
fl It evalu-
ates instability related to the posterolateral com-
partment of the knee (arcuate ligament complex:
arcuate ligament, lateral collateral ligament (LCL),
popliteus muscle, and the lateral head of gastrocne-
mius muscle). A posterior subluxation of the lateral
plateau reveals posterolateral instability; however,
the physical examination of both knees must be
compared to avoid false positive test (13).
Other tests
Other tests include recurvatum test and external
rotation test (Dial test) (assess to posterolateral
corner) (6).
Classifification systems of knee ligament instability
Lyon school classification
Henry Dejour reported the laxity resulting from
chronic ACL defificiency in the following manner
(Table 2) (12).
Anterior laxity
Complete and isolated anterior laxity
Lachman-Trillat and pivot shift tests are frankly
positive, and there is a differential
ff anterior tibial
translation of 2–4 mm with the normal knee. Car-
tilage and menisci are normal.
Partial and isolated anterior laxity
Initially, it can result from a partial rupture of the
ACL, but we think that more frequently it results
from the healing of some fi fibers of the ACL over the
PCL as described by Trillat. It may sometimes be
the rupture of one bundle, more often the antero-
medial bundle. Clinically, this type of laxity is well
tolerated by the patients, and frequently, there is
no knee instability. It presents the same anterior
tibial translation as in complete and isolated ante-
Table 2 – Dejour’s classification of triad.
Medial Lateral
Hemarhrosis Recurvatum Lachman
laxity laxity
Anteromedial + + 0 0
Anterior
Anterolateral
triad + 0 + +
Posteromedial
+ + to 0° 0 0 0
Posterior
triad Posterolateral
+ 0 + ±
Classification of knee laxities 87
rior laxity; however, a delayed stop is found in the
Lachman-Trillat test, and the pivot shift test is
negative. It must be emphasized that it can become
a complete anterior laxity if patients return to the
same level of sports activity.
Anterior medial laxity or advanced anterior laxity
Compared to the isolated laxity, anterior medial
laxity shows a markedly positive anterior trans-
lation graded as 6–10 mm. It is associated with
medial meniscal, capsular, and ligamentous inju-
ries. It must be underscored that these peripheral
injuries are secondarily produced by repeated acci-
dents in the 2 or 5 years following ACL disruption.
Anterior posterolateral laxity
This type of laxity is secondary to ACL disruption
associated with injury of the posterior lateral com-
plex. Clinically, it is presented as a simple lateral
laxity as well, a recurvatum test as described by
Hughston, and frequently, the radiographic evalu-
ation shows an asymmetric lateral opening, par-
ticularly if there is a bilateral varus knee. However,
anterior tibial translation is not marked.
Anterior laxity associated with pre-arthritis
This advanced stage of instability is the result of
5–10 years of evolution. It can also be the conse-
quence of a limited surgical procedure such as a
total menisectomy. Lateral radiographs show a
minimum anterior tibial translation of 10 mm
associated to a medial or lateral knee pre-arthritis.
Anterior lateral laxity associated with arthritis
In this stage, the arthritis is well established.
Twenty to 30 years of ACL defi
ficiency is identifi
fied
in these cases. Lachman-Trillat and pivot shift
tests are markedly positive. Lateral radiographs
allow the diagnosis, showing the medial condyle
embedded in the posterior medial tibial cupula.
Posterior laxity
Posterior laxity is the result of PCL injury, either
isolated or associated to peripheral ligament injury.
It can be subclassifi
fied as follows (14).
Posterior Special
Pivot Anterior
drawer tests and
shift drawer test
test lesions
+ + + 0
Hughston
+ + 0 ±
test
A delayed
0 ±
stop
A delayed
0 0 +
stop
88 The Traumatic Knee
Pure or isolated posterior laxity
As its name implies, pure posterior laxity is pro-
duced by an isolated PCL injury. Clinically, the pos-
terior drawer test is less pronounced in internal as
compared to neutral and external rotations.
Posterior medial laxity
Posterior medial laxity is considered a rare type
of posterior laxity. It is the consequence of injury
to the PCL and medial capsular and ligamentous
structures. Clinically, it presents as a valgus laxity,
in 30° of flexion as well as in full extension. The
posterior drawer test is positive with the foot neu-
trally aligned as well as in internal rotation; how-
ever, the posterior drawer test in external rotation
remains normal.
Posterior lateral laxity
Posterior lateral laxity is the result of a com-
bined injury to the PCL and the posterior lateral
corner of the knee joint. Clinical features are a
minimum of 10 mm of posterior tibial transla-
tion, an augmented varus laxity in 30° of flexion
and in full extension, as well as an augmented
recurvatum and a positive tibial external rota-
tion test (6).
Isolated peripheral laxity
External rotatory laxity
This exceptional type of laxity is produced by
an isolated injury to the posterolateral corner
of the knee joint. Physical examination shows
an augmented varus laxity at 30° of knee flex-
ion, a hyper mobility of the lateral femoro-tibial
compartment, a positive recurvatum-external
rotation test, a reverse pivot shift test, and an
increase of the tibial external rotation in flexion
at 90°.
Isolated medial rotatory laxity
This laxity results from an isolated injury of the
posteromedial corner. Clinically, it displays a val-
gus laxity at 30° of knee flexion;
fl however, there is
no valgus laxity with the knee in extension.
Table 3 – Hughston’s classification and related ligament injuries.
Type of instability
Medial
Lateral
Straight
Posterior
Anterior
Anteromedial
Combined simple Anterolateral
Posterolateral
Anterolateral + posterolateral
Combined rotational
Anterolateral + anteromedial
Isolated lateral rotatory laxity
Isolated lateral rotatory laxity is seldom encoun-
tered as it results from an isolated injury of the
LCL, which is usually associated to an injury of the
posterior lateral corner.
Hughston’s classification
fi
In 1976, Hughston and colleagues and the Amer-
ican Orthopedic Society of Sports Medicine
Research and Education Committee developed a
classifi
fication based on rotation of the knee about
the central axis of the PCL. The instabilities are
classifi
fied as straight or non-rotatory, and simple
or complex rotatory instability (Table 3) (6,15,16).
Rotational instability
It is defi
fined as instability where the rotation of the
knee is controlled by an intact PCL. Clinically, this
type of knee ligament instability is subclassified
fi as
anterolateral, anteromedial, posterolateral, pos-
teromedial, and combined.
Anterolateral rotatory instability
This instability is produced by an ACL rupture
associated to injuries to the lateral capsular liga-
ment and the arcuate complex. Sometimes, the ili-
otibial band may be damaged, most commonly its
deep fibers. Clinically, it presents as an excessive
internal tibial rotation and anterior subluxation of
the lateral tibial plateau. Positive clinical tests are
the Lachman-Trillat test, pivot shift test, anterior
drawer test, and varus test at 30° of flexion.
fl
Anteromedial rotatory instability
This instability results from a disruption of medial
capsular ligament, medial collateral ligament, pos-
terior oblique ligament, and ACL. Sometimes, a
medial meniscus tear can be associated. Physical
examination shows a marked external rotation of
the tibia and anterior tibial displacement produced
by anteromedial subluxation of the medial tibial
plateau on the medial femoral condyle. A positive
Lesion
Medial compartment + LCP
Lateral compartment + LCP
LCP + post obl lig + arcuate lig
AM and AL capsule ± LCA
Medial compartment ± LCA
1/3 ant lateral capsule ± LCA
1/3 post lateral capsule
All lateral compartment
1/3 third med compartment + lat

valgus stress test at 30° of knee fl
flexion, a positive
anterior drawer test, and a positive Lachman-Tril-
lat test confi
firm the diagnosis.
Posterolateral rotatory instability
This instability characterizes the injuries of the
posterolateral corner (arcuate ligament, LCL,
popliteus tendon). It is sometimes associated to an
injury of the biceps tendon. Clinically, the patient
may present a lateral thrust during his gait, result-
ing from lateral tibial plateau rotation on the lat-
eral femoral condyle and posterolateral ligament
defi
ficiency. Positive external rotation recurvatum
and posterolateral drawer tests are also observed.
The levels of injury of the LCL and iliotibial band
are directly related to the magnitude of varus
stress test performed at 30° knee flflexion. Anterior
and posterior drawer tests, Lachman-Trillat test,
and pivot shift test are all negative.
Posteromedial rotational instability
The disruptions of posteromedial corner (medial
collateral ligament, the medial capsular ligament,
and the posterior oblique ligament), the ACL, and
the posteromedial capsule generate this type of
instability. A semimembranosus tendon injury
can be associated to this instability as minor or
major tears. Clinically, it is manifested by poste-
rior rotation of the medial plateau on the femoral
condyle.
Combined anteromedial and anterolateral rotatory instability
Th instability is produced by injury of the medial
This
and lateral supporting structures of the knee in
association with an ACL tear. Laterally, the mid-
dle third of the lateral capsule, the iliotibial band,
and the biceps tendon (short head) are torn.
Physical examination is characterized by positive
adduction stress, Lachman-Trillat, and anterior
drawer tests.
Combined anterolateral and posterolateral rotatory instability
This instability is produced by a disruption of all
lateral capsular structures associated or not with a
tear of the iliotibial band. Th
The PCL is intact and the
ACL is disrupted. Clinically, the adduction test is
markedly positive. The Th Lachman-Trillat and ante-
rior drawer tests are also positive.
Combined anteromedial and posteromedial rotatory instability
This instability occurs as a result of medial and
posteromedial injuries associated to ACL and semi-
membranosus complex injury.
Straight instability
Straight instability is defi
fined by an absence of
rotatory translation or subluxation as a result of
PCL injury. It is subdivided in four types: lateral,
medial, anterior, and posterior.
Classification of knee laxities 89
Straight lateral instability
This instability is produced by a tear of lateral sup-
porting structures (lateral capsular ligament, LCL,
arcuate complex) and the PCL. Th The axis of tibial
rotation is consequently shifted toward the MCL.
Clinical examination shows a lateral opening dur-
ing the adduction stress test performed at 0° and
30° of knee flexion. The degree of lateral open-
ing is directly related to the level of injury to the
iliotibial band. Th
The clinical examination shows a
positive posterior drawer test in neutral rotation
and an increased translation with the knee rotated
externally.
Straight medial instability
This instability is caused by a disruption of medial
supporting structures (MCL, middle third of the
capsular ligament, and the posterior oblique liga-
ment). The
Th axis of tibial rotation is shifted toward
the LCL. Clinically, the abduction stress test at 30°
and 0° shows a medial space joint opening. If the
ACL is torn, the anterior drawer test will be posi-
tive in all three rotational positions. A positive
posterior drawer test will be present if the PCL is
torn.
Straight posterior instability
This instability results from an isolated tear of the
PCL. However, it might be injury to the arcuate
complex and to the posterior oblique ligament,
and the MCL, LCL, and ACL are intact. Clinically,
this instability is manifested by a markedly posi-
tive posterior drawer test with rotation.
Straight anterior instability
Straight anterior instability is produced by an iso-
lated disruption of the ACL. Clinically, a positive
anterior drawer test in neutral rotation is present,
with no rotational displacement. Hughston con-
sidered straight anterior instability as an injury
related to the PCL. He emphasized that there can
be no anterior displacement great enough to injure
the PCL without damaging the MCL and LCL.
Structural classifification
This classifi
fication is based on the anatomic struc-
tures that are damaged. The instability is classifi
fied as
anterior, posterior, lateral, and medial (Table 4). This
Th
classifi
fication is close to Hughston’s classifi
fication.
Knee dislocation
Knee dislocation is defi
fined as a complete loss of
contact between the articular surfaces of the tibia
and the femur. There are several ways to classify
90 The Traumatic Knee
knee dislocations. Considering the fi
final position of
the tibia with respect to the femur, the dislocation
could be classifi
fied as anterior, posterior, medial,
lateral, or rotatory. (Table 1). However, this ana-
tomic classifi
fication is not useful when the knee
dislocation is reduced as it happens in pentad inju-
ries (17).
Classifification system of Schenck
Considering the injury pattern, as well as any asso-
ciated neurovascular injury, a classifi
fication system
has been described by Schenck (18):
– KD1: intact PCL with variable injury to collateral
ligaments;
– KD2: both cruciate ligaments disrupted with
intact collateral ligaments (rare);
– KD3: both cruciate ligaments disrupted with
medial or lateral ligament disrupted;
– KD4: both cruciate ligaments and both collateral
ligaments disrupted;
– KD5: knee dislocation with periarticular frac-
ture.
This classifi
fication allows for establishing and orga-
nizing the clinical and surgical treatment of these
injuries.
Another classifi fication was described during the
ESSKA’s Symposium and redefined fi in the 10th
Journées Lyonnaises de Chirurgie du Genou to
contemplate the pentad injuries and knee disloca-
tion. In this system of classification,
fi it is possible
to identify the ligament injuries starting from the
mechanism and the relative positions of the tibia
and femur (19,20).
The pentads
These injuries are produced by low-energy trauma,
where the knee is submitted to a valgus, varus, or
hyperextension trauma. First, a collateral ligament
disruption happens and is followed by the disrup-
tion of a cruciate ligament (triad) followed by the
disruption of a second cruciate ligament (pentad).
The forces applied to one side of the knee joint
induce a collateral ligament disruption on the con-
tralateral side. Clinically, this presents as medial or
Table 4 – Anatomic classification (Jacques Witvoët – Saint Louis Hospital 80).
Type of instability
Only anterior
Anterolateral
Anteromedial
Anterior global
Straight posterior
Posterolateral
Posterior-posterolateral
lateral opening of the knee joint during valgus and
varus stress testing, respectively. ThThe knee rota-
tion is guided by anteroposterior axes of femoral
condyles with respect to the plan formed by the
non-injured tibial plateau.
After the trauma, joint congruence is preserved
with no residual translation of the tibial and fem-
oral joint surfaces. Many injury scenarios can be
described:
– valgus force trauma® anteromedial triad (disrup-
tion of the medial structures and of a single cru-
ciate ligament);
– medial pentad (disruption of the medial struc-
tures and of both cruciate ligaments);
– varus force trauma® posterolateral triad (disrup-
tion of the lateral structures and of a single cruci-
ate ligament);
– lateral pentad (disruption of the lateral struc-
tures and of both cruciate ligaments);
– hyperextension trauma® posterior pentad (dis-
ruption of both cruciate ligaments).
Medial and both cruciate injuries (medial pentad)
These injuries are the result of a valgus-external
rotation trauma to the knee joint with the foot
fixed on the ground, leading to a disruption of the
MCL (medial gaping), posterior medial supporting
structures, and both cruciate ligaments. Injuries
of the medial and lateral meniscus can be present
and, sometimes, associated to osteochondral frac-
tures of the lateral compartment. Exceptionally, an
injury of the pes anserinus can occur (distal avul-
sion of the sartorius, gracilis, and semitendinousus
tendons). Vascular complication is exceptionally
reported with this type of injury (Fig. 2A).
Lateral and both cruciate injuries (lateral pentad)
There are diff fferent clinical presentations for this
type of injury (Fig. 2B).
a. Anterolateral. This type of pentad results from ili-
otibial band, LCL, and popliteus tendon ruptures.
Frequently, the lateral meniscus is torn; however,
the posterolateral corner is intact.
b. Posterolateral. This type of pentad is created by
injuries of LCL, popliteus tendon, posterolateral
corner, and lateral meniscus.
Injury
Isolated LCA
ACL + anterolateral capsule
MCL + posteromedial corner ± ACL
ACL + popliteus + posterolateral corner
PCL
PCL + LCL + posterolateral corner
PCL + LCL + popliteus + posterolateral corner

Table 5 – Combined bicruciate disruption: medial (lateral dislocation) or lateral (medial dislocation).
Bicruciate disruption Joint opening
Medial (medial pentad) Medial
Lateral (lateral pentad) Lateral
c. Hyperextension pentad. All lateral supporting struc-
tures are disrupted (from iliotibial band to lateral
gastrocnemius). Clinically, it is manifested by an
important lateral joint opening. An injury of the
sciatic popliteus nerve frequently happens result-
ing from the traction force.
Posterior and both cruciate injury (posterior pentad)
The posterior pentad is produced by a trauma to
the anterior aspect of the tibia or by knee hyperex-
tension secondary to a fall. In the latter case, one
can observe two mechanisms: the femoral condyles
resist and an impaction fracture of the anterior
part of the tibial occurs, or the femoral condyles
break and a disruption of both cruciate ligaments
is observed. The following sequence is noted: a
rupture of the femoral condyles if the recurvatum
reaches 30°, a rupture of the ACL, then PCL and
also an injury of the popliteal artery if the recurva-
tum reaches 50° (6) (Fig. 2C).
Dislocation
Pure anterior bicruciate disruption (anterior dislocation)
The denomination of pure bicruciate disruption is
proposed because, in cases of anterior dislocation
(but also posterior dislocation), it is completely
possible that the collateral ligaments remain in
continuity in spite of the knee dislocation. ThThe
anterior bicruciate disruption generally occurs
after a movement of hyperextension and then
follows the mechanism described in the pos-
Fig. 2 – Classification of pentads
Classification of knee laxities 91
Subperiosteal detachment of the contralateral supporting structure
Lateral
Medial
terior pentad. The tibia ends up in front of the
femur by a phenomenon of anterior translation;
in some exceptional cases, this dislocation can
occur without a rupture of the PCL. The damage
of the popliteal artery is frequent in this type of
injury (Fig. 3A).
Pure posterior bicruciate injury (posterior dislocation)
This type of knee dislocation is a result of a vio-
lent blow to the anterior part of the proximal tibia
on a flexed knee or hyperextension. The posterior
translation of the tibia is made possible by PCL dis-
ruption. Seldom, a posterior translation can hap-
pen without any damage to the ACL.
In this type of knee dislocation, the tibia ends up
behind the femoral condyles. Sometimes, it can
be associated with a disruption of the patellar or
quadriceps tendon, a patellar fracture, or a lateral
dislocation of the patella resulting in an impor-
tant posterior translation of the tibia. The damage
of vascular structures was present in 25% of the
cases (Fig. 3B).
Combined bicruciate disruption: medial (lateral dislocation) or
lateral (medial dislocation)
These types are defifined by a bicruciate ligament
disruption associated to an injury of one collateral
ligament. A detachment of the contralateral sup-
porting structures is produced by the residual trau-
matic energy after the pentad injury has occurred.
In that context, the following sequences can be
observed (Table 5; Fig. 3C and D).
92 The Traumatic Knee
Fig. 3 – Classification of Knee dislocation.
In this mechanism, a rotation occurs around an antero-
posterior axis located in one compartment followed
by a translation toward this same compartment. In
medial combined bicruciate disruption, we observe a
rotation around an anteroposterior axis located in the
lateral compartment, followed by a lateral translation
of tibia that ends in lateral knee dislocation. In this
pattern of injury, as in the medial pentad, we observe
the disruption of MCL, posteromedial supporting
structures, ACL, and PCL. Medial or lateral meniscus
injury and an avulsion fracture of fibular
fi head can be
present in these cases. A marked lateral translation
can be associated with knee extensor mechanism dis-
ruptions and neurovascular injuries.
Complex and combined bicruciate disruption
This pattern of injury is produced by a bicruciate
disruption associated to medial and lateral support-
ing structure disruptions. All the lesions not finding
description with the current classification,
fi such as
rotatory dislocations, can be placed in this category.
In fact, in rotatory dislocations, there is often only
one element of the collateral supporting structures
(like the tendon of the muscle popliteus or the poster-
olateral corner), which is respected and which remains
the only hinge linking the tibia with the femur. Vascu-
lar injuries are frequent, and it is related to the great
displacement of the tibia under the femur (Fig. 3E).
Conclusion
Those diff
fferent classifi
fications will be improved with
new knowledge of knee kinematics. We may expect
that the classifi
fication system will be more precise
relating to ACL and PCL anatomy (double bundle)
and understanding of knee ligament injury.
References
1. Fung YC (1993) The meaning of the constitutive equation.
In: Fung YC, editor. Biomechanics – mechanical properties
of living tissues. New York: Springer: 23–65
2. Woo SL, Abramowitch SD, Kilger R, Liang R (2006) Bio-
mechanics of knee ligaments: injury, healing, and repair.
J Biomech 39(1):1–20
3. American Orthopedic Society of Sports Medicine Research
and Education Committee: 1976.
4. Andrews JR, Axe MJ (1985) The Th classifi
fication of knee liga-
ment instability. Orthop Clin North Am. 16(1):69–82
5. Daniel DM (1990) Diagnosis of ligament injury. In: Daniel
DM, Akeson WA, O’Connor JJ, editors. Knee ligaments.
New York: Raven Press
6. Hughston JC, Norwood LA (1980) The Th posterolateral
drawer test and external rotational recurvatum test for
posterolateral rotatory instability of the knee. Clin Orthop
147:82–87
7. Noyes FR, Grood ES, Torzilli PA (1989) Current concepts
review: the defi
finition of terms for motion and position of
the knee and injuries of the ligaments. J Bone Joint Surg
Am 71:465–472

8. Torg JS, Conrad W, Kalen V (1976) Clinical diagnosis of
anterior cruciate ligament instability in the athlete. Am J
Sports Med 4:84–93
9. Galway RD, Beaupre A, MacIntosh DL (1972) Pivot shift:
a clinical sign of symptomatic anterior cruciate insuffi-
ffi
ciency. J Bone Joint Surg (BR) 54B:763–4
10. Matsumoto H (1990) Mechanism of the pivot shift. J
Bone Joint Surg Br 72:816–821
11. Noyes FR, Grood ES (1987) Classifi fication of ligament
injuries: why an anterolateral laxity or anteromedial lax-
ity is not a diagnostic entity? Instr Course Lect 36:185
12. Dejour H, Walch G, Deschamps G, Chambat P (1987)
Artrose du genou sur laxité chronique antérieure. Rev Chir
Orthop 73:151–170
13. Jakob P, Hassler H, Staubli HU (1981) Observations on
rotatory instability of the lateral compartment ot the
knee. Experimental studies on the functional anatomy
and the patomechanism of the true and reversed pivot
shift sign. Acta Orthop Scand Suppl 191:1–32
14. Dejour H, Walch G, Peyrot J, Eberhard Ph (1988) Histoire
naturelle de la rupture du ligament croisé postérieur. Rev
Chir Orthop 74:35–43
Classification of knee laxities 93
15. Hughston JC, Andrews JR, Cross MJ, Moshi A (1976)
Classifi
fication of knee ligament instabilities. Part I. The
medial compartment and cruciate ligaments. J Bone Joint
Surg Am 58:159–172
16. Hughston JC, Andrews JR, Cross MJ, Moshi A (1976)
Classifi
fication of knee ligament instabilities. Part II. The
lateral compartment. J Bone Joint Surg Am 58:173–179
17. Larson RL, Jones DC (1984) Dislocation and ligamentous
injuries of the knee. In: Rockwood CA, Jr., Green DP, edi-
tors. Fractures in adults, 2nd ed, vol 2. Philadelphia: Lip-
pincott: 1, 480, 591
18. Schenck RC, Jr. (1994) The Th dislocated knee. American
Orthopaedic Surgeons Instr Course Lect 43:127–136
19. Neyret Ph, Rongieras F, Versier G, Aït Si Selmi T (2002)
Physiopathologie, mécanismes et classification
fi des lésions
bicroisées. In: Le genou du sportif. Paris: Sauramps Médi-
cal: 375–386
20. Neyret Ph (1996) Lésions ligamentaires complexes
récentes: triades, pentades et luxations. In: Saillant G,
éd. Pathologies chirurgicales du genou du sportif. Cahiers
d’enseignement de la SOFCOT. Expansion Scientifique fi
Française, vol. 59, pp. 37–52.

B.E. Heyworth, R.H. Brophy,
R.G. Marx
Scoring the knee
The use of knee rating scales for clinical
outcome: historical perspective
T
he move toward evidence-based medicine has
brought a new emphasis on the use of sound
outcome measures to evaluate patients and
the treatments provided to them. While the assess-
ment of orthopaedic surgical procedures dates
back to the origins of the field,
fi the use of tradi-
tional measures of success following surgery, such
as physical examination and radiographic criteria,
is now considered only one component of a com-
plete evaluation process. In the past three decades,
outcome assessment following orthopaedic sur-
gery has focused increasingly on the perspective of
the patient, rather than the surgeon. However, the
role of radiologic and physical exam parameters
remains pivotal, and patient-oriented outcomes
must be viewed as having a critical, though com-
plimentary, role in analyzing the results of treat-
ment.
With the increasing significance
fi of assessment
and accountability, termed by one author as the
“third revolution” of health care (1), orthopaedic
surgeons and researchers have developed a num-
ber of rating scales to assess patients with disor-
ders of the knee. The common goal of these scales
has been the estimation of patients’ symptoms
and disability caused by these knee disorders, and
the degree to which those disorders are addressed
by treatments. However, the impact on individu-
als may vary widely, depending on the individual.
For example, an elderly patient with knee arthrosis
may have vastly diff
fferent degree of disability than
an elite athlete with a ligamentous injury limiting
performance in competitive play. Therefore, rating
systems must be judged not only on their ability to
accurately assess changes in knee pain and mobil-
ity but also on their appraisal of function within
the realm of a given patient population’s goals for
treatment.
This chapter will describe measures of clinical out-
come that may be used to evaluate different
ff treat-
ments for patients with disorders of the knee. ThThe
properties inherent in all rating systems, and the
components that make for a sound and usable
Chapter 9
outcomes tool, will be discussed. Finally, general
health status measures, joint and condition-spe-
cifi
fic instruments, and measures of activity level
will be detailed.
Properties of rating systems
For any rating system to have value, it must be
both reproducible (“reliable”) and accurate (“valid”).
Because outcome tools assess health status, they
must also detect changes over time (“responsiveness”
or “sensitivity to change”), demonstrating improve-
ment or worsening in symptoms, disability, and/or
function, either in the presence or in the absence of
a treatment intervention. Below we will discuss the
commonly utilized criteria of reliability, validity, and
responsiveness in rating systems.
Reliability
If an outcomes instrument measures something
in a reproducible fashion, it is considered reliable.
Assessing the reliability, or reproducibility, of a rat-
ing scale usually entails surveying a stable patient
twice or more in a short period of time, which
should result in very similar or identical scores (2).
This is also known as test-test reliability.
However, the appropriate time period between
administrations of surveys – usually from 2 days
to 2 weeks (3) – must be utilized. Too short of an
interval between testing will allow a patient to
remember their previous answer, while too long
of an interval may permit a subtle change in the
patient’s health status.
The statistical measures of reliability typically uti-
lized are the intraclass correlation coefficient
ffi t (4,5)
and/or the limits of agreement statistic (6–8). The Th
intraclass correlation coeffi
fficient is an index of con-
cordance for dimensional measurements ranging
between zero and one, where ≥0.75 is considered
appropriate for use in a clinical trial (9). It is impor-
tant to diff
fferentiate the intraclass correlation coef-
ficient from the Spearman or Pearson correlation
coeffi
fficients, which do nott measure agreement and
96 The Traumatic Knee
should not be used for studies of reliability. For
instance, if a first measure is twice as high as the
second measure for all subjects in a study of reli-
ability, correlation would be high but agreement
would be poor. The limit of agreement statistic is
a diff
fferent measure, equal to the mean diff fference
between the two tests ± two standard deviations
(7). Ninety-five
fi percent of the diff fferences between
the two tests will lie within this interval (7), pro-
viding the investigator with an estimate of the pre-
cision of the measure.
One factor that may aff ffect reliability is the man-
ner in which a knee scoring system is administered.
Most outcome surveys are completed by patients,
but may also be conducted by an interviewer in per-
son or over the telephone, and many studies have
utilized telephone surveys, due to the difficulties
ffi of
patient follow-up, particularly at longer time peri-
ods. One study has shown that diff fferent scores may
be reported by the same patients, depending on
the technique by which knee scoring systems are
administered (10). However, these authors demon-
strated only a 3-point difffference in scores resulting
from self-administration of the Lysholm knee scale,
compared to those resulting from completion of the
scale by an interviewer with the same patients on
the same day. While this difference
ff was found to
be statistically signifi
ficant, the clinical signifi ficance
of this diff
fference is questionable. Nevertheless, the
findings underscore the importance of consistency
in the methods of collection of outcome measures.
Another method for assessing reliability is known
as internal consistency. Internal consistency is com-
monly reported in the field of psychometrics, a
discipline concerned with the study of educational
and psychological differences
ff between individuals
or groups of individuals, such as those determined
by knowledge, attitude, aptitude, and personality
traits (11). Unlike test-test reliability, calculating
internal consistency involves the inter-correlation
of responses to survey questions on a single admin-
istration, and is described by Cronbach’s alpha,
which ranges from zero to one, with one indicat-
ing perfect reliability (12). While Cronbach’s alpha
has been used to evaluate the reliability of a knee
rating scale (13), the application of psychometric
principles to the measurement of symptoms and
disability remains in question. In practice, ortho-
paedic surveys have been shown to have a high
Cronbach’s alpha value when they measure a wide
range of clinical phenomena (14).
Validity
Validity is the ability of an instrument to measure
what it is designed to measure. Several different
ff
types of validity, or approaches to validation of a
rating scale, have been described. Criterion valid-
ity involves comparing the results of a rating scale
to an accepted “gold” standard. Although a simple
form of survey validation, this is not applicable to
surveys that involve assessment of quality-of-life
(QOL) metrics, since there exists no gold standard.
Face validity is present when an expert clinician
deems that a questionnaire’s components measure
the overall concept being tested. Although simple,
face validity has an important role in the devel-
opment of sound outcome tools. Content validity
is similar to face validity, but measures whether
a scale includes representative samples of the
concept being measured. For example, if a rating
scale was measuring QOL, the content of the scale
should include measures of physical, mental, and
social health to provide adequate content valid-
ity. Construct validity determines whether a survey
behaves in relation to other measures as would
be expected, via the development and testing of
hypotheses regarding the positive or negative cor-
relation of survey results with other related or
unrelated measures or constructs.
Responsiveness
The use of rating scales in orthopaedic surgery is
most commonly geared toward assessment of oper-
ative or non-operative interventions. Therefore,
only instruments that are able to measure improve-
ment in health-related QOL following treatment
are useful. This is the quality of responsiveness, for
which there are many statistics (15,16). TheTh most
commonly utilized statistic in orthopaedic surgery
research is called the standardized response mean,
which is calculated by the observed change divided
by the standard deviation of change (17–19). By
incorporating the standard deviation in the statis-
tic, the response variance is considered and allows
for testing of the response means (20).
Quality of life
While the properties of reliability, validity, and
responsiveness of a rating scale are critical fea-
tures of their design, increasing attention has also
been paid in the past two decades toward the abil-
ity of an outcome measure to incorporate patients’
perspectives on their knee conditions or interven-
tions (3). Subjective sections of knee scales, which
include questions completed by the patients, have
been emphasized as a means by which the scale
measures the frequency and severity of symptoms
and patient function, and, in turn, the degree to
which a patient’s QOL is aff ffected. A recent study
by Tanner et al. analyzed the subjective sections of

11 knee-specifi
fic instruments in 153 patients with
anterior cruciate ligament (ACL) ruptures, isolated
meniscal tears, or osteoarthritis to investigate how
eff
ffectively they assessed QOL (21). They demon-
strated a wide range in the ability of knee scales to
measure patients’ interpretation of their injury or
condition and their perceived improvement expe-
rienced following an intervention, citing different
ff
instruments as being most effffective for evaluating
QOL in each of the three conditions. Clearly, con-
siderations toward the property of QOL assessment
will gain only greater importance in the future, as
new scales are developed and existing scales are
enhanced, with emphasis on the larger goal of
improving patients’ global health and QOL.
Outcome tools for the knee
When considering the variety of outcome tools
that may be used in assessment of disorders of
the knee and their treatments, it is important
to remember the goals of intervention. Not only
should a procedure have a positive effect
ff on the
patient’s symptoms, but that effect
ff should also
translate into improvements in the patient’s activ-
ity level, general health, and QOL. The range of
scoring instruments, from general to specific,
fi are
therefore reviewed, with an emphasis on the goals
of each and their applicability to the various sub-
sets of patients with knee disorders.
Generic and specific
fi outcome tools
Generic health status outcome tools have been
used with increasing frequency in orthopaedic
surgery in recent years. By incorporating a broader
perspective of health, including emotional, social,
mental, and physical components, rather than
attribution to a particular disorder, these instru-
ments allow comparisons across conditions and
treatments (22,23). The
Th drawback of these sur-
veys is that they are generally less responsive to
clinically important change because a change in
an isolated problem may not be reflected
fl in the
score of the more global measure (22,24–26). By
far the most commonly used generic health sta-
tus instrument is the SF-36, a 36-item question-
naire that allows for a measurement of a patient’s
general health, and from which either a physical
component scale (PCS) or a mental component
scale (MCS) can be derived (27–29). Th The use of
the SF-36 is encouraged as a compliment to knee-
specifi
fic instruments for studies of ACL-injured
patients (30)and for patients undergoing total
knee arthroplasty (22).
Scoring the knee 97
By contrast, disease-specific,
fi condition-specifi fic, or
joint-specifi
fic measures have the advantage of being
generally more responsive to change in a specific fi
phenomenon, as well as being more relevant to a
specifi
fic group of patients. Thus a patient’s symp-
toms or complaints can be attributed more directly
to the disorder of interest than a more global
health measure (22,31). For example, a joint-spe-
cifi
fic instrument for the knee may ask patients if
they have diffi
fficulty getting dressed due to their knee
problem.
Knee rating scales for athletic patients
A number of diff fferent scales have been developed
to assess outcome in athletic patients with knee
disorders. While there is a wide range in levels of
competition and activity levels amongst athletes,
nine of the most commonly used knee rating scales
for athletic patients are described below, most of
which have been applied to a variety of athletic
sub-populations.
The modified
fi Lysholm knee scale (32) is an eight-
item questionnaire that was designed in 1982 and
subsequently modifi fied 3 years later to evaluate
patients following knee ligament surgery (33). Th The
100-point scale is divided into 25 possible points
for knee stability, 25 for pain, 15 for locking, 10
each for swelling and stair climbing, and 5 each
for limp, use of a support, and squatting (32). ThThe
Lysholm scale, which has been used extensively
for clinical research studies (30,34–36), has been
demonstrated to have adequate test-retest reliabil-
ity and construct validity not only for evaluating
patients with injuries and treatment for ligamen-
tous disorders of the knee but also for patients with
chondral and meniscal injuries as well (33,37–39).
Modififications of the Cincinnati Knee Rating System,
first published in 1983, incorporated additional
questions that considered occupational activi-
ties, athletic activities, symptoms, and functional
limitations with sports and daily activities (40,41).
Among the instrument’s 11 components are sec-
tions for physical examination findings, laxity of
the knee based on instrumented testing, and radio-
graphic evidence of degenerative joint disease (42).
This instrument is reliable, valid, and responsive to
clinical change (39,42).
The American Academy of Orthopaedic Surgeons
(AAOS) Sports Knee Rating Scale (43), was pub-
lished in 1998 as part of the Musculoskeletal Out-
comes Data Evaluation and Management System
(MODEMS). It contains 23 questions in five fi sub-
sections – designed to be reported separately –
which evaluate the following metrics: (1) stiffness,
ff
swelling, pain, and function (seven questions); (2)
a locking or catching during activity (four ques-
98 The Traumatic Knee
tions); (3) giving way during activity (four ques-
tions); (4) current activity limitations due to the
knee (four questions); (5) pain during activity due
to the knee (four questions). When the fi five sub-
scales are combined for a calculated mean, the
measurement properties of this instrument were
found to be satisfactory (39). However, one practi-
cal limitation of the instrument is its inclusion of a
possible response of “cannot do for other reasons”
for many questions. The scoring manual states that
such an item should be “dropped” for this response,
which may be interpreted as a missing score (39).
Th Activities of Daily Living Scale of the Knee Out-
The
come Survey, designed to assess outcome in patients
with knee arthrosis as well as various sports-related
injuries and disorders, has a 7-question section for
symptoms and a 10-question section for functional
disability. Analysis has demonstrated good reliabil-
ity, excellent construct validity, and higher rates of
responsiveness than the Lysholm, Cincinnati, and
AAOS scales (13,39). The questions that make up
this tool are presented in Appendix A.
Th Single Assessment Numeric Evaluation (SANE)
The
is a uniquely simple rating scale in which patients
are asked to rate their knee, from 0 to 100, with
100 being normal. While the wider applicability
of the instrument for a range of knee disorders
remains unclear, its utility for evaluating college-
age patients following ACL reconstruction has
been borne out in one study showing high corre-
lation with the Lysholm scale in this narrow sub-
population, which it was designed to study (44).
The Knee Injury and Osteoarthritis Outcome Score
(KOOS) was developed with input from patients
who underwent meniscal surgery, but has also been
shown to have adequate reliability, validity, and
responsiveness in patients undergoing ACL recon-
struction (45). There
Th are five diff
fferent sections in
the instrument, specifi fically those for pain, symp-
toms, activities of daily living, sport, and recreation
function and knee-related QOL. One benefit fi of the
KOOS is that the Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC) scale,
a commonly used instrument for assessing outcome
in patients with osteoarthritis, is included in, and
can be determined from, the KOOS. A recent study
analyzing outcomes in patients with a mean age
of 71 having undergone total knee replacements
(TKRs) suggested that the KOOS had similar or
improved validity and responsiveness, compared to
the WOMAC, suggesting its applicability to a very
diff
fferent patient population (46).
Developed in 1998, the quality of life outcome mea-
sure for chronic anterior cruciate ligament defificiency
has 31 questions constructed by surveying ACL-
defi
ficient patients, primary care sports medicine
physicians, orthopaedic surgeons, athletic thera-
pists, and physical therapists (47). The
Th instrument
considers symptoms, physical complaints, work-
related concerns, recreational activities, sports
participation, lifestyle, and social and emotional
health status as they relate to the knee. However,
the measure is limited by its narrow role in the
assessment of ACL-defi ficient patients, for whom it
has been shown to have satisfactory validity and
responsiveness (47).
In 1993, the International Knee Documentation
Committee (IKDC) presented a seven-parameter
scale in which the clinician or “observer” graded
each of the following as normal, nearly normal,
abnormal, or severely abnormal: effusion,
ff motion,
ligament laxity, crepitus, harvest site pathology,
x-ray findings, and one-leg hop test (48). This scale
was unique in that it was designed to be applied
more broadly to a wider range of knee disorders
than most of the other, more specific fi scales, as well
as the approach utilized for scoring, in which the
lowest grade for a parameter determines the final fi
patient grade. More recently, the IKDC Subjective
Knee Form was synthesized. Like the initial form,
it was constructed to be knee specific, fi rather than
disease specific.
fi However, the score was deter-
mined exclusively from patient responses to ques-
tions regarding knee symptoms, sports activities,
and functional abilities, such as walking stairs,
squatting, running, and jumping. Validation and
reliability studies showed internal consistency and
test-retest reliability of 0.92 and 0.95, respectively,
as well as a correlation to concurrent measures of
physical function (rr = 0.47 to 0.66) (49). Not only
does the IKDC Subjective Knee Form allow com-
parisons of outcome across groups with differentff
knee problems, newly published normative data,
calculated from a compilation of scores for 5246
knees from the general population, will allow for
comparisons of patient scores to age- and gender-
matched peers (50).
Knee rating scales for patients with degenerative
disorders of the knee
Outcome measures geared toward assessment of
knee arthritis or other degenerative knee disor-
ders tend to diff
ffer slightly from those investigating
knee symptoms and function in athletic patients,
in that they survey greater degrees of disability,
overall.
In one of the first outcome studies on TKR, Rana-
wat and Shine presented a new scale from the Hos-
pital for Special Surgery for “knee disability assess-
ment” in 1973 (51). Three years later the scale was
modifified slightly and presented in a study by Insall
et al. (52), which compared outcomes following
four difffferent models of TKR prostheses. What
became known as the HSS Knee Scale has a maxi-

mum score of 100 points, with 30 for pain, 22 for
function, 18 for range of motion, 10 for strength,
10 for flexion deformity, 10 for instability, and sub-
tractions for walking aids, extension lag, or varus/
valgus deformity. Total scores are divided into
“excellent” (>85), “good” (70–84), “fair” (60–69),
or “poor” (<60). While some feel the HSS Knee Scale
has been superceded by more recently developed
instruments (23), overall it has been shown to
have good interobserver reliability (53) and is one
of the most commonly utilized scales in knee sur-
gery (23). Moreover, its use has extended beyond
patients with knee arthritis, including assessment
of operative and non-operative treatment of ACL
rupture (54–56).
The American Knee Society Score (AKS) is an out-
come measure instrument developed by Insall et
al. in 1989 (57), in which trained assessors evalu-
ate candidates for knee arthroplasty or post-TKR
patients. It features two parts: the knee score,
in which pain, stability, and range of motion are
considered, and the function score, of which walk-
ing distance and stair climbing are the most sig-
nifi
ficant parameters. The use of this tool is limited
by its need for administration by an experienced
observer, such as a clinician trained in arthroplasty
surgery, a limitation borne out by an interobserver
reliability study in which scoring by assessors with
varying levels of training was analyzed (58).
Like the AKS, the index of severity for osteoarthritis of
the knee (59) was developed in 1987 as an observer-
administered questionnaire. However, a validated
version allowing for independent patient comple-
tion (60) has made the survey (also referred to as
the Lequesne-algofunctional index)x more applicable.
It contains five pain questions, one walking ques-
tion, and four activities of daily living questions,
and is therefore relatively short and easy to use.
The Oxford Knee Scale (OKS) includes 12 multiple-
choice questions, each with 5 responses. It has
been demonstrated, with a prospective group of
117 patients undergoing TKA, to be reliable, valid,
and responsive (61–63).
The Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC) (64–66) includes 5
questions relating to pain, 2 relating to stiffness,
ff
and 17 relating to diffi
fficulty with activities of daily
living (see Appendix B). The
Th scale is the most fre-
quently used scale for arthrosis, for which it has
high responsiveness and validity (22,60,67).
Measures of activity level for patients with disorders
of the knee
For studies comparing two groups of patients, it is
important for the activity levels of the two groups
to be similar in order to avoid a biased comparison
Scoring the knee 99
(68). Therefore, a number of activity level rating
scales have been developed, generally to be used in
conjunction with outcome instruments. Use of these
scales is critical not only to differentiate
ff athletic
patients from more sedentary arthritis patients but
also to make distinctions within subgroups, such as
highly active post-arthroplasty patients from house-
hold ambulators or middle-aged “weekend warriors”
from elite professional athletes, each of which may
warrant separate analysis.
One of the most commonly utilized activity level
rating scales is the Tegner Activity Scale, which
was introduced in 1985 as a complement to the
Lysholm functional outcome measure for patients
treated for knee ligament instability (32). Th The
Tegner score ranges from 0 to 10, with 10 repre-
senting participation in elite, competitive sports
and 6 in recreational sports. In addition to its role
in assessing patients with ligamentous knee injury,
the Tegner Activity Scale has been shown to have
reliability, validity, and responsiveness for patients
with a meniscal injury of the knee (37).
Interestingly, a recent systematic literature review
(68) analyzed five activity level rating scales that
are potentially applicable to outcome studies in
sports (32,69–72). Inherent problems with each
of the instruments were discussed, including those
with the Tegner Activity Scale. As a result, a new
rating scale – with four questions on the frequency
of running, cutting, pivoting, and decelerating –
was developed specifi fically for knee outcome stud-
ies in the athletic population (68). It has been
demonstrated to be reliable and valid (68). Since
its introduction in 2001, a number of studies have
referenced the scale in analysis of outcomes related
to knee interventions (37,73–75). It has also been
cited as a model in studies proposing activity scales
for the ankle (76) and shoulder (77).
More recently, a lower-extremity activity scale
(LEAS) designed to measure activity levels among
a broader population of patients, including those
undergoing knee arthroplasty, was developed (75).
The LEAS was constructed to refl flect four major
levels of lower extremity activity: (1) housebound
(minimal ability or inability to walk), (2) ordinary
walking about the house, (3) walking about the
community, and (4) walking about the commu-
nity and substantial work or exercise. Saleh et al.
demonstrated high responsiveness, reliability, and
validity in a cohort of patients who underwent
revision total knee arthroplasty (75).
Knee rating scales: the international perspective
A recent surge of literature has emerged in which
translations, validations, and cross-cultural adap-
tation of English-language-based knee scores
100 The Traumatic Knee
are performed (62,78–81). For example, the
WOMAC scale has been translated into a num-
ber of languages with accompanying validation
analyses (62,64,79). This
Th is an important trend,
in part because it permits enrollment of foreign-
speaking patients into studies in English-speak-
ing countries. More importantly, surgeons and
researchers throughout the international ortho-
paedic and rheumatologic community are able
to utilize common analytical tools in outcome
research, and their results become more broadly
interpretable and applicable to a larger health
care population.
Conclusion
A wide variety of knee scoring systems have been
developed for use by clinicians and researchers
alike. We have summarized the knee scoring sys-
tems in a quick reference table grouped by type (see
Table 1). Understanding the fundamental proper-
ties of a rating scale, and choosing the appropriate
instrument for a particular cohort of patients, is
critical to the optimization of any outcome analy-
sis – from a sophisticated, multi-center clinical
trial to a simple follow-up assessment in the office.
ffi
As evidence-based medicine practices continue to
Table 1 – Scoring system for the knee.
Scoring Systems for the Knee
Category Scoring System
General Short Form 36 (SF-36)
Modified Lysholm Scale
Cincinnati Knee Rating System
AAOS Sports Knee Rating Scale
Sports- ADL Scale of the Knee Outcome Survey
Related Knee
Single Assessment Numeric Evaluation (SANE)
Injuries &
Conditions Knee Injury and Osteoarthritis Outcome Score (KOOS)
Quality of Life for Chronic ACL Deficiency
International Knee Documentation Committee (IKDC)
IKDC Subjective Knee Form
West. Ontario/McMaster U. Osteoarthritis Index (WOMAC) 1998
Index of Severity for Knee Disease
Degenerative
Knee MODEMS Knee Core Rating Scale
Disease & Oxford Knee Scale
Arthroplasty
American Knee Society (AKS) Scale
Hospital for Special Surgery (HSS) Knee Score
Tegner Activity Scale
Activity
Marx Activity Scale
Scales
Lower-Extremity Activity Scale (LEAS)
become more widely accepted and broadly incorpo-
rated into the subspecialty of orthopaedic surgery
and the field of health care at large, such an under-
standing will not only enhance one’s skill set but
also help to improve the delivery of health care to
those in need.
References
1. Relman AS (1988) Assessment and accountability:
the third revolution in medical care. N Engl J Med
319(18):1220–1222
2. Streiner DL, Norman GR (1989) Health measurement
scales: a practical guide to their development and use.
Oxford: Oxford University Press
3. Marx RG, Menezes A, Horovitz L, et al. (2003) A com-
parison of two time intervals for test-retest reliability of
health status instruments. J Clin Epidemiol 56(8):730–
735
4. Bartko JJ (1966) The
Th intraclass correlation coeffi
fficient as a
measure of reliability. Psychol Rep 19(1):3–11
5. Deyo RA, Diehr P, Patrick DL (1991) Reproducibility
and responsiveness of health status measures: statistics
and strategies for evaluation. Control Clin Trials 12(4
Suppl):142S–58S
6. Bland JM, Altman DG (1995) Comparing methods of
measurement: why plotting diff fference against standard
method is misleading. Lancet 346(8982):1085–1087
7. Bland JM, Altman DG (1990) A note on the use of the
intraclass correlation coeffi
fficient in the evaluation of
agreement between two methods of measurement. Com-
put Biol Med 20(5):337–340
Introduction Brief Description
1993 Generic measure of general health
1985 Emphases on ligament stability, pain
1983 Diverse measures for athletic patients
1998 Specific component of the more generic MODEMS
1998 Impact of range of disorders on activities of daily living
2000 Specific for college-age patients undergoing ACL surgery
1998 Assesses pain, symptoms, sport/recreation function, quality of life
1998 Very specific measure for non-op pts
1993 Seven 'objective' parameters; lowest score used
2001 Assesses symptoms, sports activities and ability to function
Most commonly used scale for osteoarthritis
1987 Developed for NSAID clinical trials
1998 Subset of MODEMS specific for osteoarthritis
1998 Developed for patients undergoing total knee arthroplasty
1989 Interviewer assesses TKR candidates or post-op patients
1973 Assesses pain, function, ROM, strength, deformity, stability
1985 Determines patients' activity level; used w/ outcome scores
2001 Assesses running, cutting, pivoting, and decelerating
2005 Assesses activity in patients undergoing TKR

8. Bland JM, Altman DG (1986) Statistical methods for
assessing agreement between two methods of clinical
measurement. Lancet 1(8476):307–310
9. Rosner B (1995) Fundamentals of biostatistics. Toronto:
Duxbury Press
10. Hoher J, Bach T, Munster A, et al. (1997) Does the mode of
data collection change results in a subjective knee score?
Self-administration versus interview. Am J Sports Med
25(5):642–647
11. Wright JG, Feinstein AR (1992) A comparative contrast
of clinimetric and psychometric methods for constructing
indexes and rating scales. J Clin Epidemiol 45(11):1201–
1218
12. Nunnally JC, Bernstein IH (1994) Psychometric theory.
New York: McGraw-Hill, Inc.
13. Irrgang JJ, Snyder-Mackler L, Wainner RS, et al. (1998)
Development of a patient-reported measure of function
of the knee. J Bone Joint Surg Am 80(8):1132–1145
14. Marx RG, Bombardier C, Hogg-Johnson S, Wright JG
(1999) Clinimetric and psychometric strategies for devel-
opment of a health measurement scale. J Clin Epidemiol
52(2):105–111
15. Beaton DE, Hogg-Johnson S, Bombardier C (1997) Evalu-
ating changes in health status: Reliability and responsive-
ness of five generic health status measures in workers with
musculoskeletal disorders. J Clin Epidemiol 50(1):79–93
16. Wright JG, Young NL (1997) A comparison of different ff
indices of responsiveness. J Clin Epidemiol 50(3):239–246
17. Kirkley A, Griffi
ffin S, McLintock H, Ng L (1998) The devel-
opment and evaluation of a disease-specifi fic quality of life
measurement tool for shoulder instability. Th The Western
Ontario shoulder instability index (WOSI). Am J Sports
Med 26(6):764–772
18. L’Insalata JC, Warren RF, Cohen SB, et al. (1997) A self-
administered questionnaire for assessment of symptoms
and function of the shoulder. J Bone Joint Surg Am
79(5):738–748
19. Martin DP, Engelberg R, Agel J, Swiontkowski MF (1997)
Comparison of the musculoskeletal function assess-
ment questionnaire with the short form-36, the Western
Ontario and McMaster universities osteoarthritis index,
and the sickness impact profile fi health-status measures. J
Bone Joint Surg Am 79(9):1323–1335
20. Liang MH, Fossel AH, Larson MG (1990) Comparisons of
five health status instruments for orthopedic evaluation.
Med Care 28(7):632–642
21. Tanner SM, Dainty KN, Marx RG, Kirkley A (2007) Knee-
specific
fi quality-of-life instruments: which ones measure
symptoms and disabilities most important to patients?
Am J Sports Med 35(9):1450–1458
22. Bombardier C, Melfi fi CA, Paul J, et al. (1995) Comparison
of a generic and a disease-specific fi measure of pain and
physical function after knee replacement surgery. Med
Care 33(4 Suppl): AS131–AS144
23. Davies AP (2002) Rating systems for total knee replace-
ment. Knee 9(4):261–266
24. Guyatt GH, Feeny DH, Patrick DL (1993) Measuring
health-related quality of life. Ann Intern Med 118(8):622–
629
25. MacKenzie CR, Charlson ME, DiGioia D, Kelley K (1986)
A patient-specifific measure of change in maximal function.
Arch Intern Med 146(7):1325–1329
26. MacKenzie CR, Charlson ME, DiGioia D, Kelley K (1986)
Can the sickness impact profi file measure change? An exam-
ple of scale assessment. J Chronic Dis 39(6):429–438
27. McHorney CA, Ware JE, Jr., Raczek AE (1993) The Th MOS
36-item short-form health survey (SF-36): II. Psychomet-
ric and clinical tests of validity in measuring physical and
mental health constructs. Med Care 31(3):247–263
28. McHorney CA, Ware JE, Jr., Rogers W, et al. (1992) The Th
validity and relative precision of MOS short- and long-
Scoring the knee 101
form health status scales and dartmouth COOP charts.
Results from the medical outcomes study. Med Care 30(5
Suppl): MS253–MS265
29. Ware JEJ, Snow KK, Kosinski M, Gandek B (1993) SF-36
health survey manual and interpretation guide. Boston:
The Health Institute
30. Shapiro ET, Richmond JC, Rockett SE, et al. (1996) The Th
use of a generic, patient-based health assessment (SF-36)
for evaluation of patients with anterior cruciate ligament
injuries. Am J Sports Med 24(2):196–200
31. Bergner M, Rothman ML (1987) Health status measures:
an overview and guide for selection. Annu Rev Public
Health 8:191–210
32. Tegner Y, Lysholm J (1985) Rating systems in the evalu-
ation of knee ligament injuries. Clin Orthop Relat Res
198:43–49
33. Lysholm J, Gillquist J (1982) Evaluation of knee ligament
surgery results with special emphasis on use of a scoring
scale. Am J Sports Med 10(3):150–154
34. Gauffi
ffin H, Pettersson G, Tegner Y, Tropp H (1990) Func-
tion testing in patients with old rupture of the anterior
cruciate ligament. Int J Sports Med 11(1):73–77
35. Odensten M, Hamberg P, Nordin M, et al. (1985) Surgi-
cal or conservative treatment of the acutely torn anterior
cruciate ligament. A randomized study with short-term
follow-up observations. Clin Orthop Relat Res 198:87–93
36. Roberts TS, Drez D, Jr., McCarthy W, Paine R (1991) Ante-
rior cruciate ligament reconstruction using freeze-dried,
ethylene oxide-sterilized, bone-patellar tendon-bone
allografts. Two year results in thirty-six patients. Am J
Sports Med 19(1):35–41
37. Briggs KK, Kocher MS, Rodkey WG, Steadman JR (2006)
Reliability, validity, and responsiveness of the Lysh-
olm knee score and Tegner activity scale for patients
with meniscal injury of the knee. J Bone Joint Surg Am
88(4):698–705
38. Kocher MS, Steadman JR, Briggs KK, et al. (2004) Reli-
ability, validity, and responsiveness of the Lysholm knee
scale for various chondral disorders of the knee. J Bone
Joint Surg Am 86-A(6):1139–1145
39. Marx RG, Jones EC, Allen AA, et al. (2001) Reliability,
validity, and responsiveness of four knee outcome scales
for athletic patients. J Bone Joint Surg Am 83-A(10):1459–
1469
40. Noyes FR, Matthews DS, Mooar PA, Grood ES (1983)
The symptomatic anterior cruciate-defi ficient knee. Part
II: The results of rehabilitation, activity modifi fication, and
counseling on functional disability. J Bone Joint Surg Am
65(2):163–174
41. Noyes FR, Mooar PA, Matthews DS, Butler DL (1983) The Th
symptomatic anterior cruciate-deficient fi knee. Part I: The
long-term functional disability in athletically active indi-
viduals. J Bone Joint Surg Am 65(2):154–162
42. Barber-Westin SD, Noyes FR, McCloskey JW (1999) Rigor-
ous statistical reliability, validity, and responsiveness test-
ing of the Cincinnati knee rating system in 350 subjects
with uninjured, injured, or anterior cruciate ligament-re-
constructed knees. Am J Sports Med 27(4):402–416
43. American Academy of Orthopaedic Surgeons (1998) Scor-
ing algorithms for the lower limb outcomes data collection
instrument version 2.0
44. Williams GN, Taylor DC, Gangel TJ, (2000) Comparison of
the single assessment numeric evaluation method and the
Lysholm score. Clin Orthop Relat Res 373:184–192
45. Roos EM, Roos HP, Lohmander LS, et al. (1998) Knee injury
and osteoarthritis outcome score (KOOS) – development
of a self-administered outcome measure. J Orthop Sports
Phys Ther 28(2):88–96
46. Roos EM, Lohmander LS (2003) The knee injury and
osteoarthritis outcome score (KOOS): from joint injury to
osteoarthritis. Health Qual Life Outcomes 1(1):64
102 The Traumatic Knee
47. Mohtadi N (1998) Development and validation of the
quality of life outcome measure (questionnaire) for
chronic anterior cruciate ligament defificiency. Am J Sports
Med 26(3):350–359
48. Hefti F, Muller W (1993) Current state of evaluation of
knee ligament lesions. The Th new IKDC knee evaluation
form. Orthopade 22(6):351–362
49. Irrgang JJ, Anderson AF, Boland AL, et al. (2001) Develop-
ment and validation of the international knee documenta-
tion committee subjective knee form. Am J Sports Med
29(5):600–613
50. Anderson AF, Irrgang JJ, Kocher MS, et al. (2006) Interna-
tional Knee Documentation Committee. The international
knee documentation committee subjective knee evaluation
form: Normative data. Am J Sports Med 34(1):128–135
51. Ranawat CS, Shine JJ (1973) Duo-condylar total knee
arthroplasty. Clin Orthop Relat Res 94:185–195
52. Insall JN, Ranawat CS, Aglietti P, Shine J (1976) A com-
parison of four models of total knee-replacement prosthe-
ses. J Bone Joint Surg Am 58(6):754–765
53. Bach CM, Nogler M, Steingruber IE, et al. (2002) Scoring
systems in total knee arthroplasty. Clin Orthop Relat Res
399:184–196
54. Buss DD, Min R, Skyhar M, et al. (1995) Nonoperative
treatment of acute anterior cruciate ligament injuries in
a selected group of patients. Am J Sports Med 23(2):160–
165
55. Buss DD, Warren RF, Wickiewicz TL, et al. (1993)
Arthroscopically assisted reconstruction of the ante-
rior cruciate ligament with use of autogenous patellar-
ligament grafts. Results after twenty-four to forty-two
months. J Bone Joint Surg Am 75(9):1346–1355
56. Plancher KD, Steadman JR, Briggs KK, Hutton KS
(1998) Reconstruction of the anterior cruciate ligament
in patients who are at least forty years old. A long-term
follow-up and outcome study. J Bone Joint Surg Am
80(2):184–197
57. Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale
of the knee society clinical rating system. Clin Orthop
Relat Res 248:13–14
58. Liow RY, Walker K, Wajid MA, et al. (2000) The Th reliabil-
ity of the american knee society score. Acta Orthop Scand
71(6):603–608
59. Lequesne MG, Mery C, Samson M, Gerard P (1987)
Indexes of severity for osteoarthritis of the hip and knee.
Validation – value in comparison with other assessment
tests. Scand J Rheumatol Suppl 65:85–89
60. Theiler R, Sangha O, Schaeren S, et al. (1999) Superior
responsiveness of the pain and function sections of the
Western Ontario and McMaster universities osteoar-
thritis index (WOMAC) as compared to the Lequesne-
algofunctional index in patients with osteoarthritis of the
lower extremities. Osteoarthritis Cartilage 7(6):515–519
61. Dawson J, Fitzpatrick R, Murray D, Carr A (1998) Ques-
tionnaire on the perceptions of patients about total knee
replacement. J Bone Joint Surg Br 80(1):63–69
62. Dunbar MJ, Robertsson O, Ryd L, Lidgren L (2000) Trans-
lation and validation of the Oxford-12 item knee score for
use in Sweden. Acta Orthop Scand 71(3):268–274
63. Whitehouse SL, Blom AW, Taylor AH, et al. (2005)
The Oxford knee score; problems and pitfalls. Knee
12(4):287–91
64. Bellamy N (1995) Outcome measurement in osteoarthri-
tis clinical trials. J Rheumatol Suppl 43:49–51
65. Bellamy N, Sothern RB, Campbell J (1990) Rhythmic vari-
ations in pain perception in osteoarthritis of the knee. J
Rheumatol 17(3):364–372
66. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J,
Stitt LW (1988) Validation study of WOMAC: a health
status instrument for measuring clinically important
patient relevant outcomes to antirheumatic drug therapy
in patients with osteoarthritis of the hip or knee. J Rheu-
matol 15(12):1833–1840
67. Kirkley A, Webster-Bogaert S, Litchfield
fi R, et al. (1999)
The eff
ffect of bracing on varus gonarthrosis. J Bone Joint
Surg Am 81(4):539–548
68. Marx RG, Stump TJ, Jones EC, et al. (2001) Development
and evaluation of an activity rating scale for disorders of
the knee. Am J Sports Med 29(2):213–218
69. Daniel DM, Stone ML, Dobson BE, et al. (1994) Fate of the
ACL-injured patient. A prospective outcome study. Am J
Sports Med 22(5):632–644
70. Noyes FR, Barber SD, Mooar LA (1989) A rationale for
assessing sports activity levels and limitations in knee dis-
orders. Clin Orthop Relat Res 246:238–249
71. Seto JL, Orofi fino AS, Morrissey MC, et al. (1988) Assess-
ment of quadriceps/hamstring strength, knee ligament
stability, functional and sports activity levels five years
after anterior cruciate ligament reconstruction. Am J
Sports Med 16(2):170–180
72. Straub T, Hunter RE (1988) Acute anterior cruciate liga-
ment repair. Clin Orthop Relat Res 227:238–250
73. Gobbi A, Francisco R (2006) Factors aff ffecting return to
sports after anterior cruciate ligament reconstruction
with patellar tendon and hamstring graft: a prospec-
tive clinical investigation. Knee Surg Sports Traumatol
Arthrosc 14(10):1021–1028
74. Mithoefer K, Williams RJ, 3rd, Warren RF, et al. (2006)
High-impact athletics after knee articular cartilage repair:
a prospective evaluation of the microfracture technique.
Am J Sports Med 34(9):1413–1418
75. Saleh KJ, Mulhall KJ, Bershadsky B, et al. (2005) Devel-
opment and validation of a lower-extremity activity scale.
Use for patients treated with revision total knee arthro-
plasty. J Bone Joint Surg Am 87(9):1985–1994
76. Halasi T, Kynsburg A, Tallay A, Berkes I (2004) Develop-
ment of a new activity score for the evaluation of ankle
instability. Am J Sports Med 32(4):899–908
77. Brophy RH, Beauvais RL, Jones EC, et al. (2005) Measure-
ment of shoulder activity level. Clin Orthop Relat Res
439:101–108
78. Roos EM, Roos HP, Ekdahl C, Lohmander LS (1998)
Knee injury and osteoarthritis outcome score (KOOS) –
validation of a Swedish version. Scand J Med Sci Sports
8(6):439–448
79. Wigler I, Neumann L, Yaron M (1999) Validation study of
a Hebrew version of WOMAC in patients with osteoarthri-
tis of the knee. Clin Rheumatol 18(5):402–405
80. Xie F, Li SC, Lo NN, Yeo SJ, et al. (2007) Cross-cultural
adaptation and validation of Singapore, English and Chi-
nese versions of the Oxford knee score (OKS) in knee
osteoarthritis patients undergoing total knee replace-
ment. Osteoarthritis Cartilage 15(9):1019–1024
81. Xie F, Thumboo J, Lo NN, et al. (2007) Cross-cultural adap-
tation and validation of Singapore, English and Chinese
versions of the Lequesne algofunctional index of knee in
Asians with knee osteoarthritis in Singapore. Osteoarthri-
tis Cartilage 15(1):19–26
 Appendix A – Activities of daily living scale 103

Appendix A – Activities of daily living scale

104 The Traumatic Knee
 Appendix B – Womac knee scale 105

Appendix B – Womac knee scale

The Menisci

J.C. Panisset, J.L. Prudhon Arthroscopic meniscectomy
Summary
T
he basic principles of arthroscopic menis-
cectomy are described. After reminding the
diff
fferent installations and the diff
fferent ens-
sential and complementary instruments, menis-
cectomy techniques are described making the dif-
ference between the lateral meniscectomy and the
medial meniscectomy.
Introduction
The knee arthroscopy (1) <Comp: Delete the
endnotes, in superscript, once the reference
list is properly styled.>is successful thanks to
the first pioneers and meniscectomy is no more
achieved through arthrotomy anymore. This
technical procedure requires a long training to
get a great efficiency and an innocuous menis-
cectomy implementation. An important learn-
ing curve is needed to achieve easily and safely a
meniscectomy for the patient. The bases of this
surgery must be accurately acquired to answer
to the different pathologic situations of the
meniscus.
We have made the difference between the medial
meniscectomy and the lateral meniscectomy,
which must be carried out differently since they
have their own characteristics. Actually, the por-
tals are not the same, and the installation may
be slightly different. Postoperative management
is also not comparable. Arthroscopy for menis-
cectomies remains a surgical procedure with
possible risks. These risks must be precisely
assessed and explained to the patient. To con-
clude, a meniscectomy will only be carried out
after an accurate diagnosis, requiring modern
imagery; arthrography, arthro-scanner, and
MRI. The expected time for recovery is short,
but long terms consequences will be explained
to the patient.
Chapter 10
Installation
Tourniquet
Its use has become systematic for a better sur-
geon comfort. Actually, by avoiding any bleeding
we improve the intra-joint visibility. Nevertheless,
several studies (2–4) have shown that muscular
cells could be altered, which is proved by electro-
myographic modifications.
fi These alterations are
visible among 22% of patients after 15 min of tour-
niquet and among 80% of patients after 60 min of
tourniquet, which is an exceptional case after a
meniscectomy. The revolving to normal state can
last for several months (5–6 months), without any
long-term damage.
Some studies have shown (5) that the use of tour-
niquet was increasing the post-surgery pains and
the risk of post-surgery complications and, above
all, had a negative effffect on physiotherapy, essen-
tially from the muscular sideration.
So, it is absolutely possible and better to achieve a
meniscectomy without any tourniquet, above all,
after a period of training.
Therefore, the use of tourniquet must last a
short time. Obviously, the counter-indications
must be respected, such as the vascular ante-
cedents. An irrigation of good quality must be
respected to allow a good intra-joint visibility
with or without tourniquet. The current use of
an arthro-pump can also be an alternative to the
tourniquet use.
The installation
There are two main possible installations, accord-
ing to the surgeon habits:
– Patient is installed in dorsal decubitus, the leg
being free at the end of the table, with the thigh
fastened.
– Patient supine the lower limb lying down on
the table, with a wedge on the lateral side of the
thigh, and another wedge at the end of the foot
(Fig. 1).
110 The Traumatic Knee
Fig. 1 – classical installation , patient in dorsal decubitus.
Each of these installations has its own advantages
and disadvantages.
• The pendent leg position enables to carry out
an arthroscopy without any lateral help, and the
thigh fixation permits a good control of rota-
tions that is very important in meniscectomies.
The exploration of the lateral compartment is
made without the Cabot handling, which tends
to obstruct the irrigation of this compartment.
Nevertheless, patello-femoral joint exploration is
diffi
fficult and requires an extension of the patient’s
foot against the examiner. On the other hand,
there are more important asepsis mistakes due to
the low position of the foot.
• The position of the lying leg enables an excellent
vision of the femoro-patellar joint; it requires
the Cabot handling for the exploration of the lat-
eral compartment and procedures on the lateral
meniscus. This Cabot handling is achieved by put-
ting the foot on the opposed knee, while imposing
a flexion and a slight varus constraint. The whole
lateral meniscus is visualized by this technique.
For the exploration of the medial meniscus, a val-
gus constraint is held by positioning the foot on
the arthroscopist’s hip. Thus, by playing with the
flexion and extension of the knee, the exploration
fl
of the medial compartment is carried out without
any diffi
fficulty. We must keep moderated on the
valgus constraints as the developed strength can
be important and risks of medial collateral liga-
ment lesions are possible (Picture 2).
Irrigation
There are two possibilities to achieve a meniscec-
tomy:
– Simple irrigation by gravity using physiological
salt solution, which drip is placed at a high level
to get a good intra-joint pressure; in addition, a
blood pressure cuff
ff could be interesting.
– Arthro-pump, which enables a constant pressure
in the joint, the pressure adjusted on the blood
pressure, limiting the bleeding in case of no tour-
Fig. 2 – Valgus constraint to open the medial compartment.
niquet. This pressure must be weak to avoid any
risk of compartmental syndrome.
The first technique is the most often used for a
meniscectomy since it enables a suffi fficient rinsing
out of the joint. Th
The second benefi
fit is to be economi-
cal too. The arthro-pump is often used with a shaver,
so the indication will depend on the use of this tool,
which is quite useful in degenerative lesions.
The instrumentation
Equipment has highly evolved since the origin of
arthroscopy. To achieve a meniscectomy, few tools
are required. They must be chosen with care and
experimented before purchase, because of their
high cost.
We have the choice between motorized tools
(shaver), whose use in meniscectomies is not
compulsory. Arthroscopic optics and a camera are
unavoidable. The ideal optics is generally a great
angular optics (25° or 30°), and a 70° optics is
rarely necessary. The
Th optics will be selected to be
autoclave to answer to the modern specifications
fi
of sterilization. The camera will be mono CCD or
three CCD type. TheTh first type is highly suffi
fficient
for the meniscectomy procedures. Arthro trocar
sleeve enables the penetration of the optics in the
knee and the frontal irrigation opposite the arthro-
scope itself, which improves the display.
Non-motorized tools
The palpater hook is the first instrument that is
introduced into the knee by the instrumental por-
tal. There must be a 3-mm mossy hook at its end
to palpate without producing cartilage injuries.
It must be suffi
fficiently rigid to enable a meniscus
reduction. Thanks to its size, we can assess the
spread and the depth of injuries. With the gradu-
ations on its surface, we can appreciate the size of
the lesions.
Basket forceps, named rongeurs, are unavoid-
able since they enable to perform or to complete
a meniscectomy. Many types come to the market

with difffferent sizes, diff
fferent shapes, and several
angulations.
The basic surgery box must contain a right 3.5-mm
forceps that can reach the posterior segment and a
90° angled forceps working on the meniscus ante-
rior segment. It can be completed with bigger ron-
geurs of 4.5 and 5 mm, providing a faster splitting
up of the meniscus tissue, in the most easily acces-
sible zones.
Many rongeurs come to the market; with distal
angulations, with a handle curved to the right or
to the left. These diff fferent types of rongeurs are
very practical and can perform an easier meniscec-
tomy. Their use is not unavoidable, and their cost
is high.
The most useful rongeur is the one which permits to
slide under the condyle without the risks of produc-
ing cartilage lesions. For this purpose, it must be of
double curve with upper concavity in its distal third.
It is commonly named «curved on the fl flat side».
Scissors are useful to start a meniscectomy in
medium segment elegantly, their use is not advis-
able in posterior segment since they are very
bulky and the cartilage lesion risk is high. Th There
are straight scissors and angled scissors at their
end to choose a more accurate and proper angle. A
3.5-mm diameter seems to be a good compromise
between effi fficiency and low bulking.
The forceps is essential; this forceps in its prin-
ciple presents two small teeth at its ends, which
are going to bite the meniscus. It is aimed either to
remove a free fragment from the joint or to draw
the meniscus that is not still detached (three-por-
tal technique). Its use is only recommended in the
anterior compartment of the joint. Actually, since
it is bulky, its passage through the condyle is lim-
ited. It is advisable to select a forceps whose open-
ing and closing can be done with only two fingers
either from the left hand or from the right hand.
The meniscotomes are straight or curved. Also
named tenotomes or Smillie scissors, their use
mainly concerns the three-portal technique. So,
the meniscus excision is performed on a drawn
meniscus. One must be cautious while using
these instruments; it is advisable to have very
sharp scissors to avoid any escape and a poste-
rior escape in particular, which could be brought
about by an excessive pressure on the instrument.
That is why single-use tenotomes exist where the
Th
blade can be replaced as a bistouri blade. As ever
in surgery, any strain on these instruments must
be avoided. We can find also 90° angled menisco-
tomes that can be useful in diffi fficult conditions,
on an anterior segment of the lateral meniscus
for instance.
These instruments represent the minimum for a
meniscectomy, possibly completed according to
the practices of the surgeon. Th The instruments must
Arthroscopic meniscectomy 111
be regularly checked up and sharpened, to avoid
any surprise along the intervention, modifying the
surgical procedure and its length.
Motorized tools
The shaver is not compulsory to carry out a menis-
cectomy. Meanwhile, it enables to straighten the
meniscus wall, to complete a difficult
ffi meniscec-
tomy of the posterior segment of the medial or
lateral meniscus. Its use is more interesting in the
lateral meniscus cysts that can be treated by intra-
joint portal. At last, it permits to straighten a fl
flap
located on the lower side or to neaten an anterior
segment of the lateral meniscus.
The motorized blades are alternatively used, which
enables the spontaneous throwing away of menis-
cus parts. They are small to slide under the con-
dyles without damaging cartilage. Some blades can
be twisted.
The laser use to achieve a meniscectomy is more
and more reported. Since it is expensive, its use
is not common. Its harmlessness is not proven;
cartilage injuries can occur after a too long use,
and they depend on the dose (energy) and length
of the use. The meniscectomy is implemented by
cauterization. This technique is not yet common,
so works are being carried out to precise modifica-
fi
tions and eff
ffects of laser on cartilage.
The first studies achieved in the departments of
Prof. Beaufifils and Prof. Benoît since 1992 had
shown the immediate harmlessness and effi fficiency
of laser Ho:Yag. This retrospective study showed
the superiority of laser meniscectomy vs. the clas-
sical arthroscopic technique. A randomized study
carried out by Blin and colleagues (7) in 1995, com-
paring mechanical arthroscopic meniscectomy and
laser meniscectomy, did not show the superiority
of laser to achieve an arthroscopic meniscectomy.
Laser can represent an extra advantage in certain
cases such as locked knees, but its excessive cost
and its limited use must not justify such a pur-
chase. We are unaware of the long-term effect ff on
cartilage and under-chondral bone.
Medial meniscectomies
Fundamentals
Before deciding a medial meniscectomy, it is highly
recommended to have a precise diagnosis of the
type of lesion of this meniscus and its location. It
is even very important to precise exactly the car-
tilage state of the knee. These
Th precautions enable
to warn the patient about the surgery follow-ups.
A retrospective study (8) that we have carried
112 The Traumatic Knee
out with the Société Française d’Arthroscopie
has shown the evolution of meniscectomies over
15 years. This study has shown that there were
22% of radiographic abnormalities concerning a
medial femoro-tibial reshape or an interline nar-
rowing. The long-term result is much better with a
young patient, with a traumatic lesion and a con-
servation of the meniscus wall without any carti-
lage lesion.
This is to say, we must extremely be cautious to
Th
carry out a meniscectomy for a patient older than
50 years. This indication should only be done in
case of the uneffifficiency of a good medical treat-
ment.
Therefore, it is recommended to perform paraclini-
cal examinations before any minescectomy:
– With the patient younger than 50 years: simple
face and profifile x-ray with monopodal stand up
and a 30° axial view of the patella. An arthro-
TDM or an MRI enable to precise the meniscus
lesion (Pictures 3 and 4).
Picture 3 – arthro-TDM vertical medial meniscus tear.
Picture 4 – MRI and medial meniscus lesion.
– With the patient over 50 years: the simple x-ray
standing up with a schuss x-ray will enable to
determine a posterior narrowing (Picture 5).
Complementary examinations will be discussed
according to the context. An arthro-scanner is
ideal to target cartilage lesions and their depth and
spread. But an MRI is interesting (9) to avoid an
osteonecrosis of the medial condyle, which can be
a diff
fferential diagnosis of the degenerative medial
meniscus lesion.
These precautions will enable to perform a menis-
cectomy in the best conditions by limiting the risks
of complications (10).
The employed technique depends on the operator
habit and on the meniscus lesion type. Two previ-
ous procedures must be solved before starting the
meniscectomy:
– Adjusted meniscectomy or splitting up
– Partial or subtotal meniscectomy
Several studies (11,12) have shown that there
was a direct relation between the long-term result
and the importance of the meniscectomy. Th This is
an important argument to achieve “economical”
meniscectomies.
In most of the cases, it is advisable to remove the
meniscus lesion as a whole. This is easy when it is a
bucket handle. In other cases, the progressive split-
ting up by rongeurs is necessary. Very often there is an
association of the two techniques. Th The meniscus tis-
sue must be left sound and safe by the meniscectomy.
The meniscectomy is said to be total if it concerns
the capsule-meniscus junction, i.e., if the meniscus
wall is removed. Trillat (13,14) has shown that it
was important to keep the meniscus wall by per-
forming an intra-wall meniscectomy. Th The menis-
cectomy is said to be partial when a good meniscus
wall is left. It is the basic technique, and it enables
to remove the mobile part and leaves a stable
meniscus remnant.
The meniscectomy is performed as far as the cir-
cular fibers of the meniscus wall. We speak of a
Picture 5 – Schuss X Ray, medial narrowing.

subtotal meniscectomy when the importance of
the lesion requires the excision as far as the menis-
cus wall of an important functional segment of a
meniscus, for instance, a posterior segment.
fils (15) has risen this problem of a «partial
P. Beaufi
meniscectomy» and suggests to use a terminology
making reference, on the one hand, to the inter-
ested segments and, on the other hand, to the
meniscus excision quantity for each segment. Th The
excision of the whole back segment of the medial
meniscus is called total meniscectomy of the pos-
terior segment and not partial meniscectomy.
This terminology is very important for the writing
of the surgical report and to assess the evolution.
Techniques
It is a standard to oppose the two-portal technique
and the three-portal technique.
Two-portal technique (Picture 6)
Th antero-medial and antero-lateral portals are
The
suffi
fficient to achieve the majority of medial menis-
cectomies.
First, the antero-lateral portal will be performed to
introduce the arthro-trocar sleeve and the arthro-
scope. This portal will be performed in the dihedral
angle formed by the lateral edge of the inside patel-
lar tendon and the point of the patella up at 1.5 cm
from the upper edge of the lateral tibial plateau.
Arthro trocar sleeve will be introduced after cut-
ting the skin and the patella with a bistouri. The Th
arthro trocar sleeve will be directed to the inter-
condylar notch, the knee being flexed
fl at 30° or 45°.
Then, the arthroscope will be directed to the knee
femoro-patellar joint, knee being in extension,
to start the knee exploration. The Th latter will be
systematic, with the following exploration in the
medial femoro-tibial compartment by going down
Picture 6 – two portal approach, medial portal for arthroscope and lateral
portal for other tools.
Arthroscopic meniscectomy 113
along the medial condyle, then in the intercondylar
notch, and finally in the lateral femoro-tibial com-
partment in the Cabot position. This exploration is
very important; it must be performed before doing
the second instrumental portal. It enables to pre-
cise the type of lesion and mainly its importance. It
enables to check the cartilage state and a possible
diffi
fficulty to set the knee into forced valgus.
The antero-medial portal will be performed by
trans-illumination in the dihedral antero-medial
angle above the anterior segment of the medial
meniscus. Then the palpater will be introduced and
palpate both menisci on their two sides by lifting
them and the two cruciate ligaments. The Th antero-
medial portal will be more or less high and medial
according to the lesion localization.
Bucket handle and vertical longitudinal lesion (Picture 7)
The two-portal technique needs only one instru-
ment, the arthroscope being in the second portal.
To treat a dislocated bucket handle of the medial
meniscus with this technique, we must perform
the following:
(a) Reduce the meniscus lesion with the hook
(Fig. 1).
The arthroscope is introduced through the antero-
lateral portal. The palpater is introduced through
the antero-medial portal, the reduction is per-
formed by a pressure at the top of the handle and
by a slight valgus strain at the tibia level, and the
increase of the flexion is often necessary to achieve
the reduction.
(b) Cut the posterior part at the posterior segment
levels (Fig. 2).
This procedure is performed by the antero-medial
portal, with a rongeur, a bistouri, or a tenotome.
It is advisable to leave a small flap to avoid the
Picture 7 – Bucket handle of medial meniscus.
114 The Traumatic Knee

Fig. 1

Fig. 2
Fig. 3
escape of the meniscus once the anterior part is
being cut. This procedure is more easily done with
a valgus strain on the tibia to open the medial
compartment. Thus, the arthroscope goes more
deeply into the medial compartment giving a
higher visibility of the posterior segment of the
medial meniscus.
(c) Cut the anterior part (Figs. 3 and 4).
There are two techniques to do this procedure:
Th
either with angled scissors through the antero-
medial portal or with an inversion of optics and
instrument.
With the first technique, we must be careful not to
leave a too big stump on the anterior segment; the
antero-medial portal is not easy. With the second
technique, the optics is placed through the antero-
medial portal and the instrument, and a rongeur Fig. 4
through the antero-lateral portal. ThisTh method
enables a direct access of the anterior segment by
the rongeur or scissors. – Diffi
fficulties of reduction exist with the aging
(d) Remove the bucket handle with a forceps. bucket handles. We must insist in doing little
The forceps grasps the meniscus fragment at the
Th flexion extension movements associated with a
level of the anterior segment. A soft tear is enough valgus strain while straining the top of the han-
to break the posterior bridge. dle with a more rigid palpater or sometimes the
Some problems can occur: mossy arthro trocar.
 Arthroscopic meniscectomy 115

– In case of an impossibility of reduction, it enables
to cut the posterior segment of the medial menis-
cus with a fine rongeur or a curved meniscotome
introduced by the antero-medial portal. This ges-
ture is diffi
fficult and requires to take very cautious
measures in the process not to damage the pos-
terior cruciate ligament.
– The loss of the meniscal fragment may occur. It
must be avoided if what has been described previ-
ously is respected. The most annoying is the going
back of the posterior segment if the anterior seg-
ment is removed first. Otherwise, we must look
for the flap to be dislocated at the front with the
palpater at the rear of the medial condyle. Then,
Th
it will be fixed on a forceps introduced by a second
antero-medial portal performed outside the fi first
one. To avoid the lost of the fragment, a second
antero-medial portal may be done. Meanwhile,
some artifi fices are possible, such as the passage
of a suture thread by the antero-medial portal,
which will permit the tear and even the extrac-
tion of the bucket handle after the section of the
posterior segment (16).
The procedure finishes with a neat checking of the
meniscus remnant by the palpater and a regulariza-
tion with a rongeur. In case of a longitudinal lesion,
lesion of type 3 of Trillat, the principle is identical.
tion is done by a rongeur introduced by the antero-
medial portal, the optics being antero-lateral. Th
This
part of the posterior segment is often narrow,
the passage of the rongeur is delicate, and a val-
gus strain must be applied to open this compart-
ment. The condyle cartilage lesion must be avoided
by opening up the rongeur. A small-sized rongeur
with upper concavity curve is used at its best.
(c) Medial flap displaced under the meniscus
The flap base is located in the anterior segment or
medial of the meniscus. The palpater introduced
through the antero-medial portal extracts this lesion
(Pictures 8 and 9). We can switch the instruments
and optics in the diff
fferent portals. The arthroscope
is introduced through the antero-medial portal and
the instruments through the antero-lateral portal.
The rongeur starts the meniscectomy at the base
of the flap on the anterior or medial segment. Its
access is direct. The meniscectomy is then per-
formed to the posterior segment with the rongeur
introduced through the antero-medial portal. Th The
flap is extracted and the meniscus regulated.

Meniscus flap
Meniscus flaps are resected, and the meniscus is
regularized according to the lesion spread.
(a) Postero-medial flap with medial base (Fig. 5)
The flap resection is made by introducing a ron-
geur through antero-medial portal, the optics
being antero-laterally located. The regularization is
spread as far as the posterior segment. The rongeur
is placed uphill from the lesion. The
Th flap is extracted Fig. 6
either by the forceps or directly by the rongeur. Th The
meniscus remnant is carefully checked.
(b) Postero medial flap with posterior base (Fig. 6)
This type of flap is diffi
fficult to extract since it dislo-
cates back to the posterior segment. The regulariza-

Fig. 5 Picture 8 – Medial flap displaced under the meniscus.

116 The Traumatic Knee

this posterior segment raises occasional problems

with locked knees, and a manual postero-medial
pressure by the assistant enables the posterior seg-
ment to go into the medial compartment. This Th arti-
fice is often useful on degenerative meniscus.
Therefore, the lesion is totally removed. Sometimes
it is useful to do this one-part meniscectomy in two
parts. Indeed, to have a better visibility of the pos-
terior segment, the anterior segment is split off ff by
a transverse incision at the level of the medial seg-
ment. The anterior fragment is removed first.
Three-portal techniques
This technique, commonly used by J.L. Prudhon
enables to perform a “one-part” meniscectomy in
front of any type of medial meniscus lesion. It per-
mits to maintain under strain the meniscus frag-
ment during the whole meniscectomy.
With this technique, it is compulsory to use the
Picture 9 – The palpater introduced through the antero-medial portal median portal of Gillquist (17) for the arthroscope
extracts this lesion. in «the one-part meniscectomy». A third portal can
also be used for the treatment of a bucket handle or
Tear lesion a longitudinal lesion.
Horizontal tear of the medial meniscus requires a
One-part meniscectomy
large excision, named “regulated meniscectomy or
Three main steps are necessary:
one part-meniscectomy.” This meniscectomy can be
(a) Section of the anterior strip (Fig. 7)
performed successfully by a two-portal technique.
The optics is in median situation, through the patellar
It can assess the quantity of the removed meniscus
tendon 1 cm below the top of the patella. A first
fi ante-
tissue.
ro-medial instrumental portal is carried out above the
(a) Incision in the anterior segment
anterior meniscus segment. The section of the free
This incision is directly made by bistouri through
Th
edge of the meniscus is performed with a 11 mm bis-
the antero-medial portal, the arthroscope located
touri or with a 60° angled scissor introduced through
in antero-lateral. This incision goes the farthest to
the antero-medial portal, and this section is carried
the medial and posterior segment with a tenotome
on as long as obtaining a 1/2-cm meniscus fl flap.
or a rongeur introduced through the antero-medial
(b) Section of the medial segment (Fig. 8)
portal. Th
This anterior section can also be made with a
A second antero-lateral instrumental portal is carried
rongeur introduced through the antero-lateral por-
out, lower than the arthroscopic medial portal. A for-
tal while the arthroscope is into the antero-medial
ceps is introduced through this portal and draws the
portal and displays the anterior segment.
meniscus flap previously detached. A 3 mm menisco-
(b) Section of the medial segment
tome is introduced through the antero-medial portal
This section is performed either through the antero-
Th and goes progressively into the diedre of: (Picture 10)
medial portal with angled scissors or a bistouri or
through the antero-lateral portal with a rongeur.
The palpater enables to check the anterior section
and, above all, to move the flap to assess the size of
the base on the posterior segment.
(c) Section of the posterior segment
The rongeur is introduced through the antero-me-
dial portal, with a valgus strain, the section being
made at the flap base. The section is performed to
the medial segment. A little tractus must be left not
to lose the meniscus fragment.
(d) Extraction of the meniscus
The forceps introduced through the antero-medial
portal grasps the meniscus fragment through its
anterior segment. The posterior tractus splits off ff
under the traction. The meniscus remnant is checked
out and regulated with a rongeur. The regulation of Fig. 7 – Section of the anterior strip.

Fig. 8 – Section of medial segment with meniscotome, through the antero-
medial portal, and the forceps draws the anterior segment by the antero-
lateral portal.
Picture 10 – A 3 mm meniscotome is introduced through the antero-me-
dial portal and goes progressively into the diedre of : inside the detached
meniscus segment and outside the meniscus wall.
– inside the detached meniscus segment;
– outside the meniscus wall.
This progression is carried on as far as the angle
postero-medial point, and then backward the
medial condyle.
The meniscus segment detached in such a way
can then be dislocated in the intercondyle notch.
This is the guarantee of the total section of medial
strips of the meniscus.
(c) Section of the posterial strip (Fig. 9)
It is easy if the segment is dislocated. Th The for-
ceps introduced through the antero-lateral portal
strongly draws the meniscus while the menisco-
tome cuts the posterior strip. The
Th meniscotome is
introduced through the antero-medial portal and
the optics through the medial portal.
Sometimes a rongeur can be used to help this pro-
cedure. By this technique, the meniscus lesion is
Arthroscopic meniscectomy 117
Fig. 9 – Section of the posterior strip.
Fig. 10 – Removing the meniscus flap.
totally removed (Fig. 10). The meniscectomy is
completed on demand with the rongeur.
Bucket handle and longitudinal lesion
We have previously seen in the treatment of the
bucket handle and longitudinal lesions that there
was a risk to lose the meniscus flap by the two-
portal technique. Thus, we absolutely can carry
out a third portal to give a strain to the meniscus
flap. With this technique, it is not compulsory to
carry out a patellar tendon portal but a classical
arthroscopic antero-lateral portal.
The meniscectomy procedure includes the following:
(a) Reduction of the meniscus lesion with the pal-
pater hook
The arthroscope is introduced through the antero-
lateral portal. The palpater is introduced through
the antero-medial portal.
(b) Section of the posterior strip at the level of the
posterior segment
This procedure is performed through an antero-
medial portal, with a rongeur, a bistouri, or a teno-
tome, while leaving a small-size posterior strip.
(c) Section of the anterior strip
This procedure is performed through the antero-
medial portal with angled scissors, or through
the antero-lateral portal with a rongeur. ThThen, we
carry out a closer and lower portal to the patellar
tendon through a meniscotome, or a rongeur can
be introduced.
118 The Traumatic Knee

(d) Extraction of a bucket handle with a forceps

and a complete posterior section
The forceps grasps the meniscus flap at the level
of the anterior segment. Th This forceps is introduced
through the medial portal closest to the patellar
tendon. A soft traction strains the meniscus frag-
ment, while the meniscotome or the rongeur com-
pletes the posterior section. These
Th latter tools are
introduced through the portal closest to the patel-
lar tendon.
With this technique, we can cut the anterior seg-
ment before the posterior segment since the latter
will be handled by a forceps.
The procedure ends by a careful checking of the
meniscus remnant with the palpater and a regula-
tion with the rongeur. In the case of a longitudi-
nal lesion, Trillat type 3 lesion, the principle is the
same.

Picture 11 – medial portal for lateral meniscus tear in cabot position.

Lateral meniscectomies related to skin plans, which considerably hampers

The lateral meniscus shows anatomic particular-
ities different from those of the medial menis-
cus. The accessibility of the anterior segment
is often difficult. Its thickness is more impor-
tant and can raise some problems of section.
The existence of the popliteus tendon and its
hiatus makes this meniscus more fragile, and
the meniscectomy must preserve the meniscus
bridge at the utmost in front of the hiatus, not
to transform a partial meniscectomy in a total
one. In case of the break of the meniscus bridge,
the posterior segment is too much unsteady to
be kept.
The lateral meniscus presents anatomic variations
(discoid meniscus) and may need a meniscectomy.
In addition, it is the core of cystic formations,
which are in fact pseudocyst meniscus more often
related to longitudinal fi
fissure meniscus injuries or
across clivages.
Portals
Two portals are usually sufficient
ffi to perform a
lateral meniscectomy. Th The antero-lateral portal is
suffi
fficient to explore the whole meniscus from its
anterior segment to its posterior segment. It will
be carried out in the same way as in the medial
meniscectomy.
The antero-medial portal is generally located
higher to treat a medial meniscus lesion. It will be
done by trans-illumination that avoids injuring a
superfificial vascular element.
The Cabot position (Picture 11) or the simple varus
position and medial rotation slide the patellar plans
the tool introduction. To avoid this phenomenon,
it is appropriate to make the portal in the Cabot
position, which enables to have a direct access to
the lateral compartment.
The common technique uses the antero-lateral
portal for the arthroscope and the antero-medial
portal as a tool portal. The gestures on the antero-
lateral meniscus can be also carried out by using
the medial portal for the arthroscope and the ante-
ro-lateral for the tools to reach the posterior seg-
ment of the lateral meniscus. We should not hesi-
tate in changing the tool and arthroscopic portals
to improve the vision conditions on the one hand
but also the ergonomic placement of the tools on
the other hand.
Bucket handle, longitudinal injuries (Picture 12)
In case of dislocated bucket handle, it is compul-
sory to reduce the lesion.
– The reduction (Fig. 11) is performed with a pal-
pater hook introduced through the antero-me-
dial portal. Th
The latter is sometimes diffifficult and
requires the mobilization of the joint in flexion
fl
with a varus strain to open the lateral compart-
ment.
– The section of the posterior strip is performed
through the medial portal with scissors or forceps
(Fig. 12), the optics being in antero-lateral posi-
tion. Sometimes, it is necessary to go through
the lateral portal (Fig. 13) if the longitudinal fis-
fi
sure is in the most posterior part of the posterior
segment.
A small posterior bridge will be kept.
 Arthroscopic meniscectomy 119

Picture 12 – Bucket handle of lateral meniscus. Fig. 12 – Section of the posterior strip through the medial portal.

Fig. 11 – Reduction of the bucket handle.

– The section of the anterior strip (Fig. 13) is also

Fig. 13 – Section of the anterior strip.
performed either with a rongeur or a bistouri
introduced through the medial portal or with 90°
angled scissors introduced through the lateral
portal. Th
The meniscus section must be neat and
must grasp the whole lesion at once, to avoid a
flap being left on the anterior segment, which is
more diffi
fficult to regulate when the bucket handle
is removed.
– The lesion extraction (Fig. 14) is carried out
with a forceps introduced through the medial
portal. The meniscus is regulated with a ron-
geur, and the meniscus remnant is palpated
with care.
Sometimes the lateral bucket handle is hard to be
treated, even with an impossibility to reduce the
lesion. Then, the bucket handle must be cut in site.
Therefore, a third portal can be useful to hold the
fragment. While cutting the bucket handle in site,
care should be taken not to damage the anterior
cruciate ligament. Fig. 14 – Extraction of the lesion with the forceps.
120 The Traumatic Knee
Radial lesions
They are frequent in the median segment. The
regulation through the antero-medial portal is
easy since the tool is opposite the lesion. Th The
regulation is carried out from part to part of the
lesion. It is performed with a rongeur by split-
ting up. The free side must be regular at the end
of the surgery. We must take care to respect the
meniscus bridge in front of the popliteus hiatus
(Picture 13).
Picture 13 – lateral meniscus and respect of the popliteus hiatus.
Meniscus strips
Th pedicle of the strip is cut off
The ff, and the free side
regulated to avoid any step. The danger is to lose
the strip when cutting it. The use of a rongeur as
a forceps is ever possible with small strips; oth-
erwise, a thin tractus must be left, which will be
tracted with a proper forceps. The
Th tools are more
often introduced through the antero-medial por-
tal. If the strip has its base on the posterior seg-
ment, the antero-lateral instrumental portal is
very interesting.
Horizontal clivage
This kind of lesions often spread from the anterior
segment to the posterior segment. The Th first step
of the treatment is to palpate the whole lesion to
assess its spread and, above all, its relation with
the hiatus popliteus.
The regulation is more often carried out through a
splitting up with a rongeur alternating the portals:
lateral portal for the posterior segment and fi first
medial portal for the anterior and median seg-
ments.
It is sometimes diffi
fficult to reach one of the two
leaves on the anterior segment or at the junc-
tion. Thus, the 90° angled rongeurs are useful;
they are introduced through the medial portal
(Picture 14). The shaver can be helpful to treat
the anterior lesions by using a curved blade or a
right blade.
Picture 14 – treatment of an anterior lesion of lateral meniscus with the
90°angled rongeur.
Cyst of the lateral meniscus (Figs. 15–18)
The therapeutics of lateral meniscus cysts has
deeply evolved, from Phemister (18), who was
practicing a total medial meniscectomy through
arthrotomy, to Muddu (19), who proposed the
treatment by corticoid infi filtration. Chassaing
(20,21) proposes to treat the cyst by arthroscopy.
Parisien (22) as well uses the shaver to perform the
cyst intra-joint debridement.
The aim of arthroscopy is, on the one hand, to treat
the meniscus lesion by respecting the meniscus
wall and, on the other hand, to treat the excision
of the cyst content.
The arthroscopy has enabled to limit the impor-
tance of the meniscectomy, and the latter is partial
while maintaining a maximum of sane tissue and,
above all, the meniscus bridge en regard of the hia-
tus popliteus.
The surgery starts by the treatment of the menis-
cus lesion by respecting the meniscus wall. For
some people, the treatment stops there; the cyst
is cured when the meniscus lesion is treated. Then,
 Arthroscopic meniscectomy 121

Fig. 15
Fig. 16

Fig. 17 Fig. 18

the notch opposite the cyst is opened with a ron- a splitting up with a rongeur is very efficient
ffi but
geur or with a meniscotome (23). laborious. The procedure starts from the axial
The last step of the surgery is the exeresis of the side often thick, diffi
fficult to split up, and getting
cyst content. At best, it is removed by using a away under the rongeur. Thus, we must go from
motorized blade or «shaver» introduced through the antero-medial to the antero-lateral portal, to
the meniscus communication of the cyst. The Th reach the free side in the best conditions. ThThe ron-
shaver sweeping inside the cyst will sharpen the geur introduced through the lateral portal begins
cyst walls and raises a bleeding improving the
cicatrization. The angled shaver is useful when the
perforation is located in the anterior segment or at
the junction of the anterior and median segments.
Hulet and Locker (24,25) point out that the recidi-
vation of the cyst is in most of the cases due to an
unsatisfactory treatment of the meniscus lesion.
Persistant meniscus lesion of the anterior seg-
ment. According to him, the use of angled instru-
ments and the change of portal are imperative to
leave no lesion.

Discoid meniscus (Picture 15)

Th type of meniscus can be at the origin of
This
a painful lateral syndrome, above all, when it
cracks. The partial meniscectomy or «menisco-
plasty» is sometimes very difficult,
ffi and a subto-
tal meniscectomy is often necessary. A meniscus
with a proper shape must be reshaped. Therefore,
Th Picture 15 – discoid meniscus.
122 The Traumatic Knee
the meniscoplasty on the posterior segment. We
continue in the median segment far from the
meniscus wall. Later we can change arthroscope
and tools to cut the anterior part of the meniscus
with the rongeur introduced through the medial
portal. At least, we remove the flap, and the rem-
nants become like a normal meniscus with the
time (26).
The follow-ups
The arthroscopy ends up with a cautious clean-
ing of the knee. Any meniscus fragments must be
removed off ff, without any remnants in the portal,
sources of chronic pains. The tourniquet is released
before the joint draining off;ff this enables to ensure
no intra-joint important bleeding or at the portal
levels.
The closure of the portals is carried out by several
ways: unresorbable wires, resorbable wires, or even
adhesive bandage.
Some infl flammatory granulomes have been
observed at the entry points. Th These induration
points may come from small meniscus fragments
embedded in the portal. A particularly cautious
cleaning must be done a these portals.
This surgery is often carried out in ambulatory
hospitalization. The procedure can be performed
under local anesthesia as shown by Béguin and
Locker (27,28); nevertheless, the other forms of
anesthesia are more currently carried out: rachi-
anesthesia, crural block and general anaesthesia.
Patients go out the same day of the surgery. Th The
surgeon must provide information to the patient
on the surgery and its expected follow-ups.
The surgery report is an important moment. It
must be accurate, and precise the amount of the
removed meniscus, the remaining part, and the
aspect of the meniscus wall. Finally, it is important
to precise whether this meniscectomy has been
diffi
fficult, laborious, or easy. This is an indicator for
the evolution and the meniscectomy prognosis. It
must also give details on the cartilage state with
the diff
fferent steps of gravity and the extension of
lesions for a long-term prognosis. The iconogra-
phy is an important element: photo or video. Th The
development of the digital photography and soft-
ware for filing these photos are interesting data for
the clinical file of the patient.
The walking is possible at once without any help.
Sports activity is possible after 1 month post-sur-
gery in case of no complication and, above all, in
the context of a traumatic meniscus lesion. In the
context of degenerative lesions, sports activity will
depend above all on the degree of coexistent carti-
lage lesions.
Physiotherapy is systematically proposed, and
some physiotherapy sessions sound to be profit-
able. Physiotherapy must be soft and unpainful.
For this goal, a precise protocole must be given
to the physiotherapist. The goal is to recover
the knee mobility without any pain. The work
of muscular strengthening is carried out with
a lot of care with the association of systematic
stretching of the anterior and posterior muscu-
lar chains.
At last, we must be pinpoint that the follow-ups of
the lateral meniscectomy are longer and more dif-
ficult than the medial meniscectomy (29).
Conclusion
The meniscectomy techniques have become daily
procedures of an orthopaedist surgeon. Mean-
while, these procedures must not be generalized
since these procedures require a long learning
curve to be correctly performed. The surgery indi-
cation must be decided with great care and caution
since the consequence of a meniscectomy may be
severe with the probability of a long-term arthritis
development.
A good development of a meniscectomy is per-
formed with an accurate surgery indication, and
additional proper examinations are asked respect-
ing the technical principles.
References
1. Watanabe M, Ikeuchi H L’arthroscopie. Encycl Med Chir,
Paris, Appareil locomoteur, 14001:10, 4-1981<AQ: Please
check Refs. 1, 6, and 10 for completeness. Please provide
year of publishing in these refs.>
2. Dobner JJ, Nitz AJ (1982) Post meniscectomy tourniquet
palsy and functionnal sequelae.Am J Sports Med 10:211–
214
3. Johnson DS, Stewart H, Hirst P, Harper NJ (2000) Is tour-
niquet use necessary for knee arthroscopy. Arthroscopy
16:648–651
4. Thorbald J, Ekstarnd J, Hamberg P, Gillquist J (1985) Mus-
cle rehabilitation after arthroscopic meniscectomy with or
without tourniquet control. A preliminary randomized
study. Am J Sports Med 13:133–135
5. Daniel DM, Lumkong G, Stone ML, Pedowitz RA (1995)
Eff
ffects of tourniquet use in anterior cruciate ligament
reconstruction. Arthroscopy 11:307–311
6. Orengo P, Zahlaoui J Chirurgie des ménisques. Encycl Med
Chir, Paris, Techniques chirurgicales, Orthopédie trauma-
tologie, 44785, 4.10.06, 18 p
7. Blin JL, Tremoulet J, Hardy Ph, et al. (1995) Méniscecto-
mie au laser Holmium:Yag versus méniscectomie méca-
nique sous arthroscopie. Etude comparative prospective
randomisée. (Résulats précoces sur 96 sujets) nnales de la
Société Française d’arthroscopie
8. Chatain F, Robinson Ah, Adeleine P, et al. (2001) The
Th natural
history of the knee following arthroscopy medial meniscec-
tomy. Knee Surg Sports Traumatol Arthrosc 9:19–27

9. Folinais D, Thelen Ph (1993) L’imagerie des ménisques des
genoux après 50 ans. Rev Chir Orthop 79:320–334
10. Panisset JC Conduite à tenir en cas d’échec du traitement
arthroscopique. Actualités dans la rééducation. Le genou
dégénératif. Sauramps Médical 10/2000
11. Northmore-Ball MD, Dandy DJ (1982) Long term results
of arthroscopic partial meniscectomy. Clin Orthop
167:34–42
12. Neyret Ph, Walch, Dejour H (1988) La méniscectomie
interne intra-murale selon la technique de A. Trillat: résul-
tats à long terme de 258 interventions. Rev Chir Orthop
74:637–646
13. Trillat A (1973) Les lésions méniscales internes. Les
lésions méniscales externes. Chirurgie du genou. Journées
Lyonnaises de chirurgie du genou. 04/1971. Simep, ed.,
Villeurbanne
14. Trillat A (1962) Lésions traumatiques du ménisque interne
du genou, classifi
fication anatomique et diagnostic clinique.
Rev Chir Orthop 48:551–560
15. Beaufifils P (1993) L’arthroscopie opératoire dans la
pathologie mécanique du genou. Apport et limites.
Cahiers d’enseignement de la SOFCOT. Conférences
d’enseignement, pp. 93–108
16. Binnet Mehmet SMD, Gurkan Ilksen MD, Cetin Cem MD
(2000) Arthroscopic resection of bucket-handle tears with
the help of a suture punch: a simple technique to shorten
operating time. Arthroscopy 16(6):665–669
17. Gillquist J, Oretorp N (1982) Arthroscopic partial menis-
cectomy. Clin Orthop 167:29–33
18. Phemister DB (1923) Cysts of th lateral semi-lunar carti-
lage of the knee. JAMA 80(9):593–595
Arthroscopic meniscectomy 123
19. Muddu BN, Barrie JL, Morris MA (1992) Aspiration
and injection for meniscal cysts. J Bone Joint Surg
74-b(4): 627–628
20. Chassaing V, Parier J, Artigala P (1985) L’arthroscopie
opératoire dans le traitement du kyste du ménisque
externe. J Med Lyon 66(1406):449-453
21. Chassaing V (1985) Chirurgie du genou par arthroscopie.
Conf. d’enseignement de la SOFCOT 1985, n 23, pp. 103–
120. Expansion scientififique Française, Paris
22. Parisien JS (1990) Arthroscopic treatment of cysts of the
menisci. Clin Orthop 252:154–158
23. Glasgow MMS, Allen PW, Blakeway C (1993) Arthroscopic
treatment of cysts of the lateral méniscus. J Bone Joint
Surg 75-b(2):299–302
24. Hulet C (1993) Les kystes du ménisque externe. Etude
rétrospective d’une série de 124 kystes traités par arthros-
copie. Thèse Médecine 1993 Caen
25. Locker B, Hulet C, Vielpeau C (1992) Lésions traumatiques
des ménisques du genou.Editions techniques. Encycl Méd
Chir (Paris, France), Appareil locomoteur, 14084 A10:12
26. Vandermeer RD, Cunnigham FK (1989) Arthroscopic
treatment of the discoid lateral meniscus: results of long
terme follow-up. Arhroscopy 5:101–109
27. Beguin J, Locker B (1981) Arthroscopie du genou sous
anesthésie locale. J Med Lyon 1932:7–9
28. Locker B, Beguin J, Th
Thomassin G, et al. (1990) L’anesthésie
intra-articulaire en arthroscopie du genou. Rev Chir
Orthop 76(Suppl 1):152–153
29. Panisset JC, Neyret P (2002) Méniscectomie sous
arthroscopie. Encycl Med Chir. Techniques chirurgicales-
Orthopédie-traumatologie, 44-765:12

P. Wilmes, D. Pape, R. Seil Meniscal sutures
Introduction
B
iomechanical and clinical trials have demon-
strated the importance of the menisci for the
function of the knee. The menisci increase the
surface area for femoro-tibial load transmission, aid
in the mechanics of joint lubrication, and act as sec-
ondary stabilizers in anterior cruciate ligament (ACL)-
defi
ficient knees. Thus the focus in the treatment of
meniscal tears has shifted from systematic removal of
the menisci toward preservation and repair whenever
possible. Nonetheless, most investigators estimate
that only 10–15% of meniscal tears are reparable,
usally in association with ACL reconstructions (1,2).
The aim of meniscal repair is to reduce pain and possi-
bly to restore ideal knee function by keeping the origi-
nal meniscus. Indications for meniscal repair are:
– full-thickness, vertical longitudinal tears >10 mm;
– partial-thickness unstable vertical longitudinal
tears (generally in tears >10 mm);
– location at the meniscosynovial junction or in the
vascularized red-red and red-white zones (less than
3 mm away from the meniscosynovial junction);
– little secondary meniscal degeneration.
Previous studies have shown improved results with
concomitant ACL reconstructions, peripheral lesions
(rim width <4 mm), repair within 8 weeks of injury
and tear length of less than 2 cm. The Th ideal candi-
date for meniscal repair is the active, young patient,
although no general upper age limit has been defined.
fi
In patients over 40, meniscal repair is worth consid-
ering, depending on tear morphology and tissue
quality, whereas in children, meniscal repair should
always be considered as the standard procedure.
Preoperative patient information must include the
necessity for long and intensive rehabilitation as well
as absence from pivoting sports for about 6 months.
Surgical technique
Healing enhancement
After arthroscopic identification
fi and evaluation
of the meniscal tear, it is necessary to perform a
Chapter 11
debridement of the bradytrophic meniscus tis-
sue. Especially in isolated meniscal tears, this
is of foremost importance, whereas simultane-
ous ACL reconstructions have a beneficial fi eff
ffect
on meniscus healing, presumably because of the
increased intraarticular concentration of growth
factors due to the postoperative hematoma. Tear
debridement and local synovial, meniscal, and
capsular abrasion are performed with a shaver or
fic meniscal rasps to stimulate a proliferative
specifi
fibroblastic healing response and remove necrotic
tissue. The tear rim should be rasped in order to
remove necrotic tissue and stimulate bleeding.
Synovial abrasion can induce a similar effffect, espe-
cially with a meniscus lesion situated more than
3 mm away from the periphery (zones 2–3). Abra-
sion should be performed on the femoral and on
the tibial side (3). Thus a healing process similar
to the one known from other connective tissues
is induced (4).
A further possibility that has been mentioned in
the literature to stimulate the healing process after
meniscal repair is meniscal trephination. Using an
18-gauge spinal needle to penetrate the peripheral
meniscus to the synovium (needling), bleeding and
revascularization might be stimulated (5,6).
When isolated tears are to be repaired, addition
of a fibrin clott has been considered. Using veni-
puncture, an aliquot of 5–10 mL of whole blood is
obtained, and then a fibrin clot is prepared using
a frosted glass stirring rod. Th
The clot can be intro-
duced arthroscopically into the meniscal tear (7).
Outside-to-inside technique
This technique is most appropriate for tears located
in the middle and anterior aspects of either menis-
cus (Fig. 1). Two spinal needles are inserted from
outside through the skin into the joint, perforat-
ing the meniscal basis and the central meniscus
fragment. Through a first needle, a suture loop is
introduced. A second suture is introduced through
the posterior needle. It is grasped with a specific
fi
instrument and drawn through the suture loop
into the ventral needle. By drawing the loop back,
126 The Traumatic Knee
Fig. 1 – Outside-to-inside technique: (A) punction with filled cannulas, (B)
horizontal mattress suture. (From Ref. 8.)
the free end of the posterior suture is brought to
the outside. Both suture ends can then be tied
together over the capsule. This
Th technique has the
advantage over inside-to-outside sutures that it
can be performed percutaneously and that it does
not require large skin incisions. Furthermore, it
is very cheap, is technically easy to perform, and
does not require any specific
fi instruments.
Inside-to-outside technique
A very popular technique for meniscal repair is the
repair from inside to outside (Fig. 2). It is especially
recommended for posterior horn repairs. It requires
specifi
fic instruments: single or double cannulas and
sutures provided with long and fl flexible needles.
The cannulas are positioned under arthroscopic
view from the anterior portals at the tear site. TheTh
needles are directed through these cannulas into
the meniscus substance. An accessory longitudi-
nal, posteromedial, or posterolateral incision must
be performed to identify and retract the needles.
After soft-tissue preparation to the capsule, a soft-
tissue retractor provides the necessary protection
for the neurovascular structures when the needles
and suture material are passed from the intraar-
ticular space through the meniscus and capsule to
the outside. At the end of the procedure, the suture
ends are tied over the capsule.
Fig. 2 – Inside-to-outside technique: (A) abrasion, (B) positioning of the
first cannula, (C) control of knot and suture. (From Ref. 8.)
All-inside technique
Originally, the fi
first all-inside meniscal suture tech-
nique has been described by Morgan et al. These
authors used the posterior capsular space to enter
a specifi
fic suture passer through either a postero-
lateral or a posteromedial approach, especially for
lesions located at the meniscosynovial junction (9).
As an alternative to improve repairs of the menis-
cus tissue in the area of the posterior horn, spe-
cifi
fic all-inside meniscus fixation techniques and
devices have been developed at the beginning of
the 1990s. These techniques were designed to be
easy to use and to lower the potential risk of inju-
ries to the neurovascular structures. The implants
diff
ffer in shape (barbed arrows, with or without
arrowheads; screws; staples) and material (biode-
gradable, nonabsorbable) (Fig. 3).
In order to decrease their potential risk of carti-
lage injuries (10,11), some implants such as the
ContourTM Meniscus ArrowTM (Conmed Linvatec,

Fig. 3 – All-inside meniscal repair devices, from left to right: FasT-FixxTM (Smith & Nephew), H-FixxTM (Mitek), Meniscal DartTM (Arthrex), Meniscal
StaplerrTM (Arthrotek), BioStingerrTM (Linvatec), Meniscus Arrow
wTM (Linvatec), Clearfix Screw
Largo, FL, USA) have been improved over the
years to lower the profile
fi of the part of the implant
lying on the surface of the meniscus (12). Despite
these improvements, these implants should not be
used to repair centrally located tears (zone 3). Bio-
mechanical trials revealed comparable results to
meniscal sutures (13–15). Some authors combine
repair with devices and standard meniscal sutures,
using the implants only to complete the repair
close to the insertion area of the posterior horn
(16). It is recommended to place the implants with
intervals of 5 mm. The use of endosopic meniscal
repair devices is not recommended in unstable
knees, in the anterior horn area, in chronic dis-
located bucket handle tears, and in tears near the
meniscosynovial junction (zones 0–1) and near the
popliteal gap. They should be used with an appro-
priate length because, if they are too long, they can
cause irritations at the capsule or even in the sub-
cutaneous tissue.
Some of the above-mentioned relative contraindi-
cations have been overcome with the development
of hybrid repair techniques such as the currently
very popular FasT-FixTM (Smith & Nephew, Inc.,
Memphis, TN, USA), which combines the presence
of an implant with a suture (17–23) or devices
designed to facilitate all-inside sutures such as the
Meniscal ViperTM (Arthrex, Inc., Naples, FL, USA)
(Fig. 4), even if for the latter the surgeon should be
familiar with arthroscopic knot-tying (24,25).
These instruments allow for arthroscopic repair of
Th
a meniscal tear from anterior portals and can be
used in areas such as the popliteal space at the pos-
terior horn of the lateral meniscus where the use of
an inside-out technique or repair with an implant
is either diffi
fficult or not recommended.
Meniscal sutures 127
wTM (Mitek), SD Sorb StapleeTM (Surgical Dynamics).
One of the latest all-inside devices is the Meniscal
CinchTM (Arthrex, Inc., Naples, FL, USA), intro-
duced in 2008. Designed to be used through a low
arthroscopic portal, near the surface of the tibia,
it allows an all-inside repair without intraarticu-
lar knot-tying, similar to the FasT-FixTM (Smith
& Nephew, Inc., Memphis, TN, USA). Clinical
follow-up studies will show its place amongst the
established devices.
Biomechanical evaluation of meniscal repair
Biomechanical testing is intended to evaluate and
to improve the mechanical factors of meniscus
healing, either for meniscus sutures or for new
meniscal repair devices. In order to be as close
as possible to the clinical setting, biomechanical
studies have been performed under different
ff con-
ditions, each of them simulating a specific fi period
after meniscal repair:
1. Immediately after repair (tt = 0): so-called time-
zero cadaver studies.
2. During the healing period (tt = 0–12 weeks): such
studies have been performed either as tissue-
culture models or as animal experiments.
3. After the initial healing phase (tt > 12 weeks). So
far, the biomechanical properties of meniscus
repair at this period have only been addressed in
animal studies.
Time-zero studies
Most of the studies dealing with laboratory testing
of meniscus repair have been performed as time-
128 The Traumatic Knee

zero studies, testing the tensile fixation strength
(TFS) of either sutures or sutures compared to fi fix-
ation devices (13,14,26,27,28,29,30,31,32,33,34,3
5,36,37,38,39,40,41,42,43) (Arnoczky et al. 2001,
Kohn et al. 1989).
In the first laboratory study on meniscus repair,
Kohn and Siebert (44) described the two basic
principles of meniscus repair biomechan-
ics. The authors compared open meniscus repair
techniques to arthroscopic techniques. They found
that the circumferentially oriented horizontal col-
lagen fiber bundles were responsible for the higher
TFS for vertical sutures compared to horizontal
sutures. They further showed the importance of
the superfi
ficial, dense layer of thin collagen fibrils,
which increased the TFS of mattress sutures com-
pared to sutures including only deeper layers of
collagen bundles.
In later biomechanical studies, many variables
infl
fluencing the TFS of meniscus sutures or
repair devices could be identified.
fi These variables
included the nature of the tested menisci (animal
(until today bovine and porcine menisci have been
used) vs. human origin; young vs. old specimen),
the suture strength, the insertion angle of repair
devices, their design (form of head, barbs, etc.),
their mechanical properties such as thickness and
elasticity, etc. Furthermore, biomechanical testing
varied from study to study since there is no con-
sensus regarding the exact testing conditions. Th
This
might explain the large variations encountered
with some repair devices in different
ff studies and
makes a comparison of the TFS between dif-
ferent studies extremely difficult
ffi .
In several studies, the TFS of some of the devices
approached the TFS of sutures. However, the

Fig. 4 – All-inside repair with the Meniscal ViperrTM device (Arthrex, Inc., Naples, FL, USA): (A) tear identification with a
probe, (B) introduction of the device, (C) perforation of the meniscus for suture placement, (D) placement of the suture
material, (E) cutting of the excess suture material with a special knot cutter, (F) final result with all-inside suture.

Fig. 5 – (A) Meniscal CinchTM (Arthrex, Inc., Naples, FL, USA). (B) Principle of all-inside repair with the CinchTM.
 Meniscal sutures 129

Fig. 6 – The main parameter that has been used in these stud-
ies was the tensile fixation strength (TFS) and, in more recent
publications, also the linear stiffness of a single suture or a menis-
cal repair device. The fixation strength has always been analyzed
on a materials testing machine. After creating an artificial tear in
either human or animal menisci, a uniaxial load is applied to the
repaired meniscus in an axis parallel to the long axis of the suture
or the implant to be tested. The ultimate tensile load is recorded
on a load-displacement curve.

sutures still have to be considered as the gold stan- Table 1 – Animal studies investigating the tensile failure strength of
dard of meniscus repair. repaired menisci.
Animal Time after Tensile failure
model surgery strength
Biomechanics of the repair during the early healing (months)
phase Ref. 48 Goat 4 30% of normal
tissue
Two mechanical factors have been analyzed dur- Ref. 49 Dog 3 Up to 80% of
ing this phase: the evolution of TFS of the sutures/ normal tissue
devices over time (45) (Arnoczky et al. 2001) and Roeddecker Rabbit 3 Fibrin glue: 42%
the eff
ffect of repetitive loading on meniscus repairs K, 1994Ref. Suture: 26%
(40,42,46). 50 No therapy: 19%
The effffect of hydrolysis time on sutures/devices Ref. 51 Dog 12 SD staple > suture
has been analyzed in a tissue culture model. In Ref. 52 Goat 1,5 <50% of normal
these studies, the menisci were incubated after tissue
the repair over a defi fined period, after which the
Ref. 53 Dog 6 50% of normal
TFS were evaluated. Using PDS sutures, Dienst et
tissue
al. (45) found a significant
fi decrease in the TFS of
nearly 50% after 6 weeks, whereas the TFS of non-
months of up to 80% of the intact control menis-
absorbable suture material did not change. Arnoc-
cus in dogs, the other authors found data that were
zky and Lavagnino (47) found no decrease in TFS
far from normal. This shows that meniscal scar tis-
for the BioStingerTM, the Meniscus ArrowTM, and
sue does not reach its initial biomechanical prop-
the Clearfifix ScrewTM (Mitek Products Inc., A Divi-
erties after a period of 3–4 months. Koukoubis et
sion of Ethicon, Inc., Westwood, MA, USA) over a
al. (51) observed an increase in TFS of repaired dog
period of 24 weeks. However, the SD stapleTM (Sur-
menisci over a 1-year period. In a recent biomechni-
gical Dynamics, Inc., Norwalk, CT, USA) and the
cal trial in dogs, Cook et al. (53) studied the effects
ff
Mitek Meniscal Repair SystemTM (Mitek Products
of introducing a bioabsorbable conduit into avascu-
Inc., A Division of Ethicon, Inc., Westwood, MA,
lar meniscal tears. Functional healing with bridging
USA) showed a complete loss of fixation strength
tissue and biomechanical integrity were noted in
after 24 and 12 weeks, respectively.
71% of avascular meniscal defects 6 months after
Repetitive, cyclic loading of meniscus sutures
surgery. The tissue revealed a failure strength at
showed the appearance of a gap between the two
6 months of 50% compared to normal tissue.
parts of the meniscus (40), even with low loads of
only 10 N (36). Gapping was most important with
the commonly used PDS 2-0 sutures. Cyclic testing Forces acting in vivo
led to failure of sutures and new devices. ThThe fail- In vitro testing of meniscus repair has been per-
ure of the devices was inversely related to the size formed with tensile forces only. ThThe tensile forces
of their head (14). acting on meniscal repairs in vivo are unknown.
Furthermore, there are not only tensile but also
compressive and shear forces acting on the menis-
Biomechanics of the repair during the late healing phase cus. These complex forces are diffi
fficult to reproduce
in vitro. Only few studies tried to analyze this
During this phase, laboratory testing of meniscus question. Kirsch and Kohn investigated the tensile
repair is essentially performed in animal studies forces acting on posterior horn sutures of the medial
analyzing the failure strength of the scar tissue meniscus in a cadaver model. They were lower
(Table 1). Even if Kawai (49) found TFS after 3 than expected, as they never exceeded 10 N (54).
130 The Traumatic Knee
Dürselen et al. (34) studied the eff ffect of cyclic joint
loads on the initial fixation strength of diff fferent
meniscal repair techniques. Th Three diff
fferent menis-
cal refi
fixation implants and one suturing technique
(Meniscal FastenerTM, Meniscal ArrowTM, ClearFix
ScrewTM, and a horizontal suture [PDS 1]) were
tested for initial stability in porcine knee joints after
cyclic joint loading. Whereas the horizontal suture
showed the highest pullout force (103 N, SD 19 N),
the Meniscal ArrowTM (52 N, SD 18 N), the Menis-
cal FastenerTM (29 N, SD 3 N), and the Meniscal
ScrewTM (22 N, SD 8 N) failed at signifi ficantly lower
loads; cyclic loading led to a decreased initial pull-
out force only for the horizontal suture (82 N, SD
26 N) and the Meniscal FastenerTM (23 N, SD 5N).
It was concluded that cyclic joint loading can lead
to reduced fixation strength, especially of menis-
cal refi
fixation implants and sutures with relatively
low stiffffness. Uncertainty remains as to which fixa-
tion strength is necessary to provide conditions for
meniscal healing. Many meniscal fixation
fi implants
have low pullout forces, yet it is still unknown if
these forces are higher than the forces the implants
must resist in vivo. Therefore, it was hypothesized
by Dürselen et al. (55) that meniscal repair with the
meniscal screw as an example for a device of low
pullout force signifi ficantly reduces tear gapping.
The authors set longitudinal tears in the posterior
Th
horn of the medial menisci of porcine knee joints,
then the knees were moved in a loading and motion
simulator under various external moments and
axial loads, and gapping of the tear was registered.
The measurements were repeated after fixation
Th
of the tears with three ClearFix ScrewsTM, which
show a low pullout force of 20 N only; maximum
gapping (median 1.6 mm, min/max 1.1/1.8 mm)
occurred at 200-N axial joint load under the combi-
nation of a valgus and external rotation moment.
Fixation with the ClearFix ScrewTM signifi ficantly
reduced tear gapping in all load cases, and moder-
ate joint loads only led to small gaps of meniscal
tears. Meniscal fixation with the ClearFix ScrewTM
prevents longitudinal meniscal tears from gapping.
This could indicate from a biomechanical point of
view that fixation implants of low pullout strength
are not in danger of failure in a normal rehabilita-
tion regimen. Studying the distraction forces on
repaired meniscus bucket-handle lesions, Becker
et al. (56) found data suggesting that distraction
forces are not the primary factor in the mechani-
cal stability of meniscal repair. They assumed that
other factors such as shear forces are of greater sig-
nifi
ficance. Zantop et al. (57) designed a shear force
scenario for evaluation of biomechanical proper-
ties of meniscal sutures, hypothesizing that menis-
cal repair using a vertical suture technique would
result in signifi ficantly less elongation when sub-
jected to a cyclic loading protocol than that result-
ing from a horizontal suture technique. The
Th results
from their investigation, however, did not support
their hypothesis, as horizontal sutures were found
to be superior to vertical suture techniques. They
concluded that meniscal repair with horizontal
suture techniques can withstand elongation due to
shear forces more eff
ffectively than can vertical mat-
tress sutures.
The biological healing factors
of meniscus repair
As early as in 1936, King wrote that for a menis-
cal tear to heal, the torn meniscus must commu-
nicate with its peripheral blood supply. Arnoczky
and Warren described the vascularization of the
meniscus in 1982, showing that the inferior and
superior medial and lateral geniculate arteries
give rise to a perimeniscal capillary plexus enter-
ing the outer 10–30% of the meniscus tissue.
Furthermore, they found that a vascular synovial
tissue (synovial fringe) extends over the menis-
cal rim and contributes markedly to the repara-
tive response. Recently, Bray et al. found a fast
and prolonged increase in meniscal vascularity in
a rabbit model after injury, showing that there is
a vascular response of the meniscus to a traumatic
event (58,59). In 1992, Arnoczky et al. classifi fied
the meniscus tissue into three diff fferent healing
zones according to the degree of vascularization of
the injured meniscal region. Th The well-vascularised
periphery of the meniscus was defi fined as the “red-
red zone” because both sides of a tear in this area
appear to be red under arthroscopic control. On
the opposite, the central, non-vascularized region
of the meniscus was called “white-white zone” and
the area in between, the “red-white zone”. In the
latter the peripheral side of the tear appears to be
red under arthroscopy, whereas the central side
appears white. Grossly each zone corresponds to a
third of the width of the meniscus. Corresponding
to this classifi
fication, a good healing capacity has
been observed in the red-red zone (60), whereas no
healing or only a very low healing response can be
expected in the central zone (61).
The healing process of the meniscus basically does
not diff
ffer from the classic wound healing pathway,
which is differentiated
ff into an infl
flammatory phase, a
granulation phase with the formation of a fi fibroblastic
scar and vascular ingrowth, and finally the ingrowth
of undiff
fferentiated mesenchymal stem cells.
In order to allow for increased meniscal preserva-
tion in the future, it is necessary to identify poten-
tial ways to improve meniscal healing in general and
healing in the avascular area in particular. Recent
eff
fforts have been made to understand meniscal

healing on a cellular basis. Verdonk et al. character-
ized the meniscus cell phenotypes and found that
the meniscus was populated by diff fferent cell types
(62). Several studies showed that meniscal cells of
all zones have the potential to participate in the
reparative response. Bhargava et al. (63) showed
fic growth factors (PDGF and HGF) were
that specifi
able to stimulate the migration of cells from all
zones of bovine menisci. Tumia et al. (64) found
that BFGF stimulated cell proliferation and extra-
cellular matrix formation from all zones of bovine
menisci. Kambic et al. (65) and Lin et al. (66) ana-
lyzed the expression of smooth muscle actin (SMA),
a wound-healing protein in human and canine
menisci. They found an SMA production in the
meniscal tissue, expression which differed
ff accord-
ing to the depth of the cell layers and showed that
meniscal cells have the capacity to contribute to
wound contraction. In a study on rabbit meniscal
tears, Becker et al. (67) found an increased expres-
sion of vascular endothelial growth factor at the
periphery and the central zone of the meniscus.
Despite this, they could not observe any meniscal
healing in the inner zone. They concluded that the
central, avascular zone has no intrinsic capacity to
induce angiogenesis in the healing process.
These findings show that the meniscus has an intrin-
sic reparative potential that must not necessarily be
limited to areas with blood supply. Based on such
findings, biologically based therapies might be devel-
oped in the future. In a recent study, such a strategy
has been presented in an animal model. Peretti et al.
(68) filled a porcine meniscus tear in the avascular
zone with an allogenic meniscal scaffold
ff seeded with
autologous chondrocytes. They observed a complete
healing in these animals, whereas no healing could
be noted in their control groups.
Postoperative weight-bearing conditions
and rehabilitation
Th is no consensus regarding the type of rehabil-
There
itation after meniscus repair. Individual protocols
differ
ff with respect to type and length of immobi-
lization, weight-bearing, and postoperative range
of motion. Most authors prefer to limit the range
of motion in the first 6 weeks following surgery by
using a brace and allow only touch-down weight-
bearing. Alternatively, full weight-bearing can be
allowed with the knee in full extension in a brace.
Passive range-of-motion exercises are generally
recommended, usually not exceeding 90° of knee
flexion during the first 6 weeks in order to limit
the load on the posterior horns and to avoid an
excessive stress of the repaired tissue and fixation
fi
mode. Some authors apply a different
ff rehabilita-
Meniscal sutures 131
tion regime depending on the repair of a medial
or a lateral meniscus. Non-pivoting sports such as
cycling or jogging can be started at 3 months. If
the patient experiences knee pain or swelling, such
eff
fforts should be postponed. Return to pivoting
sports can usually be considered after 6 months.
Complications
According to Small (69), the complication rate
after meniscal sutures amounts to 2.6%. ThThe most
common complication after arthroscopic suture
of a medial meniscus is a lesion of the saphenous
nerve. The frequency of this complication can be
up to 12.9% of inside-out sutures of the medial
meniscus (70–78). TheTh lesion of the main nerve
induces numbness, paresthesias, or pain in the
innervation area on the inner side of the calf. It
can result from an intraoperative pressure trauma
or from tying the knot over the nerve. In case of
injury of the infrapatellar branch, running distally
from the incision for the inside-to-outside tech-
nique to the ventral side, the paraesthesia is lim-
ited to its innervation area, about 8–10 cm under
the patella. Most nerve injuries recover within a
few months, and it is rarely necessary to perform
a neurolysis. Kimura et al. (73) described a medial
meniscal cyst after meniscal suture. Th
The structure
on the lateral side most frequently at risk is the
common peroneal nerve (79).
The use of meniscal repair implants can implicate
certain specifific problems. Migration of broken
arrows into the subcutaneous fat tissue (80), for-
eign body reactions, prolonged eff ffusion (81) and
chondral lesions on the femoral condyle (11,82,83)
were described.
Results
For evaluation of healing rates, short- and long-
term results must be taken into consideration. Th
The
analysis of short-term results should evaluate
anatomical and clinical healing aspects. ThThe ana-
tomical criteria are classifi
fied into complete heal-
ing, incomplete healing, and failed healing (84).
An appropriate evaluation is only possible with a
second-look arthroscopy or, more recently, with
arthro-CT scans or arthro-MRI (magnetic reso-
nance imaging). The
Th clinical criteria include the
presence or absence of meniscal signs and joint
eff
ffusion. By using only clinical criteria for evalu-
ation of healing rates, the results are usually too
optimistic. Over 50% of the anatomically incom-
plete or failed meniscal sutures are not recognized
132 The Traumatic Knee
clinically (1,85,86). The Th clinical and anatomical
healing rates vary between 50% and 91% (87) (Seil
2001). This
Th is related on the one hand to diff ffering
evaluation criteria, and on the other hand to the
following factors:
– Stability of the knee joint, concomitant ACL
reconstruction: The best healing rates (ana-
tomical criteria) were seen in meniscal repairs
with concomitant ACL reconstruction (86). In
most of the studies, these rates amounted to
over 75%. The healing rates of isolated meniscal
refi
fixations in stable joints were indicated with
50–75%, whereas sutures in unstable joints with-
out concomitant ACL reconstruction showed the
smallest healing rates with less than 50% (60).
These data allow the conclusion that a concomi-
tant ACL reconstruction possibly permits a bet-
ter meniscus healing. One of the hypotheses to
explain this phenomenon was that the hemar-
thros following ligamentoplasty would induce a
“biological healing reaction” (1,3). However, this
connection could not be confirmed fi in all of the
studies (85).
– Distance from tear to meniscal base: Because
of the good vascularization, tears located at the
meniscal periphery have a better healing process
than central tears (61,86).
– Type and size of tear: Meniscal healing after
suture is furthermore infl fluenced by the type and
the size of the tear. It is well known that radial
and complex tears have unfavorable healing rates.
Complex and chronically displaced bucket handle
tears showed lesser healing rates than non-dis-
located longitudinal tears (88). Some authors
found no correlation between meniscal disloca-
tions and the failure rate of suture repairs (1,89)
(. Cannon and Morgan (90) could demonstrate
that the failure rate was proportional to the tear
length (<2 cm: 15%, 2–4 cm: 20%, >4 cm: 59%).
Valen and Molster (89) confi firmed these results,
whereas other authors found no influence fl of
these specifi fic factors on healing (1,91,92).
Other factors of infl fluence are the time between
injury and surgery (86,89,91–93) as well as a
concomitant injury of the opposite meniscus
(2,86,93). Reparable injuries are more frequent in
young individuals.
The lack of studies following the criteria of evi-
dence-based science such as prospective study
design, randomization, control groups, sufficientffi
patient number, and complete follow-up make the
evaluation of long-term results after meniscal
suture diffi
fficult. Ten studies dealing with the long-
term outcomes after open or arthroscopic menis-
cal repair (>7 years) (60,94–102) and two studies
on late midterm results after all-inside repair with
the Meniscus ArrowTM (≥6 years) (103,104) have
been published until now.
Long-term results after meniscal suture can be
evaluated by the following three criteria:
– Rerupture rate, which can be determined accord-
ing to diff
fferent criteria (arthroscopic, clinic,
MRI)
– Radiologic signs of arthritis, as indirect signs
for the biomechanical function of the repaired
meniscus
– Joint function, evaluated by diff fferent scoring
systems
Joint function
The primary goal of meniscal repair is to restore
joint function. With adequate rehabilitation, this
is achieved in most patients. Considering the
reviewed investigations (60,94–104), normal knee
function is reestablished after meniscal repair in
71–100% of the patients. Although the comparabil-
ity of these results is difficult
ffi from a scientifi
fic point
of view, with diff
fferent scoring systems in use (HSS,
OAK, IKDC, Lysholm, Tegner, Cincinnati, SF-36),
they all tend in the same direction (Table 2). Menis-
cal repair was commonly performed in stable knees,
ACL ruptures being surgically treated in most cases
(94,95,97,98,100,101,103,104). Only four authors
(60,96,99,102) also report on meniscal sutures
under unstable conditions (Table 2).
DeHaven et al. (60) found reruptures only in
unstable joints, either with known ACL tears
that had not been treated or with repaired ACLs.
Muellner et al. (99) also report two reruptures out
of three unstable joints with side-to-side differ- ff
ences in passive sagittal knee laxity of more than
3 mm. Interestingly, Johnson et al. (96), after
clinical evaluation of joint function, found a nor-
mal knee function in 76% of the cases, while 100%
of the patients were subjectively satisfied fi with
the surgical outcome. Th The five patients defi fined
as unsuccessful repairs were also assessed unsta-
ble according to clinical criteria. A comparison
with the rerupture rate, however, is not possible
because it was evaluated clinically in eight of nine
cases. Steenbrugge et al. (102) report a HSS score
of more than 75% of their population, with 85%
of the patients having a normal knee function;
out of the seven patients with an ACL rupture at
follow-up examination, five had good to excellent
results. Similar conclusions were made by Kimura
et al. (97), with all the patients presenting good to
excellent functional results according to the Lysh-
olm and Tegner scores.
There is, however, a discrepancy between these
good clinical results and the third-grade changes
of the meniscal tissue found in up to 40% of
the patients on MRI scans. Steenbrugge et al.
(102), describing hyperintense areas in 6 out of
Table 2 – Long-term results after meniscal repair.
Long-term follow-up (>7 years) after meniscal suture (open and arthroscopic)
Follow-
Authors Year Patient number ACL rupture ACL repair Reruptures RX Function
up
Rate Arthritis Normal
Open ASC Stable Unstable Total + - + - Years ASC MRI Clinic Scores
(%) rate (%) (%)
DeHaven Lysholm,
1 1995 33 - 12 21 33 25 8 17 8 10.9 6 - 1 21 24 90
et al. Tegner
2 Eggli et al. 1995 - 52 52 - 52 5 47 - 52 7.5 12 ! - 23 - 90 IKDC
3 Muellner et al. 1999 23/(33) - 19 4 23 7 16 7 - 12.9 1 ! 1 9 26 91 OAK, Tegner
4 Johnson et al. 1999 - 38/(70) 32 6 38 ? ? - - 10.8 1 - 8 24 8 76 Clinic
Rockborn & Lysholm,
5 2000 30/(33) - 30 - 30 - 30 - - 13 7 - - 23 43 90
Messner Tegner
Rockborn & Lysholm,
6 2000 31/(34) - 31 - 31 - 31 - - 13 9 - - 29 23 80
Gillquist Tegner
7 Steenbrugge et al. 2002 - 13/(20) 6 7 13 7 6 1 6 13 - 1 - 8 - 85 HSS
Lysholm,
8 Kimura et al. 2004 - 28/(54) 28 - 28 20 8 20 - 10.2 - 10 - 36 43 100
Tegner
Lysholm,
9 Majewski et al. 2006 - 88/(116) 88 - 88 - 88 - - 10 21 - - 24 20 78
Tegner
IKDC, m.
10 Abdelkafy et al. 2007 - 41/(93) 41 - 41 16 41 16 - 11.7 5 - - 12 34 88
Lysholm
Late midterm follow-up (≥ 6 years) after arthroscopic all-inside repair with the Meniscus ArrowTM
11 Lee et al. 2005 - 28/(32) 21 7 28 32/32 - 32/32 - 6.6 7 - 1 29 - 71 IKDC
IKDC,
12 Siebold et al. 2007 - 95/(113) 95 - 95 75/113 38/113 75/113 - 6 27 - - 28 - 90
Lysholm
Ad 1: 30 patients, 33 menisci; Lysholm ≥ 80: normal knee function.
Ad 2: 5 patients with arthroscopically diagnosed, clinically stable ACL ruptures; radiographic and MRI exams were only performed in asymptomatic patients; 25 out of 40 patients without reruptures available for MRI examination, 24 of
these presenting 3rd or 4th grade lesions.
Ad 3: 10/32 patients (33 menisci) were not available for follow-up, thus a higher rerupture rate must be assumed; 19 patients underwent MRI scans, with 10 of them presenting 3rd grade lesions (the arthroscopic rerupture included).
Ad 4: Stability criterion was a pathologic clinical exam; no ACL lesions were described during primary surgery; only one rerupture was surgically treated.
Ad 5 + 6: Comparing both studies leads to the assumption that in part the same group was examined.
Ad 7: In this study, 7 ACL ruptures were diagnosed by MRI, one of these was treated surgically; the 7 knees are assumed to be unstable; rerupture rate was assessed by MRI.
Ad 8: None of the patients examined at follow-up had clinical meniscal signs, all knees were assessed with normal function; the rerupture rate of 36% was deduced from the ACL cases with 3rd grade lesions on MRI scans.
Ad 9: 24/88 patients were excluded from clinical and radiograpical follow-up because of reruptures or other complications.
Ad 11: In the best case scenario, in which it is assumed that the 4 patients who were lost to follow-up went on to successful meniscal healing, the success rate is 75%.
Ad 12: Not all the patients were assessed with the same scores; the 90% normal knee function result from the 41 patients assessed with the IKDC; the rerupture patients were not considered.
Meniscal sutures 133
134 The Traumatic Knee
13 patients, presumed that asymptomatic menisci
produce abnormal MRI signals, even though they
have stable unions, and that MRI signals at the site
of repair represent edematous scar tissue, not true
non-unions. Eggli et al. (95) came to similar con-
clusions in their study. They stated, after analyz-
ing their MRI results, that MRI deos not provide
further information concerning the healing prop-
erties of the repaired menisci because of its lack
of signal specification.
fi They recommended its use
only in the evaluation of shape and anatomic posi-
tion of the sutured meniscus.
DeHaven et al. (60) made similar observations for
joint function in case of rerupture of the menis-
cus. The average Lysholm score for patients with
retears was 84, and the average Tegner score 6.1,
thus indicating a normal knee function. Ninety-
six percent of the patients returned to athletic
levels of activity (postoperative Tegner scores
between 5 and 10), with 91% of the patients with
successful repairs maintaining such levels during
the 10 years of follow-up. Although the rerupture
rate was 24%, Johnson et al. (96) reported 100%
subjectively satisfied
fi patients. There seems to be
a mismatch between the functional results and
meniscus morphology; a non-union of the tear,
respectively, an incomplete meniscal healing are
not necessarily associated with a bad functional
outcome (Table 2).
The mid- and long-term functional outcome of
Th
meniscal suture repairs with the natural history of
the uninjured knees of each of a cohort of patients
was assessed retrospectively by Majewski et al. (98)
in 64 patients. The mean Tegner activity level was
6 points (range, 3–10 points), the mean Lysholm
score 94 points (range, 26–100 points). Seventy-
eight of the patients had a normal knee function,
and a diff
fference between the injured and the unin-
jured joint could not be established.
Two studies by Rockborn et al. (2000) deal with
the long-term results of meniscal repair, retrospec-
tively compared to a control group after meniscec-
tomy. Startingly, at the 13-year follow-up, results
between groups were comparable for joint func-
tion, subjective complaints, and manual findings.
The authors therefore recommend to weigh the
Th
high functional scores after arthroscopic meniscec-
tomy against the inconvenience of long rehabilita-
tion and long sick leave after meniscal repair.
Recently, a retrospective study with a long-term
follow-up evaluation of the outside-in technique
of arthroscopic meniscal repair was published by
Abdelkafy et al. (94). Out of the 41 patients avail-
able for follow-up evaluation, 36 repairs were clini-
cally successful and 5 were considered as failures.
Eighty-eight percent of the patients had normal
knee function according to the IKDC- and SF-36
scores.
In the recent literature, two papers report on
late midterm results after meniscal repair with
all-inside devices. In 2005, Lee et al. presented a
case series investigating the outcome of menis-
cal repair with the Meniscus ArrowTM (103). The Th
study was an extended follow-up of an original
series of 32 patients with outcomes analysis. All
patients underwent meniscal repair with exclusive
use of the arrow, and all repairs were performed
in the context of a concomitant ACL reconstruc-
tion. Intermediate follow-up at a mean of 2.3
years yielded a success rate of 90.6%. Th The mean
follow-up then had been extended to 6.6 years.
The extended follow-up analysis revealed a sub-
stantial attrition in the success rate of this series
of patients undergoing meniscal repair with the
arrow. A 90.6% success rate at a mean follow-up
of 2.3 years deteriorated to 71.4% at 6.6 years. At
the time of publication, the study provided the
longest follow-up in the literature of any of the
all-inside meniscal repair implants. Th The authors’
conclusion was that the Meniscus ArrowTM demon-
strated late midterm meniscal healing rates infe-
rior to those found in the literature for inside-out
suture repair techniques. Similar conclusions were
made by Siebold et al. (104). In a level IV study,
they recently evaluated 113 consecutive patients
with an arthroscopic all-inside Meniscus ArrowTM
repair. The mean length of follow-up was 6 years;
concomitant ACL reconstruction was performed in
66% of patients. TheTh Meniscus ArrowTM showed a
high clinical failure rate of 28%. Furthermore, over
80% of all failures occurred during the fi
first 3 post-
operative years, suggesting that the initial refix-
fi
ation potential of the Meniscus ArrowTM is low. On
the other hand, 90% of the patients were assessed
to the IKDC categories A or B, suggesting a normal
knee function.
Especially the study by Siebold et al. (104) indi-
cates that the total failure rate of meniscal repair
with the Meniscus ArrowTM is comparable to that
of meniscal suture repair after 6 years. Th Thus, the
conclusions that all-inside repair is inferior to
suture repair must be reformulated.
Rerupture rate
In about a quarter of the patients, a second inter-
vention with partial meniscal resection or resuture
becomes necessary. The
Th rerupture rate in unstable
knee joints is higher than under stable conditions
(60,99). The reviewed publications indicate a rerup-
ture rate between 8–36% for meniscal sutures and
28 resp. 29% for all-inside devices (Table 2).
Some authors did not deduce the rerupture rate
from the results of second-look arthroscopies,
because the clinical situation did not justify an

intervention, although imagery showed signs of
meniscal lesions. The results presented in this
review issue from arthroscopic, MRI, and clini-
cal findings (Table 2). Thus the comparability and
interpretation of these studies is limited.
Joint stability has been considered a crucial out-
come factor; two out of four authors who per-
formed meniscal repair in unstable knees report a
higher number of reruptures in the ACL-deficientfi
group (60,99). Th
These results are concise with those
found in the literature (105). DeHaven et al. (60),
however, conclude that their 67% survival rate sup-
ports the practice of meniscal repair for patients
who chose not to have ACL surgery on an unstable
knee.
The rerupture rates of open and arthroscopic
meniscal repair do not seem to diff ffer in the long-
term follow-up. Also the latest publications on
late midterm results after meniscal repair with all-
inside devices suggest rerupture rates similar to
those of the conventional techniques (103,104).
In a long-term follow-up investigation, MRI
showed a meniscal rupture in 1 out of 13 patients
and signs of mucoid degeneration or scar tissue in
46% of the examined patients (102). TheseTh results
are backed by data provided by Kimura et al. (97).
In a group of 28 patients, treated either by isolated
meniscal repair or meniscal repair and concomit-
tant ACL reconstruction, at a mean follow-up of 10
years, the evaluation of MRI scans showed grade 3
meniscal changes in 36% of the patients, all from
the ACL group. However, no meniscal signs or
symptoms were present, and no significant fi rela-
tionship between findings of radiographs and MRI
scans was apparent. Thus MRI must be viewed crit-
ically as an appropriate diagnostic device for diag-
nosis of meniscus reruptures.
In a recent retrospective analysis of 88 arthroscop-
ically performed meniscal sutures (mean follow-up
of 10 years) in isolated, longitudinal, vertical
tears of one of the menisci within a stable knee,
the rerupture rate was indicated with 21% for the
lateral meniscus (8/38) and 26% for the medial
meniscus (13/50). The total rerupture rate was
23.9% (21/88) (98). In the group examined by
Abdelkafy et al. (94), there were 12.2% reruptures
at a mean follow-up of 11.7 years. Out of initially
93 cases, only 41 patients were available for the
follow-up evaluation; therefore, a higher number
of failures might be suggested.
Radiologic signs of arthritis
The biomechanical function of a sutured meniscus
can indirectly be evaluated by the radiological signs
of arthritis. Supposing that a repaired meniscus has
a similar function than the original tissue, the rate
Meniscal sutures 135
of degeneration should not exceed the typical age-
related osteoarthritis rate. Long-term follow-up
studies showed radiological degenerative changes
in 8–43% of the patients (Table 2). The radiologi-
cal changes were signifi ficantly higher in reruptures
compared to patients without reruptures (57–15%
(60) resp. 57–13% (100,101). In a study compar-
ing a group with partial meniscectomy and a group
with meniscal repair, Rockborn and Gillquist (101)
found a trend to fewer signs of osteoarthritis in
the repair group even if the groups were too small
to show significant
fi diff
fferences.
The best results for postoperative manifestation of
radiologic signs of arthritis were published by John-
son et al. (96). In 38 knees available for follow-up,
only 3 showed minimal signs of degeneration on
x-rays; the control side presented 3% of radiologic
osteoarthritis signs. Thirty-two joints were stable,
and 6 unstable; the correlation between degenera-
tive joint changes on x-rays and joint stability was
not evaluated.
Muellner et al. (99) report three out of five patients
with degenerative changes on x-rays that had a
concomitant ACL reconstruction at the time of
meniscal repair. However, no mention of stability
assessment in these patients was made.
In the above-mentioned study by Majewski et
al. (98), both the injured and the uninjured knee
were radiographically examined in a retrospective
follow-up. Twenty-four out of 88 patients were
excluded from the radiographic exam because
of reruptures or other complications. From the
remaining 64 patients, 46 presented osteoarthritic
changes, compared with 27 of the uninjured knees
(P = .004). However, 42 of the patients had no
diff
fference in the grade of osteoarthritis between
the injured and the uninjured knee. According to
the authors, the eff ffects of arthroscopic meniscal
repair on the risk of secondary osteoarthritis are
not clear.
With a similar purpose, Abdelkafy et al. (94) com-
pared pre- and postoperative x-rays after menis-
cal repair. Preoperatively, 21 out of 24 knees were
considered as normal, whereas at follow-up, only
12 out of 41 patients had no radiographic signs of
osteoarthritis. This was interpreted as a progres-
sion of arthritis.
As a summary of the previously mentioned stud-
ies, a rerupture seems to occur in about 20–30% of
meniscal repairs in the long term. Repaired menisci
seem to be able to fulfi fill their original function
both from the biomechanical and from the clini-
cal point of view. However, the exact influence
fl of
meniscal repair on the development of osteoarthri-
tis has not completely been elucidated yet. Recent
investigations indicate that repair with meniscal
repair devices might be less favorable than initially
expected. However, further studies are needed to
136 The Traumatic Knee
confi
firm the benefifit of meniscal repairs, either with
sutures or all-inside devices, over partial meniscec-
tomies in the long term.
References
1. Scott GA, Jolly BL, Henning CE (1986) Combined poste-
rior incision and arthroscopic intra-articular repair of the
meniscus. J Bone Joint Surg Am 68:647–661
2. Morgan CD, Wojtys EM, Casscells CD, Casscells SW (1991)
Arthroscopic meniscal repair evaluated by second- look
arthroscopy. Am J Sports Med 19:632–637
3. Henning CE, Lynch MA, Clark JR (1987) Vascularity for
healing of meniscus repairs. Arthroscopy 3:13–18
4. Arnoczky SP, Warren RF (1983) The Th microvasculature of
the meniscus and its response to injury. Am J Sports Med
11:131–141
Arnoczky SP (1992) Gross and vascular anatomy of the
meniscus and its role in meniscal healing, regeneration
and remodelling. In: Mow VC, Arnoczky SP, Jackson DW,
editors. Knee meniscus: basic and clinical foundations.
New York: Raven Press
5. Fox JM, Rintz KG, Ferkel RD (1993) Trephination of
incomplete meniscal tears. Arthroscopy. 9(4):451–455
6. Zhang Z, Arnold JA (1996) Trephination and suturing of
avascular meniscal tears: a clinical study of the trephina-
tion procedure. Arthroscopy 12(6):726–731
7. McAndrews PT, Arnoczky SP (1996) Meniscal repair
enhancement techniques. Clin Sports Med 15(3):499–510
8. Kohn D (1997) Diagnostische und operative Arthroskopie
großer Gelenke. Stuttgart: Thieme
Th
9. Morgan CD, Casscells SW (1986) Arthroscopic meniscus
repair: a safe approach to the posterior horns. Arthros-
copy 2(1):3–12
10. Ross G, Grabill J, McDevitt E (2000) Chondral injury after
meniscal repair with bioabsorbable arrows. Arthroscopy
16(7):754–756
11. Seil R, Rupp S, Dienst M, Müller B, et al. (2000) Chondral
lesions after arthroscopic meniscus repair using meniscus
arrows. Arthroscopy 16(7): E17
12. Zantop T, Eggers AK, Musahl V, et al. (2004) A new rigid
biodegradable anchor for meniscus refixation: fi biome-
chanical evaluation. Knee Surg Sports Traumatol Arthrosc
12(4):317–324
13. Becker R, Schroeder M, Starke C, et al. (2001) Biomechani-
cal investigations of different
ff meniscal repair implants in
comparison with horizontal sutures on human meniscus.
Arthroscopy 17:439–444
14. Seil R, Rupp S, Jurecka C, et al. (2003) Réparation ménis-
cale par fixations biodégradables : étude biomécanique
comparative. Rev Chir Orthop 89:35–43
Shoemaker SC, Markolf KL (1986) The Th role of the menis-
cus in the anteroposterior stability of the loaded anterior
cruciate-defi
ficient knee: effffects of partial versus total exci-
sion. J Bone Joint Surg Am 68:71–79
15. Zantop T, Eggers AK, Weimann A, et al. (2004) Initial
fixation strength of flexible all-inside meniscus suture
anchors in comparison to conventional suture tech-
nique and rigid anchors: biomechanical evaluation of
new meniscus refi fixation systems. Am J Sports Med
32(4):863–869
16. Benedetto KP, Ellermann A, Große C (2001) Expertenmei-
nung: Meniskusrefixation.
fi Arthroskopie 14:276–290.
17. Borden P, Nyland J, Caborn DN, Pienkowski D (2003) Bio-
mechanical comparison of the FasT-Fix meniscal repair
suture system with vertical mattress sutures and menis-
cus arrows. Am J Sports Med 31(3):374–378
18. Cohen SB, Boyd L, Miller MD (2007) Vascular risk associ-
ated with meniscal repair using Rapidloc versus FasT-Fix:
comparison of two all-inside meniscal devices. J Knee
Surg 20(3):235–240
19. Haas AL, Schepsis AA, Hornstein J, Edgar CM (2005)
Meniscal repair using the FasT-Fix all-inside meniscal
repair device. Arthroscopy 21(2):167–175
20. Kocabey Y, Chang HC, Brand JC, et al. (2006) A biome-
chanical comparison of the FasT-Fix meniscal repair
suture system and the RapidLoc device in cadaver menis-
cus. Arthroscopy 22(4):406–413
21. Kotsovolos ES, Hantes ME, Mastrokalos DS, et al. (2006)
Results of all-inside meniscal repair with the FasT-Fix
meniscal repair system. Arthroscopy 22(1):3–9
22. Nyland J, Chang H, Kocabey Y, et al. (2007) A cyclic testing
comparison of FasT-Fix and RapidLoc devices in human
cadaveric meniscus. Arch Orthop Trauma Surg
23. Zantop T, Eggers AK, Musahl V, et al. (2005) Cyclic testing
of flexible all-inside meniscus suture anchors: biomechan-
ical analysis. Am J Sports Med 33(3):388–394
24. Chang HC, Nyland J, Caborn DN, Burden R (2005) Bio-
mechanical evaluation of meniscal repair systems: a com-
parison of the Meniscal Viper Repair System, the vertical
mattress FasT-Fix Device, and vertical mattress ethibond
sutures. Am J Sports Med 33(12):1846–1852
25. Chang HC, Caborn DN, Nyland J, Burden R (2006) Effect ff
of lesion location on fixation strength of the menis-
cal viper repair system: an in vitro study using porcine
menisci. Arthroscopy 22(4):394–399
26. Albrecht-Olsen P, Lind T, Kristensen G, Falkenberg B
(1997) Failure strength of a new meniscus arrow repair
technique: biomechanical comparison with horizontal
suture. Arthroscopy 13:183–187
27. Asik M, Sener N, Akpinar S, et al. (1997) Strength of dif-
ferent meniscus suturing techniques. Knee Surg Sports
Traumatol Arthrosc 5:80–83
Asik M, Sener N (2002) Failure strength of repair devices
versus meniscus suturing techniques. Knee Surg Sports
Traumatol Arthrosc 10(1):25–29
28. Barber FA, Herbert MA (2000) Meniscal repair devices.
Arthroscopy 16(6):613–618
29. Barber FA, Herbert MA, Richards DP (2004) Load to fail-
ure testing of new meniscal repair devices. Arthroscopy
20(1):45–50
Barrett GR, Field MH, Treacy SH, Ruff ff CG (1998) Clinical
results of meniscus repair in patients 40 years and older.
Arthroscopy 14:824–829
30. Becker R, Starke C, Heymann M, Nebelung W (2002)
Biomechanical properties under cyclic loading of seven
meniscus repair techniques. Clin Orthop 400:236–45
31. Bellemans J, Vandenneucker H, Labely L, Van Audeker-
cke R (2002) Fixation strength of meniscal repair devices.
Knee 9(1):11–14
32. Boenisch UW, Faber KJ, Ciarelli M, et al. (1999) Pull-out
strength and stiff ffness of meniscal repair using absorbable
arrows or Ti-Cron vertical and horizontal loop sutures.
Am J Sports Med 27:626–631
33. Dervin GF, Downing KJ, Keene GC, McBride DG (1997)
Failure strengths of suture versus biodegradable arrow for
meniscal repair: an in vitro study. Arthroscopy 13:296–
300
34. Dürselen L, Schneider J, Galler M, et al. (2003) Cyclic joint
loading can aff ffect the initial stability of meniscal fixation
implants. Clin Biomech (Bristol, Avon) 18 (1):44–49
Dürselen L, Hebisch A, Claes LE, Bauer G (2003) Gapping
phenomenon of longitudinal meniscal tears. Clin Biomech
(Bristol, Avon) 18(6):505–510
35. Fisher SR, Markel DC, Koman JD, Atkinson TS (2002)
Pull-out and shear failure strengths of arthroscopic menis-
cal repair systems. Knee Surg Sports Traumatol Arthrosc
10(5):294–249
36. McDermott ID, Richards SW, Hallam P, et al. (2003) A bio-
mechanical study of four diff fferent meniscal repair systems,

comparing pull-out strengths and gapping under cyclic
loading. Knee Surg Sports Traumatol Arthrosc 11(1):23–29
37. Post WR, Akers SR, Kish V (1997) Load to failure of com-
mon meniscal repair techniques: eff ffects of suture tech-
nique and suture material. Arthroscopy 13:731–736
38. Rankin CC, Lintner DM, Noble PC, et al. (2002) A bio-
mechanical analysis of meniscal repair techniques. Am J
Sports Med 30(4):492–497
39. Rimmer MG, Nawana NS, Keene GC, Pearcy MJ (1995)
Failure strengths of diff fferent meniscal suturing tech-
niques. Arthroscopy 11:146–150
Rockborn P, Gillquist J (1995) Outcome of arthroscopic
meniscectomy: a 13-year physical and radiological fol-
low-up of 43 patients under 23 years of age. Acta Orthop
Scand 66:113–117
40. Seil R, Rupp S, Kohn D (2000) Cyclic testing of meniscus
sutures. Arthroscopy 16(4):1–8
41. Seil R, Rupp S, Jurecka C, Kohn D (2001) Biomechanical
evaluation of new meniscus fixation devices. ISAKOS, May
14–18, Montreux, Switzerland
Seil R, Rupp S, Mai C, Kohn D (2001) The footprint of
meniscus fixation devices on the femoral surface of the
medial meniscus: a biomechanical cadaver study. ISAKOS,
May14–18, Montreux, Switzerland
42. Seil R, Rupp S, Jurecka C, et al. (2001) Der Einfluß fl ver-
schiedener Nahtstärken auf das Verhalten von Meni-
skusnähten unter zyklischer Zugbelastung. Unfallchirurg
104(5):392–398
43. Song EK, Lee KB (1999) Biomechanical test comparing the
load to failure of the biodegradable meniscus arrow versus
meniscal suture. Arthroscopy 15(7):726–732
44. Kohn D, Siebert W (1989) Meniscus suture techniques:
a comparative biomechanical cadaver study. Arthroscopy
5:324–327
45. Dienst M, Seil R, Kühne M, Kohn D (2001) Cyclic testing
of meniscal sutures after in vitro culture. Congress of the
International Society of Arthroscopy, Knee Surgery and
Orthopaedic Sports Medicine, Montreux, May 14–18
46. Seil R, Rupp S, Kohn D (2001) Technik und Biomechanik
der Meniskusrekonstruktion. Arthroskopie 14:254–266
47. Arnoczky SP, Lavagnino M (2001) Tensile fixation fi
strengths of absorbable meniscal repair devices as a func-
tion of hydrolysis time. An in vitro experimental study.
Am J Sports Med 29(2):118–123
48. Port J, Jackson DW, Lee TQ, Simon TM (1996) Menis-
cal repair supplemented with exogenous fi fibrin clot and
autogenous cultured marrow cells in the goat model. Am J
Sports Med 24:547–555
49. Kawai Y, Fukubayashi T, Nishino J (1989) Meniscal suture.
An experimental study in the dog. Clin Orthop Relat Res
243:286–293
50. Roeddecker K, Muennich U, Nagelschmidt M (1994) Menis-
cal healing: a biomechanical study. J Surg Res 56:20–27
51. Koukoubis TD, Glisson RR, Feagin JAJ, et al. (1997) Menis-
cal fixation with an absorbable staple. An experimental study
in dogs. Knee Surg Sports Traumatol Arthrosc 5:22–30
52. Guisasola I, Vaquero J, Forriol F (2002) Knee immobili-
zation on meniscal healing after suture: an experimental
study in sheep. Clin Orthop Relat Res 395:227–233
53. Cook JL, Fox DB (2007) A novel bioabsorbable conduit
augments healing of avascular meniscal tears in a dog
model. Am J Sports Med 35(11):1877–1887
54. Kirsch L, Kohn D, Glowik A (1999) Forces in medial and
lateral meniscus sutures during knee extension – an in
vitro study. J Biomech31(Suppl 1):104
55. Dürselen L, Hebisch A, Wagner D, et al. (2007) Meniscal
screw fixation provides suffifficient stability to prevent tears
from gapping. Clin Biomech (Bristol, Avon) 22(1):93–99
56. Becker R, Brettschneider O, Gröbel KH, et al. (2006) Dis-
traction forces on repaired bucket-handle lesions in the
medial meniscus. Am J Sports Med 34(12):1941–1917
Meniscal sutures 137
57. Zantop T, Temmig K, Weimann A, et al. (2006) Elongation
and structural properties of meniscal repair using suture
techniques in distraction and shear force scenarios: bio-
mechanical evaluation using a cyclic loading protocol. Am
J Sports Med 34(5):799–805
58. Bray RC, et al. (2000) Prolonged meniscal hyperaemia fol-
lowing anterior cruciate ligament injury. Trans Orth Res
Soc
59. Bray RC, et al. (2001) Vascular response of the meniscus to
injury: eff
ffect of immobilization. J Orthop Res
60. DeHaven KE, Lohrer WA, Lovelock JE (1995) Long term
results of open meniscal repair. Am J Sports Med 23:524–
530
61. Rubman MH, Noyes FR, Barber-Westin SD (1998)
Arthroscopic repair of meniscal tears that extend into the
avascular zone: A review of 198 single and complex tears.
Am J Sports Med 26:87–95
62. Verdonk PC, Forsyth RG, Wang J, et al. (2005) Characteri-
sation of human knee meniscus cell phenotype. Osteoar-
thritis Cartilage 13(7):548–560
63. Bhargava MM, Attia ET, Murrell GA, et al. (1999) The Th
eff
ffect of cytokines on the proliferation and migration of
bovine meniscal cells. Am J Sports Med 27(5):636–643
64. Tumia NS, Johnstone AJ (2004) Promoting the prolifera-
tive and synthetic activity of knee meniscal fibrochondro-
fi
cytes using basic fibroblast growth factor in vitro. Am J
Sports Med 32(4):915–920
65. Kambic HE, Futani H, McDevitt CA (2000) Cell, matrix
changes and alpha-smooth muscle actin expression in
repair of the canine meniscus. Wound Repair Regen
8(6):554–561
66. Lin BY, Richmond JC, Spector M (2002) Contractile actin
expression in torn human menisci. Wound Repair Regen
10(4):259–266
67. Becker R, Pufe T, Kulow S, et al. (2004) Expression of
vascular endothelial growth factor during healing of
the meniscus in a rabbit model. J Bone Joint Surg Br
86(7):1082–1087
68. Peretti GM, Gill TJ, Xu JW, et al. (2004) Cell-based therapy
for meniscal repair: a large animal study. Am J Sports Med
32(1):146–158
69. Small NC (1986) Complications in arthroscopy: the knee
and other joints. Arthroscopy 4:253–258
70. Benedetto KP (1989) Die Bedeutung und Indikation der
Meniskusnaht. Chirurg 60:760–764
71. Cameron H (1990) Tips of the trade 20. A simple method
of meniscal suture. Orthop Rev 19:103–104
72. Janousek A, Beer T, Pelinka H, Hertz H (1998) Langzeitergeb-
nisse nach Meniskusrefifixation. Arthroskopie 11:94–97
73. Kimura M, Hagiwara A, Hasegawa A (1993) Cyst of the
medial meniscus after arthroscopic meniscal repair. Am J
Sports Med 21:755–757
74. Miller DB (1988) Arthroscopic meniscal repair. Am J
Sports Med 16:315–320
75. Rühmann O, Kohn D, Sander-Beuermann A (1996)
Läsionen des N. saphenus durch arthroskopische medi-
ale Meniskusnaht und ihre Vermeidung. Arthroskopie
9:281–284
76. Ryu RK, Dunbar WH (1988) Arthroscopic meniscus repair
with two-year follow-up: a clinical review. Arthroscopy
4:168–173
77. Salisbury RB, Nottage WM (1989) A simple method of
meniscus repair. Arthroscopy 5:346–347
78. Villiger A, Mayer M (1997) Mittelfristige Ergebnisse nach
arthroskopischer Meniskusnaht. Swiss Surg 3:149–153
Walsh SP, Evans SL, O’Doherty DM, Barlow IW (2001)
Failure strengths of suture vs. Biodegradable arrow
and staple for meniscal repair: an in vitro study. Knee
8(2):151–156
79. Jurist KA, Greene PW, Shirkhoda A (1989) Peroneal nerve
dysfunction as a complication of lateral meniscus repair: a
138 The Traumatic Knee
case report and anatomic dissection. Arthroscopy 5:141–
147
80. Oliverson TJ, Lintner DM (2000) Biofi fix arrow appearing
as a subcutaneous foreign body. Arthroscopy 16:652–655
81. Menche DS, Phillips GI, Pitman MI, Steiner GC (1999)
Infl
flammatory foreign-body reaction to an arthroscopic bio-
absorbable meniscal arrow repair. Arthroscopy 15:770–772
82. Anderson K, Marx RG, Hannafi fin J, Warren RF (2000)
Chondral injury following meniscal repair with a biode-
gradable implant. Arthroscopy 16:749–753
Arnoczky SP, Warren RF (1982) Microvasculature of the
human meniscus. Am J Sports Med 10(2):90–95
83. Ménétrey J, Seil R, Rupp S, Fritschy D (2002) Chondral
damage after meniscal repair with the use of a bioabsorb-
able implant. Am J Sports Med 30(6):896–899
84. Henning CE (1983) Arthroscopic repair of meniscus tears.
Orthopedics 6:1130–1132
85. Albrecht-Olsen P, Kristensen G, Burgaard P, et al. (1999)
The arrow versus horizontal suture in arthroscopic
meniscus repair. A prospective randomized study with
arthroscopic evaluation. Knee Surg Sports Traumatol
Arthrosc 7:268–273.
86. Cannon WD, Vittori JM (1992) The incidence of healing in
arthroscopic meniscal repairs in anterior cruciate ligament
reconstructed knees versus stable knees. Am J Sports Med
20:176–181
87. Seil R, Kohn D (2001) Meniskusrekonstruktion – bewährte
und innovative Verfahren. Unfallchirurg 104(4):274–287
88. Asahina S, Muneta T, Yamamoto H (1996) Arthroscopic
meniscal repair in conjunction with anterior cruciate liga-
ment reconstruction: factors aff ffecting the healing rate.
Arthroscopy 12:541–545
89. Valen B, Molster A (1994) Meniscal lesions treated with
suture: a follow-up study using survival analysis. Arthros-
copy 10:654–658
90. Cannon WD, Morgan CD (1994) Meniscal repair: arthroscopic
repair techniques. Instr Course Lect 43:77–96. Review
Cannon WD (1996) Arthroscopic meniscal repair. In:
McGinty JB, Caspari RB, Jackson RW, editors. Operative
arthroscopy. Philadelphia: Lippincott-Raven:299–315
91. Buseck MS, Noyes FR (1991) Arthroscopic evaluation of
meniscal repairs after anterior cruciate ligament recon-
struction and immediate motion. Am J Sports Med
19:489–494
92. Tenuta JJ, Arciero RA (1994) Arthroscopic evaluation of
meniscal repairs.Factors that effffect healing. Am J Sports
Med 22:797–802
93. Horibe S, Shino K, Maeda A, et al. (1996) Results of iso-
lated meniscal repair evaluated by second-look arthros-
copy. Arthroscopy 12:150–155
94. Abdelkafy A, Aigner N, Zada M, et al. (2007) Two to
nineteen years follow-up of arthroscopic meniscal repair
using the outside-in technique: a retrospective study. Arch
Orthop Trauma Surg 127(4):245–252
95. Eggli S, Wegmüller H, Kosina J, et al. (1995) Long-term
results of arthroscopic meniscal repair. An analysis of iso-
lated tears. Am J Sports Med 23(6):715–720
96. Johnson MJ, Lucas GL, Dusek JK, Henning CE (1999)
Isolated arthroscopic meniscal repair: a long-term out-
come study (more than 10 years). Am J Sports Med
27(1):44–49
97. Kimura M, Shirakura K, Higuchi H, et al. (2004) Eight-
to 14-year followup of arthroscopic meniscal repair. Clin
Orthop Relat Res 421:175–180
King D. (1936) The healing of semilunar cartilages. J Bone
Joint Surg Am 18:333–342
98. Majewski M, Stoll R, Widmer H, et al. (2006) Midterm and
long-term results after arthroscopic suture repair of iso-
lated, longitudinal, vertical meniscal tears in stable knees.
Am J Sports Med 34(7):1072–1076
99. Muellner T, Egkher A, Nikolic A, et al. (1999) Open menis-
cal repair: clinical and magnetic resonance imaging fi find-
ings after twelve years. Am J Sports Med 27:16–20.
100. Rockborn P, Messner K (2000) Long-term results of
meniscus repair and meniscectomy: a 13-year functional
and radiographic follow-up study. Knee Surg Sports Trau-
matol Arthrosc 8:2–10
101. Rockborn P, Gillquist J (2000) Results of open meniscus
repair. Long-term follow-up study with a matched unin-
jured control group. J Bone Joint Surg Br 82:494–498
102. Steenbrugge F, Verdonk R, Verstraete K (2002) Long-term
assessment of arthroscopic meniscus repair: a 13-year
follow-up study. Knee 9(3):181–187
103. Lee GP, Diduch DR (2005) Deteriorating outcomes after
meniscal repair using the Meniscus Arrow in knees under-
going concurrent anterior cruciate ligament reconstruc-
tion: increased failure rate with long-term follow-up. Am
J Sports Med 33(8):1138–1141
104. Siebold R, Dehler C, Boes L, Ellermann A (2007) Arthroscopic
all-inside repair using the Meniscus Arrow: long-term clinical
follow-up of 113 patients. Arthroscopy 23(4):394–399
105. Rosenberg TD, Scott SM, Coward DB, et al. (1986) Arthro-
scopic meniscal repair evaluated with repeat arthroscopy.
Arthroscopy 2(1):14–20
 Chapitre 12

P. Verdonk,
P. Vansintjan, R. Verdonk
Meniscal allograft transplantation

History Meniscal allograft transplantation was first

introduced into clinical practice by Milachowsky

T
he surgical treatment of meniscal lesions is et al. in 1989. The senior authors started per-
the most common procedure in the ortho- forming this type of procedure in the same year.
paedic field today. Over 400,000 surgical We can now look back on a well-established
cases involving the meniscus are being performed series of over 250 patients treated with this type
annually in Europe and over 1 million in the United of surgery.
States. The majority of these lesions result in a
meniscectomy, while only a small percentage can
be successfully repaired. The discovery 50 years
ago that complete removal of a meniscus in the Biological basis
knee joint led to development of cartilage degen-
eration in the long term changed substantially The general biological basis of allograft transplan-
the therapeutic approach to this common work or tation is the concept of a timely colonization of the
sports injury (1). acellular scaff
ffold or allograft tissue by host cells,
Total meniscectomy is now almost completely which are probably derived from the synovium
abandoned in favor of partial meniscectomy and and joint capsule (Fig. 1) (9,10). The phenotype of
meniscus-repairing procedures. Both procedures these host-derived scaff ffold-colonizing cells ulti-
have the theoretical advantage of being less dam- mately determines the biochemical composition
aging to the articular cartilage. Long-term data and biomechanical behavior of these repopulated
to substantiate this hypothesis are, however, still scaff
ffolds or tissues.
missing. Nevertheless, total or subtotal meniscec- Another critical variable in this approach is the
tomy remains necessary for large irreparable tears. time needed for colonization of the scaff ffold or
In case of a meniscectomy, it appears logical to tissue: since these scaffffolds or tissues are biode-
substitute the lost meniscal tissue in order to pre- gradable, the colonization and healing by host
vent cartilage degeneration, to relieve pain, and to cells should be faster than the degradation pro-
improve function. cess, for the regeneration or healing of the menis-
In order to restore normal knee biomechanics and cal substitute to be successful.
anatomy and thus prevent further cartilage degen-
eration after meniscectomy, a number of surgi-
cal approaches including the use of autologous or
allogenic tissues were being suggested, e.g., ten-
don, pediculated Hoff ffa fat pad, periosteal tissue,
perichondral tissue, meniscal allografts, menis-
cal scaff
ffolds based on native polymers (collagen
and hyaluronic acid), or purely synthetic scaffolds
ff
such as poly-lactic acid, poly-glucuronic acid, and
poly-urethane (2–8). Besides meniscal allografts,
a collagen type I-based meniscal scaff ffold (CMI®,
Regen Biologics, Franklin Lakes, NJ, USA), and a
poly-urethane-based scaff fit®, Orteq, Lon-
ffold (Actifi
don, UK), none of these tissues have advanced to
human clinical use.
While scaffffolds are mainly used to substitute for Fig. 1 – Acellular meniscal grafts or scaffolds (*) are colonized by host cells
partial loss, meniscal allografts are generally used (arrows) which are probably derived from the synovium and the joint cap-
in total or subtotal meniscectomized patients. sule (**).
140 The Traumatic Knee
Previous animal studies have provided evidence that
fresh “viable” and deep-frozen “acellular” meniscal
allografts are quickly invaded by host cells within 1
month after transplantation (9,11). In the human
model, however, only limited data are available. A
previous study performed at our institution has
provided evidence that this process of colonization
is considerably slower in the human model: DNA
fingerprint analysis, performed on human viable
meniscal allograft biopsies taken up to 36 months
after transplantation, showed that these allografts
contained only donor-derived cells in a number of
cases (12). These
Th data substantiate observations
published elsewhere on transplanted human deep-
frozen meniscal allografts and collagen scaffolds.
ff
Histological sections of these specimens showed
a decreased cellularity after transplantation, indi-
cating decreased repopulation of the graft (10–13).
Hence, an increase of the initial cell number at
the defect site and thereby a decrease of the time
needed for colonization can be accomplished by
(1) transplantation of an in vitro cultured “viable”
meniscal allograft, (2) seeding autologous cells
with a proven meniscus repair potential on or
in a biodegradable scaff ffold or allograft prior to
implantation, or (3) structural and chemical modi-
fication of the scaff
ffold or graft to enhance cellular
ingrowth. Except for the transplantation of viable
meniscus allograft, most of these proposed strate-
gies are still under investigation.
In the clinical situation, several graft preserva-
tion techniques are available: lyophilization,
deep-freezing, cryopreservation, and cultured or
so-called “viable” allografts. Except for lyophiliza-
tion, no signifificant clinical diff
fferences have been
observed between the diff fferent preservation tech-
niques (14,15). Lyophilization, on the other hand,
has been abandoned due to inferior tissue qual-
ity and increased risk of clinical failure (16–19).
Deep-freezing renders the graft completely acel-
lular but preserves its biomechanical character-
istics. Cryopreservation has been shown to pre-
serve only 10–40% of the meniscus cells vital
and functional (20,21). Preservation of meniscus
cell viability and functionality can be guaranteed
for 2–3 weeks if the meniscus allograft tissue is
cultured in vitro using standard culture medium
supplemented with 20% acceptor serum, the so-
called “viable meniscus allograft” culture protocol
(22). The authors have extensive experience with
both deep-frozen and viable allografts (23). The Th
biological activity of the cells within the “viable”
scaff
ffold remains to be determined and is subject
of current clinical research protocols within our
department.
Indications and contraindications (24)
Indications
The indications for meniscal allograft transplanta-
tion have yet to be comprehensively defined.fi Cur-
rent recommendations suggest that the procedure
is indicated in three clinical scenarios:
1. Young patients with a history of meniscectomy
who have pain localized to the meniscus-deficientfi
compartment, a stable knee joint, no malalign-
ment, and articular cartilage with only minor evi-
dence of osteochondral degenerative changes (no
more than grade 3 according to the International
Cartilage Repair Society (ICRS) classifi fication sys-
tem) are considered ideal candidates for this pro-
cedure. Because of the more rapid deterioration in
the lateral compartment (25), a relatively common
indication for meniscal transplantation would be a
symptomatic, meniscal-deficient,
fi lateral compart-
ment.
2. ACL-defificient patients who have had prior
medial meniscectomy (who might benefit fi from the
increased stability aff
fforded by a functional medial
meniscus) in conjunction with concomitant ACL
reconstruction. It is the author’s conviction that an
ACL graft is signifi
ficantly protected by the menis-
cus allograft as much as the meniscus is protected
by an ACL graft (26).
3. A third context for meniscal transplantation has
also been advocated by some. In an effort
ff to avert
early joint degeneration, young, athletic patients
who have had complete meniscectomy might be
considered as meniscal transplantation candidates
prior to symptom onset (27).
Contraindications
Advanced chondral degeneration is considered
as a contraindication to meniscal allograft trans-
plantation, although some series suggest that
cartilage degeneration is not a significant
fi risk
factor for failure (23). In general, articular car-
tilage lesions greater than grade 3 according to
the ICRS classifi
fication system should be of lim-
ited surface area and localized. Localized chon-
dral defects may be treated concomitantly —
the meniscus transplantation and the cartilage
repair or restoration may benefitfi each other in
terms of healing and outcome (28). Chondrocyte
transplantation or osteochondral grafting proce-
dures should be performed after completion of
the meniscal transplantation in order to prevent
accidental damage to the patch or graft during
meniscal allograft insertion (29). Radiographic
evidence of signifi ficant osteophyte formation

or femoral condyle flattening is associated with
inferior postoperative results as these structural
modififications alter the morphology of the femo-
ral condyle (20). Generally, patients over age 50
have excessive cartilage disease and are subopti-
mal candidates.
Axial malalignment tends to exert abnormal pres-
sure on the allograft leading to loosening, degen-
eration, and failure of the graft (15). A corrective
osteotomy should be considered for greater than 2°
of deviation toward the involved compartment, as
compared with the contralateral limb mechanical
axis. Varus or valgus deformity may be managed
with either staged or concomitant high tibial or
distal femoral osteotomy (20). However, as in any
situation in which procedures are thus combined,
it becomes unclear which aspect of the procedure
is implicated in symptom resolution, such as relief
of pain (15).
Other contraindications to meniscal transplanta-
tion include obesity, skeletal immaturity, instabil-
ity of the knee joint (which may be addressed in
conjunction with transplantation as above), syn-
ovial disease, infl
flammatory arthritis, and previous
joint infection.
Technique
Preoperative considerations
In contrast to the use of deep-frozen allografts,
a strict time schedule from harvest to trans-
plantation is mandatory for viable allografts.
The transplantation of viable meniscal allografts
implies the availability of viable donor tissues,
cultured in vitro immediately following harvest.
Sizing of the graft is critical for correct implan-
tation. For deep-frozen allografts, the medio-
lateral and anteroposterior lengths of the tibial
plateau of the receptor are measured on a cali-
brated x-ray and transferred to the tissue bank.
Since viable meniscal allografting is more limited
in size options due to the fact that there is only
one donor and a limited number of acceptors,
the most appropriate acceptor is chosen based
on corresponding donor-acceptor height and
weight criteria. Once a patient is deemed to be
a candidate for this type of procedure, 30–50 ml
of autologous serum is prepared and frozen
at −21°C. The waiting time for a viable menis-
cal allograft averages 2 months – ranging from
14 days to 6 months – at our institution. Once
an appropriately sized meniscal allograft is har-
vested, the patient is notifi
fied and an operation is
planned within the next 14 days.
Meniscal allograft transplantation 141
Surgical technique
Introduction
The purpose of this technical chapter is to pres-
ent medial and lateral meniscal allograft trans-
plantation (1) as an open procedure or (2) as an
arthroscopically assisted procedure. Both tech-
niques use primarily soft tissue fixation
fi of the
allograft to the native meniscal rim. Additional
transosseous fixation of the anterior and posterior
horn is used in the arthroscopic technique, while a
tag on the anterior horn is used in the open proce-
dure for soft tissue-bone fixation.
fi
Anesthesia and surgical preparation
These items are identical for the open and
arthroscopic procedure. TheTh choice of anaesthesia
is made in consultation between the surgeon, the
anaesthesiologist, and the patient and depends on
the patient’s age, comorbidity, and history with
regard to previous anesthesia. General anesthesia
is preferred at our institution.
The patient is then positioned supine on the oper-
ating table. A lateral leg-holder is positioned at the
height of the tourniquet with the leg positioned in
90° of flexion. A foot holder is used to hold the leg
in 90° and 110° of flexion as needed. Previous skin
incisions are marked. The limb is exsanguinated
and the tourniquet is inflated.
fl The limb is then
prepared with chlorhexidine gluconate-alcohol
solution (Hibitane, Regent Medical Overseas Lim-
ited, Manchester, UK) and draped at the mid-thigh
level.
Allograft preparation for the open procedure
As previously described elsewhere, the allograft is
positioned and fixed on a specially designed cork
board with three 25-gauge needles (Fig. 2A) (30).
With a scalpel, the residual synovial tissue is dis-
sected from the allograft meniscus at the menisco-
synovial junction level and discarded.
The upper side of the allograft is marked with a
methylene blue skin marker.
Horizontal 2/0 polydioxanone surgical sutures
(PDS II mounted on a double small needle, Ethi-
con, Somerville, NJ, USA) or 2/0 non-absorbable
polypropylene sutures (Prolene mounted on a dou-
ble small needle, Ethicon, Somerville, NJ, USA) are
placed every 3–5 mm through the posterior horn,
the body, and the anterior horn of the allograft
and fixed onto a specially designed suture holder
(holder A) (Fig. 2A). The senior surgeon (RV) pre-
fers the use of 2/0 Prolene sutures for the poste-
rior horn since this suture material comes with
slightly smaller needles and therefore has easier
surgical handling in the more narrow posterior
joint space. The sutures are fixed onto the suture
142 The Traumatic Knee
A B
Fig. 2 – (A) Open meniscal allograft transplantation. A lateral parapatellar incision is made, with the knee in 90° of flexion, to gain access to the lateral
compartment of the joint. (B) Open meniscal allograft transplantation. To further open the lateral compartment, the LCL and PT are detached with a
curved osteotomy on the femoral side.
holder in sequence from posteriorly to anteriorly.
Generally, six to eight sutures are needed to cover
the complete allograft.
Open meniscal allograft transplantation
A medial or lateral parapatellar incision of approxi-
mately 8 cm is made with the knee in 90° of fl flex-
ion to gain access to the involved compartment of
the knee joint (Fig. 2A). Th
The joint capsule is then
opened and the anterior horn of the meniscus
remnant is transected.
For the lateral procedure, the iliotibial band is
released subperiostally from its distal attach-
ment. To further open up the lateral compart-
ment, the insertions of the lateral collateral
ligament (LCL) and popliteus tendon (PT) are
detached with a curved osteotomy on the fem-
oral side (Fig. 2B) The center of the osteotomy
bone block is first predrilled with a 2.7-mm drill.
This facilitates subsequent refixation with a
screw and washer. The osteotomy is done in a
clockwise direction from the 8 o’clock position
to the 4 o’clock position and is approximately 1.5
cm deep and conically shaped. The bone block is
gently folded out using a bone clamp, and then
the osteotomy is completed inferiorly from the 4
o’clock to the 8 o’clock position using the osteot-
ome. The lateral joint space can now be opened
up easily 1–2 cm by placing the knee in the fig-
ure of 4 position in 70–90° of flexion with the
index foot positioned across the contralateral
limb (Fig. 2A).
For the medial procedure, the medial collateral
ligament is detached on the femoral side with an
osteotomy (31). A flake osteotomy (0.5–1 cm in
thickness) is done with a straight osteotome at the
level of the medial femoral epicondyle. The
Th soft tis-
sues posterior to the medial collateral ligament are
left in continuity. By gently placing the knee in a
valgus position, the medial compartment can now
be opened up in a controlled fashion.
The meniscus remnant is trimmed preferably to a
stable meniscal rim with a scalpel anteriorly and
with arthroscopic instruments posteriorly. Most
often, the insertion of the posterior horn is still
intact and in continuity with the tibial plateau. The
Th
insertion of the posterior horn is also trimmed to
fit the allograft. The meniscal rim deserves surgical
attention, as it serves as a strong envelope encap-
sulating the medial or lateral compartment of the
knee.
The meniscal remnant level is then marked with
a small mosquito clamp anteriorly as landmark
for the correct level of subsequent fifixation of the
allograft. Next, the previously prepared viable
meniscal allograft is introduced into the knee
compartment. The sutures are taken from the
holder in the correct sequence from posteriorly to
anteriorly and driven through the meniscal rim
one by one in an all-inside fashion from inferiorly
to superiorly and transferred to a second suture
holder (holder B), again in a sequence from pos-
teriorly to anteriorly. The lateral allograft is also
sutured to the popliteus tendon. We have found
on follow-up arthroscopies that the popliteal
hiatus will recreate itself naturally. Th The inser-
tion of the anterior horn of the meniscus is not
yet sutured at this stage of the operation. Once
the sequence of suture transfer from holder A
through the meniscal rim (and popliteal tendon)
to holder B is completed, the allograft is intro-
duced into the compartment by gently pulling
on each suture in a sequence from posteriorly
to anteriorly. Generally, this procedure has to be
performed progressively to establish a secure fi fit
of the allograft to the meniscal rim. Th The suture
knots are then securely tied and cut. A fine-tipped
fi
suture driver and knot pusher are frequently

required to securely tighten the posterior sutures.
The knee is now positioned again in a normal 90°
flexed position. The bone block of the collateral
fl
ligament and popliteus tendon is repositioned
and fixed using a 35- or 40-mm 2.9 AO cancellous
screw with a spiked washer. ThThe anterior horn of
the allograft is then fixed to the tibia using an
anchor (GII, Depuy Mitek, Raynham, Massachu-
setts, USA). Th
The Hoffffa fat pad and knee capsule
are closed using interrupted Vicryl 1/0 (Ethicon,
Somerville, NJ, USA) cross-stitches after haemo-
stasis.
Allograft preparation for the arthroscopic procedure
The allograft is positioned and fixed on a specially
designed cork board with three 25-gauge needles.
With a scalpel, the residual synovial tissue is dis-
sected from the allograft meniscus at the menisco-
synovial junction level and discarded.
The upper side of the allograft is marked with a
methylene blue skin marker.
Non-resorbable high-strength (Fiberwire, Arthrex,
Naples, USA) sutures are placed in the anterior
and posterior horn of the allograft. Generally,
three whipstitches are placed on the inner and
outer rim of the horn of the allograft (Fig. 3).
An additional vertical non-resorbable suture
(Ethibond 2, Somerville, NJ, USA) is placed at
the posteromedial or posterolateral corner of
the medial or lateral allograft, respectively. For
the lateral allograft, the posterolateral suture is
positioned just anteriorly to the popliteus ten-
don hiatus as this will serve as a landmark dur-
ing arthroscopy (Fig. 3).
Arthroscopically assisted lateral meniscal allograft
transplantation
The classic anteromedial and anterolateral por-
tals are made. An additional anteromedial portal
is positioned very medially to gain easy instru-
Fig. 3 – Prepared lateral meniscal allograft for arthroscopic meniscal trans-
plantation. Whip stiches (WS) on the inner and outer rim of anterior (AH)
and posterior horn (PH). A vertical non-resorbable suture (NRS) is placed on
the posterolateral corner, just anterior of the PT hiatus.
Meniscal allograft transplantation 143
mental access for the debridement and resec-
tion of the anterior portion of the native lateral
meniscus. Using shaver and punch, the remnant
meniscus is debrided to the level of the meniscal
rim.
A modifi fied ACL aiming device, with a low-profifile
tip, is inserted through the medial portal and posi-
tioned at the anatomical posterior horn of the
lateral meniscus just posterior to the ACL (Fig. 4).
A guide pin is drilled first and subsequently over-
drilled by a 4.5-mm cannulated drill. A double-
looped metal wire is introduced through the tunnel
from outside-in and picked up intra-articularly with
an arthroscopic grasper and pulled out through
the lateral portal. Subsequently, a suture passer
(Acupass, Smith and Nephew, Memphis, Tennes-
see, USA) is introduced twice from outside-in just
anterior to the LCL and the popliteus tendon into
the joint: one just below and the second above the
native meniscal rim (Fig. 5). The
Th looped wires are
picked up and pulled out again through the lateral
portal. Next, the posterior horn pull suture and
the posterolateral pull suture are pulled through
using the double-looped metal wire and the dou-
ble-looped suture pass wire. The prepared lateral
allograft is subsequently introduced into the lateral
Fig. 4 – Modified ACL aiming device, with low profile tip. This device is
positioned at the anatomical posterior horn of the lateral meniscus, just
posterior to the ACL.
Fig. 5 – A suture passer (Acupass® Ap) is introduced twice from outside-in,
just anterior to the LCL and the PT, superior and inferior of the native menis-
cal rim (NMR).
144 The Traumatic Knee
Fig. 6 – Arthroscopic views of a lateral meniscal allograft in place. (A) Ante-
rior horn, outside in vertical. (B) Corpus, inside out oblique. (C) Posterior
horn, all- inside Fastfix®.
compartment throughout an enlarged lateral por-
tal by pulling progressively on the posterolateral
pull suture and the posterior horn pull suture. Care
should be taken that the graft does not fl flip upon
introduction and that pull wires do not intertwine.
Risk for intertwining wires is greatly reduced by
using a double-looped metal wire for the posterior
horn (Fig. 6).
The posterior horn is now positioned correctly.
Th
Its position can be slightly modified
fi more toward
the posterolateral corner or more toward the pos-
terior horn by pulling more on the posterolateral
or posterior horn traction wire. One or two all-
inside meniscal fixation devices (Fastfi fix, Smith
and Nephew, Memphis, Tennessee, USA) are used
to fix the allograft to the meniscal rim. Fixation
should be started in the posterolateral corner.
Subsequently, inside-out horizontal Ethibond 2/0
sutures are used for fixing the body of the allograft.
The anterior horn is fixed using outside-in PDS or
Ethibond 2/0 sutures.
Prior to making the sutures knots, the anterior
horn is introduced into the knee joint and the ana-
tomical insertion site is identifi
fied and prepared is
a same manner as for the posterior tunnel. If nec-
essary, its position can be slightly adapted to the
graft position. Similar to the procedure of the pos-
terior horn, the anterior tunnel is prepared and the
traction suture is pulled through.
First, the meniscal inside-out sutures are knot-
ted. Subsequently, the anterior and posterior
horn traction sutures are knotted to each other
over a bone bridge on the anteromedial side of
the tibia. This procedure reduces the possibly
stretched capsule and native meniscal rim tied
to the meniscal allograft, by pulling on the ante-
rior and posterior horn by a transosseous suture
fixation.
Arthroscopically assisted medial meniscal
allograft transplantation
A similar procedure as for the lateral allograft trans-
plantation is performed for the medial allograft
transplantation. However, some steps are different
ff
and will be highlighted in this section.
Additional to the classic anteromedial and ante-
rolateral portal, a posteromedial portal should be
Fig. 7 – Arthroscopic view of the posteromedial portal used in arthroscopi-
cally assisted medial meniscal allograft transplantation. The custom ACL
guide in introduced through the intercondylar notch on the anatomical
posterior horn insertion of the native medial meniscus.
used to identify the original posterior horn attach-
ments of the native meniscus (Fig. 7). Using the
same drill guide, the transosseous tunnels can be
prepared. These tunnels should be prepared start-
ing on the anterolateral side of the tibia. This
Th direc-
tion is more in line with the forces on the traction
sutures.
A posteromedial traction suture is used, as in
accordance to the lateral allograft. On the medial
side, however, we lack a clear anatomical land-
mark such as the popliteal hiatus on the lateral
side.
The anterior horn of the native medial meniscus
may in some cases be very anterior on the tibial
plateau resulting in a very short transosseous
anterior tunnel.
Special note on soft tissue vs. bone block fixation (32–36)
Biomechanical cadaver studies have shown the
superiority of a bony fixation
fi over a soft tissue
fixation technique, although a recent cadaver
study showed comparable results. Bony fi fixa-
tion however, has also been shown to be associ-
ated with increased risk for cartilage lesions if
implanted incorrectly and an increased immu-
nological potential due to the presence of allo-
geneic bone. It is the authors’ experience that
perfect allograft size matching is essential if
bony fixation
fi is to be used. A malpositioned bone
block or plug can infl flict damages to the overly-
ing cartilage. Too small a graft will result in a
need to overtension the inside-out sutures and
possible failure of the soft tissue fifixation. There-
fore, limited oversizing of the graft is commonly
advocated using bone plugs or blocks. Separate
bone plugs have the potential advantage that the
implantation can be somewhat more variable
compared to a single bone block. In addition, on
the lateral side, a straight bone block sometimes
induces the need to sacrifi fice some posterolateral
fibers of the ACL.

Today, clinical and/or radiological differences
ff have
not been shown between soft tissue or bone block
fi
fixation.
Rehabilitation
Rehabilitation is initially focused on providing
mobility to the joint without endangering ingrowth
and healing of the graft. Th
Therefore, 3 weeks of non-
weight-bearing are prescribed followed by 3 weeks
of partial weight-bearing (50% of body weight).
Progression to full weight-bearing is allowed from
week 6 on to week 10 postoperatively. Th The use of
a knee brace is not strictly necessary and depends
on the morphology and profile fi of the patient. For
the same reasons, the range of motion is limited
during the first
fi 2 weeks from 0 to 30, to increase
by 30° each 2 weeks.
Isometric muscle tonifi fication and co-contraction
exercises are prescribed from day 1 post-surgery
on. Straight leg raise, however, is prohibited dur-
ing the first 3 weeks. Proprioception training is
started after week 3.
Swimming is allowed after week 6, biking after
week 12, and running is progressively promoted
starting at week 20.
Results
Clinical outcome
All mid- and long-term studies have shown that
medial and lateral meniscal allograft transplan-
tation signifi
ficantly reduces pain and improves
function of the involved knee joint (7,20,37–43).
Despite signifi
ficant improvement in the long run,
substantial disability and symptoms have been
observed at more than 10 years of follow-up as
documented with patient-related outcome scor-
ing systems (Knee Osteoarthritis Outcome Score)
(23).
In a recent series, mean survival times and cumu-
lative survival rates of approximately 70% at 10
years were comparable between isolated lateral
and medial allografts (7). Previous studies have
shown that risk factors for failure and reduced
survival time are lower limb malalignment,
ACL deficiency, and grade 4 cartilage lesions
(37,39,44,45). Moreover, the additional benefi-
cial effect of a corrective osteotomy in case of
a varus malalignment and the importance of a
stable knee joint have been clearly demonstrated
(23). The exact position of an associated correc-
Meniscal allograft transplantation 145
tive osteotomy in the valgus knee needs further
refinement. More recent studies have not con-
firmed a significant correlation between the ini-
tial cartilage status and clinical failure, challeng-
ing the contraindications for arthrosis severity
(7,23).
Radiological outcome
In order to overcome the observed discrepancy
between clinical outcome and the status of the
meniscal allograft and to analyze any progres-
sion of degenerative articular changes after this
type of surgery, objective outcome measures such
as MRI have to be included in outcome studies
(Fig. 7). Limited data are present in the litera-
ture reporting that meniscal allografting halts or
slows down further degeneration (14,21). In one
recent long-term study, progression of cartilage
degeneration according to MRI and radiologi-
cal criteria was halted in a number of patients,
indicating a potential chondroprotective effect
(23). A recent controlled large animal study
was also able to confirm this chondroprotective
effect (46). These data could support the use of
prophylactic meniscal transplantation in menis-
cectomized patients without clinical symptoms,
thus potentially limiting the cartilage degenera-
tion secondary to a meniscectomy. Further pro-
spective comparative studies are needed to test
this hypothesis.
Using MRI, extrusion of the meniscal allograft
has been described independent of the surgi-
cal fixation technique (Fig. 8). In our experience
using soft tissue fixation in the open technique,
the extrusion is observed in the corpus and ante-
rior horn of the graft, while the posterior horn
is most frequently within normal values (23,47).
This extrusion lowers the functional surface of
the graft and thus reduces its biomechanical func-
tion. The authors hypothesize that this extrusion
is caused by both a biological as well as a biome-
chanical phenomenon. Attention has been mainly
focused on the surgical fixation
fi technique of the
graft within the knee joint. Biomechanical cadaver
studies have clearly shown the superiority of a
bony fixation
fi over a soft tissue fixation technique
(48–50). Comparative clinical and radiological
results, however, lack the power to substantiate
this in vitro finding. Biological reasons for the
observed extrusion post-transplantation could
include progressive stretch and failure of the cir-
cumferential collagen bundle due to insufficient
ffi
repair potential or increased catabolism. Future
research should focus on the biology involved in
ongoing metabolic and cellular processes after
transplantation.
146 The Traumatic Knee

Fig. 8 – (A) MRI-image: extrusion of a lateral meniscal allograft and native

A medial meniscus in a left knee. (B) MRI-image: well-positioned medial
meniscal allograft and native lateral meniscus in a right knee.

References
1. Fairbank TJ (1948) Knee joint changes after meniscec-
tomy. J Bone Joint Surg Br 30:664–670
2. Kohn D, Wirth CJ, Reiss G, et al. (1992) Medial meniscus
replacement by a tendon autograft. Experiments in sheep.
J Bone Joint Surg Br 74(6):910–917
3. Milachowski KA,, Kohn D,, Wirth CJ (1990) [Meniscus
replacement using Hoffa's ff infrapatellar fat bodies – ini-
tial clinical results] . Unfallchirurgie. Aug;16(4):190–195.
German
4. Walsh CJ,, Goodman D,, Caplan p AI,, Goldbergg VM (1999)
Meniscus regeneration in a rabbit partial meniscectomy
model. Tissue Eng 5(4):327–337
5. Bruns J, Kahrs J, Kampen J, et al. (1998) Autologous per-
ichondral tissue for meniscal replacement. J Bone Joint
Surg Br 80(5):918–923
6. Gastel JA, Muirhead WR, Lifrak JT, et al. (2001) Menis-
cal tissue regeneration using a collagenous biomaterial
derived from porcine small intestine submucosa. Arthros-
copy 17(2):151–159
7. Verdonk PC, Demurie A, Almqvist KF, et al. (2005) Trans-
plantation of viable meniscal allograft. Survivorship anal-
ysis and clinical outcome of one hundred cases. J Bone
Joint Surg Am 87(4):715–724
8. Rodkey WG, Steadman JR, Li ST (1999) A clinical study of
collagen meniscus implants to restore the injured menis-
cus. Clin Orthop Relat Res 367(Suppl): S281–S292
9. Arnoczky SP, DiCarlo EF, O'Brien SJ, Warren RF (1992) Cel-
lular repopulation of deep-frozen meniscal autografts: an
experimental study in the dog. Arthroscopy 8(4):428–436
10. Rodeo SA, Seneviratne A, Suzuki K, et al. (2000) Histologi-
cal analysis of human meniscal allografts. A preliminary
report. J Bone Joint Surg Am 82-A(8):1071–1082

11. Jackson DW,, Whelan J,, Simon TM (1993) Cell sur-
vival after transplantation of fresh meniscal allografts.
DNA probe analysis in a goat model. Am J Sports Med
21(4):540–550
12. Verdonk P, Almqvist KF, Lootens L, et al. (2002) DNA
Fingerprinting of fresh viable meniscal allografts trans-
planted in the human knee. Osteoarthritis Cartilage
10(Suppl A): S43: P71
13. Reguzzoni M, Manelli A, Ronga M, et al. (2005) Histology
and ultrastructure of a tissue-engineered collagen menis-
cus before and after implantation. J Biomed Mater Res B
Appl Biomater 74(2):808–816
14. Wirth CJ, Peters G, Milachowski KA, et al. (2002) Long
term results of meniscal allograft transplantation. Am J
Sports Med 30:174–181
15. Rijk PC (2004) Meniscal allograft transplantation—part I:
background, results, graft selection and preservation, and
surgical considerations. Arthroscopy. 20:728–743
16. Milachowski KA, Weismeier K, Wirth CJ (1989) Homolo-
gous meniscal transplantation: experimental and clinical
results. Int Orthop 13:1–11
17. Siegel MG, Roberts CS (1993) Meniscal allografts. Clin
Sports Med 12:59–80
18. Garrett JC, Stevensen RN (1991) Meniscal transplanta-
tion in the human knee. A preliminary report. Arthros-
copy 7:57–62
19. Jackson DW, Windler GE, Simon TM (1990) Intraarticular
reaction associated with the use of freeze-dried, ethylene
oxide-sterilized bone-patella tendon-bone allografts in
the reconstruction of the anterior cruciate ligament. Am
J Sports Med 18:1–11
20. Cole BJ, Carter TR, Rodeo SA (2003) Allograft meniscal
transplantation: background, techniques, and results.
Instr Course Lect 52:383–396
21. Hommen JP,, Applegate
pp g GR,, Del Pizzo W (2007) Menis-
cus allograft transplantation: ten-year results of cryopre-
served allografts. Arthroscopy 23(4):388–393
22. Verbruggen G, Verdonk R, Veys EM, et al. (1996) Human
meniscal proteoglycan metabolism in long-term tis-
sue culture. Knee Surg Sports Traumatol Arthrosc
4(1):57–63
23. Verdonk PC, Verstraete KL, Almqvist KF, et al. (2006)
Meniscal allograft transplantation: long-term clinical
results with radiological and magnetic resonance imag-
ing correlations. Knee Surg Sports Traumatol Arthrosc
14(8):694–706
24. Lubowitz JH, Verdonk PC, Reid JB 3rd, Verdonk R (2007)
Meniscus allograft transplantation: a currenct concepts
review. Knee Surg Sports Traumatol Arthrosc 15(5):476–
492
25. Walker PS, Erkman MJ (1975) The Th role of the menisci in
force transmission across the knee. Clin Orthop Relat Res
109:184–192
26. Barber FA (1994) Accelerated rehabilitation for meniscus
repairs. Arthroscopy 10:206–210
27. Johnson DL, Bealle D (1999) Meniscal allograft transplan-
tation. Clin Sports Med 18(1):93–108
28. Rodeo SA (2001) Meniscal allografts—where do we stand?
Am J Sports Med 29:246–261
29. Cole BJ, Cohen B (2000) Chondral injuries of the knee. A
contemporary view of cartilage restoration. Orthop Spec
Ed 6:71–76
30. Verdonk PC, Demurie A, Almqvist KF, et al. (2006) Trans-
plantation of viable meniscal allograft. Surgical technique.
J Bone Joint Surg Am 88:109–118. Review
31. Goble EM, Verdonk R, Kohn D (1999) Arthroscopic and
open surgical techniques for meniscus replacement –
Meniscal allograft transplantation 147
meniscal allograft transplantation and tendon autograft
transplantation. Scand J Med Sci Sports 9(3):168–176
32. Messner K, Verdonk R (1999) It is necessary to anchor
the meniscal transplants with bone plugs? A mini-battle.
Scand J Med Sci Sports 9(3):186–187
33. Paletta GA Jr, Manning T, Snell E, et al. (1997) The
Th eff ffect
of allograft meniscal replacement on intraarticular con-
tact area and pressures in the human knee. A biomechani-
cal study. Am J Sports Med 25:692–698
34. Huang A, Hull ML, Howell SM (2003) The Th level of com-
pressive load aff
ffects conclusions from statistical analyses
to determine whether a lateral meniscal autograft restores
tibial contact pressure to normal: a study in human cadav-
eric knees. J Orthop Res 21:459–464
35. Chen MI, Branch TP, Hutton WC (1996) Is it important to
secure the horns during lateral meniscal transplantation?
A cadaveric study. Arthroscopy 12:174–181
36. Alhalki MM, Howell SM, Hull ML (1999) How three meth-
ods for fixing a medial meniscal autograft aff
ffect tibial con-
tact mechanics. Am J Sports Med 27:320–328
37. Cameron JC, Saha S (1997) Meniscalallograft transplan-
tation for unicompartmental arthritis of the knee. Clin
Orthop 337:164–171
38. Graf KW Jr, Sekiya JK, Wojtys EM (2004) Long-term
results after combined medial meniscal allograft trans-
plantation and anterior cruciate ligament reconstruction:
minimum 8.5-year follow-up study. Arthroscopy 20:129–
140
39. Noyes FR, Barber-Westin SD (1995) Irradiated meniscus
allografts in the human knee. Orthop Trans 19:417
40. Peters G, Wirth CJ (2003) The Th current status of menis-
cal allograft transplantation and replacement. Knee
10:19–31
41. van Arkel ER, de Boer HH (1995) Human meniscal trans-
plantation. Preliminary results at 2 to 5-year follow-up. J
Bone Joint Surg Br 77:589–595
42. Rath E, Richmond JC, Yassir W, et al. (2001) Meniscal
allograft transplantation. Two- to eight-year results. Am
J Sports Med 29(4):410–414
43. Noyes FR, Barber-Westin SD, Rankin M (2004) Meniscal
transplantation in symptomatic patients less than fifty
years old. J Bone Joint Surg Am 86-A(7):1392–1404
44. van Arkel ER, de Boer HH (2002) Survival analysis of
human meniscal transplantations. J Bone Joint Surg Br
84(2):227–231
45. de Boer HH, Koudstaal J (1994) Failed meniscus trans-
plantation. A report of three cases. Clin Orthop 306:155–
162<AQ: Please check the volume number in Ref. 45.>
46. Kelly BT, Potter HG, Deng XH, et al. (2006) Meniscal
allograft transplantation in the sheep knee: evaluation of
chondroprotective eff ffects. Am J Sports Med 34(9):1464–
1477
47. Verdonk P, De Paepe Y, Desmyter S, et al. (2004) Normal
and transplanted lateral knee meniscus: evaluation of
extrusion by ultrasound and MRI. Knee Surg Sports Trau-
matol Arthroscopy 12(5):6.411–419
48. Chen MI, Branch TP, Hutton WC (1996) Is it important
to secure the horns during lateral meniscal transplanta-
tion? A
49. cadaveric study. Arthroscopy 12(2):174–181
50. Paletta GA Jr, Manning T, Snell E, et al. (1997) The
Th eff ffect
of allograft meniscal replacement on intraarticular con-
tact area and pressures in the human knee. A biomechani-
cal study. Am J Sports Med 25(5):692–698
51. Alhalki MM, Howell SM, Hull ML (1999) How three meth-
ods for fixing a medial meniscal autograft aff
ffect tibial con-
tact mechanics. Am J Sports Med 27:320–328
The ACL

B.T. Kean, R.T. Burks Diagnostic and surgical decision ACL
tears
Clinical history and examination
of the ACL-deficient
fi knee
T
he first step in the evaluation of any patient
with a suspected ACL (anterior cruciate liga-
ment) injury is a thorough history and physi-
cal examination. With a complete understanding
of the injury, including, mechanism, time elapsed
since injury, initial and current symptoms, as well
as reinjuries, the clinician can perform a focused
clinical examination. The synthesis of this history
and a focused physical examination guides the
examiner to an accurate diagnosis or to further
diagnostic testing.
Injuries to the knee can be direct contact injuries
or, more commonly, non-contact injuries during
sudden deceleration and rotational maneuvers
during cutting and jumping (1). The Th contact inju-
ries are frequently hyperextension or valgus-type
blows to the knee. There is also a subset of patients
who suffffer injuries in high-velocity trauma, such as
motor vehicle accidents. These patients often have
combined musculoskeletal and systemic trauma.
Often a high degree of suspicion and a thorough
secondary survey can identify and diagnose these
injuries. Most times these injuries are not isolated
ACL ruptures but have more combined ligament
injuries.
Female athletes deserve special mention because
they are at signifificantly greater risk of ACL injury
than male athletes in the same high-risk sports (2).
The mechanism of ACL injury is a combination of
valgus positioning of the lower extremity, relative
extension with unbalanced weight distribution,
and the plantar surface of the foot being fi fixed in
position, away from the center of mass of the body
(3). In female athletes, the dynamic positioning of
the knee demonstrates increased valgus collapse of
the lower extremity in the coronal plane (4).
Inadequate neuromuscular control of the body’s
trunk or “core” is thought to compromise dynamic
stability of the lower extremity, resulting in val-
gus collapse and increased abduction torque at the
knee, which increase strain on the knee ligaments
and lead to injury (3,5–7). Training of the trunk
musculature may increase control of hip adduction
Chapitre 13
and internal rotation during weight bearing func-
tional activities and decrease the tendency toward
valgus collapse (7–9). Neuromuscular training
studies that incorporate core stability exercises
decrease knee injury risk, which further supports
the theory that neuromuscular control of the core
is related to dynamic knee stability (10–12). In
a prospective cohort study, female athletes who
participated in a neuromuscular training program
that included core stability exercises demonstrated
a 72% decrease in the incidence of knee ligament
(including ACL) injuries compared with female ath-
letes who did not participate in the program (3).
Neuromuscular training reduces hip adduction
and knee abduction torques during landing, which
are associated with increased knee and ACL injury
risk (3,13,14).
Patients often recall a “popping” sensation at the
time of their ACL injury. Although not sensitive
for an ACL tear, it has been reported that 33–90%
of patients rupturing their ACL experience this
“popping” (15). Athletes are usually unable to con-
tinue athletic participation after an ACL rupture
and often have diffi fficulty bearing weight on the
extremity. After the injury, patients may describe
a sensation of knee instability or have episodes of
the knee giving out. The
Th acute ACL develops a knee
eff
ffusion within the first 4–12 h after injury (16).
In the setting of traumatic hemarthrosis, up to
three quarters of patients have ACL ruptures. It is,
however, important to remain mindful that other
injuries cause hemarthrosis, and that the absence
of a hemarthrosis does not preclude ACL injury. A
chronically ACL-deficient
fi knee often accumulates
additional injuries with time, including meniscal
tears, osteochondral injuries, and, rarely, other
ligamentous injuries.
As with any history, the physician must also assess
the patient as a whole. The patient’s age, recre-
ational activity level, job requirements, and future
goals can influence
fl the decision for reconstruction.
It is also important to understand the social and
economic environment surrounding the patient,
which can infl fluence surgical timing, as well as the
ability to complete successful postoperative reha-
bilitation.
152 The Traumatic Knee
Physical examination
In the acute setting, such as on the athletic fi field,
it is important to have a global view of the lower
extremity injured patient. It is important to note
any extreme deviation from normal that could
represent a fracture or dislocation about the knee
and/or patella. A quick neurovascular exam should
be performed, as well as palpation of the extremity
for crepitus. With regards to the ACL, the examina-
tion at the time of the injury is most accurate. It is
often before swelling, pain, and muscle guarding
occur. After 4–12 h, the examination may become
more diffi
fficult and should be repeated after several
days for a more accurate assessment.
The standard examination begins with inspection
and palpation of the uninjured knee. Th This helps
build rapport with the patient and, hopefully, facil-
itates a more relaxed exam of the injured knee. It
also serves as a control to compare findings against
the injured knee.
Inspection of the knee begins with assessing the
overall alignment of the extremity. An effusion
ff
may represent a meniscal injury, osteochondral
injury, patella dislocation, PCL (posterior cruciate
ligament) injury, intra-articular fracture, as well as
ACL rupture. An absence of a knee effusion
ff does
not rule out intra-articular injury. In severe inju-
ries the capsule about the knee can be disrupted,
allowing hemarthrosis to escape from the knee.
Palpation starts with confifirmation of the presence
or absence of effusion.
ff The medial and lateral joint
lines are then palpated for peri-articular tender-
ness and meniscal pathology. Continuing along the
joint line, the proximal and distal insertions of the
collateral ligaments are examined for tenderness.
The exam should also assess for patella tenderness,
Th
tracking, medial and lateral translation, and appre-
hension.
The examiner then needs to assess the passive and
Th
active range of motion. The inability to actively
extend the knee or hold a straight leg raise indi-
cates an incompetent extensor mechanism. Th The
inability of the examiner to obtain full passive
range of motion can be secondary to pain, large
eff
ffusions, or a mechanical block. The etiology of
mechanical extension block can include displaced
meniscal tears, torn ACL stump, or loose osteo-
chondral fragments.
Global knee stability is assessed with attention to
anterior, posterior, varus, valgus, and rotational
laxity testing of the knee. With respect to anterior
knee laxity testing, the workhorse is the Lachman
test (17). The Lachman test is performed with
knee flexed between 20° and 30°, while an ante-
rior force is directed on the proximal tibia as the
distal femur is stabilized with contralateral hand.
The knee must remain in neutral rotation during
Th
the examination because internal and external
rotations can decrease the anterior translation
(18). The
Th absence of a firm endpoint indicates an
ACL-defi ficient knee. Laxity is graded compared to
the contralateral knee controlling for the normal
laxity variation in the population: grade 1 laxity is
a 1- to 5-mm increased translation, grade 2 is a 6-
to 10-mm increased translation, and grade 3 is a
10- to 15-mm increased translation. The authors
do not feel laxity grading is particularly helpful for
the ACL-defi ficient patient as it is for injuries of the
collateral ligaments.
There are some technical pearls when performing
the Lachman tests that help to improve its applica-
tion. One is having the examiner place his or her
flexed knee underneath the patient’s thigh. This
helps the patient’s knee to rest in a relaxed posi-
tion and also allows it to drape over the examiner’s
thigh at approximately 20–30° of flexion ready for
testing. In patients who are signifi ficantly larger
than the examining physician, it can be helpful
to place the injured leg over the side of the table.
The examiner then sits in a chair with the patient’s
calf across the lap. This again facilitates relaxation,
places the knee at 20–30° of flexion, and also
enhances the examiner’s control over the leg.
Anterior drawer testing also evaluates anterior
translation of the tibia. In this test the knee is
flexed to 90°, while the foot is stabilized and ante-
rior directed force is applied to the posterior tibia.
The presence or absence of an endpoint is tested.
With all tests for anterior instability, competence
of the PCL should be assessed carefully.
In the flexed ACL-defi ficient knee, as in the anterior
drawer posture, the posteromedial corner is a sec-
ondary stabilizer against anterior translation of
the externally rotated tibia. This
Th is the basis for the
Slocum test. The Slocum test is performed in the
same manner as that of the anterior drawer test,
except the foot is placed in approximately 15° of
external rotation, tightening the posteromedial cor-
ner, reducing the positive anterior drawer. A posi-
tive test represents a failure of the tibial external
rotation to diminish the anterior drawer in an ACL-
defi
ficient knee (19). When presented with a positive
Slocum test, the diagnosis can be either antero-
medial (AM) rotatory instability or posterolateral
rotatory instability because either the AM tibia is
rotating anterior relative to the medial femoral con-
dyle or the posterolateral tibia is rotating posteri-
orly relative to the lateral femoral condyle. In this
scenario the examiner tries to determine where the
tibia is moving in relation to the condyles.
The pivot shift test is performed with the knee
starting in extension followed by slow flexion
fl with
a combination of valgus stress and axial load placed
on the internally rotated tibia. When the knee
reaches 30° of flexion, the tibial plateau reduces.

Th test is based on the anterior subluxation and
The
reduction of both tibia plateaus relative to the fem-
oral condyles in the ACL-deficient
fi knee. It is often
considered a rotational test because the lateral
side of the knee subluxates to a greater extent dur-
ing testing (20,21). The test is grade 0 if no shift
is present, grade 1 if the tibia reduces smoothly,
grade 2 if the tibia jerks back into place, and grade
3 if there is transient locking of the subluxed tibia
before reduction. Similar to the Lachman test,
positioning of the extremity can aff ffect the grading
of the pivot shift. Abduction and flexion at the hip
with external rotation of the tibia can increase the
magnitude of the pivot shift. Although the pivot
shift test is reported to be more diffi
fficult to perform
on awake patients, secondary to muscle guarding,
the authors feel that in experienced hands it can be
reliably performed.
The accuracy of these three tests to diagnose ACL
Th
ruptures has been reported in multiple articles
(16,22–26). The methodologic quality of these
studies is inconsistent; patients primarily had
known ACL injuries, different
ff reference standards
were used, and blinding of the clinical and reference
test was rarely done. A meta-analysis of this large
data pool reports that based on positive predictive
value, a positive result for the pivot shift test is the
best for ruling in an ACL rupture, whereas a nega-
tive result to the Lachman test is the best for ruling
out an ACL rupture. Using sensitivity and specific- fi
ity values, the Lachman test is a better overall test
at both ruling in and ruling out ACL ruptures. Th The
anterior drawer test appears to be inconclusive for
drawing a conclusion either way (27).
Instrumented laxity testing
Th KT-1000 and its off
The ffspring KT-2000 provide
objective measurements of anterior tibial transla-
tion relative to the femur. The KT-2000 is identical
to its predecessor the KT-1000 with the exception
of its data recording; the KT-2000 can graphically
record data on X- X Y coordinates. The two devices
require the same patient positioning, application
of the instrument, and force application.
During testing the patient is placed supine with
a support underneath the thighs to maintain the
knee in approximately 20–30° of flexion. The heels
are placed symmetrically on the positioning foot-
rest to maintain the tibia in neutral rotation. The
Th
device is aligned with joint line, and the two force
sensing pads are positioned on the patella and
the tibial tubercle. The body of the arthrometer
is secured to the anterior tibia with Velcro straps.
Next, several anterior and posterior forces are
applied to the tibia with the use of the handle to
Diagnostic and surgical decision ACL tears 153
gain relaxation and to determine and calibrate the
zero point. After calibration, measurements are
then taken with 15 lb (67 N) and 20 lb (89 N) of
anterior force applied. An audible tone sounds at
15 lb (67 N) and 20 lb (89 N), and for the KT-2000
an additional tone has been added at 30 lb for
larger patients. After each test, the arthrometer
needs to be re-zeroed.
There are several technical considerations that
should be highlighted when using this instru-
ment. The first is patient relaxation. When the
patient is guarding during testing, the needle on
the arthrometer will shift eff ffecting the measured
translation.
The arthrometer must also be placed on the joint
line. Positioning the arthrometer 1 cm proximal to
the joint line produces larger anterior translations,
while placing it 1 cm distal to the joint line pro-
duces smaller measurements. The anterior force
must also be directed in line with the handle of the
device to ensure reproducible measurements (28).
The rotation of the tibia can aff ffect the results of
KT testing. Specifi fically, internal rotation of the
tibia causes decreased translation. This Th is clini-
cally relevant during an examination under anes-
thesia when excessive external rotation at the hip
can place the tibia in internal rotation. When this
occurs, a bump under the affected
ff side or a derota-
tional strap can be used.
The maximum manual anterior displacement test
with the KT devices clinically approximates the
Lachman test. It is performed with the KT device
appropriately positioned with a maximum anterior
force applied by the examiner’s hand on the pos-
terior calf. The force generated by the maximum
manual test ranges from 135 to 180 N depending
on the examiner’s strength. The Th manual maximum
test is the most useful arthrometric measurement
in predicting ACL rupture (29,30).
An additional feature off ffered by the recording capa-
bilities of the KT-2000 devices is compliance index
determination. The compliance index is the dis-
placement in millimeters between the 15 lb and 20
lb testing result. Compliance index can be affected
ff
by the rate of force application during testing with
slower rates of anterior force application, resulting
in lower compliance (31).
The KT series of testing devices are reliable and
accurate. Authors have tested the interobserver,
intraobserver, and intraclass reliability of these
devices and found high reliability and intraclass
coeffi
fficients (28,32,33). It is this consistency that
has made the KT series the workhorse of instru-
mented ligament testing. ThereTh are other commer-
cially available arthrometers: Stryker Knee Laxity
Tester, Acufex Knee Signature System, Dyonics
Dynamic Cruciate Tester, and Genucom Knee
Analysis System. Some of these systems demon-
154 The Traumatic Knee
strate similar diagnostic accuracy and measure-
ment reproducibility (34,35). However, none of the
above systems have been as vigorously tested as
the KT series. Another consideration given along
with the reliability of the KT series is its prevalence
in the orthopedic literature as an outcomes mea-
surement.
In clinical practice, the KT testing series can be used
to make a diagnosis. A maximum manual transla-
tion greater than 10 mm, a maximum side-to-side
difference
ff greater than 3 mm, or a compliance
index greater than 2 mm is consistent with ACL
rupture (29). Along this same line, the device can
be used to assess the competency of an ACL recon-
struction. As a research tool, KT testing allows
for reproducible analysis of results and compari-
son across the literature of various diff fferent ACL
reconstructions. It is an objective criterion to com-
pare results; however, it can be independent of a
patient’s clinical result (36). A patient’s perception
of his or her result cannot be measured by a KT
alone. It is only one measure of success or failure.
Imaging the ACL-deficient
fi knee
Although there are plain radiographic markers
for ACL injury, such as a lateral capsular avulsion
fracture known as the Segond fracture, they are
rarely used for the diagnosis of acute ACL injuries.
As mentioned earlier, the diagnosis of an ACL rup-
ture is usually made through history and physical
Fig. 1
exam. The plain films are, however, used to screen
for associated ossesous injuries and avulsion frac-
tures.
In the chronic setting, plain fi films can reveal the
“lateral notch sign” (Fig. 1), which is an expansion
of the normal indentation of the lateral condyle to
a depth of 2 mm or more (37). As an ACL injury
becomes more chronic, the literature reports pro-
gression to osteoarthritis (OA) at 10–20 years
after injury anywhere from 10% to 90% (38–40).
The course of radiographic progression from ACL
insuffi
fficiency to OA has been documented with an
increasing severity as time from injury elapses.
The presence of meniscectomy or meniscal tear in
combination with ACL insuffi fficiency was also more
closely correlated with development of OA(41).
MRI has evolved as the imaging modality of choice
in the ligament-injured knee patient. MRI has the
advantage of providing non-invasive multiplanar
images delineating normal structures and patho-
logic processes in the knee. ThThe normal ACL is seen
on MRI as a well-defi fined band of low signal inten-
sity running through the intercondylar notch usu-
ally on two to three consecutive sagittal images.
MRI sensitivity and specifi ficity for ACL tear range
from 92% to 100% and 89% to 97%, respectively
(42–44). The acute ACL injury on MRI demon-
strates a loss of fiber continuity, an ill-defi
fined liga-
ment substance, and a mixed signal intensity of
local hemorrhage and edema (Fig. 2) (45). When
there is uncertainty about ACL injury on MRI, the
presence and pattern of bone bruises can imply
injury. The presence of bone contusions at the
Fig. 2

anterior aspect of the lateral femoral condyle and
the posterior aspect of the tibial plateau occurs as
a result of impaction injury from anterior transla-
tion of the tibia relative to the femur; the location
of these contusions is highly specifi fic for ACL injury
(Figs. 3 and 4) (46–49). In addition to confi firming
or diagnosing an ACL tear, MRI imaging can reveal
bone bruises and meniscal and chondral injuries.
These associated injuries can aff ffect surgical plan-
ning and possibly prognosticate a longer recovery
in the setting of bone bruise patients (50).
Despite the imaging advantages of MRI, it is an
expensive tool that adds little to clinical diagno-
sis of the majority of ACL injuries. Although MRI
imaging has been found to be reliable in diagnos-
ing ACL ruptures in the literature, the results in the
community may not be as good; a blinded prospec-
tive study of 750 patients showed 90% accuracy
for ACL rupture in the community setting (51).
In another study of 67 patients, Lachman test-
ing demonstrated 100% sensitivity and specifi ficity
compared with 94% sensitivity and 82% specifi ficity
for MRI (52). In terms of treatment decisions, MRI
does not change the decision to proceed with sur-
gery. The added information on associated injuries
also does little to change the treatment of most ACL
ruptures; however, it can help guide the treatment
of associated pathology. In these cases, an MRI can
diagnose and aid in the treatment planning of ACL
ruptures associated with displaced meniscal tears,
chondral injuries, and collateral ligament injuries.
As mentioned above, the one theoretical advantage
MRI may have is the ability to prognosticate recov-
ery and possible long-term sequelas in the set-
Fig. 3
Diagnostic and surgical decision ACL tears 155
ting of bone bruises. Osteochondral bone bruises
occur with impaction of the lateral femoral condyle
against the posterior aspect of the lateral tibial
plateau as the joint subluxes during injury. They
are reported in the lateral compartment of 80%
or more of ACL injuries (50,53–55). TheTh question
investigators have posed is whether these articu-
lar lesions are of any long-term consequence. ThThe
current literature suggests that some of these bone
bruises linger on MRI up to 6 years after injury
(53,56–58). Some of these same reports, however,
also report that even patients who have occult
bone bruises 2–6 years after injury do not have any
diff
fference in their clinical outcomes (56,57,59).
Indications for surgery
Based on the current orthopedic literature, no rigid
criteria exist for patient selection for ACL recon-
struction, although most clinicians would agree
that high-risk behavior requiring heavy labor,
sports, or recreational activities and/or recurrent
instability of the knee after adequate rehabilita-
tion are strong indications for operative treatment
(60). These
Th criteria are based on the 50–86% inci-
dence of instability during strenuous activities
that ACL-defi ficient patients experience (61–63).
These episodes result in pain, swelling, and dis-
ability that can last for days. It is also well docu-
mented that ACL-defi ficient patients rarely return
to strenuous sports, and even those who do show a
diminished capacity (61–63).
Fig. 4
156 The Traumatic Knee
When comparing sports that require cutting, jump-
ing, and pivoting with 50 or more sporting hours a
year even in the ACL-reconstructed patient, there
is a documented decrease in the level of sporting
activity (18%); however, a greater decrease occurs
in those treated non-operatively (23%) (60). In this
same study, greater than 50 h of participation in
cutting, jumping, and pivoting was also the most
important variable for predicting meniscal sur-
gery or ligament surgery for patients who initially
postpone surgery. It has been demonstrated in the
literature that early ligament reconstruction after
ACL injury reduces the risk of subsequent meniscal
injury and late surgery, compared to non-operative
treatment (60,61,64–67). This protective eff ffect of
ACL reconstruction along with prophylaxis against
instability symptoms and activity limitations
guides our indications for ACL reconstruction.
It is, however, important to note that ACL recon-
struction does not always yield improved outcomes
compared to the natural history. Patients who are
able to “cope” with ACL defificiency may have equiv-
alent outcomes in some respects with patients who
have reconstruction (60). There are reports in the
literature that have been unable to demonstrate
higher activity levels among patients who have had
reconstruction compared to those who have not
(68–70).
Given that some individuals are able to “cope” with
the ACL-defificient knee and some patients do not, it
would be helpful to be able to identify these groups
prospectively. Two recent prospective algorithm
studies have attempted to address this question
with some success (71,72). In one study, performed
over a 6-year period, an algorithm selected patients
with acute ACL tears for surgical or non-surgical
treatment based on arthrometry measurements
and exposure to high-risk sports. The algorithm
recommended non-surgical treatment for patients
deemed to be at low riskfor reinjury and ACL recon-
struction for those felt to be in a high-risk group
(71). Athletes who fell into a moderate-risk group
were quasi-randomized according to the day that
they presented. The algorithm off ffered a treatment
recommendation; however, the patients were free
to choose whichever treatment they preferred. The Th
result of this treatment flexibility was a high par-
ticipation rate at the expense of introducing pos-
sible confounding factors into the study (71).
The algorithm successfully distinguished individu-
als who were at lower risk for an undesirable result
from non-operative treatment from the other
two groups. Because the moderate- and high-risk
patients fared the same, the authors recommend
that these two groups be combined. The surgery
patients had less frequent instability, lower mea-
sured laxity, and higher International Knee Docu-
mentation Committee (IKDC) scores than did
those treated non-surgically. Early surgery resulted
in a higher Tegner activity; however, even the sur-
gical patients did not return to the same functional
levels as before the injury (71).
Non-surgically treated patients were approxi-
mately 20% more likely to require meniscal surgery
compared to those undergoing early reconstruc-
tion (71). Interestingly, the reconstructed patients
who had normal or repaired menisci had the same
risk of changes on radiographs as those who had
meniscectomy. These changes were mild, yet they
were common among all subjects, and those in
the early reconstruction group had a higher preva-
lence of degenerative changes on radiographs than
the non-surgically treated patients. It is unclear
whether this finding was due to the surgery itself
or the increased activity level that the surgery
made possible (71).
The second algorithm study attempted to deter-
mine the potential for highly active individuals to
succeed with non-operative care after ACL injury
(72). It was a prospective study performed over a
10-year period that included patients with IKDC
level I and level II activity. After excluding patients
for contaminant pathology, such repairable menis-
cus tears, and full-thickness articular cartilage
lesions, patients underwent screening examina-
tion and were classifi fied as potential copers versus
non-copers. Patients were classifi fied as potential
copers using the following criteria: (1)  1 episode
of giving way since the index injury, (2)  80% on
a 6-min timed hop test, (3)  80% on the post-
timed hop test KOS-ADLS, and (4)  60% on the
global rating scale (a single number between 0%
and 100% assigned by the patient to rate their cur-
rent function). Failure to meet any of the criteria
resulted in classifification as a non-coper. Patients
classifi
fied as non-copers were referred back to the
orthopaedic surgeon as surgical candidates, and
potential copers were counseled that as rehabili-
tation candidates, they had the option to pursue
non-operative versus surgical management (72).
This design does introduce selection bias into the
study.
The results demonstrate statistically more non-co-
pers than potential copers among the samples who
completed the screening examination. Th The per-
centage of subjects classifiedfi as potential copers,
although, was quite large (42%/146 patients),
indicating that a trial of non-operative manage-
ment is a viable option for many highly active
patients with ACL insuffi fficiency. Sixty percent
(88 patients) of this group elected to pursue non-
surgical care, and of this group 72% (63 patients)
were able to successfully return to preinjury sports
activities without further episodes of instability or
a reduction in functional status. Yet terminal out-
comes for this group of patients reveals only 25, or

28% of the original coper group who elected not
to have surgery, did not have ACL reconstruction
in the long term (72). They do not comment on
which patients and for what reasons these patients
selected delayed reconstruction.
The relationship of ACL defi ficiency, ACL recon-
struction, and OA has yet to be fully delineated.
It has been estimated that at 10–20 years after
ACL injury, approximately half of those patients
will have OA of the aff ffected knee (73). The ability
to prospectively identify these individuals from
either an injury or a patient characteristics stand-
point has not yet been determined. Although the
role of ACL reconstruction in preventing the long-
term sequela of OA has been embraced by many
American orthopedists (74), this is not supported
in the literature (39,73,75). There is, however, evi-
dence that ACL reconstruction provides protection
against future meniscus surgery (71,76,77). Th The
meniscal protection provided by improved knee
stability may result in decreased OA development.
Several recent retrospective studies with 10- to
17-year follow-up after bone patella bone ACL
reconstruction demonstrate 20–79% rate of radio-
graphic arthritis. This collection of studies sug-
gests that meniscectomy, chondral defects, laxity,
and extension loss are risks factors for the pro-
gression to arthritis (78–81). Th There is one prospec-
tive study comparing bone patella bone vs. four-
strand hamstring ACL reconstruction with greater
than 10-year follow-up (82). This study reports
an increased incidence of mild radiographic OA in
the bone patella bone group compared to the ham-
string group, implicating bone patella bone har-
vest as a culprit for developing arthritic changes in
the knee. They also report that additional knee sur-
gery and less than 90% single leg hop test at one
year are risk factors for radiographic arthritis. One
important fact to consider in all of these studies is
that despite the radiographic evidence of arthritis,
the majority of patients still report good to excel-
lent clinical results.
From a basic science perspective, the effectff of ACL
reconstruction on articular cartilage was investi-
gated by measuring proteoglycan fragments (PFs)
in synovial fluid
fl collected from patients who had
undergone ACL reconstruction (83). Synovial
fluid samples were obtained from patients with
fl
chronic ACL defi ficiency preoperatively, as well as
at 1, 3, 6, and 12 months postoperatively. Syn-
ovial fluid taken from the contralateral asymp-
tomatic knees served as controls. Preoperative PF
levels were signifi ficantly larger than controls and
reached the maximum value in the first month
postoperatively and then gradually decreased. At
6 and 12 months, it was signifi ficantly lower than
preoperative values but still greater than controls.
This same group monitored PFs in two groups of
Diagnostic and surgical decision ACL tears 157
patients who had ACL reconstruction with either
patellar tendon or quadruple semitendinosus
tendon autografts (84). Synovial samples were
collected at 6 weeks, 3 months, and 18 months
after the operation. Both groups demonstrated
a sudden increase of PFs at 6 weeks with respect
to preoperative quantities. A signifi ficant decrease
occurred in the bone patella bone group at 3
months that continued to trend downward such
that at 18 months, it was signifi ficantly below the
preoperative values. TheTh decrease in semitendino-
sus cases relative to 6 weeks was insignificant fi at
3 months and did not drop below the preopera-
tive levels at 18 months. No diff fference was noted
between the groups at 18 months in terms of
activity level and functional scores.
There is also basic science research trying to deter-
mine whether early degenerative changes charac-
teristic of idiopathic OA are induced in articular
cartilage following ACL injury (40). In this study
a small sample of femoral articular cartilage was
removed at surgery, as part of ACL reconstruction
for acute and chronic injuries. Control cartilages
were obtained from the same site from autopsy
specimens. Histological analyses and immunoas-
says from these two groups revealed a rapid onset
of damage to type II collagen and an initial increase
in proteoglycan content characteristic of experi-
mental OA post-ACL injury. Th The authors concluded
that these observations reveal joint instability
resulting from ACL injury results in degenerative
changes characteristic of those seen in idiopathic
OA and in experimental OA following ACL surgery.
These changes may contribute to the development
of post-traumatic OA that is commonly observed
following ACL injury.
From a clinical perspective, arthroscopic evalua-
tion of articular cartilage at the time of ACL recon-
struction and at second-look arthroscopy demon-
strates a signifificant worsening of the status of the
articular cartilage (85). In this study, the worsening
was seen at all articular surfaces except the lateral
femoral condyle, and most of the changes involved
softening or fibrillation. Anterior laxity and menis-
cal lesion had no correlation with a progression of
degenerative change of articular cartilage. Patient
age greater than 30 infl fluenced the progression of
articular cartilage damage after reconstruction.
The fact that ACL reconstruction has not been
proven in the literature to prevent OA might be
explained by the lack of quality studies on the
subject (73). It could also be that current surgical
techniques to restore the mechanics of the knee
fail to suffi
fficiently do so, or as mentioned above,
the arthritic process initiates at the time of injury
and our current treatments fail to halt the pro-
gression. Regardless, in order to demonstrate the
benefifits and shortcomings of current treatments,
158 The Traumatic Knee
there needs to be higher quality long-term studies
performed.
The rationale for reconstruction, in our hands, is
Th
the prevention of instability symptoms, additional
meniscal injury and to return patients to full activ-
ity. We attempt to stratify patients according to
their athletic and occupational activity level. We
do not base our decision to proceed with surgery
on arthrometry measures, performance on func-
tional tests, and/or patient surveys. If patients
have limited exposure to heavy labor and pivoting/
cutting athletics, or are willing to avoid these high-
risk behaviors, a trial non-operative treatment is
ffered. However, before proceeding with non-op-
off
erative care, we obtain MRI to assess the presence
of full-thickness articular cartilage lesions, repair-
able meniscus tears, and associated ligamentous
injury. The presence of these associated injuries
risks further damage to the knee if non-operative
care is pursued.
Non-surgical care focuses on activity modification
fi
and rehabilitation focusing on regaining full range
of motion, quadriceps/hamstring strengthening,
and proprioceptive training. If these patients con-
tinue to have instability with activities of daily liv-
ing or light recreational activities, we offer
ff either
a trial of functional bracing or ACL reconstruction
depending on the patient’s wishes. On the other
hand, we strongly encourage operative interven-
tion in any patient who participates in organized
or moderate- to high-level recreational athletics,
as well as those with physically demanding occupa-
tions.
The discussion of operative versus non-operative
Th
intervention also arises in setting of the partial
ACL rupture. The question the surgeon and the
patient must answer is whether the remaining
ACL will permit normal activities, or will return to
those activities cause progression to complete rup-
ture and additional intra-articular injury. ThThe inci-
dence of partial tears ranges from 10% to 48% of
all ACL injuries (1,16,86,87). Unfortunately, there
is little consensus on how to defi fine/diagnose a
partial tear of the ACL, the natural history of these
lesions, and when surgical reconstruction is war-
ranted. Some authors suggest that KT arthrom-
eter laxity less than 3 mm compared to the unin-
jured is an indication for non-operative treatment
(60). Others report that a positive pivot shift test
under anesthesia establishes the diagnosis of ACL
injury regardless of findings during surgery (88).
There are no reports in the literature characteriz-
ing partial ACL on MRI. Th There is one report in the
literature with direct arthroscopic visualization of
partial ACL injury and long-term follow-up. The Th
results indicate if three-quarters of the ACL remain
intact, the ligament remains competent; if half of
the ACL is torn 50%, progress to complete rupture;
and if three-quarters of the ACL is torn, 86% prog-
ress. They also report that if there is a 5-mm diff
ffer-
ence on laxity testing under anesthesia, patients
do poorly (89). One long-term study with 18- to
25-year follow-up on partial ACL injuries with less
than 50% involvement by direct visualization and
1+ instability with examination under anesthesia
suggests a benign course. Of the 21 patients, none
required surgery and 18 had no or minimal limita-
tions with sports (90).
Recently, there has been a renewed interest in
partial ACL rupture with the emergence of double
bundle reconstruction. This interest in the double
bundle reconstruction has led some surgeons to
defi
fine partial ACL injuries not as a percentage
of ACL torn or on KT testing, rather as rupture
of either the anterior-medial or posterior-lateral
bundles. One report places the rate of partial rup-
ture as high as 10% in which the majority were
anterior-medial bundle injuries (91). The Th reports
in literature, however, are sparse with regards to
the outcomes of these augmentation procedures.
There is one report in the literature of 40 cases
of augmented isolated AM ruptures compared to
40 single-bundle reconstructions of complete ACL
tears (92). The
Th authors describe their indication for
augmentation as bridging ACL remnant one-third
the diameter of the native ACL, and in follow-up,
they compare KT-2000 at 30 lb between the two
groups. The results for the AM augmentation group
were 5.3 mm ± 2.6 mm preoperatively to 0.7 mm ±
1.8 mm postoperatively. ThThe complete reconstruc-
tion groups went from 6.0 mm ± 2.4 mm to 1.8 mm
± 2.1 mm in the single-bundle group.
Our own clinical experience with partial ACL rup-
tures is again individualized. Th
There are two scenar-
ios frequently encountered with the partial ACL
injury. The first is the patient who presents with
the provisional diagnosis of ACL incompetence
from MRI or from history. On exam the patient has
a slightly increased Lachman with a firm
fi endpoint.
These patients usually describe a knee that does
not feel 100%, yet they do not describe any sublux-
ation events either. We present these patients with
two options depending on their desires or needs to
participate in at risk behaviors: continued non-op-
erative observation or augmentation/reconstruc-
tion of their ACL.
Surgical timing
Historically, ACL reconstruction in the immediate
period following an ACL injury has been associ-
ated with an increased incidence of arthrofi
fibrosis
and motion loss after surgery (93–95), although
this association has been challenged (56,96–98).

Another consideration is that preoperative motion
has been shown to predict postoperative loss of
motion (60,98–100). A recent study using the
more strict IKDC criteria to defifine loss of exten-
sion demonstrated that loss of extension was sig-
nificantly
fi associated with preoperative extension,
time from injury to surgery, and use of autograft
(P < .05) (101).
As a result of this experience, some authors advo-
cated a period of 3–4 weeks for the patient to regain
their range of motion and quadriceps control, and
to allow their swelling/effusion
ff to subside. With
this approach patients had a decrease in arthrofi- fi
brosis and faster recovery (99,102,103).
In our practice, we do not necessarily wait a pre-
determined period of time before embarking on
reconstruction. Rather we assess the condition
of the injured knee for motion loss, quadriceps
control, and swelling/eff
ffusion, and proceed given
the state of the knee. With this in mind, most
patients who present to our clinic are evaluated by
our physical therapy department and entered into
a preoperative therapy protocol. Th This educational
program incorporates modalities to control swell-
ing/eff
ffusion and home conditioning exercises to
increase motion and prevent muscle atrophy of the
lower extremity. The goal is to have the knee feel-
ing “normal” before ACL reconstruction.
References
1. Adachi N, Ochi M, Uchio Y, Sumen Y (2000) Anterior
cruciate ligament augmentation under arthroscopy. A
minimum 2-year follow-up in 40 patients. Arch Orthop
Trauma Surg 120:128–133
2. Ait Si Selmi T, Fithian D, Neyret P (2006) The
Th evolution of
osteoarthritis in 103 patients with ACL reconstruction at
17 years follow-up. Knee 13:353–358
3. Andersson C, Odensten M, Gillquist J (1989) Early
arthroscopic evaluation of acute repair of the anterior cru-
ciate ligament. Arthroscopy 5:331–335
4. Asano H, Muneta T, Ikeda H, et al. (2004) Arthroscopic
evaluation of the articular cartilage after anterior cruciate
ligament reconstruction: a short-term prospective study
of 105 patients. Arthroscopy 20:474–481
5. Bach BR, Jr., Warren RF, Flynn WM, et al. (1990) Arthro-
metric evaluation of knees that have a torn anterior cruci-
ate ligament. J Bone Joint Surg Am 72:1299–1306
6. Bendjaballah MZ, Shirazi-Adl A, Zukor DJ (1997) Finite
element analysis of human knee joint in varus-valgus. Clin
Biomech (Bristol, Avon) 12:139–148
7. Braunstein EM (1982) Anterior cruciate ligament injuries:
a comparison of arthrographic and physical diagnosis. Am
J Roentgenol 138:423–425
8. Clancy WG, Jr., Ray JM, Zoltan DJ (1988) Acute tears of
the anterior cruciate ligament. Surgical versus conserva-
tive treatment. J Bone Joint Surg Am 70:1483–1488
9. Cobby M, Schweitzer M, Resnick D (1992) The Th deep lateral
femoral notch: an indirect sign of a torn anterior cruciate
ligament. Radiology 184(3):855–858
10. Cohen M, Amaro JT, Ejnisman B, et al. (2007) Anterior
cruciate ligament reconstruction after 10 to 15 years:
Diagnostic and surgical decision ACL tears 159
association between meniscectomy and osteoarthrosis.
Arthroscopy 23:629–634
11. Cosgarea AJ, Sebastianelli WJ, DeHaven KE (1995) Pre-
vention of arthrofi fibrosis after anterior cruciate ligament
reconstruction using the central third patellar tendon
autograft. Am J Sports Med 23:87–92
12. Costa-Paz M, Muscolo DL, Ayerza M, et al. (2001) Mag-
netic resonance imaging follow-up study of bone bruises
associated with anterior cruciate ligament ruptures.
Arthroscopy 17:445–449
13. Daniel DM, Stone ML, Dobson BE, et al. (1994) Fate of the
ACL-injured patient. A prospective outcome study. Am J
Sports Med 22:632–644
14. DeHaven KE (1980) Diagnosis of acute knee injuries with
hemarthrosis. Am J Sports Med 8:9–14
15. DeLee J, Drez DJ, Miller M (2003) DeLee & Drez’s ortho-
paedic sports medicine. Philadelphia, PA: Saunders
16. Dunn WR, Lyman S, Lincoln AE, et al. (2004) The Th effffect
of anterior cruciate ligament reconstruction on the risk of
knee reinjury. Am J Sports Med 32:1906–1914
17. Faber KJ, Dill JR, Amendola A, et al. (1999) Occult osteo-
chondral lesions after anterior cruciate ligament rupture.
Six-year magnetic resonance imaging follow-up study. Am
J Sports Med 27:489–494
18. Falconiero R, Baldiuni F, Marcelli E, Crovetti M (1994)
The accuracy of MRI for the knee in a community setting.
Orthop Trans 18
19. Fischer MD, Gustilo RB, Varecka TF (1991) The timing
of flap coverage, bone-grafting, and intramedullary nail-
ing in patients who have a fracture of the tibial shaft
with extensive soft-tissue injury. J Bone Joint Surg Am
73:1316–1322
20. Fithian DC, Paxton EW, Stone ML, et al. (2005) Prospec-
tive trial of a treatment algorithm for the management of
the anterior cruciate ligament-injured knee. Am J Sports
Med 33:335–346
21. Fu FH, Bennett CH, Ma CB, et al. (2000) Current trends in
anterior cruciate ligament reconstruction. Part II. Opera-
tive procedures and clinical correlations. Am J Sports Med
28:124–130
22. Galway HR, MacIntosh DL (1980) The Th lateral pivot shift:
a symptom and sign of anterior cruciate ligament insuf-
ficiency. Clin Orthop Relat Res: 45–50
23. Galway RD, Cruess RL (1972) Enzyme activity in articular
cartilage after synovectomy of the knee in the rabbit. J
Bone Joint Surg Br 54:360–370
24. Gelb H, Galsgow S, Sapega A (1994) Th The clinical value and
cost eff
ffectiveness of magnetic resonance imaging (MRI) in
the management of knee disorders in a sports medicine
practice. Orthop Trans 18:1012
25. Gentili A, Seeger LL, Yao L, Do HM (1994) Anterior cruci-
ate ligament tear: indirect signs at MR imaging. Radiology
193:835–840
26. Gillquist J, Messner K (1999) Anterior cruciate ligament
reconstruction and the long-term incidence of gonarthro-
sis. Sports Med 27:143–156
27. Gross SM, Carcia CR, Gansneder BM, Shultz SJ (2004)
Rate of force application during knee arthrometer testing
aff
ffects stiff
ffness but not displacement measurements. J
Orthop Sports Phys Ther Th 34:132–139
28. Gurtler RA, Stine R, Torg JS (1987) Lachman test evalu-
ated. Quantifi fication of a clinical observation. Clin Orthop
Relat Res: 141–150
29. Hanten WP, Pace MB (1987) Reliability of measuring
anterior laxity of the knee joint using a knee ligament
arthrometer. Phys Ther Th 67:357–359
30. Hanypsiak BT, Spindler KP, Rothrock CR, et al. (2008)
Twelve-year follow-up on anterior cruciate ligament
reconstruction: long-term outcomes of prospectively
studied osseous and articular injuries. Am J Sports Med
36:671–677
160 The Traumatic Knee
31. Hardaker WT, Jr., Garrett WE, Jr., Bassett FH, 3rd (1990)
Evaluation of acute traumatic hemarthrosis of the knee
joint. South Med J 83:640–644
32. Harner CD, Honkamp NJ, Ranawat AS (2008) Anterome-
dial portal technique for creating the anterior cruciate
ligament femoral tunnel. Arthroscopy 24:113–115
33. Harner CD, Irrgang JJ, Paul J, et al. (1992) Loss of motion
after anterior cruciate ligament reconstruction. Am J
Sports Med 20:499–506
34. Harter RA, Osternig LR, Singer KM, et al. (1988) Long-
term evaluation of knee stability and function following
surgical reconstruction for anterior cruciate ligament
insuffi
fficiency. Am J Sports Med 16:434–443
35. Hawkins RJ, Bell RH, Anisette G (1986) Acute patellar dis-
locations. The natural history. Am J Sports Med 14:117–
120
36. Hewett TE, Ford KR, Myer GD, et al. (2006) Gender differ-
ff
ences in hip adduction motion and torque during a single-
leg agility maneuver. J Orthop Res 24:416–421
37. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR (1999)
The effffect of neuromuscular training on the incidence of
knee injury in female athletes. A prospective study. Am J
Sports Med 27:699–706
38. Hewett TE, Myer GD, Ford KR, Heidt RS, Jr., et al. (2005)
Biomechanical measures of neuromuscular control and
valgus loading of the knee predict anterior cruciate liga-
ment injury risk in female athletes: a prospective study.
Am J Sports Med 33:492–501
39. Hewett TE, Stroupe AL, Nance TA, Noyes FR (1996)
Plyometric training in female athletes. Decreased impact
forces and increased hamstring torques. Am J Sports Med
24:765–773
40. Hunter RE, Mastrangelo J, Freeman JR, et al. (1996) The Th
impact of surgical timing on postoperative motion and
stability following anterior cruciate ligament reconstruc-
tion Arthroscopy 12:667–674
41. Hurd WJ, Axe MJ, Snyder-Mackler L (2008) A 10-year
prospective trial of a patient management algorithm and
screening examination for highly active individuals with
anterior cruciate ligament injury: Part 1, outcomes. Am J
Sports Med 36:40–47
42. Johnson DL, Urban WP, Jr., Caborn DN, et al. (1998) Artic-
ular cartilage changes seen with magnetic resonance imag-
ing-detected bone bruises associated with acute anterior
cruciate ligament rupture. Am J Sports Med 26:409–414
43. Justice WW, Quinn SF (1995) Error patterns in the MR
imaging evaluation of menisci of the knee. Radiology
196:617–621
44. Karlsson J, Kartus J, Magnusson L, et al. (1999) Subacute
versus delayed reconstruction of the anterior cruciate liga-
ment in the competitive athlete. Knee Surg Sports Trau-
matol Arthrosc 7:146–151
45. Kostogiannis I, Ageberg E, Neuman P, et al. (2007) Activ-
ity level and subjective knee function 15 years after ante-
rior cruciate ligament injury: a prospective, longitudinal
study of nonreconstructed patients. Am J Sports Med
35:1135–1143
46. Kowalk DL, Wojtys EM, Disher J, Loubert P (1993) Quan-
titative analysis of the measuring capabilities of the
KT-1000 knee ligament arthrometer. Am J Sports Med
21:744–747
47. Krosshaug T, Nakamae A, Boden BP, et al. (2007) Mecha-
nisms of anterior cruciate ligament injury in basketball:
video analysis of 39 cases. Am J Sports Med 35:359–367
48. Linko E, Harilainen A, Malmivaara A, Seitsalo S (2005)
Surgical versus conservative interventions for anterior
cruciate ligament ruptures in adults. Cochrane Database
Syst Rev: CD001356
49. Liu SH, Kabo JM, Osti L (1995) Biomechanics of two types
of bone-tendon-bone graft for ACL reconstruction. J Bone
Joint Surg Br 77:232–235
50. Lohmander LS, Englund PM, Dahl LL, Roos EM (2007)
The long-term consequence of anterior cruciate ligament
and meniscus injuries: osteoarthritis. Am J Sports Med
35:1756–1769
51. Lohmander LS, Roos H (1994) Knee ligament injury, sur-
gery and osteoarthrosis. Truth or consequences? Acta
Orthop Scand 65:605–609
52. Lubowitz JH, Bernardini BJ, Reid JB, 3rd (2008) Current
concepts review: comprehensive physical examination for
instability of the knee. Am J Sports Med 36:577–594
53. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. (2005)
Eff
ffectiveness of a neuromuscular and proprioceptive
training program in preventing anterior cruciate ligament
injuries in female athletes: 2-year follow-up. Am J Sports
Med 33:1003–1010
54. Marcacci M, Zaff ffagnini S, Iacono F, et al. (1995) Early
versus late reconstruction for anterior cruciate ligament
rupture. Results after five
fi years of followup. Am J Sports
Med 23:690–693
55. Markolf KL, Burchfi field DM, Shapiro MM, et al. (1996)
Biomechanical consequences of replacement of the ante-
rior cruciate ligament with a patellar ligament allograft.
Part I: insertion of the graft and anterior-posterior test-
ing. J Bone Joint Surg Am 78:1720–1727
56. Markolf KL, Burchfi field DM, Shapiro MM, et al. (1995)
Combined knee loading states that generate high anterior
cruciate ligament forces. J Orthop Res 13:930–935
57. Marx R, Jones E, Angel M, et al. (2003) Beliefs and atti-
tudes of members of the American Academy of Orthopae-
dic Surgeons regarding the treatment of anterior cruciate
ligament injury. Arthroscopy 19(7):762–770
58. McCauley TR, Moses M, Kier R, et al. (1994) MR diagnosis
of tears of anterior cruciate ligament of the knee: impor-
tance of ancillary findings. Am J Roentgenol 162:115–
119
59. McConnell J (2002) The physical therapist’s approach to
patellofemoral disorders. Clin Sports Med 21:363–387
60. McDaniel WJ, Jr., Dameron TB, Jr. (1980) Untreated rup-
tures of the anterior cruciate ligament. A follow-up study.
J Bone Joint Surg Am 62:696–705
61. Messner K, Maletius W (1999) Eighteen- to twenty-five- fi
year follow-up after acute partial anterior cruciate liga-
ment rupture. Am J Sports Med 27:455–459
62. Meunier A, Odensten M, Good L (2007) Long-term results
after primary repair or non-surgical treatment of ante-
rior cruciate ligament rupture: a randomized study with a
15-year follow-up. Scand J Med Sci Sports 17:230–237
63. Mirza F, Mai DD, Kirkley A, et al. (2000) Management of
injuries to the anterior cruciate ligament: results of a sur-
vey of orthopaedic surgeons in Canada. Clin J Sport Med
10:85–88
64. Myer GD, Ford KR, Brent JL, Hewett TE (2006) Th The eff
ffects
of plyometric vs. dynamic stabilization and balance train-
ing on power, balance, and landing force in female ath-
letes. J Strength Cond Res 20:345–353
65. Myklebust G, Engebretsen L, Braekken IH, et al. (2003)
Prevention of anterior cruciate ligament injuries in female
team handball players: a prospective intervention study
over three seasons. Clin J Sport Med 13:71–78
66. Myrer JW, Schulthies SS, Fellingham GW (1996) Rela-
tive and absolute reliability of the KT-2000 arthrom-
eter for uninjured knees. Testing at 67, 89, 134, and
178 N and manual maximum forces. Am J Sports Med
24:104–108
67. National Collegiate Athletic Association (2002) NCAA
Injury Surveillance System Summary. National Collegiate
Athletic Association, Indianapolis, IN
68. Nelson F, Billinghurst RC, Pidoux I, et al. (2006) Early
post-traumatic osteoarthritis-like changes in human
articular cartilage following rupture of the anterior cruci-
ate ligament. Osteoarthritis Cartilage 14:114–119

69. Neuschwander DC, Drez D, Jr., Paine RM, Young JC (1990)
Comparison of anterior laxity measurements in anterior
cruciate defi
ficient knees with two instrumented testing
devices. Orthopedics 13:299–302
70. Noyes F, Mooar L, Moorman Cr, McGinniss G (1989) Par-
tial tears of the anterior cruciate ligament. Progression
to complete ligament defi ficiency. J Bone Joint Surg Br
71(5):825–833
71. Noyes FR, Bassett RW, Grood ES, Butler DL (1980)
Arthroscopy in acute traumatic hemarthrosis of the knee.
Incidence of anterior cruciate tears and other injuries. J
Bone Joint Surg Am 62:687–695, 757
72. Noyes FR, Grood ES, Butler DL, Malek M (1980) Clinical
laxity tests and functional stability of the knee: biome-
chanical concepts. Clin Orthop Relat Res: 84–89
73. Noyes FR, Mooar LA, Moorman CT, 3rd, McGinniss GH
(1989) Partial tears of the anterior cruciate ligament. Pro-
gression to complete ligament defi ficiency. J Bone Joint
Surg Br 71:825–833
74. Noyes FR, Mooar PA, Matthews DS, Butler DL (1983) The Th
symptomatic anterior cruciate-deficient
fi knee. Part I: the
long-term functional disability in athletically active indi-
viduals. J Bone Joint Surg Am 65:154–162
75. O’Shea KJ, Murphy KP, Heekin RD, Herzwurm PJ (1996)
The diagnostic accuracy of history, physical examination,
and radiographs in the evaluation of traumatic knee disor-
ders. Am J Sports Med 24:164–167
76. Ochi M, Adachi N, Deie M, Kanaya A (2006) Anterior cru-
ciate ligament augmentation procedure with a 1-incision
technique: anteromedial bundle or posterolateral bundle
reconstruction. Arthroscopy 22:463 e461–465
77. Pinczewski LA, Lyman J, Salmon LJ, et al. (2007) A 10-year
comparison of anterior cruciate ligament reconstructions
with hamstring tendon and patellar tendon autograft: a
controlled, prospective trial. Am J Sports Med 35:564–574
78. Robertson PL, Schweitzer ME, Bartolozzi AR, Ugoni A
(1994) Anterior cruciate ligament tears: evaluation of
multiple signs with MR imaging. Radiology 193:829–834
79. Roos H, Ornell M, Gardsell P, et al. (1995) Soccer after
anterior cruciate ligament injury – an incompatible com-
bination? A national survey of incidence and risk factors
and a 7-year follow-up of 310 players. Acta Orthop Scand
66:107–112
80. Rose NE, Gold SM (1996) A comparison of accuracy
between clinical examination and magnetic resonance
imaging in the diagnosis of meniscal and anterior cruciate
ligament tears. Arthroscopy 12:398–405
81. Rosen MA, Jackson DW, Berger PE (1991) Occult osseous
lesions documented by magnetic resonance imaging asso-
ciated with anterior cruciate ligament ruptures. Arthros-
copy 7:45–51
82. Salmon LJ, Russell VJ, Refshauge K, et al. (2006) Long-
term outcome of endoscopic anterior cruciate ligament
reconstruction with patellar tendon autograft: minimum
13-year review. Am J Sports Med 34:721–732
83. Sandberg R, Balkfors B, Nilsson B, Westlin N (1987) Oper-
ative versus non-operative treatment of recent injuries
to the ligaments of the knee. A prospective randomized
study. J Bone Joint Surg Am 69:1120–1126
84. Seitz H, Schlenz I, Muller E, Vecsei V (1996) Anterior
instability of the knee despite an intensive rehabilitation
program. Clin Orthop Relat Res: 159–164
85. Seon JK, Song EK, Park SJ (2006) Osteoarthritis after
anterior cruciate ligament reconstruction using a patellar
tendon autograft. Int Orthop 30:94–98
86. Shelbourne KD, Davis TJ (1999) Evaluation of knee sta-
bility before and after participation in a functional sports
Diagnostic and surgical decision ACL tears 161
agility program during rehabilitation after anterior cruci-
ate ligament reconstruction. Am J Sports Med 27:156–
161
87. Shelbourne KD, Foulk DA (1995) Timing of surgery in
acute anterior cruciate ligament tears on the return of
quadriceps muscle strength after reconstruction using
an autogenous patellar tendon graft. Am J Sports Med
23:686–689
88. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M
(1991) Arthrofi fibrosis in acute anterior cruciate ligament
reconstruction. The eff ffect of timing of reconstruction and
rehabilitation. Am J Sports Med 19:332–336
89. Sherman MF, Warren RF, Marshall JL, Savatsky GJ (1988)
A clinical and radiographical analysis of 127 anterior cru-
ciate insuffi
fficient knees. Clin Orthop Relat Res 227:229–
237
90. Snearly WN, Kaplan PA, Dussault RG (1996) Lateral-com-
partment bone contusions in adolescents with intact ante-
rior cruciate ligaments. Radiology 198:205–208
91. Solomon DH, Simel DL, Bates DW, et al. (2001) The Th ratio-
nal clinical examination. Does this patient have a torn
meniscus or ligament of the knee? Value of the physical
examination. JAMA 286:1610–1620
92. Speer KP, Spritzer CE, Bassett FH, 3rd, et al. (1992)
Osseous injury associated with acute tears of the anterior
cruciate ligament. Am J Sports Med 20:382–389
93. Spindler KP, Schils JP, Bergfeld JA, et al. (1993) Prospec-
tive study of osseous, articular, and meniscal lesions
in recent anterior cruciate ligament tears by magnetic
resonance imaging and arthroscopy. Am J Sports Med
21:551–557
94. Steiner ME, Brown C, Zarins B, et al. (1990) Measure-
ment of anterior-posterior displacement of the knee. A
comparison of the results with instrumented devices and
with clinical examination. J Bone Joint Surg Am 72:1307–
1315
95. Sterett WI, Hutton KS, Briggs KK, Steadman JR (2003)
Decreased range of motion following acute versus chronic
anterior cruciate ligament reconstruction. Orthopedics
26:151–154
96. Taskiran E, Taskiran D, Duran T, Lok V (1998) Articular
cartilage homeostasis after anterior cruciate ligament
reconstruction. Knee Surg Sports Traumatol Arthrosc
6:93–98
97. Taskiran E, Taskiran D, Lok V (2005) Proteoglycan frag-
ments in anterior cruciate ligament reconstructed knees:
a comparative study of two diff fferent surgical techniques.
Knee Surg Sports Traumatol Arthrosc 13:385–392
98. Torg JS, Conrad W, Kalen V (1976) Clinical diagnosis of
anterior cruciate ligament instability in the athlete. Am J
Sports Med 4:84–93
99. Turner JM, Gordon MD (1985) Focus film fi distance of
remote control tables. Radiography 51:306
100. Vahey TN, Meyer SF, Shelbourne KD, Klootwyk TE (1994)
MR imaging of anterior cruciate ligament injuries. Magn
Reson Imaging Clin N Am 2:365–380
101. Vellet AD, Marks PH, Fowler PJ, Munro TG (1991) Occult
posttraumatic osteochondral lesions of the knee: preva-
lence, classifi
fication, and short-term sequelae evaluated
with MR imaging. Radiology 178:271–276
102. Wasilewski SA, Covall DJ, Cohen S (1993) Eff ffect of surgi-
cal timing on recovery and associated injuries after ante-
rior cruciate ligament reconstruction. Am J Sports Med
21:338–342
103. Zazulak BT, Ponce PL, Straub SJ, et al. (2005) Gender com-
parison of hip muscle activity during single-leg landing.
J Orthop Sports Phys Ther Th 35:292–299

M.J. Matava, R.W. Wright,
E.D. Ellis
Natural history of ACL tears:
from rupture to osteoarthritis
Historical perspective
T
he anterior cruciate ligament (ACL) was orig-
inally identified
fi and described as far back as
the time of Galen (1). However, a description
of an ACL injury did not occur for over a millen-
nium, as the first report of this injury can be traced
to the 1850s when Stark described two patients
with this condition (2). While attempts to surgi-
cally repair this ligament date back to the early
20th century (3,4), the routine treatment of ACL
tears did not become mainstream until the genesis
of sports medicine as a medical discipline in the
1970s. Many of the early surgeons treating ACL
injuries recognized the relevance of this ligament
to knee stability – primarily for activities that
involve cutting, twisting, or pivoting. Correspond-
ingly, it has been well documented that chronic
knee instability is associated with meniscal dam-
age and chondral injury (5–13). Therefore,Th theo-
ries abound – based on clinical experience and the
known relationship between chronic meniscal tears
and chondral injury – that untreated ACL tears are
linked with the development of osteoarthritis.
Yet, despite these theories, a causal association
remains diffi fficult to prove considering the multi-
tude of factors that aff ffect this relationship, such as
patient age, activity level, knee co-morbidities, and
the infl fluence of conservative treatment methods
(i.e., bracing and physical therapy). In addition, the
available orthopaedic literature dealing with this
topic suff ffers from considerable methodological
flaws that make it diffi fficult to establish a so-called
“natural history” of ACL tears, using evidence-
based methods. Despite these limitations, we will
attempt to summarize what is known regarding the
ACL-defi ficient knee, the effffect of patients trying to
cope with this condition, and the subsequent risk
for development of osteoarthritis.
Epidemiology
Rupture of the ACL is a common injury among the
physically active and is most commonly seen in
Chapter 14
patients under the age of 30. TheTh incidence rate
of ACL tears in the United States is estimated
to be over 250,000 per year, with approximately
107,000 of these tears reconstructed annually
(14). This rate is expected to climb over the next
few decades as children, teens, and adults become
more involved in athletic activities and remain
physically active to an older age. In terms of the
overall number of injuries, there are more abso-
lute ACL tears in males than in females. However,
as a percentage of sports participants, females are
up to eight times more likely to sustain this injury
than their male counterparts (15,16). From a cost-
ffectiveness perspective, Gottlob and Baker (17)
eff
estimated the cost of treating an ACL tear in the
United States in 1999 was $11,700 for surgical
reconstruction and its associated rehabilitation.
For conservative care of the injury, the estimated
cost was only $2300 (17). However, it should be
pointed out that this lower cost does not take
into consideration the potential expense for treat-
ment of concurrent or future meniscal and chon-
dral injuries, lost productivity, and the sequelae
of osteoarthritis that may develop in the chronic
ACL-defi ficient knee. In fact, Gottlob and Baker
(17) deemed it cost-effective
ff to reconstruct the
ACL in the young adult due to the adjusted quality
of life gained by the operation.
Diff
fferent sports have varying risks for ACL injury.
The highest incidence is seen in adolescents
involved in sports that require pivoting and cut-
ting maneuvers. In a recent epidemiologic analy-
sis of collegiate athletes conducted by Mount-
castle et al. (18), American football was the most
common sport that led to ACL rupture amongst
men, whereas basketball was the most common
sport that led to ACL rupture amongst women. In
professional soccer, the ACL injury risk has been
estimated to be 100–1000 times more likely than
that found in the general population (19,20).
Clearly, those sports that involve limited weight-
bearing or straight ahead movement, such as
cycling and running, are associated with a lower
risk for injury and are able to be continued in
those patients who are ACL defi ficient, irrespective
of the cause.
164 The Traumatic Knee
Mechanism of injury
Anterior cruciate ligament tears occur from a non-
contact mechanism 70–80% of the time (15,21,22).
There are two distinct mechanisms by which the
ACL is ruptured in a non-contact manner. The Th first
mechanism is deceleration during concomitant piv-
oting. This is a common movement used in cutting
sports such as soccer or basketball. Colby et al. (23)
has shown that normal subjects performing this
cutting maneuver initiate foot strike with the knee
flexed approximately 20° with quadriceps contrac-
fl
tion occurring at 161% of the voluntary maximum
and hamstring contraction at 22% of maximum. The Th
secondary restraints to anterior tibial translation are
minimal at this degree of flexion.
fl Therefore, the quad-
riceps causes an anterior translatory force leading to
strain, and ultimately rupture, of the ACL (23).
The second non-contact mechanism is that of land-
Th
ing on one leg and then falling with a twisting, val-
gus force while maintaining quadriceps contrac-
tion. Again, with this mechanism, the quadriceps
contraction leads to anterior tibial translation with
minimal resistance from the secondary stabilizers,
ultimately resulting in ACL rupture (23).
Neuromuscular studies have been performed compar-
ing lower extremity landing differences
ff between men
and women. Results of these studies demonstrate
that women land with a larger overall peak valgus
angle and exhibit greater anterior shear force at the
knee when fatigued (24). A study by Huston and Woj-
tys showed that female athletes possess more ante-
rior tibial laxity and signifi
ficantly less muscle strength
and endurance than the male athletes to whom they
were compared (25). This may help to explain the dif-
ference in ACL rupture rates between genders.
The most common mechanism of contact-mediated
ACL rupture involves an outside force that results
in a valgus collapse of the knee (21). An example of
this in American football is when a defensive player
dives at the knee of an opposing player from the side
in an attempt at making a tackle, thus delivering a
medially directed blow to the knee. If the player’s
foot is planted, a valgus collapse of the knee may
ensue. Another example of this is in soccer when
a defensive player attempts to slide tackle the ball
carrier while that player has his or her leg planted
and is attempting to kick with the contralateral leg.
Evaluation
Physical examination
The evaluation of any patient with a knee injury
begins with a thorough history and physical exam-
ination. An ACL tear usually occurs during athletic
participation or other activity, such as a low-energy
trauma or work-related injury that involves either
a fall from a height or other deceleration, twisting
event. Patients will often feel or even claim to have
heard an audible “pop,” and they will almost never
be able to continue their athletic event. A bloody
eff
ffusion typically develops within the ensuing 6 h,
and may become quite tense over the subsequent
24 h. Recurrent episodes of effusions
ff are also a
common complaint. With a history of a twisting
injury, a “pop,” the inability to return to sport, and
an eff
ffusion that develops within a few hours, the
likelihood of an ACL tear has been estimated to
be approximately 70% (26). The Th presentation of
a chronic ACL injury will often include recurrent
episodes of giving way or feelings of an unstable
knee, as well as a clear effffusion, especially in the
setting of associated meniscal or chondral damage.
Quadriceps atrophy may also be noted depending
upon the degree and chronicity of recurrent joint
swelling, which has an inhibitory effectff on quadri-
ceps function.
The physical examination should first start with
an evaluation of the patient’s gait and overall
limb alignment. Gait can be evaluated as simply
as having the patient walk down the hallway. This Th
assessment can be crucial for detecting coronal
instability such as a varus thrust, associated hip
pathology, or even limb-length inequalities. All
of these may become important when consider-
ing rehabilitation or operative intervention for
a patient. Formal gait analysis may also be per-
formed but is typically not available to the general
practitioner. Limb alignment should be measured
both clinically and radiographically, particularly
in the setting of a chronic ACL-deficientfi patient
considering reconstruction.
Once the gait and the limb alignment have been
evaluated, a thorough knee examination should
be performed of both knees to determine nor-
mal range of motion and physiologic knee laxity.
This practice is also helpful to ease the patient
(especially children and young adolescents) who
may be apprehensive about moving the joint. A
full discussion regarding the knee examination
is beyond the scope of this chapter. Neverthe-
less, specific
fi tests for the ACL include the Lach-
man test, the anterior drawer, and the pivot
shift. With a chronic ACL tear that is associated
with osteoarthritis, these laxity tests may be
falsely negative due to the “stabilizing” effectff of
osteophytes encroaching upon the intercondy-
lar notch. The presence of an eff ffusion may also
limit the degree of laxity perceived by the exam-
iner and the extent to which the patient is able to
flex the knee for these various exam maneuvers.
Evidence of meniscal pathology should be noted,

as well as the presence of any additional ligamen-
tous defi
ficiency. Isolated or diff
ffuse osteoarthritis
may mimic meniscal pathology, as evidenced by
joint line pain to palpation or flexion-rotation
fl
(i.e., the McMurray test). Osteoarthritis can
often be distinguished from a meniscal tear by
pain and crepitus that is present throughout the
arc of motion while a compressive force is applied
to the involved joint line. Meniscal tears usually
cause pain only with extreme fl flexion and are not
associated with crepitus, but with a painful, pal-
pable “click,” the so-called McMurray sign.
Radiographic assessment
Radiographic evaluation of the knee should be per-
formed in all patients suspected of either an acute
or a chronic ACL injury. At a minimum, weight-
bearing anteroposterior, lateral, and patellar (i.e.,
Merchant) views should be obtained. Acutely, a
tibial spine fracture may be identified
fi in the skel-
etally immature patient representing an ACL avul-
sion. Also, a small fragment of bone – the Segond
fracture – may be seen adjacent to the lateral tibial
plateau representing an avulsion of the lateral cap-
sule. This fracture, which is pathognomonic for an
ACL disruption, likely occurs as the lateral tibial
plateau shifts anteriorly in relation to the lateral
femoral condyle causing an avulsion of the lateral
capsule.
For those patients over the age of 40, or in those
with a history of chronic ACL insuffi fficiency, it is
important to include a 45°-bent knee weightbear-
ing posteroanterior (Rosenberg) view in the radio-
graphic assessment to determine the presence of
arthritic degeneration of the posterior femoral
condyles (27). Specific
fi findings of osteoarthritis in
these chronic injuries include osteophyte forma-
tion, joint space loss, subchondral sclerosis, and
cyst formation.
Magnetic resonance imaging (MRI) is the gold
standard for the radiographic evaluation of ACL
tears. In addition to the ACL, MRI has the addi-
tional benefifit of being able to clearly defi
fine all
of the other anatomic structures of the knee,
thereby helping the physician to identify associ-
ated pathology such as concurrent ligamentous,
meniscal, and chondral injuries. The MRI is greater
than 95% accurate in diagnosing an ACL injury
based on both primary and secondary character-
istics (28). A normal ACL is seen as a well-defined
fi
band of low signal intensity coursing through the
intercondylar notch on the sagittal images (29).
Primary signs indicative of an ACL tear include
an abnormal course, an abnormal signal intensity,
and discontinuity. Secondary findings include the
presence of bone contusions in the lateral com-
Natural history of ACL tears: from rupture to osteoarthritis 165
partment, an abnormal posterior cruciate line and
angle, the presence of anterior tibial displacement,
and the uncovering of the posterior horn of the
lateral meniscus (30).
Finally, a full-length, standing radiograph of both
lower extremities with the feet 10 apart is help-
ful to assess overall knee alignment as patients
with chronic ACL defi ficiency may develop coronal
plane deformities, especially following removal
of the meniscus. In order to assess the alignment
of the leg, a line is drawn from the center of the
femoral head to the center of the talar dome. In a
normally aligned knee, this line will pass through
the tibial spines. A varus deformity is the most
common condition encountered as the incidence
of medial meniscal tears is over 90% in those
patients with chronic ACL insuffi fficiency (9,13).
A “double-varus” deformity results when the pri-
mary osseous varus alignment is associated with
cruciate insuffifficiency (26). The addition of asso-
ciated ligamentous injuries such as the lateral
collateral ligament, posterolateral capsule, and/
or posterior cruciate ligament (PCL) may result
in the “triple-varus” knee (26). Th This more com-
plex deformity often requires, at a minimum,
both osseous realignment in the form of a high
tibial osteotomy and cruciate reconstruction,
with or without reconstruction of the postero-
lateral corner.
The triple-phase bone scan has been used in the
detection of osteoarthritis of the knee, and may
be worthwhile to obtain in the setting of a patient
requesting reconstruction of a chronic ACL-de-
ficient knee. Delayed images may demonstrate
areas of increased metabolic activity either dif-
fusely when generalized arthritis is present or
localized to an isolated compartment. Th The benefi
fit
of a bone scan is that it may reveal early degen-
erative changes in the setting of normal appear-
ing radiographs (31). This suggests that subtle or
early osteoarthritis may be detected on a bone
scan before it is radiographically evident, and
therefore may prove helpful in clinical decision-
making for the chronically ACL-deficientfi and/or
meniscal-defi ficient knee.
Associated injuries
In over 50% of acute ACL tears, there is an associ-
ated meniscal, cartilaginous, or ligamentous injury
(32,33). This
Th rate is increased in those with chronic
ACL insuffi
fficiency (5–13). One reason it is very dif-
ficult to determine a true natural history of the
ACL-defificient knee is that some tears may have
other concurrent injuries that aff ffect this history,
whereas other isolated ACL tears may ultimately
166 The Traumatic Knee
lead to meniscal and/or chondral injuries over
time due to the patholaxity caused by the cruciate
tear. This section will discuss the infl
fluence of these
associated injuries on the clinical outcome.
Meniscal injury
The incidence of meniscal tears in ACL-defi ficient
knees has been reported to vary between 16%
and 82% of knees with an acute ligamentous
injury, and in as many as 96% of knees with
chronic ACL defi ficiency (5–13). It would appear
that both menisci are at risk following an injury
that results in an ACL tear as one large series of
1065 knees that had undergone ACL reconstruc-
tion found that 53% of all meniscal tears were
medial and 47% were lateral (11). It may be that
the chronicity of injury is the greatest predic-
tor of specifific meniscal injury risk since in the
acute ACL-injured knee, 50% of meniscal tears
are medial and 50% are lateral (11). However, in
those knees with a chronic ACL injury, 58% of
the tears have been shown to involve the medial
meniscus and 42% involve the lateral meniscus
(11). This
Th difffference is likely due to the secondary
restraining force the medial meniscus provides to
anterior tibial translation in the absence of the
ACL (34). Pagageorgiou et al. (35) also showed
that forces in the medial meniscus were doubled
in the ACL-defi ficient knee when subjected to an
anterior and axial force. This biomechanical data
was confifirmed clinically by Murrell et al. (36), who
noted an increasing prevalence of meniscal injury
in the ACL-defi ficient knee as the time from injury
increases. This may be explained either by a recur-
rent, pathological increase in the anterior shear
force acting against the meniscus during normal
activities or from repeated minor episodes of
instability during physical exertion.
Combined, the menisci transmit over 50% of the
compressive load in the knee from 0° to 90° of flex-
fl
ion (37,38). Meniscal loss can reduce total contact
area of the tibial plateau by up to 70%, which results
in increased compressive stress to both the plateau
and the femoral condyle (39,40). A study by Baratz
et al. (41) showed an increase in contact stress of
65% after partial meniscectomy and an increase
of 235% after total meniscectomy in the involved
compartment. A separate study demonstrated that
partial meniscectomy can increase contact forces
by as much as 350% (42). Additionally, the lack of
a functionally normal ACL or meniscus alters the
static and dynamic loading patterns of the knee,
which generates elevated compressive and shear
forces in the articular cartilage, thus predispos-
ing the knee to the development of osteoarthritis
(43,44).
Associated ligamentous injury
There are at least two studies that have shown an
increased incidence of knee osteoarthritis in the
setting of an ACL tear when there is an associ-
ated PCL injury. Kullmer et al. (45) found that in
77 patients who had undergone a synthetic ACL
reconstruction, the greatest risk factor for devel-
opment of osteoarthritis was an associated PCL
rupture. This finding is tempered by the fact that
the only other significant
fi risk factor for arthritic
development was meniscal injury, which is likely to
be as relevant as any ligamentous co-morbidities.
Obviously, the use of a synthetic graft must also
be taken as a potential risk factor for osteoarthri-
tis, given the known unfavorable fate of synthetic
grafts. Similarly, Jacobsen (46) reported that all
patients with a combined ACL/PCL disruption had
developed severe osteoarthritis within 5 years of
injury when treated conservatively. Interestingly,
despite the common combined injury pattern,
there have been no studies that have evaluated the
ffect of a combined ACL and posterolateral corner
eff
injury on the risk for arthritis progression. How-
ever, it may be theorized that any injury that alters
overall limb alignment and causes increased shear
forces in the joint could ultimately lead to osteoar-
thritis.
Chondral injury
Chondral or osteochondral injuries may also occur
at the time of the injury to the ACL. In terms of
overall incidence in patients undergoing knee
arthroscopy, Curl (47) noted a 63% incidence of
chondral lesions in 31,516 knee arthroscopies, of
which 41% were grade III lesions and 19% were
grade IV lesions by the Outerbridge scale (48). In
their “younger age” group, ACL injuries were the
predominant injury associated with a chondral
lesion (47). In another study, it was found that
nearly 50% of athletes undergoing ACL recon-
struction had an associated articular cartilage
defect on at least one of the femoral condyles (49).
These lesions appear macroscopically as areas of
chondral softening, single or multiple chondral
fractures, chondral flaps, or impaction lesions.
There may also be an underlying bone bruise iden-
tifi
fied on MRI with macroscopically normal overly-
ing cartilage (see below). These
Th chondral injuries
occur most commonly in the lateral compartment
when combined with an acute ACL tear, but may
also involve the medial femoral condyle (50,51).
Due to the lack of both long-term outcome stud-
ies and a uniform classifi
fication system, the natural
history of these injuries is unclear. Nevertheless,
it is intuitive that these injuries could have a sig-

nifi
ficant negative impact on the long-term health
of the joint surface.
Partial-thickness hyaline cartilage injuries have no
reparative potential, whereas full-thickness chon-
dral injuries may heal with fibrocartilage com-
posed primarily of type I collagen. Unfortunately,
fibrocartilage does not have the same biomechani-
cal properties, resiliency, or wear characteristics of
normal hyaline cartilage (52). Related to this is the
phenomenon seen in vitro in larger lesions greater
than 2 cm² of increased peripheral, or “edge,” load-
ing that has the potential to lead to premature
degenerative changes in the surrounding normal
articular cartilage (45,53,54). Th
There is little pub-
lished data regarding the relationship between size
and location of chondral injuries and the risk for
development of osteoarthritis.
Bone bruising
Bone bruises are commonly seen on MRI in asso-
ciation with ACL tears. The reported incidence of
associated bone bruises in the acutely ACL-injured
knee is approximately 80% (55–61). Seen best on
T2-weighted sagittal images, the classic pattern
involves the mid-portion of the lateral femoral
condyle and the posterior aspect of the lateral
tibial plateau. These injuries have been classifi fied
into three types. Type I has a reticular pattern with
associated medullary edema and comprises 70% of
these injuries. Type II bone bruises (25%) have a
geographic pattern and are defined fi as a localized
signal contiguous with the subjacent articular sur-
face. Type III injuries are defined
fi as a disruption
or depression of the normal contour of the cortical
surface (61). In a study by Costa-Paz (56) evaluat-
ing the natural history of bone bruises by MRI in 21
patients at an average of 31 months post-injury, all
type I and 91% of type II lesions resolved. Unfortu-
nately, all type III lesions revealed articular cartilage
thinning and depression after 2 years of follow-up
on repeat MRI. Despite the high likelihood of type
II lesions resolving, gross and histologic analyses
of biopsies of type II lesions taken at the time of
ACL reconstruction have shown not only cartilage
softening, fissuring, and fibrillation but also loss
of proteoglycan content, decreased chondrocyte
viability, and osteocyte necrosis in adjacent sub-
chondral bone (57). In a similar study, Fang et al.
(62) analyzed the synovial fl fluid and articular carti-
lage biopsies of the knees of 12 patients with bone
bruises and found increased levels of cartilage oli-
gomeric matrix protein (COMP) in the superficial fi
cartilage matrix and an associated tenfold increase
in synovial fluid
fl COMP levels. These studies sup-
port the hypothesis that these lesions are precur-
sors of post-traumatic arthritis.
Natural history of ACL tears: from rupture to osteoarthritis 167
The long-term outcome of these osteochon-
dral lesions has not yet been fully determined,
although recent research has shed some light
on these injuries. One study (50) showed persis-
tent subchondral abnormalities on MRI in 60%
of patients with bone bruises up to 6 years after
their ACL was reconstructed. In a rabbit model,
Escalas and Curell (63) found that all type I inju-
ries ultimately resolved. Conversely, Donohue et
al. (64) showed that the outcomes of type II and
III lesions were less favorable. In a canine model,
these authors (64) showed that blunt trauma
to the articular cartilage produced a profound
histological and biochemical change despite
the absence of macroscopic surface disruption.
Other animal studies have shown that localized
injury to the articular cartilage and subchondral
bone can lead to degeneration (65). Similarly,
Mankin (66) found in humans that these lesions
are associated with persistent MRI changes in
adjacent articular cartilage and subchondral
bone with associated alteration of cartilage
homeostasis. The development of degenerative
articular changes in knees that have undergone
successful ACL reconstruction may be explained
by these occult osteochondral injuries. However,
there are no long-term outcome studies of these
lesions, and clinical symptoms do not always cor-
relate with the changes noted on MRI (44). In a
study by Wright et al. (67), patients with isolated
bone bruises were followed clinically for an aver-
age of 21.3 months. The average return to pre-
injury activity level was 3.2 months, and 91%
had returned to pre-injury activity by 6 months
or less (68).
Recent advances in cartilage-specificfi MRI sequenc-
ing may prove helpful in further delineating chon-
dral lesions. Novel techniques such as T1rho MRI,
sodium MRI, and T1-weighted imaging with intra-
venous injection of negatively charged gadolini-
um-based compounds target different
ff components
of the extracellular matrix, such as proteoglycans,
creating a detailed image of different
ff portions of
the cartilage three-dimensional structure (69).
T2-weighted and delayed gadolinium-enhanced
MRI mapping sequences provide excellent carti-
lage detail by specifi
fically targeting collagen orien-
tation (69).
There is evidence that even when there is no
cartilage injury detected on MRI or seen during
arthroscopy, the cartilage may have sustained a
considerable mechanical impact. That impact may
lead to disruption of the cartilage matrix, chon-
drocyte death, accelerated chondrocyte senes-
cence, and changes in cell metabolism (65,70,71).
These events are associated with osteoarthritic
development, even in the absence of joint insta-
bility.
168 The Traumatic Knee
Limb alignment
An alteration in the coronal knee alignment can
create increased compressive loads through a com-
partment and thus predispose the joint to either
the onset or the progression of osteoarthritis. ThThis
risk is exacerbated by prior meniscectomy or cru-
ciate ligament insuffi fficiency, as an ACL rupture,
alone, has been shown to translate the center of
knee rotation toward the medial compartment
(72). Chronic posterolateral instability may also
alter the adduction moment during weightbear-
ing, which predisposes the knee to increased varus
loads and, therefore, increased stress in the medial
compartment (73). The Th eff ffect of “normal” preex-
isting genu varum or genu valgum that is present
bilaterally has not been well quantifiedfi in terms of
its risk for arthritic development on the compres-
sive side.
Biochemical markers
In addition to the associated structural injuries that
occur at the time of an ACL tear, there is also an
alteration in the biochemical environment (74,75).
Intra-articular bleeding, routinely seen with ACL
tears, can activate the infl flammatory pathway of
the joint (76,77). Recent studies evaluating the
levels of various biomarkers of chondral metabo-
lism have shown interesting results. Elevations in
the levels of matrix metalloproteinases (MMPs),
stromolysin (MMP1), collagenase (MMP3),
inhibitors of metalloproteinases (TIMPs), and
keratin sulfate as well as increases in interleukin
(IL)-1, IL-6, IL-8, and tumor necrosis factor-alpha
(TNF-) have been noted (78–83). Cameron et al.
(84) studied the cytokine and keratin sulfate lev-
els in synovial flfluid of uninjured, acute, subacute,
and chronically ACL-deficient
fi knees. There were
signifi
ficant increases in keratin sulfate – a marker
of chondral catabolism – while levels of a chon-
droprotective cytokine, IL-1Ra, fell. Additionally,
there were transient increases in multiple interleu-
kins and TNF- for up to 3 months after injury.
Lohmander et al. (81) further noted marked eleva-
tions in COMP, MMP-1 and MMP-3, TIMP-1, and
C-propeptide of type II collagen in synovial fluid
fl
following ACL rupture, similar to that seen in pri-
mary osteoarthritis.
Biochemical markers have been monitored not
only in joint fluid
fl but also in the blood and urine
after ACL and meniscus injury. This analysis
has demonstrated an immediate and sustained
increase in the release of matrix molecular frag-
ments, proteases, and cytokines from the joint
cartilage (79,82,83,85,86). These bioactive agents
may result in damage to the type II collagen net-
work and aggrecan, which can lead to a weaken-
ing of the joint surface. With increasing time after
injury, biomarker levels generally decrease but
often remain elevated for years after injury at levels
similar to those in the osteoarthritic joint, reflect-
fl
ing an increase in metabolism (78,84). Johnson et
al. (57) hypothesized that the increased inflamma-
fl
tory response, resulting disability, and poorer out-
come seen in acute ACL ruptures associated with a
geographic bone bruise may be mediated by these
cytokines and, thus, have prognostic value (87).
ACL insuffi
fficiency and the development
of osteoarthritis
The unreconstructed ACL-injured knee is sub-
jected to abnormal loading patterns in everyday
activities as well as in sports (72). Given that most
patients with acute ACL tears are under 30 years
of age, ACL injuries may be the causative factor in
a large majority of those patients with early-onset
arthritis resulting in pain, functional limitations,
and decreased quality of life. These are the young
patients with “old” knees (88).
The main risk factors for osteoarthritis include
age, prior joint injury, developmental conditions
aff
ffecting joint growth, muscle weakness, obesity,
and family history. This last factor likely results
from a poorly defi fined genetic predisposition to
joint degeneration (89–91). The Th reported rates of
osteoarthritis after an ACL injury vary between
10% and 90% after 10–20 years following the
initial injury (7,92–94). It is nearly impossible to
report the true incidence rate of osteoarthritis
development following an ACL tear, due to the
large variability in disease definition,
fi conservative
treatment regimens, activity levels, patient body
habitus, genetic predisposition, and co-morbidi-
ties in those patients analyzed. Lohmander et al.
(88) has stated that a formal meta-analysis assess-
ing the risk for arthritic development after ACL
injury is impossible due to the inconsistent and
poor reporting of critical study variables.
Kannus and Jarvinen (95) reported their 8-year
results of non-operatively treated ACL ruptures
and noted that 70% of patients had radiographic
signs of osteoarthritis. Other authors (7,93,94)
similarly noted degenerative changes on follow-up
radiographs in 40–65% of patients treated non-op-
eratively for an ACL tear. In a study by Lohmander
et al. (92) evaluating female soccer players 12 years
following ACL rupture, 75% reported significant fi
symptoms aff ffecting their knee-related quality of life,
and 42% were thought to have symptomatic radio-
graphic osteoarthritis. Similar results were found in
an identical cohort of male soccer players (96).

Noyes et al. (22) reported on 103 “young, athleti-
cally active” patients with non-operatively managed
ACL tears at an average of 5.5 years after injury. They
reported that 64% of these patients had a “signifi- fi
cant reinjury” within 2 years, and that almost half of
the re-injuries occurred during competitive sports.
They stated that these patients were abusing their
knees by continuing to participate in strenuous ath-
letics. At final follow-up, only 35% were still partici-
pating in strenuous sporting activities, and many of
these had symptoms of pain and instability. Forty-
four percent of the patients who had been injured
more than 5 years prior were found to have moder-
ate to severe arthritis by radiographic criteria (22).
Rehabilitation protocols for the symptomatic ACL-
defi
ficient knee have not been shown to be reliably
helpful in regaining function and reducing symptoms.
In another study by Noyes et al. (97), 84 patients
were submitted to a comprehensive rehabilitation
program centered on correction of strength, power,
and endurance defi ficits with a focus on weekly main-
tenance exercises. Thirty-six percent of the patients
improved; however, their knees were deemed “still
far from normal”; 32% of patients stayed the same;
and 32% became more symptomatic (97).
Clearly, the detection of osteoarthritis following
an ACL tear is dependent upon the duration of
follow-up in the patient cohort. Maletius found
that 20 years following acute repair of an ACL
tear, 90% of knees have radiographic evidence of
osteoarthritis and many have persistent knee lax-
ity (98). Progression of arthritis was seen between
12 and 20 years in 30% of the knees. The Th nature of
the surgery and post-operative rehabilitation must
also be taken into consideration in any long-term
study that may have attempted primary ligamen-
tous repair or employed an inferior graft placed
through non-isometric tunnels. Older rehabilita-
tion protocols that involve casting and avoidance
of early knee extension may also increase the risk
for arthritic development.
Many authors have reported a poorer functional
outcome when there is a history of concomitant
medial meniscal injury or surgery (99,100). Bar-
rack et al. (99) showed that 54% of young military
personnel with ACL tears managed non-operatively
had poor results correlating with meniscal tear or
resection. Over 80% of their patients were symp-
tomatic, and over 60% had episodes of giving way
(99). In a literature review by Gillquist and Messner
(100), ACL rupture, in addition to meniscal injury,
resulted in radiographic changes of osteoarthritis
in 50–70% of patients after 15–20 years, but these
changes were infrequently associated with major
clinical symptoms.
There are no long-term, randomized, prospec-
tive, controlled studies comparing the outcomes
of operative and non-operative treatment of ACL
Natural history of ACL tears: from rupture to osteoarthritis 169
tears in young active patients. Furthermore, there
is no evidence in the literature that ACL reconstruc-
tion reduces the rate of arthritic development or
improves the long-term symptom outcome (101).
In a non-randomized, prospective study of recon-
structed and non-reconstructed knees, Daniel et
al. (67) noted a greater prevalence of radiographic
degenerative changes in the reconstructed knees at
10-year follow-up. This study contained biases and
did not control for potential confounding variables.
These included multiple surgeons, multiple graft
choices, and difffferences in the degree of cartilage
damage and presence of meniscal tears. Further-
more, a selection bias may have been present, as
those who chose surgery tended to be more symp-
tomatic had more severe injuries, often attempted
to continue playing sports despite their injuries, and
had already failed some conservative therapy (67).
Clearly, it has not been established whether recon-
struction of the ACL, and therefore elimination
of joint laxity, prevents the development of knee
arthritis. However, clinical and basic science studies
do suggest that ACL reconstruction is meniscal pro-
tective and that reconstruction may provide protec-
tion against future meniscal surgery (70,102).
Conclusions
Anterior cruciate ligament tears are significant fi
injuries that may predispose the knee to early
osteoarthritis, but the literature has not yet shown
a defi
finitive causal relationship. The associated inju-
ries (i.e., meniscus tears, bone bruises, cartilage
injury), and the potential changes of the knee’s
biochemical environment may be associated with
more severe damage to the joint than just insta-
bility. Further research is needed to identify those
patients who are more likely to develop osteoar-
thritis after an ACL tear as well as strategies to
delay or eliminate this potential risk.
References
1. Galen, C (2003) On the usefulness of the parts of the body.
Clin Orthop Relat Res 411:4–12
2. Stark, J (1850) Two cases of rupture of the crucial liga-
ment of the knee joint. Edinb Med Surg 74:267
3. Battle WH (1900) A case after open section of the knee
joint for irreducible traumatic dislocation. Clin Soc, Lon-
don Trans 33:232
4. Robson AW (1903) Ruptured crucial ligaments and their
repair by operation. Am Surg 37:716–718
5. Bonamo JJ, Fay C, Firestone T (1990) The Th conservative
treatment of the anterior cruciate defi ficient knee. Am J
Sports Med18:618–623
6. Cerabona F, Sherman MF, Bonamo JR, et al. (1988) Pat-
terns of meniscal injury with acute anterior cruciate liga-
ment tears. Am J Sports Med 16:603–609
170 The Traumatic Knee
7. Fetto JF, Marshall JL (1980) The natural history and
diagnosis of anterior cruciate ligament insuffi fficiency. Clin
Orthop Relat Res 147:29–38
8. Hawkins RJ, Misamore GW, Merritt TR (1986) Followup
of the acute nonoperated isolated anterior cruciate liga-
ment tear. Am J Sports Med 14:205–210
9. Keene GC, Bickerstaff ff D, Rae PJ, et al. (1993) The
Th natu-
ral history of meniscal tears in anterior cruciate ligament
insuffifficiency. Am J Sports Med 21:672–679
10. Noyes FR, Basset RW, Grood ES, et al. (1980) Arthroscopy
in acute traumatic hemarthrosis of the knee. Incidence of
anterior cruciate ligament tears and other injuries. J Bone
Joint Surg Am 62:687–695
11. Smith JP, Barrett GR (2001) Medial and lateral menis-
cal tear patterns in anterior cruciate ligament-deficientfi
knees. Am J Sports Med 29:415–419
12. Warren RF, Levy IM (1983) Meniscal lesions associated
with anterior cruciate ligament injury. Clin Orthop Relat
Res 172:32–37
13. Wickiewicz TL (1990) Meniscal injuries in the cruciate
defificient knee. Clin Sports Med 9:681–694
14. Owings MF, Kozak LJ (1998) Ambulatory and inpatient
procedures in the United States, 1996. Vital Health Stat
13;139:1–119
15. Arendt E, Dick R (1995) Knee injury patterns among men
and women in collegiate basketball and soccer. NCAA data
and review of literature. Am J Sports Med 23:694–701
16. Arendt EA, Agel J, Dick R (1999) Anterior cruciate liga-
ment injury patterns among collegiate men and women. J
Athl Train 34:86–92
17. Gottlob CA, Baker CL Jr, Pellissier JM, et al. (1999) Cost
eff
ffectiveness of anterior cruciate ligament reconstruction
in young adults. Clin Orthop Relat Res 367:272–282
18. Mountcastle SB, Posner M, Kragh JF, et al. (2007) Gender dif-
ferences in anterior cruciate ligament injury vary with activ-
ity: epidemiology of anterior cruciate ligament injuries in a
young, athletic population. Am J Sports Med 35:1635–1642
19. Drawer S, Fuller CW (2002) Evaluating the level of injury
in English professional football using a risk based assess-
ment process. Br J Sports Med 36:446–451
20. Hawkins RD, Fuller CW (1999) A prospective epidemiolog-
ical study of injuries in four English professional football
clubs. Br J Sports Med 33:196–203
21. Boden BP, Dean GS, Feagin JA Jr, et al. (2000) Mecha-
nisms of anterior cruciate ligament injury. Orthopaedics
23:573–578
22. Noyes FR, Mooar PA, Matthews DS, et al. (1983) The Th
symptomatic anterior cruciate-deficient
fi knee. Part I: the
long-term functional disability in athletically active indi-
viduals. J Bone Joint Surg Am 65:154–162
23. Colby S, Francisco A, Yu B, et al. (2000) Electromyographic
and kinematic analysis of cutting maneuvers. Implications
for anterior cruciate ligament injury. Am J Sports Med
28:234–240
24. Kernozek TW, Torry MR, Iwasaki M (2007) Gender dif-
ferences in lower extremity landing mechanics caused by
neuromuscular fatigue. Am J Sports Med 35:1–12
25. Huston LJ, Wojtys EM (1996) Neuromuscular perfor-
mance characteristics in elite female athletes. Am J Sports
Med 24:427–436
26. Noyes FR, Simon R (1994) The role of high tibial osteot-
omy in the anterior cruciate ligament-deficient
fi knee with
varus alignment. In: DeLee JC, Drez D, editors. Orthopae-
dic sports medicine. Principles and practice. Philadelphia:
WB Saunders
27. Rosenberg TD, Paulos LE, Parker RD, et al. (1988) The forty-
five degree posteroanterior flexion weight-bearing radio-
graph of the knee. J Bone Joint Surg Am 70:1479–1483
28. Nogalski MP, Bach BR Jr (1994) Acute anterior cruciate
ligament injuries. In: Fu FH, Harner CD, Vince KG, edi-
tors. Knee surgery. Baltimore: Williams & Wilkins
29. Turner DA, Prodromos CC, Petasnick JP, et al. (1985)
Acute injury of the ligaments of the knee: magnetic reso-
nance evaluation. Radiology 154:717–722
30. Lee K, Siegel MJ, Lau DM, et al. (1999) Anterior cruciate
ligament tears: MR imaging-based diagnosis in a pediatric
population. Radiology 213:697–704
31. McCrae F, Shouls J, Dieppe P, et al. (1992) Scintigraphic
assessment of osteoarthritis of the knee joint. Ann Rheum
Dis 51:938–942
32. Beynnon BD, Johnson RJ, Abate JA, et al. (2005) Treat-
ment of anterior cruciate ligament injuries, part I. Am J
Sports Med 33:579–1602
33. Beynnon BD, Johnson RJ, Abate JA, et al. (2005) Treat-
ment of anterior cruciate ligament injuries, part II. Am J
Sports Med 33:1751–1767
34. Levy IM, Torzilli PA, Warren RF (1982) The
Th effffect of medial
meniscectomy on anterior-posterior motion of the knee. J
Bone Joint Surg Am 64:883–888
35. Papageorgiou CD, Gil JE, Kanamori A, et al. (2001) The Th
biomechanical interdependence between the anterior cru-
ciate ligament replacement graft and the medial meniscus.
Am J Sports Med 29:226–231
36. Murrell GA, Maddali S, Horovitz L, et al. (2001) The
Th eff ffects
of time course after anterior cruciate ligament injury in
correlation with meniscal and cartilage loss. Am J Sports
Med 29:9–14
37. Seedhom BB. (1976) Loadbearing function of the menisci.
Physiotherapy 62:223
38. Walker PS, Erkman MJ (1975) The Th role of the menisci in
force transmission across the knee. Clin Orthop Relat Res
109:184–192
39. Ahmed AM, Burke DL (1983) In-vitro measurement of
static pressure distribution in synovial joints – Part 1:
Tibial surface of the knee. J Biomech Eng 105:216–225
40. Brown TD, Shaw DT (1984) In vitro contact stress distri-
bution on the femoral condyles. J Orthop Res 2:190–199
41. Baratz ME, Fu FH, Mengato R (1986) Meniscal tears: the
eff
ffect of meniscectomy and of repair on intraarticular
contact areas and stress in the human knee. A preliminary
report. Am J Sports Med 14:270–275
42. Seedhom BB, Hargreaves B (1979) Transmission of the
load in the knee joint with special reference to the role of
the meniscus: Part II. Eng Med 8:220–228
43. Andriacchi TP, Dyrby CO (2005) Interactions between
kinematics and loading during walking for the normal and
ACL defi ficient knee. J Biomech 38:293–298
44. Dye SF, Wojtys EM, Fu FH, et al. (1998) Factors contribut-
ing to function of the knee joint after injury or reconstruc-
tion of the anterior cruciate ligament. J Bone Joint Surg
Am 80:1380–1393
45. Kullmer K, Letsch R, Turowski B (1994) Which factors influ- fl
ence the progression of degenerative osteoarthritis after ACL
surgery? Knee Surg Sports Traumatol Arthrosc 2:80–84
46. Jacobsen K (1977) Osteoarthrosis following insuffi fficiency
of the cruciate ligaments in man: a clinical study. Acta
Orthop Scand 48:520–526
47. Curl WW, Krome J, Gordon ES, et al. (1997) Cartilage inju-
ries: a review of 31,516 knee arthroscopies. Arthroscopy
13:456–460
48. Outerbridge RE (1961) The etiology of chondromalacia
patellae. J Bone Joint Surg Br 43:752–757
49. Piasecki DP, Spindler KP, Warren TA, et al. (2003) Intraar-
ticular injuries associated with anterior cruciate ligament
tear: findings at ligament reconstruction in high school
and recreational athletes. An analysis of sex-based differ- ff
ences. Am J Sports Med 31:601–605
50. Faber KJ, Dill JR, Armendola A, et al. (1999) Occult osteo-
chondral lesions after ACL rupture: six-year MRI follow-up
study. Am J Sports Med 27:489–494
51. Johnson DL, Urban WP Jr, Caborn DN, et al. (1998)
Articular cartilage changes seen with magnetic resonance

imaging-detected bone bruises associated with anterior
cruciate ligament tears. Am J Sports Med 26:409–414
52. Buckwalter JA (2002) Articular cartilage injuries. Clin
Orthop Relat Res 402:21–37
53. Mandelbaum BR, Browne JE, Fu F, et al. (1998) Articular car-
tilage lesions of the knee. Am J Sports Med 26:853–861
54. Simonian PT, Sussmann PS, Wickiewicz TL, et al. (1998)
Contact pressures at osteochondral donor sites in the
knee. Am J Sports Med 26:491–494
55. Adalberth T, Roos H, Lauren M, et al. (1997) Magnetic
resonance imaging, scintigraphy, and arthroscopic evalu-
ation of traumatic hemarthrosis of the knee. Am J Sports
Med 25:231–237
56. Costa-Paz M, Muscolo DL, Ayerza M, et al. (2001) Mag-
netic resonance imaging follow-up study of bone bruises
associated with anterior cruciate ligament ruptures.
Arthroscopy 17:445–449
57. Johnson DL, Bealle DP, Brand JC Jr, et al. (2000) The Th
eff
ffect of a geographic lateral bone bruise on knee inflflam-
mation after acute anterior cruciate ligament rupture. Am
J Sports Med 28:152–155
58. Lahm A, Erggelet C, Steinwachs M, et al. (1998) Articular
and osseous lesions in recent ligament tears: arthroscopic
changes compared with magnetic resonance imaging fi find-
ings. Arthroscopy 14:597–604
59. Mink JH, Deutsch AL (1989) Occult cartilage and bone
injuries of the knee: detection, classification
fi and assess-
ment with MRI. Radiology 170:823–829
60. Rosen MA, Jackson DW, Berger PE (1991) Occult osseous
lesions documented by magnetic resonance imaging asso-
ciated with anterior cruciate ligament ruptures. Arthros-
copy 7:45–51
61. Vellet AD, Marks PH, Fowler PJ, et al. (1991) Occult post-
traumatic osteochondral lesions of the knee: prevalence,
classifi
fication and short term sequelae evaluated with MR
imaging. Radiology 178:271–276
62. Fang C, Johnson D, Leslie MP, et al. (2001) Tissue distribu-
tion of cartilage oligomeric matrix protein in patients with
magnetic resonance imaging-detected bone bruises after
anterior cruciate ligament tears. J Orthop Res 19:634–
641
63. Escalas F, Curell R (1994) Occult posttraumatic bone
injury. Knee Surg Sports Traumatol Arthrosc 2:147–149
64. Donohue JM, Boss D, Oegema TR Jr, et al. (1983) The Th
eff
ffects of indirect blunt trauma on adult canine articular
cartilage. J Bone Joint Surg Am 65:948–957
65. Buckwalter JA, Mankin HJ (1997) Articular cartilage II:
degeneration and osteoarthrosis, repair, regeneration and
transplantation. J Bone Joint Surg Am 79:612–632
66. Mankin HJ (1982) The response of articular cartilage to
mechanical injury. J Bone Joint Surg Am 64:460–466
67. Daniel DM, Stone ML, Dobson BE, et al. (1994) Fate of the
ACL-injured patient. A prospective outcome study. Am J
Sports Med 22:632–644
68. Wright RW, Phaneuf MA, Limbird TJ, et al. (2000) Clinical
outcome of isolated subcortical trabecular fractures (bone
bruise) detected on magnetic resonance imaging in knees.
Am J Sports Med 28:663–667
69. Shindle MK, Foo LF, Kelly BT, et al. (2006) Magnetic reso-
nance imaging of cartilage in the athlete: current tech-
niques and spectrum of disease. J Bone and Joint Surg
Am 88S4:27–46
70. Dunn WR, Lyman S, Lincoln AE, et al. (2004) The Th effffect
of anterior cruciate ligament reconstruction on the risk of
knee reinjury. Am J Sports Med 32:1906–1914
71. Martin JA, Brown T, Heiner A, et al. (2004) Post-traumatic
osteoarthritis: the role of accelerated chondrocyte senes-
cence. Biorheology 41:479–491
72. Lipke JM, Janecki CJ, Nelson CL, et al. (1981) The Th role
of incompetence of the anterior cruciate and lateral liga-
ments in anterolateral and anteromedial instability: a bio-
Natural history of ACL tears: from rupture to osteoarthritis 171
mechanical study of cadaver knees. J Bone Joint Surg Am
63:954–960
73. Noyes FR, Dunworth LA, Andriacchi TP, et al. (1996) Knee
hyperextension gait abnormalities in unstable knees. Rec-
ognition and preoperative gait retraining. Am J Sports
Med 24:35–45
74. Price JS, Till SH, Bickerstaff
ff DR, et al. (1999) Degradation
of cartilage type II collagen precedes the onset of osteoar-
thritis following anterior cruciate ligament ruptures.
Arthritis Rheum 42:2390–2398
75. Smith M, Ghosh P (2001) Experimental models of osteoar-
thritis. In: Moskowitz RW, Howell DS, Attman RD, et al.,
editors. Osteoarthritis: diagnosis and medical/surgical
management. Philadelphia: WB Saunders
76. Borsiczky B, Fodor B, Racz B, et al. (2006) Rapid leukocyte
activation following intraarticular bleeding. J Orthop Res
24:684–689
77. Roosendaal G, TeKoppele JM, Vianen ME, et al. (1999)
Blood-induced joint damage: a canine in vivo study.
Arthritis Rheum 42:1033–1039
78. Cameron ML, Fu FH, Paessler HH, et al. (1994) Synovial
fluid cytokine concentrations as possible prognostic indi-
cators in the ACL-defi ficient knee. Knee Surg Sports Trau-
matol Arthrosc 2:38–44
79. Barrack RL, Bruckner JD, Kniesl J, et al. (1990) The Th out-
come of nonoperatively treated complete tears of the
anterior cruciate ligament in active young adults. Clin
Orthop Relat Res 259:192–199
80. Lohmander LS, Hoerrner LA, Lark MW (1993) Metallo-
proteinases, tissue inhibitor and proteoglycan fragments
in knee synovial fluid
fl in human osteoarthritis. Arthritis
Rheum 36:181–189
81. Lohmander LS, Ionescu M, Jugessur H, et al. (1999)
Changes in joint cartilage aggrecan after knee injury and
in osteoarthritis. Arthritis Rheum 42:534–544
82. Lohmander LS, Roos H, Dahlberg L, et al. (1994) Tem-
poral patterns of stromelysin-1, tissue inhibitor, and
proteoglycan fragments in human knee joint fluid fl after
injury to the cruciate ligament or meniscus. J Orthop
Res 12:21–28
83. Lohmander LS, Yoshihara Y, Roos H, et al. (1996) Procol-
lagen II C-propeptide in joint fluid: changes in concentra-
tion with age, time after knee injury, and osteoarthritis. J
Rheumatol 23:1765–1769
84. Cameron M, Buchgraber A, Passler H, et al. (1997) The Th
natural history of the anterior cruciate ligament-deficient
fi
knee. Changes in synovial fluid cytokine and keratan sul-
fate concentrations. Am J Sports Med 25:751–754
85. Hollander AP, Pidoux I, Reiner A, et al. (1995) Damage to
type II collagen in aging and osteoarthritis starts at the
articular surface, originates around chondrocytes, and
extends into the cartilage with progressive degeneration.
J Clin Invest 96:2859–2869
86. Nelson F, Billinghurst RC, Pidoux I, et al. (2005) Early
post-traumatic osteoarthritis-like changes in human
articular cartilage following rupture of the anterior cruci-
ate ligament. Osteoarthritis Cartilage14:14–19
87. Maiotti M, Monteleone G, Tarantino U, et al. (2000) Corre-
lation between osteoarthritic cartilage damage and levels
of proteinases and proteinase inhibitors in synovial fluid fl
from the knee joint. Arthroscopy 16:522–526
88. Lohmander LS, Englund PM, Dahl LL, et al. (2003) The Th
long-term consequence of anterior cruciate ligament
and meniscus injuries: osteoarthritis. Am J Sports Med
35:1756–1769
89. Felson DT, Lawrence RC, Dieppe PA, et al. (2000) Osteoar-
thritis: new insights. Part 1: the disease and its risk fac-
tors. Ann Intern Med 133:635–646
90. Hurley MV (1999) The Th role of muscle weakness in the
pathogenesis of osteoarthritis. Rheum Dis Clin North Am
25:283–298
172 The Traumatic Knee
91. Roos EM (2005) Joint injury causes knee osteoarthritis in
young adults. Curr Opin Rheumatol 17:195–200
92. Lohmander LS, Ostenberg A, Englund M, et al, (2004)
High prevalence of knee osteoarthritis, pain, and func-
tional limitations in female soccer players twelve years
after anterior cruciate ligament injury. Arthritis Rheum
50:3145–3152
93. McDaniel WJ Jr, Dameron TB Jr (1983) The Th untreated
anterior cruciate ligament rupture. Clin Orthop Relat Res
172:158–163
94. Pattee GA, Fox JM, Del Pizzo W, et al. (1989) Four to ten
year followup of unreconstructed anterior cruciate liga-
ment tears. Am J Sports Med 17:430–435
95. Kannus P, Jarvinen M (1987) Conservatively treated tears
of the anterior cruciate ligament. Long-term results. J
Bone Joint Surg Am 69:1007–1012
96. Von Porat A, Roos EM, Roos H. (2004) High prevalence of
osteoarthritis 14 years after an anterior cruciate ligament
tear in male soccer players: a study of radiographic and
patient relevant outcomes. Ann Rheum Dis 63:269–273
97. Noyes FR, Matthews DS, Mooar PA, et al. (1983) The Th
symptomatic anterior cruciate-deficient
fi knee. Part II:
the results of rehabilitation, activity modification,
fi and
counseling on functional disability. J Bone Joint Surg Am
65:163–174
98. Maletius W, Messner K (1999) Eighteen- to twenty-four-
year follow-up after complete rupture of the anterior cru-
ciate ligament. Am J Sports Med 27:711–717
99. Lohmander LS, Atley LM, Pietka TA, et al. (2003) The Th
release of cross-linked peptides from type II collagen
into human synovial fl fluid is increased soon after joint
injury and in osteoarthritis. Arthritis Rheum 48:3130–
3139
100. Gillquist J, Messner K (1999) Anterior cruciate ligament
reconstruction and the long-term incidence of gonarthro-
sis. Sports Med 27:143–156
101. Linko E, Harilainen A, Malmivaara A, et al. (2005) Surgi-
cal versus conservative interventions for anterior cruciate
ligament ruptures in adults. Cochrane Database Syst Rev
2: CDOO1356
102. Meunier A, Odensten M, Good L (2007) Long-term results
after primary repair or non-surgical treatment of anterior
cruciate ligament rupture: a randomized study with a
15-year follow-up. Scand J Med Sci Sports 17:230–237

D.E. Bonasia, A. Amendola Graft choice in ACL reconstruction
Introduction
T
he anterior cruciate ligament (ACL) recon-
struction is the sixth most common pro-
cedure in orthopaedic surgery, with more
than 100,000 surgeries performed in the United
States per year (1). Although widely accepted and
investigated, ACL reconstruction still continues
to evolve with many technical issues under debate
and dependent on surgeon preference. Th These
include tunnel placement, use of double- vs. sin-
gle-bundle technique, type of fixation, and graft
selection (2).
The ideal graft for ACL reconstruction would con-
sist of the following : reproduce the histological
and biomechanical characteristics of the native lig-
ament ; incorporate fully and quickly within bone
tunnels ; have no risk of rejection or disease trans-
mission ; minimal donor-site morbidity ; be of suf-
ficient length and diameter ; and be cost-eff ffective
as well as readily available (2). The ideal graft and a
“gold standard” do not really exist. Many grafts are
available (Table 1), each one with advantages and
disadvantages. One of the surgeon’s roles in ACL
reconstructive surgery is to individualize the graft
choice for each patient’s need (3). In planning the
surgery and deciding the graft type, the clinical
examination, i.e., isolated vs. multiligament knee
instabilities, the age, the activity level, as well as
the occupational and recreational activities of the
patient should be considered.
As means of developing an ideal graft, with-
out donor-site morbidity, proper mechanical
strength, and no risk of disease transmission,
Table 1 – Grafts available for ACL reconstruction.
Autograft Allograft Synthetic
grafts
Bone patellar- Bone patellar-tendon Scaffolds
tendon bone bone
Hamstrings Hamstrings Stents
Quadriceps tendon Quadriceps tendon Prostheses
Fascia lata Tibialis anterior
or posterior tendon
Achilles tendon
Fascia lata
Chapter 15
many investigators have attempted to develop
and use synthetic ligament substitutes. Syn-
thetic grafts can be classified as (1) scaffolds, (2)
stents, or (3) prostheses (4). A scaffold is made
of synthetic tissue (e.g., carbon fiber) that stim-
ulated the fibrous tissue ingrowth ; a stent (e.g.,
Kennedy ligament augmentation device, LAD) is
designed to protect the healing of the biologic
graft during its incorporation phase into the
joint ; a prosthesis, mainly made of polyethyl-
ene and Gore-Tex, substitutes the biologic graft.
Unfortunately, these devices reported a higher
rate of complications compared to autograft
and allograft. Carbon fiber scaffolds have been
associated with synovitis, lack of fibrous tis-
sue ingrowth (4,5), and failed adhesion to the
bone tunnels with subsequent poor biomechani-
cal properties (4–6). Moreover the prosthetic
implants were correlated to an increased risk
of developing chronic instability, joint effu-
sions, and synovitis (4). The LAD’s outcomes are
not more encouraging, reporting complication
rates from 0 % to 63 %, with effusion, synovi-
tis, and infection as the more frequent causes
of failure (4,5,7). For all these reasons, their
use is not widely accepted, and autograft along
with allograft remain the graft type of choice in
ACL reconstruction. The question now revolves
around which autograft : patellar tendon vs.
soft tissue graft (i.e., hamstring) or allograft vs.
autograft choices.
Both autograft and allograft have reported excel-
lent results and are the most commonly used
options in ACL reconstruction. The advantages
of autograft include (2) improved measured sta-
bility, lower graft failure rate (8), lower infection
rate (9), no risk of infectious disease transmis-
sion, no risk of immune reaction (10), lower
cost (11), faster graft incorporation, and prompt
return to full activities (12). On the other hand,
the advantages of the allograft tissues (Fig. 1)
are (2) a faster immediate post-operative recov-
ery, less post-operative pain, no need for graft
harvest, no donor-site morbidity, larger variety
of graft sizes and shapes available, and improved
cosmesis.
174 The Traumatic Knee
Fig. 1 – Allografts. (A) Achilles tendon allograft. (B) Patellar tendon allograft.
Biological healing of the graft
When deciding which biologic graft to utilize in an
ACL reconstruction, it is necessary first to under-
stand the basic science of what the graft ultimately
develops into. Both autograft and allograft undergo
an incorporation process in the joint that involves
many phases (4).
The first phase is mainly centered on the degen-
eration (infl
flammatory response mediated) of the
graft, where the fibroblasts undergo cell death and
the graft acts as a scaff
ffold for host cell migration.
The second phase (from 20 days to 3–6 months after
surgery) consists of the revascularization of the
neo-ligament and the host fibroblasts’migration
(4,13). During and after the vascularization, the
“ligamentization” or “biochemichal metamorpho-
sis” phase occurs and the fibroblasts lay down a new
matrix (4,14). In this phase at the light microscope
level, there is no detectable difference
ff between
tendons and ligaments, although they appear com-
pletely diff
fferent at biochemical analysis (15). The
final (healing) phase is centered on the remodeling
of the collagen fibrils in a more organized pattern
with improvement of the graft’s strength (4). Nev-
ertheless, the biomechanical properties of the neo-
ligament never reach those of the un-implanted
grafts (16).
Biology is very important at the graft insertion
site as well. Two are the possible types of heal-
ing : bone-to-bone (grafts with a bone plug) and
tendon-to-bone healing (soft tissue grafts). It is
widely believed that bone-to-bone healing is stron-
ger and faster compared to soft tissue healing.
A bone plug autograft can heal in the femoral or
tibial tunnel within 6 weeks (4), while the soft tis-
sue autograft healing occurs at 8–12 weeks from
surgery (17). The allograft healing time is usually
longer (6–9 months) (3). Jackson et al. (4,18) com-
pared the histologic and microvascular status of
patellar tendon autografts and allografts in a goat
model. Mechanical testing of the allograft and
autograft groups showed a statistically significant
fi
( < 0.01) diff
(p fference in anteroposterior translation
at 6 months. The autograft demonstrated a more
robust biologic response, improved stability, and
increased strength-to-failure values. ThThe authors
suggested a longer period of protection for patients
with allograft ACL reconstructions than for those
with autograft (4,18).
Another factor that may infl fluence the healing of
the graft is the magnitude of the neo-ligament
 Graft choice in ACL reconstruction 175

motion in the tunnel (19). This should be particu- considering the graft fixation biomechanics) may
larly considered when using soft tissue grafts and a allow an early aggressive rehabilitation.
tendon-to-bone healing, with Sharpey fi fiber forma- Another consideration that may be inferred from
tion, is involved (17). Rodeo et al. (19) performed these studies is that the currently used sterilization
an in vivo study on a rabbit model, demonstrating techniques (cryopreservation and gamma radiation
that graft-tunnel motion was greatest at the tun- < 3 Mrad) do not impair the allografts’strength
nel apertures and least at the tunnel exit, and that (4). In the past, high dose radiation resulted in
graft healing in the femoral tunnel was inversely allograft weakening, and ethylene oxide steriliza-
proportional to the magnitude of graft-tunnel tion caused effffusions, chronic synovitis, and graft
motion. Given these considerations, the retro- failures (27).
grade drilling of the tibial socket, with minimum
aperture “blow-out,” may be a solution to minimize
the osteoclast-mediated bone resorption, the syn-
ovialization of the graft, and, therefore, the tunnel Harvesting, donor-site morbidity, and possible
widening (20,21). graft-related complications
The patellar tendon autograft requires the harvest
of both a tibial tubercle and a patellar bone plug
Biomechanics of the grafts (Fig. 2). Th
The main risks consist in patellar fractures
(intra-operative and post-operative) (Fig. 3), tibial
Many studies summarized in Table 2 reported the stress fractures, patellar articular cartilage dam-
biomechanical properties of the native ACL and age, and tendon ruptures. It has been suggested
the grafts available for ACL reconstruction (3,4). that trapezoidal bone cuts, instead of triangular
As shown in Table 2, the strength of the different
ff ones, may reduce the risk of cartilage lesions (4).
grafts is superior to that of the native ACL. Never- The patellar tendon autograft is associated with
theless, all these tests were performed on the un- an increased risk of anterior knee pain (most of all
implanted graft and, therefore, before the incorpo- during kneeling), and many studies showed that
ration phases and the subsequent weakening that the use of hamstring autograft reduces this risk
takes place in vivo. These data simply suggest that (28). The incidence of anterior knee pain is 17.4 %
every graft evaluated has mechanical properties with patellar tendon autograft and 11.5 % with
superior to the normal ACL in the very first
fi post- hamstring autograft (28). Nevertheless, there is
operative period and that the graft alone (without no diff
fference in the incidence of anterior knee pain
between patients with patellar tendon autografts
Table 2 – Biomechanical properties of different grafts available for ACL
reconstruction. and allografts (4,29). Some authors suggested
that anterior knee pain is mainly caused by poor
Graft Ultimate Stiffness Cross- rehabilitation techniques and loss of knee motion
tensile load (N/mm) sectional (4,30,31). Other complications described for patel-
(N) area lar tendon autograft include patellar tendonitis and
(mm2)
numbness in the anterolateral knee aspect (dam-
Native ACL (22) 2160 242 44 age to the infrapatellar branch of the saphenous
BPTB (10 mm) 2977 455(auto) 32 (auto)
nerve). Harvesting the central third of the patellar
auto- and allograft 620 (allo) 35 (allo) tendon does not diminish quadriceps strength or
(23) functional capacity in highly active patients who
undergo intense rehabilitation (32).
Quadrupled 4090 776 53
During hamstring harvesting, care should be
hamstring
auto- and allograft
taken in withdrawing the whole tendons, without
(24)
truncating them prematurely (Fig. 4). This may be
achieved by a close digital release of all the distal
Quadriceps tend 2174 463 62
vincula of the gracilis and semitendinosus tendons.
(10-mm)
Also the posterior mini-incision harvest technique
autograft (25)
(33) allows a good visualization and differentia-
ff
Achilles tendon 4617 685 67 tion of the tendons and their cross-connections,
(26) which, if not properly released, may cause pre-
Tibialis anterior 4122 460 48 mature amputation. Complications associated
allograft (26) with this procedure include saphenous nerve and
Tibialis posterior 3594 379 44 vein injury, femoral arterial and vein injury, sci-
allograft (26) atic nerve damage, and residual muscle weakness
Note : BPTB, bone-patellar tendon-bone. and discomfort (3). Mild knee fl flexion weakness
176 The Traumatic Knee

Fig. 2 – Patellar tendon autograft.

Fig. 3 – Post-operative patellar fracture after ACL reconstruction with

patellar tendon autograft (before and after fixation).

Fig. 4 – Hamstring harvesting. (A) Identi-

fication of the gracilis and semitendinosus
tendons below the sartorial fascia, release
of the vincula, and proximal detachment
with “pigtail” tendon stripper. The distal
insertion of the tendons is maintained. (B)
Vincula that require the release before the
harvest. (C) Cut of the periosteum and distal
detachment of the graft. (D) Debridement
of the graft from the muscular tissue. (E)
Guide sutures to the four-stranded ham-
string graft. (F) Measurement of the tendon
before tunnel drilling.

and mild internal rotation weakness are described
after hamstring ACL reconstruction, but both are
seen only at relatively high knee flexion angles and
do not cause clinical performance defi ficits (2).
The quadriceps tendon is more diffi fficult to harvest
than the patellar tendon because of its denser cortical
bone, curved proximal surface, and close adherence
to the suprapatellar pouch (4). Fulkerson et al. (34,35)
described a technique to harvest the quadriceps ten-
don safely. Through a short midline incision, starting
mid-patella, and extending proximally, a bone plug
(10 mm × 20 mm) is harvested from the proximal
patella. The tendon graft should be approximately
6 mm thick. The tendon is then harvested about 7 cm
proximally, taking care to avoid entering the supra-
patellar pouch. A drill hole is then made in the bone
plug, and a no. 5 suture is passed through the plug (4).
There are no studies evaluating hamstring or quadri-
ceps tendon strength recovery after reconstruction
with a quadriceps tendon autograft. Because quad-
riceps harvest is similar to patellar tendon harvest
in regard to extensor mechanism disruption, similar
strength testing results have been inferred (4). Th There
are no studies evaluating anterior knee pain with this
graft type (4). Nevertheless, Chen et al. (36) reported
only mild harvest site tenderness in 12 patients at an
average of 18 months after ACL reconstruction with
quadriceps autograft. Fulkerson and Langeland (34)
reported no early quadriceps morbidity in their series
of 28 patients.
The obvious advantage of allografts and synthetic
Th
grafts is that harvesting is not required during sur-
gery and that no donor-site morbidity will occur.
Nevertheless, a potential problem with allografts is
the infectious disease transmission. For this reason,
currently the controls on the tissue and the donors
are very strict and the risk of undergoing an infection
from the allograft is only theoretical. Th The American
Association of Tissue Banks stated the necessity for
a detailed medical, social, and sexual history for each
potential cadaveric donor. Extensive testing includes
blood cultures, harvested tissue cultures, and screen-
ing for antibodies to human immunodefi ficiency virus
HIV-1 and HIV-2, hepatitis B surface antigen, hepa-
titis C, syphilis, and human T-cell lymphotropic virus
(4). In the literature, only one case of HIV transmis-
sion and two of hepatitis C were described (4,37). Th The
estimated risk for HIV transmission with connective
tissue allografts is estimated to be 1 : 600,000 (38)
and for bacterial infections 26 : 1,000,000 (3).
Initial fixation
The graft fixation is a crucial issue in ACL recon-
struction. A stable fixation in the immediate post-
operative period is required to avoid the slippage
Graft choice in ACL reconstruction 177
and allow graft healing as well as early aggressive
rehabilitation. During rehabilitation, forces as high
as 450–500 N are usually applied to the graft (4,39).
Regarding fixation, the grafts should be distin-
guished in bone plug grafts and soft tissue grafts.
The gold standard in bone plug graft fixation is the
interference screw for both tibia and femur. Both
metallic and bio-absorbable screws showed compa-
rable results and strength of fixation ranging from
552 to 558 N (18). The Th factors aff ffecting interfer-
ence screws fixation are (1) screw diameter and (2)
screw divergence from the bone block. When the
gap between the bone block and the tunnel wall is
over 2 mm, the slippage of the graft is more likely
to occur (40). Positioning of the interference screw
with a divergence angle > 30° from the bone tunnel
has higher fixation failure rates (41).
The most reliable soft tissue graft fixation device
is controversial. The fixation techniques may be
divided in (1) interference fixation (interference
screws) (2) extracortical fixation (e.g., screws, sta-
ples, and Endobutton), and (3) transverse fixation fi
(e.g., Rigidfix
fi and Bio-Transfi fix). Ahmad et al. (42)
used 33 porcine femora to study interference screw,
Endobutton, Rigidfix fi cross-pin, and Bio-Transfi fix
cross-pin femoral fixation methods. Fixation slip-
page was evaluated under cyclical load from 50 to
250 N using a soft tissue single-bundle technique.
Ultimate load was determined with a single load to
failure. The interference screw and the Rigidfi fix fixa-
tion demonstrated inferior fixation biomechanics
compared to the Bio-Transfix fi and the Endobutton
techniques. Kleweno et al. (43) evaluated graft slip-
page in five diff fferent soft tissue ACL femoral fixa-
tion techniques (Bio-Transfi fix cross-pin technique,
Stratis ST cross-pin technique, Bilok ST transverse
femoral screw, Delta tapered bio-interference screw,
and single-loop TensionLok). A cyclic loading of dou-
ble-bundle grafts was performed in porcine femurs.
Cross-pin constructs appeared to be superior to cer-
tain other available fixation systems. The weak point
in an ACL reconstruction immediately after surgery
is the tibial fixation of the soft tissue graft.
Coleridge and Amis (44) compared fi five tibial fixa-
tion devices (WasherLoc, Intrafi fix fastener, and RCI,
Delta Tapered, and Bicortical interference screws)
for hamstring ACL reconstruction. Cyclic loads rep-
resenting normal walking activity (1000 cycles from
70 to 220 N) and ultimate strength tests were done,
using calf tibiae and four-strand tendon grafts. Th The
WasherLoc gave the highest ultimate strength
(945 N, p < 0.001, range 490–945 N). They con-
cluded that all devices performed well under cyclic
loads that represented normal walking activity, but
the ultimate strengths differed.
ff
Historically, widening of the tunnel, a late complica-
tion in ACL reconstruction, was attributed to exces-
sive movement of the graft in the tunnel when using
178 The Traumatic Knee
extracortical fixation devices (45,46). Clatworthy et
al. (45,47) recently evaluated tunnel widening in
259 patients who had undergone hamstring ACL
reconstruction with four different
ff fixation devices
to test this “bungy cord effect.”
ff The Endobutton/
staples construct had signifi ficantly less widening
than metal interference screws, bio-absorbable
interference screws and a bone mulch screw/staples
construct. This suggests that there is a signifi ficant
biological component that could be attributed to a
variable cytokine response to surgery or a reaction
to synovial fluid.
fl
Outcomes
The literature shows good to excellent results of ACL
reconstruction with almost every type of autograft
and allograft.
Patellar tendon
Numerous studies with a minimum follow-up of 5
years have been published (45,48–51). Using Inter-
national Knee Documentation Committee (IKDC),
Tegner, or Lysholm scores, a satisfactory outcome
was found in 78–90 % of patients. Giving-way was
eradicated in 78–98 %. TheTh best results were found
in a group of 90 patients who had normal menisci
at the time of surgery. Th The patients’scores were
normal or nearly normal in the 90 %, 98 % had a
grade 0 pivot shift, and in 97 % no degenerative
changes were seen radiographically (45,48). Better
results were reported with early surgery and with
no lesions to cartilage and menisci (49,51).
The advantages of a patellar tendon graft are (45)
(1) rapid healing of the bone blocks within ; (2)
direct rigid fixation
fi of the bone blocks close to the
aperture ; and (3) good preservation of load to fail-
ure and stiff
ffness. The disadvantages are predomi-
nantly related to the donor site and include (45)
(1) anterior knee pain ; (2) patellar tendonitis ;
(3) rupture of the patellar tendon ; (4) fracture of
the patella ; (5) increased joint stiffness
ff ; (6) late
chondromalacia ; and (7) injury to the infrapatellar
branch of the saphenous nerve (45).
Hamstring tendon
Four-strand hamstring grafts have become widely
used, consisting of either doubled semitendinosus/
gracilis or quadrupled semitendinosus tendons.
Numerous studies in the literature report results
comparable to patellar tendon grafts (52–58). The
Th
advantages of hamstring grafts are (45) (1) high
load to failure and stiffffness ; (2) a greater cross-
sectional area of tendon ; (3) easier passage of the
graft ; (4) a small incision ; (5) low post-operative
morbidity ; and (6) less donor-site morbidity. The Th
disadvantages are (45) (1) slower tendon-to-bone
healing in the tunnel ; (2) the possibility of injury
to the saphenous nerve ; (3) weakness of the ham-
string muscles after operation ; and (4) widening
of the tunnel.
In a meta-analysis, Freedman et al. (28) pooled data
from 34 studies. The study found in 1976 patients
signifi
ficantly lower rates of graft failure, less laxity,
and higher patient satisfaction in the BPTB group.
However, there was a higher incidence of anterior
knee pain in the BPTB group (59). Another meta-
analysis performed 2 years earlier by Yunes et al.
(60) only allowed 4 studies (411 patients) to fitfi into
the inclusion criteria. The authors found that the
BPTB group had signifi ficantly less laxity than the
hamstring group when evaluated by the KT-1000 at
20 lb. Furthermore, all the studies included in the
meta-analysis suggested that the BPTB group had
a higher rate of “return to pre-injury level of activ-
ity.” The study was unable to compare donor-site
morbidity between groups because the included
studies did not have comparable information (59).
Quadriceps tendon
The use of the quadriceps tendon as a graft for the
ACL has been advocated by Staubli et al. (25) and
Fulkerson and Langeland (34), who documented
the good biomechanical properties of this ten-
don (45). Chen et al. (36) described the results
of arthroscopic reconstruction of the ACL using
quadriceps tendon-patellar bone autograft in 12
patients. After a follow-up of 15–24 months, 10
returned to their level of pre-injury sports and 10
had a normal or near-normal IKDC score. How-
ever, after 1 year, the quadriceps strength was only
80 % of the normal knee in 11 patients. ThThe advan-
tages of this graft are (45) (1) a thick tendon, (2)
good biomechanical properties, and (3) decreased
anterior knee pain. The disadvantages are (45) (1)
weakness of the quadriceps after operation, (2) an
unsightly scar, and (3) graft harvest, which is tech-
nically more difficult.
ffi
Allografts
Animal studies have shown that allografts can be
used successfully in intra-articular reconstruc-
tion of the knee (45). The absence of morbidity
at the donor site and the small incisions required
for implantation have led to consideration of
the use of allograft in reconstruction of the ACL

(45). Several studies have compared the results of
allografts with autografts in reconstruction of the
ACL with no significant
fi diff
fference in knee laxity
or outcome (29,61–63). The Th results of reconstruc-
tion with allograft patellar tendon appear to be
durable. Noyes and Barber-Westin (64) found no
signifi
ficant change in knee laxity or in the overall
knee score when assessing their patients at 3 and
7 years. Studies of goat patellar tendon autograft
and allograft suggest that autografts are slightly
superior (18) with more rapid incorporation and
slightly better stability 6 months after operation.
So despite a quicker immediate recovery, allografts
have a longer incorporation time with subsequent
slower rehabilitation, compared to autografts.
Conclusions
Both autografts and allografts are excellent alterna-
tive options in ACL reconstruction. Synthetic grafts
are still not recommended because of the poor clini-
cal results. The choice of the graft should be person-
alized according to the patient (age, gender, activity
level, compliance, and occupational and recreational
activities) and his or her physical examination with
possible multi-ligamentous injuries. Th The senior
author algorithm for graft choice is described in
Table 3.
Table 3 – Algorithm for graft choice in ACL reconstruction.
Patellar tendon
– When a prompt return to play is required
– In athletes subjected to hamstring lesions (football, sprinting sports)
– In patients not compliant with rehabilitation and restrictions
– If physical examination reveals hyperextension of the knee
Hamstrings
– In patients with open growth plates
– In women with esthetic issues
– In patients with kneeling activities
– In athletes subjected to patellar tendon pathologies (basketball,
volleyball, tennis)
– In double-bundle ACL reconstruction
Allograft
– In ACL reconstruction revisions
– In multi-ligamentous knee injuries
– When all-inside technique is required by the patient
with esthetic issues
– In patients more than 40 years old, with low activity level
References
1. Brown CH, Carson EW (1999) Revision anterior cruciate
ligament surgery. Clin Sports Med 18:109–117
2. Prodromos CC, Fu FH, Howell SM, et al. (2008) Controver-
sies in soft-tissue anterior cruciate ligament reconstruc-
Graft choice in ACL reconstruction 179
tion : grafts, bundles, tunnels, fixation,
fi and harvest. J Am
Acad Orthop Surg 16 (7):376–384
3. Fu FH (2009) Anterior cruciate ligaments : graft selection
in 2009. Instructional Course Lecture 309, AAOS Annual
Meeting.
4. West RV, Harner CD (2005) Graft selection in anterior cru-
ciate ligament reconstruction. J Am Acad Orthop Surg 13
(3):197–207
5. Zoltan DJ, Reinecke C, Indelicato PA (1988) Synthetic and
allograft anterior cruciate ligament reconstruction. Clin
Sports Med 7:773–784
6. Makisalo S, Skutnabb K, Holmstrom J, et al. (1988) Recon-
struction of anterior cruciate ligament with carbon fi fiber :
an experimental study on pigs. Am J Sports Med 16:589–
593
7. Kumar K, Maff ffulli N (1999) The ligament augmentation
device : a historical perspective. Arthroscopy 15:422–
432
8. Prodromos CC, Joyce BT, Shi K, Keller BL (2007) A meta-
analysis of stability of autografts compared to allografts
after anterior cruciate ligament reconstruction. Knee Surg
Sports Traumatol Arthrosc 15:851–856
9. Crawford C, Kainer M, Jernigan D, et al. (2005) Investi-
gation of postoperative allograft-associated infections
in patients who underwent musculoskeletal allograft
implantation. Clin Infect Dis 41:195–200
10. Arnoczky SP, Warren RF, Ashlock MA (1986) Replacement
of the anterior cruciate ligament using a patellar tendon
allograft : an experimental study. J Bone Joint Surg Am
68:376–385
11. Prodromos CC, Rogowski J, Joyce B (2007) The Th economics
of ACLR. In : Prodromos CC, editor. Th The anterior cruciate
ligament : reconstruction and basic science. Philadelphia,
PA : Elsevier: 79–83
12. Malinin TI, Levitt RL, Bashore C, et al. (2002) A study of
retrieved allografts used to replace anterior cruciate liga-
ments. Arthroscopy 18:163–170
13. Falconiero RP, DiStefano VJ, Cook TM (1998) Revascular-
ization and ligamentization of autogenous anterior cruci-
ate ligament grafts in humans. Arthroscopy 14:197–205
14. Clancy WG (2009) Anterior cruciate ligaments : graft
selection in 2009. Instructional Course Lecture 309, AAOS
Annual Meeting.
15. Amiel D, Frank C, Harwood F, et al. (1984) Tendons and
ligaments : a morphological and biochemical comparison.
J Orthop Res 1 (3):257–265
16. Beynnon BD, Johnson RJ (1996) Anterior cruciate liga-
ment injury rehabilitation in athletes : biomechanical con-
siderations. Sports Med 22:54–64
17. Rodeo SA, Arnoczky SP, Torzilli PA, et al. (1993) Tendon-
healing in a bone tunnel : a biomechanical and histological
study in the dog. J Bone Joint Surg Am 75:1795–1803
18. Jackson DW, Grood ES, Goldstein JD, et al. (1993) A com-
parison of patellar tendon autograft and allograft used
for anterior cruciate ligament reconstruction in the goat
model. Am J Sports Med 21:176–185
19. Rodeo SA, Kawamura S, Kim HJ, et al. (2006) Tendon heal-
ing in a bone tunnel differs
ff at the tunnel entrance versus
the tunnel exit : an eff ffect of graft-tunnel motion ? Am J
Sports Med 34 (11):1790–1800
20. Lubowitz JH (2006) No-tunnel anterior cruciate liga-
ment reconstruction : the transtibial all-inside technique.
Arthroscopy 22 (8):900.e1–900.e11
21. McAdams TR, Biswal S, Stevens KJ, et al. (2008) Tibial
aperture bone disruption after retrograde versus ante-
grade tibial tunnel drilling : a cadaveric study. Knee Surg
Sports Traumatol Arthrosc 16 (9):818–822
22. Noyes FR, Butler DL, Grood ES, et al. (1984) Biomechani-
cal analysis of human ligament grafts used in knee liga-
ment repairs and reconstructions. J Bone Joint Surg Am
66:344–352
180 The Traumatic Knee
23. Cooper DE, et al. (1993) The strength of the central third
patellar tendon graft. A biomechanical study. Am J Sports
Med 21 (6):818–823
24. Hamner DL, et al. (1999) Hamstring tendon grafts for
reconstruction of the anterior cruciate ligament : bio-
mechanical evaluation of the use of multiple strands and
tensioning techniques. J Bone Joint Surg Am 81 (4):549–
557
25. Staubli HU, Schatzmann L, Brunner P, et al. (1999)
Mechanical tensile properties of the quadriceps tendon
and patella ligament in young adults. Am J Sports Med
27:27–34
26. Wren TA, et al. (2001) Mechanical properties of the
human Achilles tendon. Clin Biomech (Bristol, Avon) 16
(3):245–251
27. Jackson DW, Windler GE, Simon TM (1990) Intraarticular
reaction associated with the use of freeze-dried, ethylene
oxidesterilized bone-patella tendon-bone allografts in the
reconstruction of the anterior cruciate ligament. Am J
Sports Med 18:1–11
28. Freedman KB, D’Amato MJ, Nedeff ff DD, et al. (2003)
Arthroscopic anterior cruciate ligament reconstruction : a
meta-analysis comparing patellar tendon and hamstring
tendon autografts. Am J Sports Med 31:2–11
29. Shelton WR, Papendick L, Dukes AD (1997) Autograft
versus allograft anterior cruciate ligament reconstruction.
Arthroscopy13:446–449
30. Sachs RA, Daniel DM, Stone ML, Garfein RF (1989) Patel-
lofemoral problems after anterior cruciate ligament recon-
struction. Am J Sports Med 17:760–765
31. Shelbourne KD, Nitz P (1990) Accelerated rehabilitation
after anterior cruciate ligament reconstruction. Am J
Sports Med 18:292–299
32. Lephart SM, Kocher MS, Harner CD, Fu FH (1993)
Quadriceps strength and functional capacity after ante-
rior cruciate ligament reconstruction : patellar tendon
autograft versus allograft. Am J Sports Med 21:738–
743
33. Prodromos CC, Han YS, Keller BL, Bolyard RJ (2005) Pos-
terior mini-incision technique for hamstring anterior cru-
ciate ligament reconstruction graft harvest. Arthroscopy
21:130–137
34. Fulkerson JP, Langeland R (1995) An alternative cruci-
ate reconstruction graft : the central quadriceps tendon.
Arthroscopy 11:252–254
35. Theut PC, Fulkerson JP, Armour EF, Joseph M (2003)
Anterior cruciate ligament reconstruction utilizing
central quadriceps free tendon. Orthop Clin North Am
34:31–39
36. Chen CH, Chen WJ, Shih CH (1999) Arthroscopic anterior
cruciate ligament reconstruction with quadriceps tendon
patellar bone autograft. J Trauma 46:678–682
37. Simonds RJ, Holmberg SD, Hurwitz RL, et al. (1992)
Transmission of human immunodefi ficiency virus type 1
from a seronegative organ and tissue donor. N Engl J Med
326:726–732
38. Buck BE, Malinin TI, Brown MD (1989) Bone transplan-
tation and human immunodefi ficiency virus : an estimated
risk of acquired immunodefi ficiency syndrome (AIDS). Clin
Orthop 240:129–136
39. Frank CB, Jackson DW (1997) The Th science of reconstruc-
tion of the anterior cruciate ligament. J Bone Joint Surg
Am 79:1556–1576
40. Butler JC, Branch TP, Hutton WC (1994) Optimal
graft fixation—the eff ffect of gap size and screw size on
bone plug fixation in ACL reconstruction. Arthroscopy
10:524–529
41. Lemos MJ, Jackson DW, Lee TQ, Simon TM (1995) Assess-
ment of initial fixation of endoscopic interference femoral
screws with divergent and parallel placement. Arthros-
copy 11:37–41
42. Ahmad CS, Gardner TR, Groh M, et al. (2004) Mechanical
properties of soft tissue femoral fixation
fi devices for ante-
rior cruciate ligament reconstruction. Am J Sports Med
32 (3):635–40
43. Kleweno CP, Jacir AM, Gardner TR, et al. (2009) Biome-
chanical evaluation of anterior cruciate ligament femoral
fixation techniques. Am J Sports Med 37 (2):339–345
44. Coleridge SD, Amis AA (2004) A comparison of fi five tib-
ial-fi
fixation systems in hamstring-graft anterior cruciate
ligament reconstruction. Knee Surg Sports Traumatol
Arthrosc 12 (5):391–397
45. Bartlett RJ, Clatworthy MG, Nguyen TN (2001) Graft
selection in reconstruction of the anterior cruciate liga-
ment. J Bone Joint Surg Br 83 (5):625–634
46. Hoher J, Schefflffle SU, Withrow JD, et al. (2000) Mechanical
behaviour of two hamstring graft constructed for recon-
struction of the anterior cruciate ligament. J Orthop Res
18:456–461
47. Clatworthy MG, Bulow JU, Pinczewski LA, et al. (2000)
Tunnel widening in hamstring ACL reconstruction : a pro-
spective clinical evaluation and radiographic evaluation
of four difffferent fixation techniques. ACL Study Group,
Rhodes Greece
48.Deehan DJ, Salman LJ, Webb VJ, et al. (2000) Endoscopic
reconstruction of the anterior cruciate ligament with an
ipsilateral patellar tendon autograft : a prospective longitu-
dinal five-year study. J Bone Joint Surg Br 82-B:984–991
49. Jarvela T, Nyyssonen M, Kannus P, et al. (1999) Bone
patellar tendon bone reconstruction for the anterior cru-
ciate ligament : a long term comparison of early and late
repair. Int Orthop 23:227–231
50. Jomha NM, Pinczewski LA, Clingeleff ffer A, Otto DD (1999)
Arthroscopic reconstruction of the anterior cruciate liga-
ment with patellar-tendon autograft and interference
screw fixation : the results at seven years. J Bone Joint
Surg Br 81-B :775–779
51. Shelbourne KD, Gray T (2000) Results of anterior cruciate
ligament reconstruction based on meniscus and articular
cartilage status at the time of surgery. Am J Sports Med
28:446–452
52. Aglietti P, Buzzi R, Zaccherotti G, De Biase P (1994) Patel-
lar tendon versus doubled semitendinosus and gracilis
tendons for anterior cruciate ligament reconstruction. Am
J Sports Med 22:211–217
53. Aglietti P, Giron F, Buzzi R, et al. (2004) Anterior cruci-
ate ligament reconstruction : bone-patellar tendon-bone
compared with double semitendinosus and gracilis tendon
grafts. A prospective, randomized clinical trial. J Bone
Joint Surg Am.86-A (10):2143–2155
54. Beynnon BD, Johnson RJ, Kannus P, et al. (1998) A pro-
spective, randomized, clinical investigation of anterior
cruciate ligament reconstruction : a comparison of the
bone–patellar tendon–bone and semitendinosus–gracilis
autograft. Arthroscopy 14:S20
55. Corry SI, Jonathan WM, Clingeleffer ff JA, Pinczewski LA
(1999) Arthroscopic reconstruction of the anterior cruci-
ate ligament : a comparison of patellar tendon autograft
and four-strand hamstring tendon autograft. Am J Sports
Med 27:444–454
56. Gobbi A, Tuy B, Mahajan S, Panuncialman I (2003) Qua-
drupled bone-semitendinosus anterior cruciate ligament
reconstruction : a clinical investigation in a group of ath-
letes. Arthroscopy 19 (7):691–699
57. Marder RA, Raskind JR, Carroll M (1991) Prospective
evaluation of arthroscopically assisted anterior cruciate
reconstruction: patellar tendon versus semitendinosus
and gracilis tendons. Am J Sports Med 19:478–484
58. Otero AL, Hutcheson LA (1993) A comparison of the
doubled semitendinosus/gracilis and central third of the
patellar tendon autografts in arthroscopic anterior cruci-
ate reconstruction. Arthroscopy 9:143–148

59. Sherman OH, Banff ffy MB (2004) Anterior cruciate liga-
ment reconstruction: which graft is best? Arthroscopy
20(9):974–980
60. Yunes M, Richmond JC, Engels EA, Pinczewski LA (2001)
Patellar versus hamstring tendons in anterior cruciate
ligament reconstruction: a meta-analysis. Arthroscopy
17:248–257
61. Kleipool AE, Zijl JA, Wilems WJ (1998) Arthroscopic
anterior cruciate ligament reconstruction with bone patel-
lar tendon bone allograft or autograft: a prospective study
with an average follow-up of 4 years. Knee Surg Sports
Traumatol Arthrosc 6:224–230
Graft choice in ACL reconstruction 181
62. Petersen RK, Shelton WR, Bomboy AC (2000) Allograft
versus autograft patellar tendon anterior cruciate liga-
ment reconstruction: a 5 years follow-up. Arthroscopy
17:9–13
63. Victor J, Bellemans J, Witvrouw E, et al. (1997) Grafts
selection in anterior cruciate ligament reconstruction:
prospective analysis of patella autografts compared with
allografts. Int Orthop 21:93–97
64. Noyes FR, Barber-Westin SD (1996) Reconstruction of
the anterior cruciate ligament with human allograft: com-
parison of early and late results. J Bone Joint Surg Am
78-A:524–537

A. Williams, N. Devic
Introduction
T
his chapter deals with ideal placement of
tibial and femoral bone tunnels, and hence
the graft, in single-bundle ACL reconstruc-
tions. Double-bundle techniques and the use of
navigation to aid tunnel placement are dealt with
elsewhere.
History
The ACL reconstruction technique has evolved con-
siderably with time. A key issue is the provision of
tunnels in the femur and tibia that enter the joint in
positions that allow the graft to function optimally
while allowing unimpeded range of movement of
the joint. This
Th is the most important determinant of
final outcome (1,2). Suggested “ideal” positions of
these apertures have changed over time.
Incorrect placement of both tibial and femoral
tunnels has been, and remains, the most common
cause of ACL reconstruction failure. Previously,
poor surgical technique was responsible for most of
these cases. However, historical focus on isometry
and misinterpretation of anatomy have tended to
produce grafts that are excessively vertical in both
sagittal and coronal planes (Figs. 1 and 2), which
renders them less eff
ffective in countering axial rota-
Fig. 1 – A sagittal MRI appearance of a vertically oriented ACL graft.
Chapitre 16
Tunnels, graft positioning, and
isometry in ACL reconstruction
tional stresses, which is, of course, what the “pivot
shift” represents. As a result, even technically well-
done ACL reconstructions would sometimes leave
a patient with symptomatic instability of some
degree, despite restricting anteroposterior (AP)
laxity. Examination of the history of development
of ACL reconstruction explains how this situation
arose. Currently, the trend in single-bundle ACL
reconstruction is the production of a graft with good
obliquity in both sagittal and coronal planes with an
emphasis on production of biomechanics as close to
normal as possible, rather than isometricity.
Graft isometry
There has been a popular belief that all ligaments
are taut and so maintain their length (i.e., they are
isometric), throughout the whole range of move-
ment of the joint concerned. While this is a useful
concept for some ligaments, it quite clearly does not
apply to the function of many others. For example,
during knee flexion,
fl the attachments of the lateral
collateral ligament (LCL) approximate due to the
lateral femoral condyle “rollback” that occurs – thus
the lateral collateral ligament slackens as the knee
flexes. For this reason the access to the lateral com-
partment of the knee during arthroscopy improves
with placement of the knee into flexion (“the figure
Fig. 2 – Vertical graft alignment in the coronal plane (arrows).
184 The Traumatic Knee
Fig. 3 – An MRI appearance of normal ACL.
four position”). In the case of the ACL, the concept
of isometry is useful but not strictly mandatory.
In practical terms, “isometric behavior” is generally
accepted as a linear separation of the ligament of 1
mm or less, as the knee is taken through a full range
of flexion and extension. Since the ACL has a wide
attachment on the femur and tibia (Fig. 3), as soon
as the knee flexes, some fibers within the ligament
will tighten and others will slacken. The Th ACL has
been described as consisting of two functionally
distinct, although not anatomically separate, bun-
dles, named according to their tibial attachments
as the anteromedial (AM) bundle and the poste-
rolateral (PL) bundle. TheTh fibers of the AM bundle,
especially the anterior ones, have a relatively verti-
cal attachment on the femur and are relatively iso-
metric (3). The AM bundle tightens in flexion and is
relatively loose in full extension. The
Th PL bundle is
more horizontal and therefore behaves diff fferently.
It is clearly very far from isometric, being taut in full
extension, and slackening as the knee flexes (3–6).
Appreciation of these diff fferent patterns of behavior
in the functional bundles of ACL fibers have led to
interest in “double-bundle” ACL reconstruction.
For single-bundle ACL reconstruction, certain tun-
nel placement positions do mean that there is near-
isometric graft behavior. Since these positions are
suffi
fficiently close to what is currently thought to be
optimal tunnel placement, they usually resulted
in reasonable clinical outcomes. Th Therefore it was
thought that achieving graft isometry was very
important. There was even a period when intra-op-
erative “isometers” were used routinely to detect
the most isometric point on the femur.
Considerable work was done on trying to identify
“isometric points” for ideal placement of femoral and
tibial tunnels (7–9). The early studies by Hefzy and
Grood (8) identified
fi that it is the femoral attachment
of the ACL’s fiber bundles (in the sagittal plane) that
determines their functional range, with posterior
fibers tighter in extension and slacker in flexion. For
anterior fibers the reverse is true and central fibers
have almost equal length throughout the range of
motion. In contrast, the location of the tibial attach-
ment has a very small eff ffect on length patterns, but
of course has an eff
ffect on fiber orientation and intra-
articular length. Later work confi firmed not only that
the position of the femoral graft attachment in
the sagittal plane is the main determinant of graft
isometry but also that no femoral attachment site
allowed perfect isometry, with all having at least a 2
mm minimum change in the graft length (7,9).
Based on these concepts and the desire to produce
an isometric graft, the optimal position on the
femur for tunnel placement was thought to be high
and very posterior in the “11/1 o’clock” position.
Fibers attached anterior to this region tighten with
flexion, and more posterior ones tighten in exten-
sion (9). Therefore, an excessively anterior femo-
ral position, which is a common error, will restrict
knee flexion if the graft is tight, or allow full range
of flexion only if the graft is slack.
The “ACL isometry philosophy” has not stood up to
critical testing and investigation (3,10,11). It is now
generally accepted that isometry is not the most
crucial factor when reconstructing an ACL and that
the graft should be placed in the normal anatomical
attachments rather than “isometric points” (1).
Although a truly isometric placement cannot be
achieved, graft attachment sites that minimize the
change in the graft length, as the knee fl flexes, are
helpful. This minimizes graft tension and prevents
increased anterior translation, ensuring that the
replacement construct is not subjected to abnor-
mal joint loading and eventual failure (9).
Graft impingement
Graft vs. femoral notch impingement
Howell et al. identifi fied intercondylar notch roof
impingement on the graft, due to a too anteri-
orly placed tibial tunnel, as the main cause of ACL
reconstruction failure (1,4). Tibial tunnel place-
ment had previously been recommended anterior
to the anatomic center of the ACL (12) to help graft
alignment resist anterior tibial translation. Unfor-
tunately, this often led to graft-femoral notch
impingement producing problems such as fixed fi
flexion, graft failure due to attritional damage from
the impinging intercondylar roof (13), or a slack
graft in a knee that fully extended. Arthroscopic
evaluation of impinged grafts has shown that in

some cases the anterior fibers rupture, leading to
formation of fibrous nodules or “cyclops” lesions
(14), which block extension. An arthroscopic study
by Howell and Watanabe suggested that abrasion
is the mechanism by which impinged grafts fail
(15), with elevated contact pressures between the
graft and the intercondylar roof (16).
Apart from its size, whether or not a graft impinges
against the intercondylar notch will depend upon
two other factors: the position of the tibial tunnel
and dimension of the intercondylar notch. With
the recognition that graft impingement against the
notch was a problem “notchplasty” (surgical wid-
ening of the notch) was popularized and became
routine. Due to improved tibial tunnel positioning,
notchplasty is rarely now required as a part of ACL
reconstruction technique if the dimensions of the
intercondylar notch are normal. A sub-group of
patients are, without question, predisposed to ACL
rupture due to notch “stenosis” (congenital abnor-
mally narrow intercondylar notch), and such cases
often require widening of the notch.
A femoral notchplasty is not an entirely benign
procedure as it increases operative time and intra-
articular bleeding (17). Following notchplasty, a
higher than normal pre-tension needs to be applied
to the graft, prior to fixation,
fi to restore normal AP
laxity at 30° (18). This can in turn lead to high graft
forces perhaps hampering graft remodeling and
predisposing the graft to failure (18). Even a 2-mm
notchplasty causes tightening of the graft (between
20° and 90° of flexion), regardless at which position
of the “clock face” the femoral tunnel is located (10,
11, or 12 o’clock in the study quoted). Th
This excursion
profi
file is similar to that of a too anteriorly placed
femoral tunnel and has an unfavorable survival
potential (19). Aggressive notchplasty can also dam-
age articular surfaces and so may be a risk factor in
the development of subsequent osteoarthritis (OA)
(20). In addition, performing a large lateral notch-
plasty may lead to a far lateral placement of the
femoral tunnel of the ACL graft leading to abnor-
mal knee biomechanics (21). This procedure should
therefore be as limited as possible (22).
The difffferent shape of the native ACL and the
reconstructed ACL is one of the reasons why roof
impingement is a potential technical problem.
The native ligament is twice as wide at its tibial
attachment as at its femoral origin (23,24). The Th
surgeon has to decide where in the 19-mm tibial
insertion of the native ACL to place a 7- to 11-mm-
wide graft. ThThe native ACL’s anterior profi
file is con-
cave. It is impossible to replicate this anatomical
arrangement with a tubular/rectangular graft, and
therefore, if the graft’s tibial tunnel is centered in
the anterior part of the ACL “footprint,” some of
its anterior fibers will course non-anatomically
and may cause impingement during knee exten-
Tunnels, graft positioning, and isometry in ACL reconstruction 185
sion. Moving the center of the tibial tunnel 2–3
mm posterior to the center of the ACL attachment
would place all the fibers within the pathway of the
native ACL but still avoid impingement (25).
Despite the improved techniques for tibial tunnel
placement, anatomic variability means that the
same placement cannot be used for every knee.
These anatomic diff fferences need to be taken into
account when planning the placement of the tib-
ial tunnel. The useful concept of “forgiving” and
“unforgiving” knees has been proposed by Howell
(26). The “forgiving” knee is one which does not
hyperextend, and has a relatively horizontally
orientated slope of the intercondylar roof, which
therefore tolerates a more anteriorly placed tibial
tunnel without impingement. An “unforgiving
knee” is one which hyperextends and has a steep,
more vertically oriented, slope of the intercondy-
lar roof. These knees require a more posterior tib-
ial tunnel placement to avoid impingement. This Th
study (26) highlighted the need to alter tibial tun-
nel placement from patient to patient in order to
avoid impingement and excessive notchplasties.
It can be diffi
fficult to rule out graft impingement at
the time of surgery, as it occurs in terminal exten-
sion, and the surgeon may fi find it diffi
fficult to visual-
ize the graft, which may be hidden within the notch
with the knee extended. This can lead the surgeon
to underestimate the amount of impingement and
so fail to carry out a necessary notchplasty. Certain
authors (16) have even advocated ensuring a 6-mm
gap between the graft and the intercondylar roof
when the knee is in maximum hyperextension, as
a safeguard and to cope with the anterior tibial
translation caused by quadriceps contraction in late
extension. Undoubtedly, there must be some clear-
ance between the graft and the notch when the knee
is unloaded (Fig. 4); otherwise, any loading, such as
an anterior draw, would lead to impingement (1).
When in doubt as to whether impingement is pres-
ent or not, a useful intra-operative maneuver dur-
ing surgery is to insert a drill-bit or a shaver blade,
through the tibial tunnel, and assess whether they
impinge on the femur as the knee extends. If it does,
then a notchplasty will be required. Of course, it is
best to position the tibial tunnel optimally to avoid
the need for a notchplasty at all.
Post-operatively, graft impingement can be pre-
dicted on a lateral projection radiograph, with the
knee in maximum passive extension, if the line
projected from the anterior limit of the tibial tun-
nel is anterior to the slope of the intercondylar
roof (Blumensaat’s line). Th This assessment cannot
be applied to MRI scans in the sagittal plane with
such certainty. While radiographs represent a com-
pound two-dimensional representation of three-
dimensional reality, the MRI images are truly two-
dimensional. As a result, in some cases in which the
186 The Traumatic Knee
Fig. 4 – MRI appearance of well-placed ACL graft avoiding femo-
ral impingement showing good clearance from intercondylar roof
(arrows).
anterior edge of the tibial tunnel appears a little
anterior to the intercondylar roof, graft impinge-
ment is not necessarily present as the graft passes
obliquely in the coronal plane as it goes up and
posteriorly from tibia to femur, and therefore is
not necessarily going to actually have conflict
fl with
the intercondylar roof seen in that sagittal slice of
the scan in question. MRI is useful, however, as
the impinged graft usually returns increased signal
in the distal two-thirds of its intra-articular path
where it is abraded by the intracondylar roof (27),
and it may appear bowed posteriorly.
For a while focus was on avoiding graft impinge-
ment. Howell’s work on tibial tunnel placement
and impingement (25) showed that the tibial tun-
nel should be centered more posteriorly than had
previously been thought and that the ideal region
for centering it is within a 6-mm impingement free
zone (approximately 22–28 mm from the anterior
edge of the tibia). Th
This is 2–3 mm posterior to the
center of the normal ACL insertion to the tibia, and
yet the graft retains an acceptable excursion profile.
fi
Howell et al. divided the tibial attachment of the ACL
into two zones of unequal size, the anterior/larger
12-mm-deep “impingement zone” and the poste-
rior/smaller 6-mm-deep “impingement-free zone”
(25). By positioning the graft in the posterior zone,
the graft would therefore be functional but avoid
femoral impingement. Others have suggested the
ideal position to be 7 mm anterior to the PCL (28).
Graft vs. PCL impingement
As well as graft vs. femur impingement from an
excessively anterior tibial tunnel, excessive poste-
rior placement causes four potential problems. Of
course, there is the risk of a very posterior tunnel
causing drill trauma to the PCL. But even a less
marked error will lead to production of a relatively
vertical graft in the sagittal plane, which is less well
aligned to counter anterior tibial translation. Third,
Th
a posterior tunnel provides the least isometric posi-
tion for the graft on the tibia, causing too much
graft elongation/tension toward extension (3).
The fourth and most frequent problem of excessively
posteriorly positioned tibial tunnels is production of
graft impingement against the PCL (29). This Th tends
to occur when the PCL tightens during knee fl flexion.
When this phenomenon occurs, such patients will
lose range of deep flexion. Although loss of a matter
of a few degrees of deep flexion
fl sounds trivial, most
patients are genuinely unhappy with their inabil-
ity to squat comfortably. Howell et al. explored the
eff
ffect of the PCL on tension of an ACL graft (29).
These experiments confi firmed that the impinge-
ment of the graft against the PCL caused high graft
tension in flexion. This may explain why excessive
posterior tibial tunnel placement has been associ-
ated with increased risk of graft rupture.
The importance of the tibial tunnel position in the
coronal plane must also be considered. Th This was
evaluated by Romano et al. (30), who showed that
the patients who had a significant
fi loss of flexion
had a more medially placed tibial tunnel than the
patients without a flexion
fl defi
ficit, and advised that
the placement of the tibial tunnel medial to the
medial tibial spine should be avoided (intra-artic-
ular opening of the tibial tunnel should be at 45%
across the tibial plateau from medial to lateral on
the AP radiograph). TheTh restricted flexion may well
be related to impingement of the graft against the
PCL and interference with PCL motion.
In the “trans-tibial” technique of drilling the femo-
ral tunnel, the position of the tibial tunnel will
limit choice of femoral tunnel position. Drilling
the femoral tunnel trans-tibially at an angle of
75° in the coronal plane causes impingement of
the graft against the PCL increasing graft tension
in flexion, which either limits knee flexion range or
causes increased anterior laxity due to the resul-
tant stretching of the ACL graft (29,31). As a result
the authors (30) recommended drilling the tibial
tunnel at 65–70° in the coronal plane in order to
improve clinical outcome.
Tibial tunnel
Where to position the tibial tunnel
The most important aspect is that the tibial tunnel
enters the joint through the ACL “footprint.” How-

ever, the exact optimal position has not been agreed
upon. As understanding of graft impingement
against the femur increased, so a more posterior
tunnel position was recommended. It was suggested
that the graft should occupy the posterior half of
the original ACL. Jackson and Gasser described
a point halfway between the line connecting the
tibial attachment of the anterior horn of the lateral
meniscus and the medial tibial spine to achieve this
(32). They suggested that grafts placed central in
the ACL footprint or more anterior would impinge
against the femur. Another popular statement was
to state that the tunnel should emerge 7 mm ante-
rior to the PCL (28). When using an “elbow-aimer”
tibial drill guide, useful tips were that the “elbow”
of the guide should just touch the PCL, or the tip of
the guide should be hooked over the natural bony
ridge easily found just anterior to the PCL.
Later with the appreciation that the tibial tunnel
could be too posterior (the section Graft vs. PCL
impingement), and that more anterior positions
did not always cause impingement and are better
at resisting anterior tibial translation, the recom-
mended position is being reconsidered.
However, with the current trend of “anatomical”
tunnel placement, it is likely that more cases of
impingement of the graft on the femur will arise as
surgeons try more anterior tibial tunnels. Th The tra-
ditional recommendations stated in the previous
paragraph are reliable but will err toward exces-
sively posterior, and to some degree excessively
lateral, grafts that will lie too vertically and be less
eff
ffective biomechanically.
Thankfully, tibial tunnel placement error has less
impact than malpositioning of the femoral tunnel
on graft function. As a result, it is best to be cau-
tious to avoid the more serious problem of femoral
notch impingement on the graft. The Th senior author
aims to place the graft central in the ACL footprint
in the AP in coronal and sagittal planes.
Optimal tibial tunnel positioning has received much
less focus than ideal femoral tunnel placement, but
with the popularity of “double-bundle” ACL recon-
struction techniques, this will be addressed.
How to drill the tibial tunnel
As the technique of ACL reconstruction advanced,
a trend toward “trans-tibial” drilling of the femo-
ral tunnel (i.e., drilling the femoral via tibial tun-
nel) grew in popularity, especially with “all-ar-
throscopic” surgery.
The technique became “slick” and attractive. With
the knee at 90° flexion and drilling the tibia at 40°
to the joint line in the sagittal plane, the drill/
guidewire could then be “railroaded” up into the
femur to what was thought to be the ideal posi-
Tunnels, graft positioning, and isometry in ACL reconstruction 187
tion: high and posterior in the notch. Since drilling
the “trans-tibial” technique is still widely used, the
aspects of how the tibial tunnel is drilled must be
appreciated, as they have major implications for
the femoral tunnel position. For reasons to be dis-
cussed later, there is now a trend away from trans-
tibial drilling of the femoral tunnel, since drilling
the tunnels in each bone totally independently has
a number of advantages.
If the “trans-tibial technique” is used, the tibial
tunnel angle controls both the femoral tunnel
angle and the tension in the graft in this technique
(29). Howell’s group advocate drilling the tibial
tunnel at 65°, in the coronal plane, then using and
angulating the femoral aimer (within the already
drilled tibial tunnel) laterally to achieve a close-
to-60° femoral tunnel in the coronal plane.
If the knee is extended fully with the guidewire
in the notch, but not yet femur, it is essential to
ensure that there is adequate clearance of at least
half the graft diameter between the guidewire and
the femur so that subsequent drilling will provide
a tibial tunnel that prevents femoral impingement
on the graft.
With evolution of endoscopic ACL reconstruction,
the external cortical starting point has moved
distally on the AM tibia, leading to an increase in
the angle between the tunnel and the tibial pla-
teau and therefore an increase in tunnel and graft
length required.
The ideal extra-articular tibial starting point has
also been described by Morgan et al. (28) as being
1 cm above the superior margin of the pes anseri-
nus and 1.5 cm medial to the medial margin of
the tibial tubercle, consistently producing a tibial
angle of 67°. Care must be taken when drilling the
tibial tunnel to be aware of how medial an entry
point is chosen. If placed too medial, the anterior
MCL can be injured, and if the tunnel is drilled at a
shallow angle, there is the risk of the drill breach-
ing the medial tibial joint surface.
In both femoral as well as tibial tunnels, it is worth
noting that only a drill applied perpendicular to
the bone surface can produce a circular entry/
exit hole. Since all drills enter or emerge from the
bones at other angles at the apertures, the tunnels
will be oval. The steeper the angle, the closer to a
circle will be the aperture. A more circular aperture
will contain the graft better, allowing less move-
ment of the graft and hence synovial fluid leakage
into the tunnel, which might interfere with graft
– bone healing. The steeper/longer tibial tunnel is
therefore advantageous in this aspect. ThThis is espe-
cially important in the skeletally immature patient
to minimize the cross-sectional area of damage to
the growth plate.
Due to the problems, described in the section How
to drill the femoral tunnell related to “trans-tibial”
188 The Traumatic Knee
drilling of the femoral tunnel, it is attractive to drill
both tunnels totally independently. As a result,
tunnel length can be varied appropriate to graft
length. This is less critical for hamstring grafts than
for patellar tendon grafts. Nonetheless, the tunnel
can be deliberately shortened by use of less steep
angles of drilling when a short graft has been pro-
duced, or ideally be kept steep and long. For bone-
patellar tendon-bone (B-PT-B) grafts, the tibial tun-
nel length should be varied according to the graft
dimensions. In this way the situation of graft disap-
pearance up the tunnel or excess graft protruding
from the tibia, both of which affect
ff fixation quality,
can be avoided. To this end there is a useful calcula-
tion that can be performed. Once the bone block
destined for the femoral tunnel has been selected,
the length of the remaining tendon and tibial bone
block should be measured. This is the part of the
graft traversing the joint and lying in the tibial tun-
nel. Assuming the average knee has an ACL that is
25 mm long, the length of the ideal tibial tunnel
that accommodates the graft just to its external
aperture is the measurement of patellar tendon
plus the tibial bone block minus 25 mm. Th The sur-
geon can then predetermine the appropriate length
of tibial tunnel for the length of graft harvested.
Tibial guides
“Point and shoot guides” aim at intra-articular
landmarks. This technique was first introduced by
Jackson and Gasser (32), who described the ideal
point of entry of the tibial tunnel into the joint
as being halfway between the line connecting the
anterior horn of the lateral meniscus and medial
tibial spine (the section Where to position the tibial
tunnel). Th
These are the classical ACL reconstruction
tibial guides, which are “tip” or “elbow” aiming.
Some guides reference of the PCL (28) centering
the tibial tunnel 7 mm anterior to the anterior
margin of the PCL, but this may produce an unnec-
essarily large notch clearance (17). In addition, the
PCL has a variable structure, and this is not a reli-
able landmark.
Howell (17) discussed customizing the placement
of the tibial tunnel with the use of a guide that tar-
gets the intercondylar notch with the knee in max-
imum extension to provide a tibial tunnel position
guaranteeing no graft vs. femoral impingement.
This is a useful concept as numerous studies have
highlighted wide anatomical variations in the
knee. The relationship between the intercondylar
roof (Blumensaat’s line) and the tibial plateau,
in full extension, was investigated by Buzzi et al.
(33) and was found to vary widely from 56° to 86°.
Another very variable parameter is knee extension
itself. Howell et al. evaluated degrees of extension
in intact normal knees and found this to vary from
−30° to 2° (34). He also found that the slope of the
intercondylar roof (Bloomensaat’s line) varies from
26° to 46°. The relationship between the two was
found, but this was weak and not clinically useful.
This guide was validated in 2006 by Cuomo et al.
(35) in cadaver knees.
The femoral tunnel
Where to position the femoral tunnel
Correct placement of the femoral tunnel is crucial
as it has a greater effffect on graft length change dur-
ing knee flexion
fl and extension than does the tibial
tunnel. It is also closer to the center of the rotation
(the flexion axis) than the tibial attachment, and
therefore, even minor variations in femoral tunnel
placement will aff ffect graft isometry signifificantly
and much more so than variations in tibial tunnel
placement (9).
In the sagittal plane the “single-bundle” tunnel
needs to be as posterior as possible. With the tra-
ditional focus on graft isometry, sagittal plane tun-
nel placement in the femur was emphasized. Only
recently has the coronal plane positioning received
deserved attention.
As the femoral attachment of the ACL is deep in
the notch, tunnel placement errors are relatively
easy to make, and even minor ones will have big
adverse impact. With the great importance of cor-
rect femoral tunnel placement, the surgeon must
appreciate the various anatomic landmarks that
help make choice of tunnel position reproduc-
ible.
Diffi
fficulty in visualization of the “true back” (Fig. 5)
on the femoral notch has often led to excessively
anterior placement of the femoral tunnel. The bony
ridge upon which the posterior capsule blends can
easily give the false impression of being the pos-
terior limit of the notch. This so-called “registrars’
ridge” or “residents’ ridge” sits approximately 4–5
mm anterior to the true posterior limit (Fig. 6).
Whether operating “open” or “arthroscopically,”
the true posterior limit of the notch must be iden-
tifi
fied with confi fidence. Usually, there is a clear
boundary felt with a probe when traversing the
“true posterior limit.” Sometimes this is indistinct
if the notch blends smoothly with the posterior
femoral meataphysis. In such cases accurate iden-
tifi
fication of the “registrars’ ridge” can be helpful as
a guide to tunnel placement. The “registrars’ ridge”
is thus a useful landmark as well as potential pit-
fall. Care should therefore be taken when clearing
the notch of soft tissue not to destroy this ridge.

Fig. 5 – The arthroscopic appearance of the posterior femoral notch. The
bone awl is touching the true posterior limit – true back.
Fig. 7 – Center of the tunnel for a bone-patellar tendon-bone graft.
For a B-PT-B graft of 10 mm, the center of the tun-
nel should start 5 or 6 mm anterior to the poste-
rior limit of the notch. This point is usually just on
“registrars’ ridge” (Fig. 7). Being more slender, for
a hamstring graft the start point will be just poste-
rior to “registrars’ ridge.”
There are various drill guides that aim to force the
tunnel suffifficiently posteriorly. The danger as with
all guides is that they may achieve one criterion of
good tunnel positioning but at the risk of another.
Often these guides are bulky and, without care,
tend to push the femoral tunnel high in the notch
(36), closer to the “isometric” position rather than
the “anatomical” one. Sometimes they force drilling
suffi
fficiently posterior to cause tunnel “blowout.”
The most common problem regarding femoral tun-
nel placement is excessive anterior positioning
causing abnormally high graft tension in fl flexion
(8), and restricted flexion with a tight graft or one
which only allows full flexion if the graft is slack or
fails as already described. Indeed most of the senior
author’s revision cases have excessively anterior
femoral tunnels.
Tunnels, graft positioning, and isometry in ACL reconstruction 189
Fig. 6 – The arthroscopic appearance of the posterior femoral notch. The
bone awl is touching the “registrars’ ridge.”
The next issue is choice of position of the tunnel in
the coronal plane. This is usually described using
the numbers on a clock-face, whereby the apex of
the notch is 12 o’clock. Unfortunately this ignores
the aspect of “depth” within the notch and so
only details part of the localisation of the femoral
tunnel. It is likely that reference to femoral tun-
nel position combining the clock-face terminol-
ogy with a statement of positionnal depth within
the notch would be helpful and more meaningful.
There are a number of factors that must be used
together to obtain a good orientation and thence
tunnel position. First, limb positioning on the
operating table is vital: the tibia should be aligned
vertically, and not falling to one side or other, and
the knee should be at 90° flexion.
fl The posterior
apex of the notch can be identifi fied by finding the
apex of the notch anteriorly at the inferior limit
of the trochlea groove at the articular margin, and
extrapolating a line posteriorly. The lateral edge of
the PCL provides a reproducible vertical. To visual-
ize the PCL properly, the overlying synovium and
fat may need to be trimmed/shaved. Th The lateral
sidewall of the notch can be useful if the notch
is of the “Roman arch” shape with truly vertical
sidewalls. Unfortunately, many notches are of the
“classical arch” shape with slanting sidewalls. In
addition the notch walls can be altered in shape
by aggressive soft tissue clearance, and of course
when “notchplasty” is performed.
The site of recommended coronal plane placement
has steadily changed and continues to be debated.
Traditionally from the era in which graft isometry
was held to be vital, the recommended position
was 11 o’clock in the right knee and 1 o’clock in
the left knee (Fig. 8). ThThis approximates to the
origin of the AM bundle of the ACL, the anterior
fibers of which are the most isometric within the
ACL as a whole (9). Not surprisingly, since such
graft placement aligns well with the sagittal plane,
190 The Traumatic Knee
Fig. 8 – An ACL reconstruction as per traditionally recommended 11/1 o’clock
femoral placement with a very vertical graft.
it is good at resisting anterior tibial translation.
However, its relative lack of coronal plane obliq-
uity (Fig. 9A and B) hampers its ability to control
axial rotation. In the clinical setting, control of
axial rotation is more important than restriction
of anterior laxity.
It has become apparent that not only is coronal
plane positioning of the femoral tunnel impor-
tant but also the previously recommendations
A B
Fig. 9 – Vertical position of ACL graft in coronal plane resulting from “traditional” tunnel placement.
were suboptimal. Advice is therefore changing. An
arthroscopic study by Arnold et al. (36) showed
that the femoral attachment of the native ACL
lies very low, fanning out between 11 and 9 to 8
o’clock, with the center lying much lower than the
11 o’clock position. With the trend to “anatomic”
rather than “isometric” reconstruction, the advice
for ideal femoral tunnel placement now is farther
around the “clock-face.”
Several studies (37–43) have assessed the impact
of femoral tunnel positioning on kinematics and
joint laxity. This has been fueled further by the
interest in “double-bundle” ACL reconstruction
techniques. The
Th results of these studies conclude
that the traditional “high posterior” 11/1 o’clock
position gives the best restraint to anterior tibial
translation, but inferior axial rotational control,
and increased graft tensions perhaps due to PCL
impingement (the section Graft vs. PCL impinge-
ment). Moving the tunnels “around the clock-face”
such as 10/2 o’clock position (some surgeons even
go as far as to advocate 3:9 o’clock positioning),
which are closer to the PL bundle of the natural
ACL, produced slightly more anterior tibial trans-
lation (which is unlikely to be clinically relevant)
but far better rotational control (Fig. 10) This
Th is
not entirely surprising when one considers that
these positions produce a graft that lies much
more obliquely in the notch in the coronal plane.
Indeed increasingly, the senior author is aware
that in many of his revision cases, despite the pri-
mary tunnel position fulfi filling traditional advice
of placement, the graft simply lies too vertically in
the coronal plane (Fig. 11). Th
This is of course exacer-
bated with a lateral placement of the tibial tunnel.

Fig. 10 – A more oblique ACL graft with the femoral tunnel placed at
9.30/2.30 as per current recommendations.
A clinical study by Lee et al. (44) recently showed
that a residual pivot shift (and a signifi
ficantly lower
Lysholm score at a minimum 2-year follow-up) cor-
relates with a more vertical placement of the femo-
ral tunnel, whereas more oblique graft placement
enabled better rotational stability. A useful guide
to satisfactory obliquity of the graft is described by
Howell. In a well-placed graft, there should be visi-
ble a triangular space formed by the supero-medial
ACL graft, lateral edge of superior PCL, and supe-
rior arch of the femoral notch (Fig. 12A and B). The
Th
senior author advocates the 2.30–9.30 position for
the femoral tunnel.
Furthermore, these more “anatomical” positions
will place the graft away from the PCL and thereby
decrease the risk of impingement of the graft
against the PCL (29).
On post-operative radiographs, a femoral tunnel
aperture that is on Blumensaat’s line, as was once
thought ideal, is actually too high up in the notch/
on the “clock-face” – even if it is as posterior as
Fig. 12 – Well-placed ACL graft showing good coronal plane obliquity and
hence “triangle” – the space bounded by the ACL graft, PCL, and femoral
notch.
Tunnels, graft positioning, and isometry in ACL reconstruction 191
Fig. 11 – A revision case. The new graft of hamstrings is fixed in the femur
with an Endobutton (Smith and Nephew, Andover, MA). The old femoral
tunnel was too vertical and is plugged here with a metal screw allowing the
graft to occupy a better positioned new femoral tunnel.
possible. The optimal position is also distal to Blu-
mensaat’s line, i.e., on the sidewall of the notch.
Clinical results correlate positively with placement
of the femoral tunnel at least 60% posterior along
Blumensaat’s line (45).
Recent cadaveric studies have shown that the
double-bundle technique is still more effective
ff at
reproducing knee kinematics (38,43) since having
two bundles can reproduce the function of the ACL
more closely. However, until clinical advantage is
shown, those considering using a double-bundle
technique have to acknowledge the potential dis-
advantages of harming graft quality, the techni-
cally demanding nature of the procedure that make
errors easy to make, the creation of two holes in
each bone, and the lack of consensus regarding
tunnel placement.
How to drill the femoral tunnel
The femoral tunnel can be drilled via the tibial tun-
nel, i.e., “trans-tibial,” or from the joint drilling
outward via the AM portal, or by an “outside-in”
method in which an incision is made to allow drill-
ing from the lateral femur in the supracondylar
region into the joint to the desired position.
Whichever method is employed, it is a simple
maneuver to mark the femur first where the
desired femoral tunnel should be drilled and then
make sure drilling occurs at this point regardless of
which method of drilling is chosen.
Howell’s group has investigated the effects
ff of a
more oblique tibial tunnel (65° as opposed to 70°)
in the coronal plane and found that this tunnel
placement reduces anterior laxity and loss of flex-
fl
ion due to better resultant femoral tunnel posi-
tioning, i.e., farther around the “clock-face” that
11/1 o’clock positions (31). If “trans-tibial” drilling
192 The Traumatic Knee
of the femur is undertaken, then simply relying on
tibial tunnel position to determine femoral tunnel
position is unwise.
The location for the femoral tunnel is found by
reference to a number of anatomical landmarks
described above. The most reliable are the use of
the lateral border of the PCL as a vertical reference
and identifification of the apex of the intercondylar
notch as already described.
In attempting to achieve as posterior a tunnel as
possible, there a risk of posterior tunnel “blow-
out.” Having the knee highly flexed, while drilling
from the joint cavity out, mitigates the possibility
of being too posterior, as the femoral tunnel will
come more anteriorly with drilling into the femur,
even if it initially “blows out” at the aperture.
Inadequate flexion can lead to “blowout” being a
major problem, as potentially, the whole tunnel
is aff
ffected. Of course, suspensory fixation devices
such as Endobutton CL (Smith and Nephew,
Andover MA) or Transfi fix (Arthrex, Naples Fl) are
very helpful in this situation.
While knee flexion in femoral tunnel drilling is
generally helpful, especially in a thin patient,
over-flflexion of the femur is easily achieved and
only a short femoral tunnel may be possible if
the bone dimensions are small. This can be prob-
lematic especially for accommodation of the
bone block in a B-PT-B graft. Occasionally, if an
Endobutton is used and the femoral tunnel is
drilled whilst the knee is in excessive fl flexion an
unusual problem can occur. The Th Endobutton will
exit the femur more distal than usual and can
perforate both the deep and superfi ficial layers of
the suprapatellar pouch, so “stapling” the layers
together when the graft is pulled back. Th This will
limit flexion severely.
If the femoral tunnel is drilled via the tibial tunnel,
the latter will constrain where the femoral tunnel
can be placed (29). As a result the lowest position
possible is 10:2 o’clock. Even then, to achieve this,
the tibia usually needs to be internally rotated, and
the knee extended a little. Not surprisingly, guide-
wires are easily bent and even broken. In addition,
the drill bits are unable to pass through the tibial
tunnel easily and so create new “off ff-center” drilling
to eccentrically enlarge the original tibial tunnel
especially close to the joint.
Independent positioning of the femoral tunnel by
a “two-incision” out:in technique, or drilling the
femoral tunnel via the AM portal can also avoid
problems related to PCL impingement during knee
flexion (11). “Blowout” is never a problem with the
“two-incision” out:in technique.
To achieve the “anatomical” femoral tunnel posi-
tions, drilling via the AM portal is becoming
increasingly popular. While this would seem to be
an attractive option, it does mean that there is a
risk of damage to the medial femoral condyle due
to passage of instruments. Also the knee requires
more flexion than is required with the “trans-tib-
ial” technique to drill the femoral tunnel satisfac-
torily back into the femoral bone. On the other
hand, it does mean that placing an interference
screw into the femoral tunnel is more likely to
be parallel to the tunnel/graft since the angle of
knee flexion for screw insertion is the same as for
drilling.
If the femoral tunnel has been drilled via the tibial
tunnel, then when the screw is inserted via the AM
portal, more flexion, than was used in drilling, is
required for optimal screw placement in a line par-
allel to the tunnel.
Comparison of three techniques of femoral tun-
nel drilling (“double-incision” out:in, “trans-tibial,”
and drilling via the AM portal) with reference to
their ability to ensure correct femoral tunnel posi-
tion was carried out by Giron et al. (2). Aiming for
a femoral placement just below the insertion of the
AM bundle of the natural ACL bundle (due to its
isometricity and visibility), they found that each
technique was able to ensure a deep placement of
the femoral tunnel. This was assessed on lateral
x-rays by measuring the position of the femoral
tunnel and expressing it as a percentage of the con-
dylar width line (which is parallel to Blumensaat’s
line). On lateral x-rays, none of the tunnels were
placed within the posterior 35–40% of the condy-
lar width.
Due to a desire to achieve more “anatomical” place-
ment of the femoral tunnel, the senior author
uses a fully arthroscopic technique and drills the
femoral tunnel via the AM portal aiming for the
2.30–9.30 positions.
Ideal x-ray position
A recent paper by Pincziewski et al. (46) measured
the inclination of the ACL graft in the coronal plane
(defi
fined as the angle formed by the medial walls of
the tibial and femoral tunnels on anteroposterior
weightbearing views at 30° of flexion) and found
that a more vertical graft was associated with a
higher incidence of pivot glide and higher degree
of radiological OA, at 7-year follow-up. Sustained
rotational instability associated with more vertical
grafts is thought to be a major contributing factor.
Placement of tunnels such that the coronal incli-
nation of the graft is approximately 20° ensures
normal rotational stability (as assessed on pivot
shift testing), and that this can be best achieved
by drilling the tunnels independently, as the tran-
stibial technique is more likely to lead to a vertical
graft placement (46).

Conclusions
1. The “ACL isometry philosophy” has not stood up
to critical testing.
2. Excessively anterior tibial tunnel placement
leads to impingement against the femoral notch,
loss of extension, and eventual failure.
3. Excessively posterior tibial placement predis-
poses to impingement of the graft against the PCL
and loss of deep flexion.
fl
4. Notchplasty should be avoided and as limited as
possible if required.
5. The graft should be placed in the center of the
tibial “footprint.”
6. A vertical graft, which often results when “tra-
ditional” tunnel placement is employed, can resist
AP translation but is unable to control rotation,
leading to a residual pivot shift and rotational
instability.
7. A more oblique graft (in the coronal and sagittal
planes) off
ffers both better AP and rotational stability.
8. Use of AM portal has become more popular as
it allows independent drilling of the femoral and
tibial tunnels, ensuring anatomical graft position.
9. Femoral placement error has more impact than
tibial placement error.
References
1. Amis AA, Jakob RP (1998) Anterior cruciate ligament
graft positioning, tensioning and twisting. Knee Surg
Sports Traumatol Arthrosc 6 (Suppl 1): S2–S12
2. Giron F, Buzzi R, Aglietti P (1999) Femoral tunnel position
in anterior cruciate ligament reconstruction using three
techniques. A cadaver study. Arthroscopy 15:750–756
3. Sapega AA, Moyer RA, Scheneck C, Komalaharanya N
(1990) Testing for isometry during reconstruction of the
anterior cruciate ligament: anatomical and biomechanical
considerations. J Bone Joint Surg Am 72:259–267
4. Amis AA, Dawkins GPC (1991) Functional anatomy of the
anterior cruciate ligament. Fibre bundle actions related to
ligament replacements and injuries. J Bone Joint Surg Br
73-B:260–267
5. Gabriel MT, Wong EK, Woo S L-Y, Yagi M, Debski RE
(2004) Distribution of in situ forces in the anterior cruci-
ate ligament in reponse to rotatory loads. J Orthop Res
22:85–89
6. Harner CD, Hyun Baek G, Vogrin TM, et al. (1999) Quan-
titative analysis of human cruciate ligament insertions.
Arthroscopy 15(7):741–749
7. Bylski-Austrow DI, Grood ES, Hefzy MS, et al. (1990) Ante-
rior cruciate ligament replacements: a mechanical study of
femoral attachment location, flexion angle at tensioning
and initial tension. J Orthop Res 8(4):522–531
8. Hefzy MS, Grood ES (1986) Sensitivity of insertion loca-
tions on length patterns of anterior cruciate ligament
fibres. J Biomech Eng 108(1):73–82
9. Hefzy MS, Grood ES, Noyes FR (1989) Factors aff ffecting
the region of the most isometric femoral attachment.
Part 2: The anterior cruciate ligament. Am J Sports Med
17(2):108–216
10. Cooper DE, Urrea L, Small J (1998) Factors affffecting isom-
etry of endoscopic anterior cruciate ligament reconstruc-
Tunnels, graft positioning, and isometry in ACL reconstruction 193
tion: the eff
ffect of guide off
ffset and rotation. Arthroscopy
1998 14(2):164–70
11. Garofalo R, Moretti B, Kombot C, et al. (2007) Femoral
tunnel placement in anterior cruciate ligament recon-
struction: a rationale of the two incision technique. J
Orthop Surg 2:10
12. Clancy WG, Nelson DA, Reider B, Narechania RG (1982)
Anterior cruciate ligament reconstruction using one third
of the patellar ligament, augmented by extra-articular ten-
don transfers. J Bone Joint Surg Am 64(3):352–359
13. Howell SM, Taylor MA (1993) Failure of reconstruction
of the anterior cruciate ligament due to impingement by
the intercondylar roof. J Bone Joint Surg Am 75(7):1044–
1055
14. Jackson DW, Schaefer RK (1990) Cyclops syndrome; loss
of extension following intra-articular anterior cruciate
ligament reconstruction. Arthroscopy 6:171–178
15. Watanabe BM, Howell SM (1995) Arthroscopic findings
associated with roof impingement of an anterior cruciate
ligament graft. Am J Sports Med 23:616–625
16. Goss BC, Hull ML, Howell SM (1997) Contact pressure
and tension in anterior cruciate ligament grafts subjected
to roof impingement during passive extension. J Orthop
Res 15:263–268
17. Howell SM, Lawhorn KW (2004) Gravity reduces the tibia
when using a tibial guide that targets the intercondylar
roof. Am J Sports Med 32:1702–1710
18. Markolf KL, Hame SL, Monte Hunter D, et al. (2002) Biome-
chanical eff
ffects of femoral notchplasty in anterior cruciate
ligament reconstruction. Am J Sports Med 30(1):83–89
19. Aglietti P, Buzzi R, Giron F, et al. (1997) Arthroscopic-as-
sisted anterior cruciate ligament reconstruction with the
central third patellar tendon. A 5-8 year follow-up. Knee
Surg Traumatol Arthrosc 5:138–144
20. LaPrade RB, Terry GC, Montgomery RD, et al. (1998) The Th
eff
ffects of aggressive notchplasty on the normal knee in
dogs. Am J Sports Med 26:193–200
21. Fu FH, Bennett CH, Ma CB, et al. (2000) Current trends in
anterior cruciate ligament reconstruction: Part 2. Opera-
tive procedures and clinical correlations. Am J Sports Med
28:124–130
22. Hame SL, Markolf KL, Monte Hunter D, et al. (2003)
Eff
ffects of notchplasty and femoral tunnel position on
excursion patterns of an anterior cruciate ligament graft.
Arthroscopy 19(4):340–345
23. Howell SM, Clark JA, Farley TE (1991) A rationale for pre-
dicting anterior cruciate graft impingement by the inter-
condylar roof: a magnetic resonance study. Am J Sports
Med 19(3):276–282
24. Odensten M, Gillquist J (1985) Functional anatomy of the
anterior cruciate ligament and a rationale for reconstruc-
tion. J Bone Joint Surg 67A:257–262
25. Howell SM, Clark JA (1990) Tibial tunnel placement
in anterior cruciate ligament reconstructions and graft
impingement. Clin Orthop Relat Res 283:187–195
26. Howell SM (1998) Principles for placing the tibial tunnel
and avoiding roof impingement during reconstruction of
a torn anterior cruciate ligament. Kneev Surg Sports Trau-
matol Arthrosc 6(Suppl 1): S49–S55
27. Howell SM, Berns GS, Farley TE (1991) Unimpinged and
impinged anterior cruciate ligament grafts: MR signal
intensity measurements. Radiology 179:639–643
28. Morgan CD, Kalman VR, Grawl DM (1995) Definitive fi
landmarks for reproducible tibial tunnel placement in
anterior cruciate ligament reconstruction. Arthroscopy
11:275–288
29. Simmons R, Howell SM, Hull ML (2003) Eff ffects of the angle
of the femoral and tibial tunnels in the coronal plane and
incremental excision of the posterior cruciate ligament on
tension of an anterior cruciate ligament graft: an in vitro
study. J Bone Joint Surg Am 85A(6):1018–1029
194 The Traumatic Knee
30. Romano VM, Graf BK, Keene JS, Langhe RH (1993) Ante-
rior cruciate ligament reconstruction. The
Th effffect of tibial
tunnel placement on range of motion. Am J Sports Med
21:415–418
31. Howell SM, Gittins ME, Gottlieb JE, et al. (2001) The Th
relationship between the angle of the tibial tunnel in the
coronal plane and loss of flexion and anterior laxity after
anterior cruciate ligament reconstruction. Am J Sports
Med 29:567–574
32. Jackson DW, Gasser SI (1994) Tibial tunnel placement in
ACL reconstruction. Arthroscopy 10:124–131
33. Buzzi R, Zaccherotti G, Giron F, Aglietti P (1999) The
Th rela-
tionship between the intercondylar roof and the tibial pla-
teau with the knee in extension: relevance for tibial tunnel
placement in anterior cruciate ligament reconstruction.
Arthroscopy 15:625–631
34. Howell SM, Barad SJ (1995) Knee extension and its
relationship to the slope of the intercondylar roof:
implications for positioning the tibial tunnel in ante-
rior cruciate ligament reconstruction. Am J Sports Med
23:288–294
35. Cuomo P, Edwards A, Giron F, et al. (2006) Validation of
the 65° Howell guide for anterior cruciate ligament recon-
struction. Arthroscopy 22(1):70–75
36. Arnold MP, Kooloos J, van Kampen A (2001) Single-in-
cision technique misses the anatomical femoral anterior
cruciate ligament insertion: a cadaver study. Knee Surg
Sports Traumatol Arthrosc 9(4):194–199
37. Loh JC, Fukuda Y, Tsuda E, et al. (2003) Knee stabil-
ity and graft function following anterior cruciate liga-
ment reconstruction: comparison between 11 o’clock
and 10 o’clock femoral tunnel placement. Arthroscopy
19(3):297–304
38. Mae T, Shino K, Miyama T, et al. (2001) Single versus two-
femoral socket anterior cruciate ligament reconstruction
technique: biomechanical analysis using a robotic simula-
tor. Arthroscopy 17:708–716
39. Markolf KL, Hame S, Monte Hunter D, et al. (2002)
Eff
ffects of femoral tunnel placement on knee laxity and
forces in an anterior cruciate ligament graft. J Orthop Res
20:1016–1024
40. Musahl V, Plakseychuk A, VanScyoc A, et al. (2005) Vary-
ing femoral tunnels between the anatomical footprint and
isometric positions: effffect of kinematics of the anterior
cruciate ligament-reconstructed knee. Am J Sports Med
33(5):712–718
41. Scopp JM, Jasper LE, Belkoff ff SM, Moorman CT (2004)
The effffect of oblique femoral tunnel placement on rota-
tional constraint of the knee reconstructed using patellar
tendon autografts. Arthroscopy 20(3):294–299
42. Woo SL, Kanamori A, Zeminski J, et al. (2002) The Th eff
ffec-
tiveness of reconstruction of the anterior cruciate liga-
ment with hamstrings and patellar tendon. A cadaveric
study comparing anterior tibial and rotational loads. J
Bone Joint Surg Am 84-A(6):907–914
43. Yagi M, Wong EK, Kanamori A, et al. (2002) The Th biome-
chanical analysis of anatomical ACL reconstruction. Am J
Sports Med 30:660–666
44. Chul Lee M, Cheol Seong S, Lee S, et al. (2007) Vertical
femoral tunnel placement results in rotational knee laxity
after anterior cruciate ligament reconstruction. Arthros-
copy 23(7):771–778
45. Khalfayan EE, Sharkey PF, Alexander AH, et al. (1996) The
Th
relationship between tunnel placement and clinical results
after anterior cruciate ligament reconstruction. Am J
Sports Med 24:335–341
46. Pinczewski LA, Salmon LJ, Jackson WFM, et al. (2008)
Radiological landmarks for placement of the tunnels in
single bundle reconstruction of the anterior cruciate liga-
ment. J Bone Joint Surg Br 90-B:172–179
 Chapter 17

D. Longino, N. Clerk, P.J.

Fowler, J.R. Giffin
Technique in ACL reconstruction:
hamstring reconstruction

History a concurrent or staged osteotomy may be required.

Although magnetic resonance imaging (MRI) accu-

A
nterior cruciate ligament (ACL) reconstruc-
tion remains one of the most common pro-
cedures performed by orthopaedic surgeons.
Reconstructive techniques continue to evolve as
ongoing research advances our understanding of
the complexities of the native ACL. ACL recon-
struction with anatomical positioning of single-
bundle grafts using anteromedial portal drilling
techniques as well as a heightened interest in dou-
ble-bundle reconstruction are recent reflections
fl of
the ongoing attempt to replicate more accurately
the anatomy, biomechanics, and function of the
normal ACL.
rately diagnoses ACL rupture and identifies
fi con-
comitant meniscal or chondral injuries, it is not
routinely obtained prior to proceeding with sur-
gery, as it may unnecessarily delay treatment. Any
associated pathology in these structures will be
identifi
fied and treated at the time of arthroscopic
ACL reconstruction.
Patients routinely receive 1 g of cefazolin intra-
venously 30 min prior to the operation. If allergy
concerns dictate, vancomycin or clindamycin can
be substituted.
Surgical technique

Preoperative planning Patient positioning

In most cases, a thorough history and physical The patient is positioned supine on the operating
examination are suffi fficient to make the diagnosis table. An examination under anesthetic is per-
of complete ACL rupture. However, partial ACL formed. A lateral side post is placed at the level of
rupture, with sparing of some fibers
fi of either the the tourniquet, and a foot rest is used to place the
posterolateral or the anteromedial bundles, should knee in a self-supported position of 80–90° of flex-
fl
be suspected in individuals who present with a ion (Fig. 1). This is the working position for ten-
history typical for ACL injury and have asymmet- don harvest, notch preparation, and drilling of the
rical laxity on some, but not all, of the ACL stabil- tibial tunnel. A tourniquet is applied proximally on
ity tests (i.e., Lachman, anterior drawer, and pivot the thigh and set to between 250 and 300 mm Hg.
shift tests) when compared to the uninjured knee.
Care must be taken to identify any additional liga-
mentous laxity that may require repair or recon-
struction concurrently with ACL surgery.
Preoperative imaging includes (1) bilateral stand-
ing anteroposterior (AP) radiographs with the
knee in full extension and in 30° of flexion (tun-
nel view), (2) a lateral radiograph with the knee in
30° of flexion, and (3) a skyline view of the patel-
lofemoral joint. The tunnel view provides a gross
depiction of notch morphology. It also helps to
identify any subtle degenerative changes that may,
depending on the chronicity of the injury, predate
or have occurred subsequent to ACL rupture. If
any clinical or radiographic concern exists regard-
ing varus or valgus lower extremity alignment, 3-ft
standing views are obtained to determine whether Fig. 1 – Patient positioning.
196 The Traumatic Knee
The tourniquet is not routinely infl flated during the
case unless poor visualization is encountered sec-
ondary to bleeding.
Clippers are used to shave the knee from 5 cm
above the proximal pole of the patella to 5 cm dis-
tal to the tibial tubercle, taking care to incorporate
the areas of potential incisions for any meniscal
repairs. The locations for a standard superior-me-
dial outfl
flow portal and anteromedial and anterolat-
eral para-patellar portals are marked. Th The incision
for hamstring harvest and drilling of the tibial tun-
nel is outlined approximately 2 cm in length and
one thumb breadth medial and slightly distal to the
tibial tubercle (Fig. 2). The hamstring tendons can
often be palpated in this area, and care should be
taken to approximate the proximal extent of the
incision such that the tendons can be visualized and
approached slightly proximal to their insertion.
The leg is washed and the sites of proposed incisions
are pre-injected with 20 mL of 0.25% sensorcaine
with 1:200,000 (5 mg/mL) epinephrine. Intra-artic-
ular injection is avoided. The leg is prepped with a
chlorhexidine solution and allowed to air-dry before
sterile drapes are applied. An iodophor-impregnated
adhesive drape is then applied to the surgical site.
Graft harvest
A 10 blade is used to incise the skin. Elevation of
the skin edges with two rakes facilitates subcu-
taneous dissection, performed with a 15 blade.
The sartorial fascia is identifi
fied, and the graci-
lis and semitendinosus tendons should be easily
palpable. Toothed forceps lift the sartorial fascia,
proximal to the hamstring tendon insertion, ante-
Fig. 2 – Sites of arthroscopy portals and graft harvest incision.
riorly away from the underlying tibia. A 15 blade
or Metzenbaum scissors are used to puncture the
sartorial fascia. A bursal plane is opened between
the elevated sartorial fascia, with the semitendi-
nosus and gracilis tendons adherent to its under-
surface, and the underlying fibers
fi of the superfi
fi-
cial medial collateral ligament (MCL). A retractor
is placed within this plane to retract the sartorial
fascia medially.
The gracilis tendon is the proximal of two tendons
visualized on the underside of the retracted sarto-
rial fascia. It is retrieved from the wound with a
tendon hook leaving it attached at its distal inser-
tion. Any attachments or bands to the overlying
fascia are cut under direct visualization with scis-
sors. Care is taken not to blindly run the scissors
up the superior surface of the tendon as this may
risk damage to the saphenous nerve. Fingertip
palpation of the tendon confirmsfi it has been ade-
quately freed of adhesions. An open-ended tendon
harvester is then used to harvest the gracilis ten-
don taking care to strip directly in line with the
orientation of the tendon (Fig. 3).
Gentle, steady pressure is used to advance the har-
vester while avoiding the temptation to pull exces-
sively on the distal tendon. Should significant
fi resis-
tance be encountered, the harvester is removed
and the tendon rechecked for any residual fascial
attachments. Once the tendon has been stripped
from the muscle belly and pulled free of the wound,
the tendon stripper is carefully removed along the
same orientation, as it was inserted to minimize
the risk of inadvertent damage to adjacent neuro-
vascular structures. The semitendinosus tendon is
harvested in a similar fashion. Care must be taken
to identify and cut a large band of tissue, present
in most individuals, originating from the medial
head of the gastrocnemius and attaching to the
semitendinosus tendon just proximal to its tibial
insertion. Failure to release this band can result in
premature amputation of the graft.
A 15 blade is used to peel the common insertion of
both tendons as a unit off ff the proximal tibia. The
graft is immediately placed in a bowl of saline and
transferred to the back table for preparation.
Fig. 3 – Gracilis harvest with tendon stripper.

Graft preparation
Even in short-stature patients, the hamstrings are
usually of suffi
fficient length to allow a quadruple
tendon graft of at least 10–12 cm in length. By
utilizing an anteromedial portal for drilling, fem-
oral tunnel lengths between 35 and 40 mm are
consistently achieved. The 15 mm second-genera-
tion (continuous loop) EndoButton CL (Smith &
Nephew Endoscopy Inc., Andover, Massachusetts)
serves to maximize the length of graft present
within the femoral tunnel.
A preloaded EndoButton CL can be used or one
can be loaded with a 0 absorbable monofilament
fi
flipping suture on one end and two number 2
braided composite polyester pulling sutures on the
other. The EndoButton is mounted in the Acufex
GraftMaster II Table (Smith & Nephew Endoscopy
Inc., Andover, Massachusetts), and the two ten-
dons, still attached at their pes anserine conflu-
fl
ence, are placed through the continuous loop of
the EndoButton. A number 1 absorbable suture
locks the free ends of the tendons together under
equal tension and attaches them to the GraftMas-
ter. The tendon ends opposite the EndoButton are
whip-stitched together with a non-locking baseball
stitch using a number 2 braided composite poly-
ester suture. The whip stitch need only extend a
quarter of the length of the graft to ensure no non-
absorbable suture will remain within the knee joint
once the graft is passed. The remainder of the graft
is tubularized using a whip stitch of 2.0 absorbable
suture that serves to ease graft passage. The graft
is then passed through a series of calibrated cyl-
inders to determine its diameter in 0.5-mm incre-
ments. A moist sponge covers the graft after it has
been tensioned to 20 lb (Fig. 4).
Diagnostic arthroscopy and notch preparation
A standard three-portal technique is utilized, with
two main para-patellar tendon working portals
and a superior medial portal created for an outflow
fl
cannula. The anteromedial and anterolateral por-
tals are made in a vertical fashion with an 11 blade.
The anterolateral portal is placed slightly higher
Fig. 4 – Graft tensioning after final preparation in the Acufex GraftMaster II.
Technique in ACL reconstruction: hamstring reconstruction 197
than the anteromedial portal to aid visualization
during preparation and drilling of the tibial tun-
nel. The anteromedial portal should hug the patel-
lar tendon and be just proximal to the level of the
medial meniscus in order to give instruments the
best access for notch debridement. Occasionally,
an accessory medial portal is required for femoral
tunnel placement while viewing through the anter-
omedial portal. A diagnostic arthroscopy is per-
formed and additional joint pathology addressed.
An effffort is made to preserve any intact functioning
fibers of the ACL during notch debridement. Often
the residual ACL stump has scarred to the posterior
cruciate ligament (PCL). Sufficient
ffi tissue is removed
to allow unimpeded access to the femoral insertion
of the ACL. Leaving some residual fi fibers of the
native ACL, however, may have some benefits. fi The
presence of these can aid in correctly identifying
the location of the tibial insertion site. Addition-
ally, these fibers in theory act as a source of vascular
ingrowth to revascularize the tendon graft and serve
to seal the aperture of the tibial tunnel, preventing
tunnel exposure to synovial fluid,fl a potential bio-
logical contributor to tunnel widening (1).
Femoral tunnel preparation
A 4.5-mm full radius shaver is used to debride the
remnants of the femoral attachment of the native
ACL to the lateral femoral condyle. Only the femo-
ral footprint of anteromedial and posterolateral
bundle attachments of the ACL need to be cleared
(Fig. 5). Limiting the amount of soft tissue strip-
ping to this focal area provides visual feedback to
the surgeon on the ideal placement of the femoral
tunnel, regardless of the knee flexion angle.
It has also been suggested that anatomic landmarks
such as the lateral intercondylar ridge and lateral
bifurcate ridge can aid in identifying these inser-
tion sites (2). These landmarks may not be obvi-
Fig. 5 – Debridement of the lateral wall is limited to the ACL femoral inser-
tion site.
198 The Traumatic Knee

ous in all individuals (depending on from which The graft is marked in two locations from its proxi-
portal the lateral wall is visualized from) and may mal extent (EndoButton). The Th first mark corre-
be distorted with notch wall debridement using sponds to the length of the femoral tunnel as read
a mechanical shaver. Furthermore, descriptions from the 4.5-mm calibrated drill or depth gauge. The
Th
of the femoral insertion site anatomy based on a second mark is the length of the femoral tunnel plus
clock face (10 o’clock for right knee and 2 o’clock 10 mm, which roughly corresponds to the flipping
for the left knee) that have become popular in the distance required by the EndoButton. These
Th mark-
literature are ambiguous and vary depending on
the degree of knee flexion and the surgeon’s point
of reference (e.g., back or front of the notch) at the
time of surgery. We now routinely visualize the
most posterior aspect of the femoral notch to iden-
tify the proximal extent of the articular cartilage on
the lateral femoral condyle. With the knee in 90° of
flexion, our starting position for the femoral tun-
nel in most cases is positioned 4–5 mm (depending
on graft diameter) forward from this landmark.
Once this position has be identified fi and cleared,
a 45° Steadman awl is used to mark the starting
point of the femoral tunnel (Fig. 6). The Th position of
the tunnel is somewhat eccentrically placed toward
the anteromedial portion of the native ACL femo-
ral insertion. Prior to drilling, correct poisoning Fig. 6 – Starting hole placement as viewed from the anterolateral portal
of this point is confi firmed by placing the arthro- with the knee in 90° of flexion.
scope in the anteromedial portal, which provides a
broader view of the posterior aspect of the lateral
femoral condyle (Fig. 7).
Depending on graft diameter, an appropriate size
femoral off ffset guide (usually a 4- or 5-mm) is placed
through the anteromedial portal (Fig. 8). Th The knee
is then flexed greater than 130° while maintaining
visualization of the position of the off ffset guide in
relation to the previously marked starting point.
While off ffset guides are not necessary, we have
found them useful in protecting the medial femo-
ral condyle while drilling the guidewire as well as
in directing the guidewire through the portal in
order to gain adequate femoral tunnel length. A
2.7-mm Beath pin is drilled out the lateral cortex
of the femur and snapped with a Kelly. With the Fig. 7 – Starting hole placement as viewed from the anteromedial portal
knee remaining in a hyperflexedfl position, the off
ff- with the knee in 90° of flexion.
set guide is removed and a final
fi check is made that
the guidewire position will allow femoral tunnel
creation without breaching the posterior or infe-
rior aspect of the lateral femoral condyle.
A calibrated 4.5-mm EndoButton drill is passed over
the Beath pin. The depth at which the 4.5-mm drill
passes through the lateral femoral cortex is noted. If
required, a cannulated depth gauge can also be used
to confifirm tunnel length. The appropriately sized
calibrated femoral drill is drilled over the Beath pin
to 7 mm short of the lateral femoral cortex. This
drill is advanced manually, the last few millimeters
in reverse to avoid breaching the cortex. A loop of 0
non-absorbable suture is threaded through the Beath
pin. The pin and one end of the suture are retrieved
from the lateral femur. The shaver is used to clear the Fig. 8 – Femoral offset guide for femoral tunnel guidewire placement
notch and femoral tunnel of any residual reamings. placed through the anteromedial portal.
 Technique in ACL reconstruction: hamstring reconstruction 199

ings can be visualized arthroscopically at the time

of graft passage to judge if the graft is adequately
positioned to allow the EndoButton to flip.

Tibial tunnel preparation

An Acufex tibial elbow drill guide (Smith & Nephew
Endoscopy Inc., Andover, Massachusetts) set at 45°
of inclination is inserted through the anteromedial
portal. Care is taken to place the tibial tunnel ante-
riorly in the ACL footprint, corresponding more to
the site of anteromedial fiber insertion. Typically,
some residual fibers of the native ACL tibial inser-
tion remain after notch debridement to aid guide Fig. 9 – Acufex tibial elbow drill guide positioned for drilling of the tibial
placement on the tibia. If these are not present, tunnel guidewire.
one should position the guide to a point in line with
the posterior border of the anterior horn of the lat-
eral meniscus in the sagital plane and just medial to
the midpoint between the medial and lateral tibial
spines in the coronal plane (Fig. 9). The starting
point for the drill should be just lateral to the ante-
rior fibers of the superfi ficial MCL. The guidewire is
advanced until its tip is visualized within the joint.
It is advanced 2 cm further using a mallet. Th The
guidewire should not impinge on the PCL, the wall
of the notch, or the roof of the notch as the knee
is extended. Guide pin position is confirmedfi with
intra-operative fluoroscopy. The pin should mirror
the slope of the medial tibial spine on the AP view
(Fig. 10) and run slightly posterior but parallel to
Blumensaat’s line on the lateral view (Fig. 11).
The scope is reintroduced into the knee, and the tib-
ial tunnel is drilled using the appropriate graft tun-
nel sizer as a protecting sleeve. Any residual debris
in the tunnel is cleared with the shaver, and a rasp is Fig. 10 – Intra-operative AP fluoroscopy of tibial guidewire.
used to smooth its posterior aspect. A crochet hook
is used to retrieve the previously passed non-absorb-
able suture from the tibial tunnel. The periosteum
just distal to the tibial tunnel is incised with cautery
and cleared with a curette to allow the graft to be
stapled directly to the anterior aspect of the tibia.

Graft passage
The EndoButton sutures are shuttled through the
knee using the previously passed non-absorbable
suture, and the graft is advanced into the knee. The
Th
EndoButton is flipped, and with manual tension on
the distal end of the graft, the knee is cycled. Th
The
arthroscope is reinserted into the knee. The graft is
visualized while the knee is brought into full exten-
sion to ensure it does not impinge against the roof
of the notch. With the knee in 90° of flexion, a tri-
angular space should be visible at the apex of the
notch (3). The boundaries of the triangle consist of
the roof of the notch, the anteromedially directed Fig. 11 – Intra-operative lateral fluoroscopy of tibial guidewire.
200 The Traumatic Knee
Fig. 12 – Probe within the triangular space as viewed from the anterolat-
eral portal with the knee in 90° of flexion.
fibers of the PCL, and the posterolaterally directed
fibers of the ACL graft (Fig. 12). The presence of
this triangle confirms
fi correct femoral tunnel
placement and subsequent ACL graft orientation
to avoid PCL impingement.
Graft fixation
Th graft is then manually tensioned to 20 lb and
The
fixed distally to the tibia in 0° of knee flexion with
a 3M stabilizer gun and 5 staples (Fig. 13). If the
graft tapers creating a graft tunnel mismatch, an
Fig. 13 – AP radiograph showing femoral and tibial fixation.
interference screw can be utilized or the sutures
can be posted for additional fixation.
fi An examina-
tion under anesthetic is repeated to ensure any lax-
ity has been corrected.
The passing sutures are retrieved from the femur and
the tibial incision is irrigated and closed with inter-
rupted 2.0 absorbable suture followed by a running
3.0 absorbable stitch and steristrips. The superome-
dial outfl
flow cannula is used to insert an intra-artic-
ular drain. The portals are injected with 20 mL of
0.25% sensorcaine with 1:200,000 epinephrine, and
sterile dressings and cooling devices are applied.
Pearls
Femoral insertion site visualization
Poor visualization of the femoral ACL insertion site
can be frustrating and lead to compromises in tun-
nel positioning. Portal placement is important, as
an anterolateral viewing portal that has been placed
too far lateral can cause or exacerbate this situation.
An individual with a narrow notch, sometimes pre-
dicted based on the preoperative tunnel view, can
also present this dilemma. While uncommon, a
conservative notchplasty in this latter case may be
warranted. Alternatively, one can consider using a
standard anteromedial portal to view and an acces-
sory medial portal to drill the femoral tunnel.
Femoral tunnel preparation
Historically, techniques in ACL surgery have been
developed around creating a more non-anatomical
(isometric) ACL reconstruction (4). More recently,
there has been a realization that replication of the
anatomical insertion sites of the native ACL may be
paramount to success. Traditionally, single-bundle
techniques have focused on reproduction of the
anteromedial bundle of the ACL, with trans-tibial
drilling of the femoral tunnel being the most com-
mon technique used during reconstruction. Trans-
tibial drilling techniques, however, dictate femoral
socket starting position and have the potential to
cause femoral tunnel placement too high in the
intercondylar notch (5). The ability to consistently
reproduce an anatomic femoral insertion site may
only occur if one is willing to accept a more poste-
rior position of the tibial tunnel (6). This compro-
mise in tunnel position, being more representative
of the tibial insertion of the posterolateral bundle
of the ACL than that of the anteromedial bundle, is
likely to have deleterious eff
ffects on graft function
(7,8). For this reason it is strongly recommended

that drilling of the femoral tunnel be performed
through the anteromedial portal (or a rear entry
guide system), which allows easy access to the ACL
insertion on the lateral femoral condyle indepen-
dent of tibial tunnel location.
It is also recommended that the final reamer for the
femoral tunnel be passed over the Beath pin and
drilled manually. This reduces the risk of damage to
the medial femoral condyle and PCL during drill pas-
sage. The femur can also be scored a few millimeters
to determine the amount of the back wall that will
be preserved prior to reaming the remainder of the
tunnel. Finally, the technique minimizes the risk of
breaching the lateral femoral cortex when drilling.
Tibial tunnel preparation
Proper placement of the tibial guidewire is based
on a combination of intra-articular landmarks,
absence of graft impingement with knee motion,
and intra-operative fluoroscopic imaging. Signifi fi-
cant guidewire malpositioning requires redrilling.
Smaller magnitude adjustments can be made using
a parallel pin guide. More commonly, however,
only a minor correction in guidewire placement,
on the order of 1–2 mm, is required. Th This can be
accomplished by overdrilling the original 2.7-mm
guidewire with the 4.5-mm cannulated EndoBut-
ton drill. The guidewire can now be eccentrically
positioned in this 4.5-mm bone tunnel. This
Th allows
an almost 2-mm modifi fication of guidewire place-
ment, in any direction, from its original location.
The repositioned 2.7-mm guidewire is impacted
into the notch to maintain its position prior to
overdrillling with the final
fi tibial tunnel drill.
Graft passage
Care is taken during graft passage to ensure that
the EndoButton is rotated in such a manner that
the flipping suture, when tensioned, will pull the
distal extent of the vertically oriented EndoButton
in a lateral direction. Because of the angle at which
it exits the femur, this will serve to minimize the
distance the EndoButton needs to be pulled out of
the lateral femoral cortex before it can be flipped.
Complications
Short graft
Amputating the graft prematurely at the time of
harvest can add signifi
ficant time and anxiety to the
Technique in ACL reconstruction: hamstring reconstruction 201
case. An extra 2–2.5 cm of graft material can be
obtained during harvest by releasing the common
insertion site of the two tendons on the anterior
tibia with a large sleeve of attached periosteum.
In some cases this can aff
fford enough extra length
to proceed with the reconstruction as planned.
An interference screw may, however, be required
for fixation on the tibia because insuffi
fficient graft
remains for staple fixation.
fi
Graft contamination
While extremely uncommon, graft contamination
during ACL reconstruction can occur, and to date,
no clear consensus has been reached regarding
appropriate management (9). Our current pro-
tocol requires the graft be soaked for 30 min in a
solution of 500 mL 0.9% normal saline containing
Penicillin G (2 million units), Bacitracin (50,000
units), and Gentamycin (80 mg). This
Th is followed
by serial dilution baths in normal saline to further
decrease the risk of contamination and cleanse the
graft of the initial antibiotic solution. Bacterial
swabs are then taken prior to implantation.
Lateral femoral cortex breach
If the lateral femoral cortex is breached with the
final femoral reamer one may (a) still attempt to
use EndoButton fixation if the tunnel diameter is
6.5 mm or less as the EndoButton will often still
engage on the lateral the cortex, (b) use an Xten-
dobutton (XtendoButton™, Smith and Nephew,
Corp., Andover, MA) or femoral interference screw
as alternative fixation, and (c) use a two-incision
technique to secure the sutures around a femoral
post.
Postoperative care
The patient is placed on protected weight-bearing
crutches for 2–4 weeks following surgery. If no
meniscal work has been performed, the patient
does not require bracing and may start range-of-
motion exercises immediately. Dressing change
and drain removal occurs on postoperative day one
in clinic. The patient is weaned offff crutches when he
or she demonstrates suffi fficient quadriceps function
and can walk unaided with a normal gait. Focus of
the first 3 months of rehabilitation is on obtain-
ing full range of motion with gentle strengthening
exercises. A more aggressive strengthening pro-
gram is instituted after 3 months when the graft
is more securely incorporated. Return to high-risk
202 The Traumatic Knee
sports can occur after 6 months of rehabilitation
at the earliest if strengthening and propriocep-
tive parameters have been maximized. Standard
follow-up visits occur at 2, 6, and 12 weeks postop-
eratively and then at 6, 12, and 24 months prior to
release from care.
References
1. Wilson T, Kantaras A, Atay A, et al. (2004) Tunnel enlarge-
ment after anterior cruciate ligament surgery. Am J Sports
Med 32(2):543–549
2. Ferretti M, Ekdahl M, Shen W, et al. (2007) Osseous land-
marks of the femoral attachment of the anterior cruciate
ligament: an anatomic study. Arthroscopy 23(11):1218–
1225
3. Lawhorn K, Howell SM (2008) Avoiding ACL graft
impingement: principles for tunnel placement using the
transtibial tunnel technique. In: Jackson DW, editor. Mas-
ter techniques in orthopaedic surgery: reconstructive knee
surgery. Philadelphia: Lippincott Williams & Williams
4. Zavras T, Race A, Bull AM, et al. (2001) A comparative
study of ‘isometric’points for anterior cruciate ligament
graft attachment. Knee Surg Sports Traumatol Arthrosc
9:28–33
5. Golish S, Baumfeld J, Schoderbeck RJ, et al. (2007) The Th
eff
ffect of tibial tunnel starting position on tunnel length
in anterior cruciate ligament reconstruction: a cadaveric
study. Arthroscopy 23(11):1187–1192
6. Pombo M, Kopf S, Irrgang J, et al. (2008) The ability of
transtibial tunnel drilling in ACL reconstruction to restore
the anatomic femoral insertion site: a prospective study.
Pittsbg Orthop J 19:95
7. Ekdahl M, Nozaki M, Ferretti M, et al. (2008) Healing and
biomechanical properties of tendon grafts using differ- ff
ent ACL reconstruction techniques: a goat model. Pittsbg
Orthop J 19:78–79
8. Ekdahl M, Nozaki M, Ferretti M, et al. (2008) TheTh eff ffect
of tunnel placement on bone-tendon healing of anterior
cruciate ligament reconstruction in a goat model. Pittsbg
Orthop J 19:80–81
9. Izquierdo R, Cadet E, Bauer R, et al. (2005) A survey of
sports medicine specialists investigating the manage-
ment of anterior cruciate ligament grafts. Arthroscopy
21(11):1348–1353

D.R. McAllister, T.Y. Wu Technique in ACL reconstruction:
patellar tendon
Definition
fi
T
his chapter will describe in detail arthroscop-
ically assisted single-incision anterior cru-
ciate ligament (ACL) reconstruction using
bone-patellar tendon-bone graft.
History
Surgical treatment of ACL tears has evolved
over the past century, with primary repair done
as early as about 1900. Poor results including
recurrent instability eventually led to attempts
at reconstruction in the 1970s, firstfi with extra-
articular procedures. Some of these procedures,
such as the MacIntosh 1 and the Ellison proce-
dure, made use of the iliotibial band. Results of
these procedures were inconsistent, with a high
incidence of arthrofifibrosis, leading to a transition
to more anatomic intra-articular reconstructions
in the 1980s using a variety of grafts, including
iliotibial band, bone-patellar tendon-bone, and
hamstrings. Synthetic grafts made of such mate-
rials as polypropylene and Gore-Tex were also
used. However, failure rates were high because
they either stretched out or fragmented over
time, causing recurrent sterile effusions,
ff pain,
and instability (1).
Advances in technology in the 1980s allowed a
transition from open to arthroscopically-assisted
reconstruction. Bone-patellar tendon-bone grafts
and, to a lesser extent, hamstring grafts became
grafts of choice. Initially, a two-incision technique
was used, with an anterior tibial incision and a
lateral femoral incision. Each end of the graft
was fixed through each of these incisions. Devel-
opment of arthroscopic guides and instruments
allowed the popularization, in the early 1990s, of
the single-incision technique, in which the femoral
tunnel drilling and femoral fixation
fi are performed
intra-articularly (1). Th
This technique has remained
the technique of choice for many surgeons and is
described here with use of bone-patellar tendon-
bone graft.
Chapter 18
Indications
Reconstruction of the ACL is indicated in those
patients with symptomatic instability and those
who plan on returning to sporting activities that
involve cutting and pivoting. Such activities place
the ACL-defificient knee at signifi
ficant risk for fur-
ther intra-articular injury.
Contraindications
Contraindications for ACL reconstruction include
active infection, signifi
ficant arthritis, and medical
conditions making the surgical risk unacceptably
high.
Preoperative physical findings
fi
Physical findings in an ACL-defi ficient knee include
positive Lachman’s, anterior drawer, and pivot
shift tests.
Lachman’s test is performed with the knee in
20–30° of flexion. An anterior translation force is
placed on the proximal tibia while the distal femur
is stabilized by the examiner’s other hand. The Th
amount of translation of the tibia and the firm- fi
ness of the endpoint are assessed. Translation is
measured as the amount of increase in millimeters
compared to the normal contralateral side. The Th
anterior drawer test also involves anteriorly trans-
lating the proximal tibia, but with the knee in 90°
of flexion and the foot stabilized. An ACL-defificient
knee typically has a variable amount of increased
translation with no firm endpoint on Lachman’s
test. Anterior drawer testing is not very accurate
for ACL defi ficiency and may or may not be positive
with an ACL tear.
The pivot shift test is performed by placing a valgus
stress on the knee with axial loading and internal
rotation of the tibia while flexing the knee from an
extended position. The subluxed lateral plateau of
the tibia shifts to a reduced position relative to the
femur at about 30° of flexion, giving a positive test.
204 The Traumatic Knee

The test is graded as follows: 0 – negative, 1 – posi-

tive for a glide, 2 – positive for a clunk, 3 – positive
for a gross clunk.

Imaging and other diagnostic studies

Imaging studies include x-rays and MRI. X-rays may
reveal a pathognomonic lateral capsular avulsion of
the proximal tibia, or Segond’s fracture. They may
also reveal degenerative changes, malalignment,
tibial eminence avulsion in younger patients, and
acute fractures of the proximal tibia or distal femur.
MRI is highly accurate in detecting ACL tears. In
addition, it is useful for evaluating associated inju- Fig. 1 – Operative extremity after prepping and draping. Note that the
ries to the menisci and chondral surfaces as well as thigh is exposed to as proximally as possible.
bone bruises.
KT-1000 instrumented laxity testing may be used can become positive with the patient relaxed under
to supplement the clinical exam. However, we do general anesthesia. A complete ligamentous exam-
not routinely use it. ination of the knee is always performed, including
posterior drawer testing, varus and valgus laxity
testing at 0° and 30° of flexion
fl and assessment of
external rotation of the tibia on the femur at both
Surgical technique 30° and 90° of flexion.

Preoperative planning
Graft harvest
Surgical timing is a key consideration in ACL recon-
struction. To reduce risk of poor postoperative If examination under anesthesia confi firms an
range of motion (ROM), reconstruction should not ACL tear, as it does in most cases, graft harvest
be performed until full ROM is regained and the commences after preparation and draping of the
eff
ffusion resolves. This typically takes 2–4 weeks of aff
ffected extremity. In the rare cases when diagno-
physical therapy after acute injury. sis is still not defi
finitive, diagnostic arthroscopy is
performed prior to graft harvest.
Graft harvest is performed without infl flating the
Positioning of the patient tourniquet. A 5-cm-longitudinal incision is marked
from 1 cm medial to the inferior pole of the patella
Th patient is positioned supine on the operating
The to 1 cm medial to the center of the tibial tubercle.
table. An examination under anesthesia is performed. The superolateral, anteromedial, and anterolat-
The lower extremity is shaved from mid-thigh to
Th eral arthroscopic portals are also marked (Fig. 2).
mid-leg over the entire anterior, medial, and lateral
sides. A tourniquet is placed as proximally as possible
on the thigh. A post is placed lateral to the thigh to
assist in creating a valgus stress during visualization
of the medial compartment during arthroscopy. The Th
lower extremity is then prepared and draped, mak-
ing sure that the thigh is exposed to as proximally as
possible (Fig. 1). A first-generation cephalosporin is
administered prophylactically just prior to starting
the surgical portion of the procedure.

Examination under anesthesia

Lachman’s, anterior drawer, and pivot shift tests
are performed after general anesthesia has been
established. The pivot shift often cannot be elic- Fig. 2 – The graft harvest incision as well as the superolateral, anterome-
ited due to guarding with the patient awake but dial, and anterolateral arthroscopic portals are marked.

Twenty cubic centimeters of a one-to-one mixture
of 0.5 % lidocaine with epinephrine and 0.25 %
bupivacaine are injected into the incision intrad-
ermally and subcutaneously. Th The portal sites are
injected with an additional 20 cm3 of local anes-
thetic (Fig. 3).
Sharp dissection is used to incise the skin and
subcutaneous fat down to the level of the patel-
lar tendon paratenon. The paratenon is separated
from the subcutaneous tissue by blunt finger dis-
section with a sponge. It is incised in the midline
and separated from the underlying patellar tendon
using a scalpel (Fig. 4). Proximally, the prepatellar
bursal tissue is opened longitudinally and reflected
fl
to facilitate exposure of the patella. The
Th width of
the tendon is measured with a ruler (Fig. 5). A scal-
pel is used to harvest the central 1/3 or 10 mm of
the tendon, whichever is smaller. Care is taken to
stay parallel to the tendon fibers.
fi It is helpful to
have the knee in enough fl flexion so that the ten-
don fibers are straight due to tension. A scalpel is
used to mark the bone cuts on the tibial tubercle
and patella, aiming for bone plugs 25 mm in
length (Fig. 6). An oscillating saw is used to make
the bone cuts. On the tibial tubercle, the goal is to
Fig. 3 – Injection of local anesthetic.
Fig. 5 – Measurement of the width of the patellar tendon.
Technique in ACL reconstruction: patellar tendon 205
create a bone plug that is trapezoidal in shape. Th
The
medial cut is created with the saw perpendicular
to the surface of the bone. The lateral cut is angled
in medially about 20° relative to the medial cut.
The medial, lateral, and distal cuts are each of a
depth of 15 mm. The bone plug is then freed using
a curved osteotome without the use of a mallet. On
the patella, the goal is to create a bone plug that
has a triangular profile.
fi Therefore, the medial and
lateral cuts are angled in 45° and made to a depth
of 10–12 mm (Fig. 7). Ideally, the cuts should meet
and the bone plug should easily separate from the
patella. Osteotomes are not used on the patella.
The graft is carefully dissected free from the under-
lying fat pad and taken to the back table for prepa-
ration (Fig. 8).
Graft preparation
A rongeur and, if necessary, an oscillating saw are
used to shape the bone plugs such that they fi
fit into
a 10-mm-diameter sizing tube (Figs. 9 and 10).
Removed bone is saved for later grafting of the
patellar defect. The length of the tendon portion
Fig. 4 – Incision of the paratenon exposing the patellar tendon.
Fig. 6 – The bone cuts are marked using the scalpel.
206 The Traumatic Knee
Fig. 7 – An oscillating saw is used to make the bone cuts.
Fig. 9 – A ronguer is used to shape and size the bone plugs.
of the graft is measured. While the graft may be
placed in either orientation, placement of the tibial
plug into the femoral tunnel and the patellar plug
into the tibial tunnel is preferred. Loss of fixation,
fi
although rare, is more likely in the tibial tunnel.
Therefore, the patellar plug, which is denser than
Th
the tibial plug, is used in the tibial tunnel to maxi-
mize purchase with the interference screw. Once
the orientation is chosen, one drill hole is placed
in the plug going into the femoral tunnel. Two drill
holes are placed in the plug going into the tibial
tunnel, and the holes are oriented perpendicular to
each other to minimize risk of both sutures being
cut during interference screw insertion (Figs. 11
and 12). A number 5 Ethibond (Ethicon, Somer-
ville, NJ) suture is then placed through each drill
hole using a Keith needle. Th The bone-tendon junc-
tion on the side going into the femoral tunnel is
marked with a sterile marker to help with visual-
ization during graft insertion (Fig. 12). The graft
is once again passed through the sizing tube to
ensure fit.
fi The graft is wrapped in a sponge moist-
ened with saline and set aside.
Fig. 8 – Harvested graft on back table with ruler adjacent to it.
Fig. 10 – The sizing tube is used to ensure fit of the bone plugs into a
10-mm-diameter tunnel.
Diagnostic arthroscopy
A diagnostic arthroscopy is then performed
to assess and address any other intra-articular
pathology. We use a superolateral outflow
fl portal.
The anteromedial and anterolateral portals are
made immediately adjacent to the patellar tendon
to make access to the femoral notch easier. The
anteromedial portal is made through the graft har-
vest incision.
ACL debridement and notchplasty
The extremity is exsanguinated and a tourniquet
is infl
flated to 300 mm Hg to decrease bleeding and
improve visualization (Fig. 13). With the leg hang-
ing over the side of the table at about 90° of knee
flexion, a bump is placed under the thigh with
space between the bump and the posterior knee.
This helps to ensure that the posterior neurovascu-
lar structures fall away from the notch while work
is being done there (Fig. 14). A handheld motor-

Fig. 11 – Drilling of holes for suture in bone plugs.
Fig. 13 – Exsanguination of the operative extremity before tourniquet
inflation.
ized shaver is used to debride the remaining ACL
(Fig. 15). Care is taken not to damage the posterior
cruciate ligament (PCL). Enough of the tibial foot-
print should be left to help guide proper placement
of the tibial tunnel. All soft tissue should be deb-
rided from the lateral and superior aspects of the
notch back to the over-the-top position (Fig. 16).
A bur is used to perform a notchplasty as needed.
The goal of the notchplasty should be to provide
full visualization of the over-the-top position,
including removal of “resident’s ridge” anterior to
it, and ensure suffi
fficient room for the graft to pre-
vent impingement (Fig. 17).
Localization of femoral tunnel
Localization of the femoral tunnel starting point is
done by measuring anteriorly from the over-the-
top position. The tip of an angled curette is placed
through the anteromedial portal exactly at the
Technique in ACL reconstruction: patellar tendon 207
Fig. 12 – Graft with sutures placed and bone-tendon junction on the side
going into the femoral tunnel marked with ink.
Fig. 14 – A bump is place under the thigh with space between the bump and
the posterior knee to help ensure that the posterior neurovascular structures
fall away from the notch while work is being done there.
over-the-top position at 11 o’clock on the clock face
of the notch for the right knee and 1 o’clock for the
left knee. The position of the shaft of the curette
is noted relative to the skin of the incision. The
curette is then moved 6 mm anteriorly (Fig. 18).
The location of the tip of the curette is marked by
gouging out a small amount of bone (Fig. 19). Th This
will serve as the point of entry into the femur for
creation of the femoral tunnel. Reaming using the
cannulated 10-mm reamer will result in a back wall
of 1 mm. We find this technique to be more reli-
able for creating proper femoral tunnel location
compared to the used of the over-the-top offset ff
femoral guide.
Tibial tunnel
The angle on a “point-to-elbow” aimer (Acufex
Director Elbow Aimer, Smith & Nephew, Andover,
MA) is set according to the N + 7 rule : the degree
208 The Traumatic Knee

A B
Fig. 15 – (A) ACL remnant. (B) Debridement using a handheld motorized shaver.

Fig. 16 – View of notch after ACL debridement. Note that the over-the-top Fig. 17 – Notchplasty using a bur is performed as needed to ensure full
position is clearly visible posteriorly. The PCL is visible medially. visualization of the over-the-top position as well as sufficient
ffi room for the
graft to prevent impingement.

Fig. 18 – Localization of the femoral tunnel starting point. Fig. 19 – The femoral tunnel starting point is marked by gouging out a
small amount of bone using a curette.
 Technique in ACL reconstruction: patellar tendon 209

Fig. 20 – Tibial tunnel guide pin placement. Entry point into the joint is just
posterior to the center of the ACL footprint.

number is set to 7 higher than the length of the

tendinous portion of the graft in millimeters
(2). The guide arm is then inserted through the
anteromedial portal. The guide is positioned such
that the drill will enter the joint just posterior to
the center of the tibial footprint. Th This should be
roughly 7 mm anterior to the PCL and aligned with
the posterior edge of the anterior horn of the lat- Fig. 21 – Tibial guide pin angulation should allow drilling of the femoral
eral meniscus. Note that the drill will aim for the tunnel through the tibial tunnel.
laser line at the elbow and not the tip of the guide
arm. The oblique orientation of the guide should
be adjusted so that the path of the guide pin to be
drilled and thus the tibial tunnel will point from
the entry point on the anteromedial proximal tibia
toward the femoral tunnel starting point. To avoid
graft-tunnel mismatch, the length of the tunnel
as measured from the calibrated tibial drill guide
should be at least 2 mm greater than the tendon
graft length, based on the N + 2 rule (3). If the
tibial tunnel is too short, adjust by increasing the
angle setting of the guide. This will usually result in
a longer tibial tunnel.
Once satisfified with the guide arm tip position and
length and angle of the tibial tunnel, a guide pin is
placed (Fig. 20). The angulation of the guide pin is Fig. 22 – Drilling of the tibial tunnel. A large curette is used to control the
checked visually (Fig. 21). The
Th tibial tunnel is then tip of the guide pin during drilling.
created using the 10-mm cannulated drill. A cup is
used to collect the reamings for later use as bone
graft for the patellar defect. A large curette is used passed through the previously made tibial tunnel.
to control the tip of the guide pin during the drilling The Beath pin is then drilled through the femur
(Fig. 22). A rasp is used to smooth out the posterior and out the anterolateral thigh (Fig. 24). A can-
lip of the tibial tunnel entrance into the joint to pre- nulated reamer is used to create the femoral tun-
vent graft abrasion (Fig. 23). Soft tissue around the nel (Fig. 25). Reaming is stopped after the fi first
tibial tunnel entrance is removed using the shaver. 10 mm to confi firm maintenance of a 1- to 2-mm-
thick posterior wall (Fig. 26). If the tunnel is found
to be malpositioned, the Beath pin is withdrawn
Femoral tunnel and repositioned. If the tunnel position is found
to be adequate, reaming is performed to a depth of
A Beath pin is placed into the previously marked 30 mm. A large fragment AO screwdriver is placed
spot in the femoral notch. This can usually be through the anteromedial portal. It is impacted
210 The Traumatic Knee

to create a notch in the tunnel anteriorly to guide
interference screw placement (Fig. 27). Any bony
debris in the femoral tunnel is removed using a
handheld motorized shaver to help ease graft pas-
sage later.
In the case that the position of the tibial tunnel
does not allow the Beath pin to reach the desired
femoral tunnel entry point, the femoral tunnel can
be drilled through the anteromedial portal. TheTh
knee is placed into maximum fl flexion. The Beath

Fig. 23 – The posterior lip of the tibial tunnel is rasped to prevent graft Fig. 24 – The Beath pin has been placed transtibially into the femur.
abrasion.

Fig. 25 – Reaming of the femoral tunnel. Fig. 26 – Maintenance of a 1- to 2-mm back wall is confirmed before the
femoral tunnel is reamed to its full depth.

A B
Fig. 27 – (A) Creation of a notch in the femoral tunnel using a large-fragment AO screwdriver to guide interference screw placement. (B) Appearance of
femoral tunnel entrance after notching.
 Technique in ACL reconstruction: patellar tendon 211

pin is placed through the anteromedial portal
(Fig. 28A). Th
The femoral tunnel is otherwise created
as described above. After the tunnel is drilled, a
number 1 PDS (Ethicon, Piscataway, NJ) suture is
placed through the eyelet of the Beath pin and tied
to create a loop (Fig. 28B). The eyelet of the Beath
pin is then pulled into the femoral tunnel, and a
probe is used to retrieve the PDS loop through the
tibial tunnel. This loop will then be used to pass the
graft (Fig. 28C).

A B

Fig. 28 – (A) Alternative entry point for Beath pin through the antero-
medial portal. The knee is in maximal flexion. (B) Number 1 PDS suture is
placed through the eyelet of the Beath pin. (C) The suture is tied to create a
loop, and the loop is then retrieved through the tibial tunnel for use in graft
C
passage. (Medial incision is for concurrent meniscus repair.)
212 The Traumatic Knee

Fig. 29 – Graft passage. Fig. 30 – A guide wire for the femoral interference screw is placed through
the anteromedial portal between the bone plug and the femoral tunnel
anteriorly.
Graft passage
A scalpel is used to sharply excise the periosteum
around the entry into the tibial tunnel to ensure
smooth passage of the graft. TheTh suture on the
end of the graft intended for the femoral tunnel
is placed through the eyelet of the Beath pin, or
the loop of the PDS suture if the femoral tunnel
was drilled through the anteromedial portal. Th The
Beath pin is pulled using a chuck handle out the
anterolateral thigh to shuttle the suture through
the bone tunnels. The graft is then passed up the
tunnels into position using traction on the sutures
(Fig. 29). The bone plug should have its cancellous
side facing anteriorly. This
Th ensures posterior place-
ment of the graft at the femoral tunnel and also
reduces chance of graft laceration during interfer- Fig. 31 – Insertion of the femoral interference screw through the antero-
ence screw insertion. A hemostat can be used to medial portal.
rotate the graft as needed. The bone plug is left
slightly protruding from the femoral tunnel to ease (Fig. 32). If impingement is present, additional
placement of the guide wire in the next step. notchplasty may be required.

Femoral fixation Graft tensioning and cycling

With the knee in maximum flexion, a guide wire is
placed through the anteromedial portal and posi-
tioned between the graft and the tunnel anteri-
orly (Fig. 30). The graft is pulled further into the
femoral tunnel until it is flush with the surround-
ing bone. A 7- by 25-mm cannulated metal inter-
ference screw is then inserted over the guide wire
(Fig. 31). Care is taken to avoid cutting of the graft
tendon by the threads of the screw.
The scope is withdrawn from the knee. The knee is
then cycled 10 times between flexion
fl and exten-
sion while maintaining tension on the graft via
the sutures in the distal plug to reduce crimp in
the fibers (Fig. 33). During cycling, isometry of the
graft is assessed. It is normal for the graft to pull in
(i.e., tighter) a couple of millimeters over the ter-
minal 30° of knee extension.

Check for impingement
Th knee is ranged from flexion to extension
The
under arthroscopic visualization to check for any
impingement of the graft on the femoral notch
Tibial fixation
Tibial fixation is performed with the knee posi-
tioned in slight fl
flexion. Grafts that are less iso-
metric should be fifixed closer to full extension to
avoid excessive graft tension in extension after
 Technique in ACL reconstruction: patellar tendon 213

A B
Fig. 32 – Arthroscopic view of graft while the knee is ranged from flexion (A) to extension (B) to check for any impingement of the graft
r on the femoral notch.

Fig. 33 – The knee is cycled between flexion (A) and extension (B) while
A
maintaining tension on the graft to reduce crimp in the fibers.

fixation. A guide wire is placed between the graft Grafting of patella

and the tunnel to guide the interference screw.
Typically, the bone plug extends to the entrance
of the tibial tunnel, and the wire is placed poste-
rior to the plug to avoid fracture of the thin ante-
rior tunnel wall edge by the screw. While main-
taining enough tension on the graft to prevent it
from moving further into the tunnel, a 9 × 25 mm
metal interference screw is placed over the guide
wire (Fig. 34). We do not place a posterior drawer
force on the proximal tibia.
The knee is then ranged to check that there is
no loss of fixation. Lachman’s test is repeated to
confi
firm elimination of abnormal anterior laxity.
Bone from graft preparation, after morselization,
and reamings from the tibial tunnel are placed into
the patellar defect (Fig. 35).
Closure
Bursal tissue over the patellar defect is closed
using 0 Vicryl (Ethicon, Somerville, NJ) to pre-
vent migration of the bone graft. With the knee
flexed enough to take out slack in the tendon, the
patellar tendon defect is closed using 0 Vicryl.
214 The Traumatic Knee

Fig. 34 – Placement of the tibial interference screw. The knee is in slight Fig. 35 – Grafting of patellar defect.
flexion and tension is maintained on the graft.

The paratenon is closed using a running locked
3-0 Vicryl (Fig. 36). The
Th subcutaneous tissue is
closed using 2-0 Vicryl. A final layer of running
4-0 subcuticular Prolene (Ethicon, Somerville, NJ)
is placed. Mastisol adhesive is placed on the skin,
followed by steri-strips across the incision. The
Th
portals are closed using 4-0 Prolene.
Xeroform, sterile gauze, webril, and loosely
wrapped Coban are placed. The tourniquet is
defl
flated. A compression stocking is placed, fol-
lowed by a cold therapy pad and a brace locked in
extension (Fig. 37).
visualization of the back wall and to prevent
impingement of the graft on the superior and
lateral notch wall. Additional notchplasty after
insertion of the graft can be accomplished, but
this risks damage to the graft.
3. Do not bend pins – It is important not to bend the
guide pin for the tibial tunnel and the Beath pin
for the femoral tunnel. A bent pin can cause the
drill to cut the pin. While the Beath pin is going
through the knee, the flexion angle of the knee
should be maintained to avoid this problem.

Pearls and pitfalls

1. Saw orientation during graft harvest – To help
with orientation of the saw angle, the rotation
of the leg should be maintained such that the
patella faces up during bone cuts.
2. Adequate notchplasty – Although a large notch-
plasty is usually not needed, enough notch-
plasty should be performed to allow adequate

Fig. 37 – Operative extremity after placement of dressing, compression

Fig. 36 – Paratenon closure. stocking, cold therapy pad, and brace.

4. Do not cut graft with interference screw – Dur-
ing insertion of the femoral interference screw,
care must be taken to not cut the tendon graft
with the screw threads. This can be prevented
by having adequate visualization during screw
insertion.
Problem situations and solutions
Graft-tunnel mismatch
The N + 7 and N + 2 rules mentioned previously
are helpful for preventing graft-tunnel mismatch.
When mismatch does occur, the tendency is for
the graft to be too long. Solutions include femo-
ral recession of the graft by deepening the femoral
tunnel, twisting of the graft after femoral fi
fixation,
and folding of the graft. Femoral recession may
place the tendon at greater risk of being lacerated
during screw insertion. The graft can be twisted as
much as 540° degrees, providing 7–8 mm of short-
ening. Folding back of the plug for the tibial tunnel
onto the tendon graft can be performed in severe
cases of mismatch.
Alternatively, when a portion of the bone plug is
protruding from the tibial tunnel and thus not
available for interference screw fixation, the plug
A B
Fig. 38 – Postoperative AP (A) and lateral (B) x-rays.
Technique in ACL reconstruction: patellar tendon 215
can be stapled to the anteromedial proximal tibia
to re-enforce fixation.
Inablility to position Beath pin through tibial tunnel
The success of this operation is highly dependent
upon correct tunnel position. If for some reason
the correct tunnel position on the femur cannot
be reached through the tibia, an alternate tech-
nique should be used. As mentioned in the surgical
technique section, the Beath pin may be inserted
through the anteromedial portal with the knee in
maximum flexion.
Postoperative care
Patients are allowed immediate weight-bearing as
tolerated with crutches and with the brace locked
in extension. Physical therapy is begun immedi-
ately with emphasis on ROM, strengthening, and
patellar mobilization. Sutures are removed at 1
week postoperatively, and x-rays are obtained out
of the brace (Fig. 38). The
Th brace and crutches are
weaned at about 2 weeks, as the patient regains
quadriceps control. Stationary cycling can begin at
about the same time. Open-chain extension exer-
cises against resistance near full extension should
216 The Traumatic Knee
be avoided. Running can usually begin at 3 months
postoperatively, but no jumping, twisting, or piv-
oting. Return to pivoting or contact sports is usu-
ally at 8–9 months postoperatively.
Outcomes
Good results have been obtained with ACL recon-
struction using bone-patellar tendon-bone graft.
Multiple studies have reported patient satisfaction
rates of 91–98 %. Over 95 % of patients report
normal to near-normal knee function as far as
13 years from surgery (4). Mean side-to-side dif-
ference on KT-1000 testing has been consistently
reported to be less than 2 mm (5–8). Restoration to
a negative pivot shift test can be expected in over
90 % of patients, with rarely any patients having
more than a grade 1 pivot (5,7,9). Return to prior
sports level has generally been reported between
70 % and 90 % (8,10–12).
Complications
Complications include infection, graft failure, loss
of ROM, extensor mechanism disruption, and
anterior knee pain. Infection is seen in less than
0.9 % of patients (13). Graft failure rate is less than
5 % and is minimized by proper tunnel placement
as well as by ensuring that concurrent posterolat-
eral corner injuries are not missed (13). Re-oper-
ation for lack of ROM is minimized by ensuring
full ROM prior to reconstruction as well as super-
vised rehabilitation, which begins soon after sur-
gery. Patellar fracture and patellar tendon rupture
are fortunately relatively rare, with most studies
reporting no patients with extensor mechanism
disruption. Incidence of anterior knee pain can
be as high as 42 % (14), but is usually reported as
below 20 % (8,9,15,16). Pain is usually limited and
not signifificant enough to prevent high-level ath-
letic activity.
References
1. McCulloch PC, Lattermann C, Boland AL, et al. (2007) An
illustrated history of anterior cruciate ligament surgery. J
Knee Surg 20 (2) :95–104
2. Miller MD, Hinkin DT (1996) The “N + 7 rule” for tibial
tunnel placement in endoscopic anterior cruciate ligament
reconstruction. Arthroscopy 12 (1) :124–126
3. Miller MD, Olszewski AD (1997) Cruciate ligament graft
intra-articular distances. Arthroscopy 13 :291–295
4. Salmon LJ, Russell VJ, Refshauge K, et al. (2006) Long-
term outcome of endoscopic anterior cruciate ligament
reconstruction with patellar tendon autograft : mini-
mum 13-year review. Am J Sports Med 34 (5):721–732
5. Keays SL, Bullock-Saxton JE, Keays AC, et al. (2007) A
6-year follow-up of the eff
ffect of graft site on strength, sta-
bility, range of motion, function, and joint degeneration
after anterior cruciate ligament reconstruction : patellar
tendon versus semitendinosus and Gracilis tendon graft.
Am J Sports Med 35 (5):729–739
6. Liden M, Ejerhed L, Sernert N, et al. (2007) Patellar ten-
don or semitendinosus tendon autografts for anterior cru-
ciate ligament reconstruction : a prospective, randomized
study with a 7-year follow-up. Am J Sports Med 35 (5):
740–748
7. Pinczewski LA, Lyman J, Salmon LJ, et al. (2007) A 10-year
comparison of anterior cruciate ligament reconstructions
with hamstring tendon and patellar tendon autograft : a
controlled, prospective trial. Am J Sports Med 35 (4):564–
574
8. Sajovic M, Vengust V, Komadina R, et al. (2006) A prospec-
tive, randomized comparison of semitendinosus and gra-
cilis tendon versus patellar tendon autografts for anterior
cruciate ligament reconstruction : five-year follow-up. Am
J Sports Med 34 (12):1933–1340
9. Maletis GB, Cameron SL, Tengan JJ, et al. (2007) A pro-
spective randomized study of anterior cruciate ligament
reconstruction : a comparison of patellar tendon and qua-
druple-strand semitendinosus/gracilis tendons fi fixed with
bioabsorbable interference screws. Am J Sports Med 35
(3):384–394
10. Buss DD, Warren RF, Wickiewicz TL, et al. (1993)
Arthroscopically assisted reconstruction of the anterior
cruciate ligament with use of autogenous patellar-ligament
grafts : Results after twenty-four to forty-two months. J
Bone Joint Surg 75A:1346–1355
11. Heier KA, Mack DR, Moseley JB, et al. (1997) An analysis
of anterior cruciate ligament reconstruction in middle-
aged patients. Am J Sports Med 25:527–532
12. Sgaglione NA, Schwartz RE (1997) Arthroscopically
assisted reconstruction of the anterior cruciate ligament :
initial clinical experience and minimal 2-year follow-up
comparing endoscopic transtibial and two incision tech-
niques. Arthroscopy 13:156–165
13. Spindler KP, Kuhn JE, Freedman KB, et al. (2004) Ante-
rior cruciate ligament reconstruction autograft choice :
bone-tendon-bone versus hamstring : does it really mat-
ter ? A systematic review. Am J Sports Med 32 (8):1986–
1995
14. Shaieb MD, Kan DM, Chang SK, et al. (2002) A prospec-
tive randomized comparison of patellar tendon versus
semitendinosus and gracilis tendon autografts for ante-
rior cruciate ligament reconstruction. Am J Sports Med
30:214–220
15. Aune AK, Holm I, Risberg MA, et al. (2001) Four-strand
hamstring tendon autograft compared with patellar ten-
don–bone autograft for anterior cruciate ligament recon-
struction : a randomized study with two-year follow-up.
Am J Sports Med 29:722–728
16. Ejerhed L, Kartus J, Sernert N, et al. (2003) Patellar ten-
don or semitendinosus tendon autografts for anterior
cruciate ligament reconstruction? A prospective ran-
domized study with a two-year followup. Am J Sports
Med 31:19–25
 Chapter 19

G. Messerli, J. Ménétrey Place of navigation in anterior

cruciate ligament reconstruction

Fig. 1 – Knee prototyping.

Introduction

A
nterior cruciate ligament (ACL) reconstruc-
tion is one of the most frequently performed
major orthopedic procedures in the young
adult population. In North America, the incidence
of acute ACL tears is around 1/3000 per annum,
and more than 100,000 ACL repairs are performed
annually (1). The main goal of this surgery is to pro-
vide an excellent functional stability and a durable
reconstruction for an active and high-demanding
population.
Computer-assisted orthopedic surgery (CAOS) is a
recent concept defifined as the ability to utilize com-
puter algorithms to allow the surgeon to determine
three-dimensional (3-D) placement of implants in
situ. Misplacement of the femoral and tibial tun-
nels, which might cause graft failure or limited
knee range of motion, is the main reason for tech-
nical failure after ACL repair (2–7). Therefore,
Th the
major aim of CAOS is to avoid inconsistent place- ation of the robot and limb to the operating table
ment of graft tunnels during ACL reconstruction (8–10). There are also some systems where the sur-
by increasing the precision of these procedures. geons initiate the action of the robot and then the
system guided or restricted the surgeons’action as
planned on the preoperative imaging (11). Th Those
systems do not perform autonomously the surgical
act and can be named semi-active.
Defifinitions Passive systems do not perform any surgical action
by themselves. They are also called navigation sys-
Computer-assisted surgery (CAS) techniques have
tems, and their main goal is to provide information
been developed on the principle of stereotaxis,
to improve the conventional techniques or to guide
which permits the location of a structure in a plane the surgeon during a more demanding procedure.
coordinate system. First, neurosurgeons have used A new development of passive CAOS system is “the
CAS system for the location of brain tumor. custom templating technique” (Fig. 1). This
Th tech-
Computer-assisted orthopedic surgery (CAOS) nology use preoperative planning to produce 3-D
was an application of CAS to spine surgery in the template model specififics to one patient with rapid
first era and then has been extended to all other prototyping machines (12).
fields of orthopedic surgery, in particular to hip
and knee. CAOS techniques are no more a simple
stereostaxis system and now cover a large base of
applications in surgical practice, such as planning, History
simulation, guidance, assistance, and training.
The CAOS systems can be classifi
Th fied into active and We must give the credit to Claudius Galen (131
passive systems. The active system refers to a robot Pergamum, 205 Rome) for first describing the
able to perform alone a procedure under control of anatomy and the nature of the ACL. He mentions
the surgeon. In these cases, preoperative imaging them as “genu cruciata,” serving to stabilize joint
and intraoperative data are required, with rigid fi
fix- and to limit abnormal motion (13).
218 The Traumatic Knee
In 1850 Stark treated two patients with casts and
gave the description of an ACL rupture (14).The Th
first report of an ACL repair performed in 1898 is
published by Battle, in 1900 (15), but Mayo Robson
reported in 1903 an 8-year follow-up of an anterior
and posterior cruciate ligament suture using catgut
(16). The same year, Lange performs the first recon-
struction with the semi-tendinosus tendon (17).
The 1960s signed the beginning of the modern era
for the ACL reconstruction. Kenneth Jones (KJ)
used the medial third of the patellar tendon. Th The
graft was not detached from the tibia, and a plug of
patellar bone was set in a femoral tunnel (18). Major
disadvantage of this technique was shortness and
anterior placement of the graft. But Bruckner (19)
and Franke (20) improved it, drilling a tibial tunnel
and using a free transplant of patellar tendon end-
ing with tibial and patellar bone plugs. ThThe bone-
patellar tendon-bone (BPTB) autograft was borne.
In the 1980s, the modifiedfi KJ was back with the
accession of the arthroscopic surgery. Sixty-three
years after Takagi first introduced a cystoscope
in a knee, Dandy performed, in 1981, the fi first
arthroscopic ACL reconstruction (21).
Concerning CAS, the phenomenal progress in med-
ical imaging, especially the CT scan, introduced
the possibility to image-guided surgery. TheTh first
application was for brain surgery, and by exten-
sion, spine surgeons were quickly involved (22).
Then, hip and knee were gradually implicated. The
Th
first generation of CAS was active robots, and the
ROBODOC® system conceived in 1986 by Bargar
and Paul was used to assist surgeons in performing
part of a total hip replacement in 1992 (10). The Th
first generation of CAS application for ACL recon-
struction started 2 years later with the method
introduced by Dessenne (8) and Klos (9). CASPAR
(Computer Assisted Surgical Planning and Robot-
ics, ortho Maquet GmbH Co. KG, Rastatt, Ger-
many) was the first
fi active robot to drill tunnels
during ACL reconstruction procedures (23).
Active robots were progressively replaced by naviga-
tion systems also called passive systems. If the fi
first
navigation systems were based on imaging and used
CT scan, the second generation of CAS was image-
free system allowing real-time assistance surgery.
The next generation of CAS will be image-free sys-
tem with intelligent guidance and active robot.
ACL reconstruction analysis
Generality
The fact that ACL reconstruction is becoming the
first choice of treatment for ACL-defi
ficient knee
is now widely accepted around the world. If more
than 100,000 ACL repairs are realized annually (1)
in the United States, this popular procedure is per-
formed in the great majority by surgeons who do
less than 20 ACL reconstructions per year (24).
Function of the ACL plays a major role in the kine-
matics of the knee by stabilizing it in a wide range
of movements. The ACL injury usually generates
instability of the knee that will prevent a return to
the previous activity and change this cinematic in
consequence of the adaptation of other structures
to compensate the absence of the LCA, as demon-
strated by Berchuck and Andriacchi (25). Despite
this adjustment, mainly due to the muscles, this
modifification of the movement may, in time, result
in meniscus injury and cartilage lesion, motivating
a reconstruction surgery, as would tend to prove
the study by Dunn et al. (26). The choice of graft
and the precision of its location determine the bio-
mechanical qualities and the stability of the recon-
structed knee, as well as evolution and return to
previous activity level.
Although current techniques of ACL reconstruc-
tion can achieve an improvement in function, the
physiologic and biologic features of the normal
ACL are not fully restored (27). In a 10-year review
of the literature, Beasley et al. (28) report similar
subjective scores regardless of the reconstructive
technique, with an average of 80–95% of patients
reporting the feeling of a normal or nearly normal
knee. The unsatisfactory results are due to a wide
range of reasons, including recurrent pain, loss of
motion, and persistent instability (29–31).
Failed ACL reconstructions have been classifi fied by
Harner (32) and Fu (31) into three groups based
on the cause of the recurrent instability:
– Traumatic failure due to high-energy trauma and
rupture of a functional graft
– Biological failure due to infection, absence of
graft incorporation, or biomechanical tissue fail-
ure
– Technical errors (about 2/3 of failure are due to
technical errors)
Technical errors
It is important to understand the structural prop-
erties of the intact ACL, as replacement grafts
should have similar tensile, mechanical, biological,
and dimensional properties as those of the intact
ACL to best reproduce its in vivo function. Cur-
rently, the main technical errors concern:
– poor graft selection;
– inadequate graft harvest;
– improper fixation of the graft in the bony tun-
nels;
– improper tensioning of the graft;

– failure to recognize laxity in secondary con-
straints;
– inadequate notchplasty;
– non-anatomic tunnel placement.
Tunnel position in both the femur and the tibia is
crucial in ACL reconstruction (4,6). Several studies
have shown that improper tunnel placement is the
main cause of reconstruction failure (33,34).
Tunnel placement
The majority of improper tunnel placements were
related to the femoral tunnel (30,31). The
Th notion of
isometric position (4), a location in which the graft
does not undergo change in length and tension dur-
ing the movement of flexion-extension,
fl has been
abandoned. It is now generally accepted that tunnel
placement should reproduce the anatomy (35).
ACL graft can only withstand a small amount of
strain prior to sustained plastic deformation. ThThat
is why tunnels should be placed in such a way as to
limit an elongation of the graft above 2.5 mm (36).
The anterior placement of the femoral tunnel may
lead to graft lengthening in flexion and may pro-
mote the rupture (2,4,6,7,37). Placing the graft
in a too posterior position increases tension in
extension and leads to an excessive graft laxity in
flexion. In addition, the tunnel placement on the
sagittal plane should be in a more oblique position
rather than vertical to restore a better rotational
stability at the knee joint (38,39).
Less crucial but still very important, a tibial tun-
nel too far anterior will increase the tension on the
graft in both flexion and extension (36) and may
cause an impingement between the graft and the
intercondylar notch roof. This
Th will lead to a loss of
extension, anterior pain, instability, and graft fail-
ure (5,37,40,41).
The incidence of tunnel misplacement may be as
high as 40% in ACL reconstruction (42).
How improving tunnel positioning
Although the anatomic landmarks of the ACL have
been well documented (32,43–45), the identifica- fi
tion under arthroscopy of the insertion sites of
the graft can be diffi
fficult, especially on the femoral
side, even for a confi
firmed surgeon (46).
ACL reconstruction concerns a majority of young
adults who need more than 80% of good results.
CAS is expected to give us the precision we need
to place the graft in the most accurate position to
limit graft impingement, laxity, or graft failure.
At present, navigation systems, image-based or
image-free, are privileged to facilitate ACL recon-
struction.
Place of navigation in anterior cruciate ligament reconstruction 219
Agenda and duties of a navigation system
Specifications
fi
Anatomy and biomechanics are very complex in
the knee. The closed interactions between soft-
tissue structures, ligaments, tendons, and bones
require accurate surgical procedure to restore nor-
mal function of the knee joint and to avoid adverse
repercussion on the knee kinematics.
Using a navigation system in ACL reconstruction
should permit to enhance the accuracy of the pro-
cedure, especially placement of the femoral and
tibial tunnels, in several ways. If arthroscopy can
visualize inside a joint cavity, bone structures and
3-D perspective are diffi
fficult to evaluate. A naviga-
tion system can integrate preoperative planning,
allow intraoperative simulation, and have the
capability of providing information and perfor-
mance assessment in real time. Individual varia-
tion in joint geometry is also a frequent cause
of tunnel misplacement. The navigation system
is able to consider anatomical difference
ff and
to adjust calculation to each individual patient
(Figs. 2–4).
Moreover, CAS can improve reproducibility in
tunnel placement inter- and intra-operators. The Th
development of new techniques and minimally
invasive surgery need better training methods,
and navigation is a readily available tool for this. It
is also an excellent educational tool to teach junior
colleague or senior surgeon not trained to this sur-
gery (Figs. 5–7).
Furthermore, navigation offers ff objective kine-
matic data before leaving the operating room and
is a tremendous research tool giving objective mea-
sures to evaluate surgical performance and clinical
outcome.
In practice, a navigation system should be easy to
install and to use. More than 15 min of additional
time for installation is not acceptable. A wireless
system should become the gold standard. Eventu-
ally, the navigation system must be not too expen-
sive in terms of charge for the health system.
For all these reasons, the navigation system should
achieve better ACL reconstruction and therefore
better long-term results, even with less experi-
enced surgeons.
Validations
Introduction of a CAS must be made after exten-
sive testing as for any other new technique intro-
duced in medicine. CAOS needs objective data
obtained after clinical trials to validate accuracy of
the system and to standardize the procedure.
220 The Traumatic Knee

Fig. 2 – Virtual graft reconstruction in the virtual knee with Fig. 3 – Arthroscopic visualisation of K-wires after drilling
anatomical landmarks of the femur and tibia and attachment under computer guidance.
of the tunnels before drilling. Using a drill guided by the com-
puter and after navigation of the tunnel position, a K-wire is
precisely positioned at the center of the virtual graft within
the joint.

Fig. 5 – High variability, intra- and inter-surgeon. Intra-sur-

Fig. 4 – Final tunnel placement with dilators mimicking the
size of the implanted graft.
geon variability: 3.1 (±1.4) mm on the femur and 3.4 (±0.8)
mm on the tibia (unpublished data). Inter-surgeon variability:
6.3 (±3) mm on the femur and 5.6 (±1.6) mm on the tibia
(unpublished data). You see here two grafts placed by two dif-
ferent surgeons illustrating the high inter-surgeon variability.

Fig. 6 – We conducted a study in which Fig. 7 – Central point represents the ideal point of the tibial tunnel position. Yellow
we asked surgeons of different experi- line, without CAS; red line, with CAS (unpublished data): numbers 1–4, fellows;
ences to place under arthroscopy their numbers 5–10, general orthopaedic surgeons; numbers 10–14, knee surgeons.
ideal femoral and tibial tunnel. They
performed their placement five times
with and without CAS. Central point
represents the ideal point of the femo-
ral tunnel position. Yellow line, without
CAS; red line, with CAS (unpublished
data): numbers 1–4, fellows; numbers
5–10, general orthopaedic surgeons;
numbers 10–14, knee surgeons.

At present, no minimal clinical accuracy is required
to CAOS. If the acetabular component in total hip
arthroplasty accepts at least 5 degrees of version
error, 1 degree of error in pedicle screw insertion
can be a problem in spine surgery.
In ACL reconstruction, it is a question of millime-
ter. Validation and assessment of accuracy are nec-
essary to provide CAOS permitting surgical proce-
dure within an error of 1 mm or less.
Navigation system in ACL reconstruction
Introduction
Navigation is considered as a passive CAS. The
Th sur-
geon keeps full control on the computer. Although
methods of CAOS are evolving, currently available
systems allow navigation with either image-based
or image-free techniques.
Technical steps
The technical steps depend on the system of navi-
gation. It is beyond the goal of this chapter to
describe every system individually, but some steps
are common to each navigation system:
1. Image acquisition
2. Registration
3. Tracking
Acquisition of image can be either preoperative,
using a CT scan with 3-D preoperative planning, or
peroperative, using fluoroscopy-based navigation
or image-free systems.
Registration, for image-based navigation, means
collecting data of the anatomy to match them
with the images obtained preoperatively with a
CT or peroperatively with fluoroscopy. Image-free
systems lack the 3-D patient-specific fi data and
rely patient anatomy to generic model based on
statistical data with key anatomic landmarks and
joint rotation center obtained through kinematic
testing.
Tracking is the control in real time of the naviga-
tion tool’s position and bone orientation. Infrared
light-emitting diodes (LEDs) are a very common
system used in navigation because it is a fast and
accurate system.
Image-based system
Fluoroscopic navigation is based on a 2-D imag-
ing obtained with preoperative x-ray or with
peroperative fluoroscopy and needs a specifi fic
Place of navigation in anterior cruciate ligament reconstruction 221
magnifification calibration of the fluoroscopic sys-
tem during surgery. CT scan gives accurate 3-D
anatomical landmarks of the knee, but requires
preoperative CT scanning and templating of the
images obtained (9).
During the surgical procedure, these systems indi-
cate the location of the surgical tools on the images
obtained before surgery with either fluoroscopy or
CT scan. Thus, virtual images of bone tunnels and
graft are expected, allowing the surgeon to place
the graft in the optimal position (47–49).
Image-free system (Fig. 8A–E)
In this technique, the surgeon digitizes bony
landmarks and ligament attachment sites under
arthroscopic control. Then, using generic model,
the computer records and displays in real-time vir-
tual femur, tibia, and ligament in 3-D space, allow-
ing the surgeon to fifind the best insertion site to
minimize elongation and notching of the virtual
graft. When the best implantation has been found,
tunnels can be drilled in the real knee under com-
puter assistance (42).
Surgical technique and navigation material
Both systems described above are technically simi-
lar. The standard procedure is an endoscopic recon-
struction using autologous tissues.
First, arthroscopy evaluation is performed and
menisci are treated if necessary. Then, graft is
harvested, generally bone-patellar tendon-bone
(BPTB) or hamstring tendons (HT), and prepared
before to measure the diameter and to register it
in the system.
Dynamic reference bases (DRB) using the LED
technology are securely anchored to the femur
and tibia, facing the camera and allowing tracking
throughout knee flexion.
fl
Image-guided systems use a C-arm fl fluoroscope
that can be localized by the digital camera. Antero-
posterior and lateral view fluoroscopic images of
the knee with the DRB and a calibration target are
obtained simultaneously by the camera. Th The LED
drill guide is then registered to the navigation sys-
tem. The virtual bone tunnel and graft route are
traced on the navigating system, and the tibial
guide can be positioned in real time to implant the
tunnel in the most accurate position (49).
Image-free systems use also LED DRB as well as
digital camera and a palpation hook that permit
to digitize anatomic landmarks under direct visual
endoscopic control. Anatomic axes of femur and
tibia are determined and registered; then surfaces
of the tibial plateau, femoral condyle, and intercon-
222 The Traumatic Knee

A B

C D

Fig. 8 – Data and testing, tunnel positioning and graft variation. (Reprinted
with permission: courtesy of Dr P. Colombet and Praxim.) (A) 90° Drawer
test, anteroposterior laxity measurement. (B) Data from the different laxity
tests: drawer, Lachman, pivot-shift, and varus-valgus. (C) Graft impinge-
ment in the notch. Graphic of the predicted isometry profile for the selected
tunnel positions. (D) Selection of the femoral tunnel placement, effect on
notch impingement, graft anisometry, and graft length variation. (E) Isom-
etry map displayed on the lateral wall of the intercondylar notch for a given
tibial tunnel placement. Green indicates the most isometric femoral tunnel
position, and yellow the less. AM tunnel is in grey, and PL tunnel in dark
E
green.

dylar notch are digitized with the virtual potential
ACL attachment sites. The computer provides a
virtual 3-D representation of the planned graft and
virtual drill tunnel. Impingement and elongation
of this virtual planned ligament (42) are evaluated
during knee extension and flexion.
fl The attachment
point of the planned ligament can be changed at
any time. Functional graft evaluation, as Lachman
test for anterior laxity or pivot shift for anterior
and rotational laxity, is made in real time.
When the accurate and ideal graft positioning is
obtained, tunnels planned can be drilled using a
drill guide piloted by the computer. The graft is then
fixed and tensed in a standard fashion. This tech-
nique has been validated in our laboratory and has
been shown to accurate to less than 1 mm (50).

Results in ACL navigated
Introduction
Although experience with navigated ACL recon-
struction is still limited, some studies (47,48,51–55)
have reported that a navigation system enhances
accuracy of tunnel placements and good functional
results are expected.
Nevertheless, no consensus has been found to use
the same method of measure to determine the
position of these tunnels. Moreover, radiographs
are probably not the best way to analyze tunnel
positioning because of the absence of x-ray stan-
dardization or the diffifficulty to identify the tunnels
themselves. In these conditions, accuracy is diffi- ffi
cult to evaluate or to compare.
There is also no consensus to appreciate clinical
Th
data and functional results.
Clinical results
In his study, comparing conventional tunnel drill-
ing and fluoroscopic navigation, Klos (47) find
that graft placement variability from radiographic
measurement is signifi ficantly reduced when using
computer assistance. The standard deviation of
the anteroposterior graft location decreases from
6% without assistance to less than 3% with naviga-
tion for the tibial tunnel and from 9% to 3% for the
femoral graft location.
Eichhorn (56), in a series of 300 navigated recon-
structions compared with 300 standard recon-
structions, find a better tibial and femoral tunnel
positioning in the navigated group. Th The diff
fference
was not statistically significant,
fi but tibial tunnels
were too posterior and femoral tunnels too vertical
in the standard group.
In his series of 23 patients, Julliard (57) uses the
navigation system to register intraoperative data
after a standard procedure and retrospectively
finds that using the computer would allow a bet-
ter placement of the graft with a more physiologic
elongation (2.3 ± 0.6 mm with navigation vs. 4.7 ±
3.2 mm with standard procedure).
More recently, randomized clinical trials have
been published. Picard (54) compares accuracy
in tunnel placement performed with traditional
arthroscopic ACL reconstruction and navigation
technique on 20 foam knees in each group. Dis-
tances to ideal tibial and femoral tunnel placement
were 4.2 ± 1.8 mm and 4.9 ± 2.3 mm, respectively,
for the standard technique and 2.7 ± 1.9 mm and
3.4 ± 2.3 mm for the navigated group, respectively.
The diff
fferences were statistically signifi
ficant, sug-
gesting a more accurate tunnel placement with
Place of navigation in anterior cruciate ligament reconstruction 223
image-based navigation, even with experienced
surgeons in ACL reconstruction but inexperi-
enced in CAS navigation technique. Mauch (58),
in a clinical trial of 53 patients randomized into
a conventional (n = 29) and a navigation (n = 24)
group, examines the tibial tunnel placement by
evaluating the lateral radiograph. Comparing
both groups, no significant
fi diff
fference was found
in terms of location and variability of the tibial
tunnel placement. However, when comparing the
centers of the tibial tunnels with the optimal 44%
found in previous studies (2,32), the value for the
conventional group varied signifi ficantly while the
navigation group did not.
There are also some recent studies with clinical
outcomes. Hart (52) randomize 80 patients in a
clinical trial, 40 patients treated with navigation,
and 40 conventionally. Stability was evaluated
with the KT-1000 arthrometer. The Th maximum
manual side-to-side KT-1000 results were com-
parable with 2 mm in 26 patients in each group
(P < 0.41). The
Th mean diff fference in anterior laxity
compared with the contralateral side was 1.88 mm
in the navigated group and 1.93 mm in the stan-
dard group. The
Th diff fference was not signifi ficant (P <
0.52). No difffference between the pivot-shift tests
preoperatively and postoperatively were found
between the two groups. The Th same observation
was made for the IKDC score that improved from
41.3 ± 4 points in each group preoperatively to
76.5 (± 10.3) points in the navigated group and
73.1 (± 10.3) points in the standard group postop-
eratively (P < 0.87). The tunnels positioning was
analyzed using the technique described by Harner
(32). If tibial tunnel position was comparable in
both groups, they found that navigated femoral
tunnels were more accurate (P < 0.01). Plaweski
et al. (55) in a randomized series of 60 patients
(30 treated with and 30 without navigation) fi find
that 23.3% of the conventional group had more
than 3 mm side-to-side diff fference in Lachman test
in contrast to 13% of the navigated group. More-
over, 23.4% of the conventional group presented
mild pivot-shift glide compared with 13% in the
navigated group. Although, stability seems to be
improved in the navigated, those results are not
statistically significant.
fi Furthermore, no absolute
laxity was noted after dynamic stress radiographs.
A signifi
ficant diff
fference was observed in the vari-
ability of laxity with 96.7% with less than 2 mm
laxity in the navigated group compared with 83%
in the standard group (P = 0.003).
The author’s experience in a prospective non-
randomized series of 30 navigated ACL recon-
structions is described here (50). Thirty patients
underwent clinical and radiological examination
at a minimum follow-up period of 12 months. Th The
clinical outcomes were evaluated using the IKDC-
224 The Traumatic Knee
Fig. 9 – MRI post-ACL reconstruction using CAS.
2000 and anterior laxity using the KT-1000. Tun-
nel placement was determined according to Agli-
etti (2). At 12 months, 28 patients (28/30) had an
IKDC score of A, 1 had a B, and 1 suffered
ff a new
rupture of the graft after high energy trauma and
cannot be classified.
fi The objective knee stability
has been evaluated clinically with the Lachman
and pivot-shift tests. Twenty-seven patients had
a normal Lachman (0–2 mm side-to-side differ- ff
ence) and a normal pivot shift (negative). Two
patients presented a nearly normal Lachman (3–5
mm side-to-side diff fference) and a nearly normal
pivot shift (1 + glide). Th The maximum manual
differential
ff laxity measured with the KT-1000
as shown 28 patients with a normal result (0–2
mm side–to-side diff fference) and 1 patient with a
nearly normal result (3–5 mm side-to-side differ-
ff
ence). According to Aglietti (2), the femoral and
tibial tunnels were all correctly placed (Fig. 9).
Our results are comparable with the series above,
but we need more patient, longer follow-up and
randomization to draw conclusions.
Discussion
Revision surgery rate after ACL reconstruction
ranges from 10% to 40% (53); 75% of the com-
plications are due to improper tunnel positioning
(30). All the recent randomized studies reviewed
find signifi
ficant improvement in femoral tunnel
implantation when navigation is used (54,52,55).
Even in Mauch et al.’s study (58), where they con-
clude that accuracy of an experienced surgeon is
as good as a navigation system for tibial tunnel
implantation, we find
fi better results if we com-
pare their results to the supposing ideal position
of the literature. Moreover, 80% of ACL recon-
structions are performed by surgeons who do less
than 20 procedures per year (24) with only 80%
of good results (28). A navigation system is prob-
ably a tool not only to improve the accuracy of less
experienced surgeon but also to educate a junior
colleague. It is also a research tool and provides a
source of data to better appreciate knee kinematics
and factors that infl fluenced long-term ACL recon-
struction outcomes.
Long-term follow-ups are missing to evaluate the
clinical benefifit of using a navigated system. The
randomized studies from Plaweski (55) and Hart
(52) have a minimum follow-up of 24 months
only. In terms of laxity, those trials lack to show
evidence of improvement despite the better graft
position, and IKDC scores are not signifi ficantly
better after navigation. Nevertheless, these series
seem to demonstrate a better reproducibility in
tunnel and graft position, probably the fi first step
to have more homogeneity in clinical long-term
results. The next step is to improve potential
errors of the navigations systems themselves, due
to data collection, tracking, and registration proce-
dures. Surgeons must remember that navigations
systems cannot determine whether the collected
inputs are correct or incorrect. If the tracking
device is not well fixed or the registration inac-
curate, even the best anatomic landmarks will not
be able to save the operators. The actual comput-
ers are not intelligent, and every system follows
the “garbage in, garbage out” law. Next advance
must be focused on improving stability of the
reconstructed knee. Tunnel placement is only one
part of the problem. Avoiding rotational instabil-
ity could be the next revolution of the procedure.
Double-bundle reconstructions are supposed to
improve the rotational stability, and first
fi results
are encouraging (59,60). Again, CAOS is certainly
an effffective tool to evaluate global performance
of these reconstructions and is able to provide
measures of the anteroposterior and rotational
displacement. Analyzing these data should permit
better correlation with clinical outcomes in the
future. Finally, only prospective randomized stud-
ies, using a standard navigation system and proce-
dure, with at least 10-year follow-up, and standard
clinical evaluation criteria, will give critical infor-
mation to perform better long-term results in ACL
reconstruction.
Perspective
The future development of navigation systems
should follow two major axes: first,
fi improvement
of the device itself and, second, improvement of
the clinical application and enhancement of the
biomechanical data to better understand the knee
kinematics.
 Place of navigation in anterior cruciate ligament reconstruction 225
The navigation systems should be not too expen-
sive, providing a simple and intuitive system.
Although, an image-free system is more desirable,
systems using MRI that are generally used rou-
tinely as a diagnostic procedure, or ultra-sonog-
raphy to do echo-morphing (61), could provide
extra information without extra imaging and then
better accuracy and reproducibility in the recon-
struction. Optical trackers could be replaced by
electromagnetic trackers to avoid invasive inser-
tion of rigid pins into bone and the need for a con-
tentious line of sight. Ultrasounds are also under
investigation for tracking purpose. Hybrid systems
are in development, combining robotic and naviga-
tion to improve accuracy of the surgeon and lim-
iting his or her action to what has been planned
preoperatively. Improvements in data collection
with more intelligent systems able to evaluate
and to correct inappropriate information are also
in development. Moreover, we need more power-
ful computers to calculate the ideal graft position
from a single anatomic point. This
Th will allow 3-D
simulation before to implant the graft in the abso-
lute ideal position. Finally, navigation systems
that can be used in the operating room and during
the follow-up would provide all the information
to compare knee kinematics before, during, and
after surgery. This would close the loop in surgical
practice by measuring and directly relating surgical
techniques to patient outcome.
Conclusion
Navigation in ACL reconstruction has a tremen-
dous amount of potential. It is not only a tool to
improve tunnel positioning but also a learning and
a research tool that will give us the information
and measures about knee kinematics to approach
the perfect reconstruction and the best clinical
outcome in the long term.
References
1. Griffi
ffin LY, Agel J, Alholm MJ, et al. (2000) Noncontact
anterior cruciate ligament injuries: risk factors and pre-
vention strategies. J Am Acad Orthop Surg 8:141–150
2. Aglietti P, Buzzi R, Giron F, et al. (1997) Arthroscopic-as-
sisted anterior cruciate ligament reconstruction with the
central third patellar tendon: A 5-8-year follow-up. Knee
Surg Sports Traumatol, Arthrosc 5:138–144
3. Goble EM, Downey DJ, Wilcox TD (1995) Positioning of
the tibial tunnel for anterior cruciate ligament reconstruc-
tion. Arthroscopy 11:688–695
4. Hefzy MS, Grood ES (1986) Sensitivity of insertion loca-
tions on length patterns of anterior cruciate ligament
fibers. J Biomech Eng 108:73–82
5. Howell SM (1998) Principles for placing the tibial tunnel
and avoiding roof impingement during reconstruction of
a torn anterior cruciate ligament. Knee Surg Sports Trau-
matol Arthrosc 6(Suppl 1): S49–S55
6. Khalfayan EE, Sharkey PF, Alexander AH, et al. (1996).
The relationship between tunnel placement and clinical
results after anterior cruciate ligament reconstruction.
Am J Sports Med 24:335–341
7. Sommer C, Friederich NF, Müller W (2000) Improp-
erly placed anterior cruciate ligament grafts: correlation
between radiological parameters and clinical results. Knee
Surg Sports Traumatol Arthrosc 8:207–213
8. Dessenne V, Lavallée S, Julliard R, et al. (1995) Computer-
assisted knee anterior cruciate ligament reconstruction:
first clinical tests. J Image Guid Surg 1:59–64
9. Klos TVS, Banks AZ, Banks SA, et al. (1995) Computer
and radiographic assisted anterior cruciate ligament
reconstruction of the knee. In: Anderson J, editor. Pro-
ceedings of the second symposium on medical robotics
and computer assisted surgery. New York: Wiley:252–
255
10. Paul HA, Bargar WL, Mittlesstadt B, et al. (1992) Develop-
ment of a surgical robot for cementless total hip arthro-
plasty. Clin Orthop 285:57–66
11. Cobb J, Henckel J, Richards R, et al. (2004) Robot assisted
minimally invasive unicompartmental knee arthroplasty
results of first clinical trial. Comput Aided Surg 9:88
12. McGurk M, Amis AA, Potamianos P, et al. (1997) Rapid
prototyping techniques for anatomical modeling in medi-
cine. Ann R Coll Surg Engl 79:169–174
13. Galen C (1968) On the usefulness of the parts of the body.
May MT (trans). Ithaca, NY: Cornell University Press
14. Stark J (1850) Two cases of ruptured crucial ligaments of
the knee joint. Edinburg Med Surg 74:267–271
15. Battle WH (1900) A case after open section of the knee-
joint for irreductible traumatic dislocation. Clin Soc Lon-
don Trans 33:232
16. Mayo Robson AW (1903) Ruptured crucial ligaments and
their repair by operation. Am Surg 37:716–718
17. Lange F (1903) Uber die Sehnenplastik. Verh Dtsch Othop
Ges 2:10–12
18. Jones K (1963) Reconstruction of the anterior cruciate
ligament: a technique using the central one-third of the
patellar ligament. J Bone Joint Surg 45A:925–932
19. Bruckner H (1966) Eine neue Methode zur Kreuzband-
plastik. Chirurg 37:413–414
20. Franke K (1976) Clinical experience in 130 cruciate liga-
ment reconstructions. Orthop Clin North Am 7:191–193
21. Dandy DJ (1981) Arthroscopic surgery of the knee. Edin-
burg: Churchill Livingstone
22. Soni AH, Gudavalli MR, Herndon WA, et al. (1986) Appli-
cation of passive robot in spine surgery. Presented at the
Eighth Annual Conference of the IEEE/Engineer Biology
and Medical Society, 1186–1191
23. Petermann J, Kober R, Heinze P (2000) Computer-as-
sisted planning and robot-assisted surgery in anterior
cruciate ligament reconstruction. Operat Tech Orthoped
10:50
24. Eichhorn J, Girdano N (2005) Computerassistierte Rekon-
struktion des vorderen Kreuzbandes mit dem Navigation-
ssystem.. Arthroskopie 18:24–26
25. Berchuck M, Andriacchi TP, Bach BR (1990) Gait adapta-
tions by patients who have a deficient
fi anterior cruciate
ligament. J Bone Joint Surg 72A:871–877
26. Dunn WR, Lyman S, Lincolm AE, et al. (2004) The Th eff
ffect
of ACL reconstruction on the risk of knee re-injury: an
outcome study of 6567 cases. Am J Sports Med 32:1906–
1914
27. Herrington L, Wrapson C, Matthews M, et al. (2005) Ante-
rior cruciate ligament reconstruction, hamstring versus
bone-patella tendon-bone grafts: a systematic literature
review of outcome from surgery. Th The Knee 12:41–50
226 The Traumatic Knee
28. Beasley LS, et al. (2005) Anterior cruciate ligament recon-
struction: a literature review of the anatomic, biomechan-
ics, surgical consideration and clinical outcomes. Oper
Tech Orthop 15:5–19
29. Greis PE, Johnson DJ, Fu FH (1993) Revision anterior
cruciate ligament surgery: Cause of graft failure and tech-
nical considerations of revision surgery. Clin Sports Med
12:839–852
30. Harner CD (1995) Revision anterior cruciate ligament
reconstruction using fresh-frozen allograft tissue. Instruc-
tional Course at the 62nd Annual AAOS Meeting, Orlando,
FL.
31. Maday MG, Harner CD, Fu FH (1994) Revision ACL sur-
gery: evaluation and treatment, In: Feagin JA, editor. The
Th
crucial ligaments. New York, NY: Churchill Livingstone:
711–723
32. Harner CD, Baek GH, Vogrin TM, et al. (1999) Quanti-
tative analysis of human cruciate ligament insertions.
Arthroscopy 15:741–749
33. Paessler H (1997) Revisionseingriffeff nach vorderer Kreuz-
bandoperation und neuerlicher Instabilität: Ursache-
nanalyse und taktische Vorgehen. Hefte Unfallchirurg
268:447–450
34. Shelbourne KD, Klootwyk TE, Wilckens JH, et al. (1995)
Ligament stability two to six years after anterior cruciate
ligament reconstruction with autogenous patellar tendon
graft and participation in accelerated rehabilitation pro-
gram. Am J Sports Med 23:575–579
35. Fu FH, Bennett CH, Lattermann C, et al. (1999) Current
trends in anterior cruciate ligament reconstruction. Part I:
Biology and biomechanics of reconstruction. Am J Sports
Med 27:821–830
36. Fineberg MS, Zarins B, Sherman OH (2000) Practical con-
siderations in anterior cruciate ligament replacement sur-
gery. Arthroscopy 16:715–724
37. Fu FH, Bennett CH, Ma CB, et al. (2000) Current trends in
anterior cruciate ligament reconstruction. Part II. Opera-
tive procedures and clinical correlations. Am J Sports Med
28:124–130
38. Lee MC, Seong SC, Lee S, et al. (2007) Vertical femoral
tunnel placement results in rotational knee laxity after
anterior cruciate ligament reconstruction. Arthroscopy
23:771–778
39. Scopp JM, Jasper LE, Belkoff ff SM, et al. (2004) The
Th eff
ffect
of oblique femoral tunnel placement on rotational con-
straint of the knee reconstructed using patellar tendon
autografts. Arthroscopy 20:294–299
40. Jackson DW, Gasser SI (1994) Tibial tunnel placement in
ACL reconstruction. Arthroscopy 10:124–131
41. Watanabe BM, Howell SM (1995) Arthroscopic findings
associated with roof impingement of anterior cruciate
ligament graft. Am J Sports Med 23:616–625
42. Sati M, Stäubli HU, Bourquin Y, et al. (2002) Real-time
computer in situ guidance system for ACL graft place-
ment. Computer aided surgery 7:25–40
43. Dienst M, Burks RT, Greis PE (2002) Anatomy and bio-
mechanics of the anterior cruciate ligament. Orthop Clin
North Am 33:605–620
44. Girgis FG, Marshall JL, Monajem A (1975) The Th cruciate
ligaments of the knee joint. Anatomical, functional and
experimental analysis. Clin Orthop 106:216–231
45. Odensten M, Gillquist J (1985) Functional anatomy of the
anterior cruciate ligament and a rationale for reconstruc-
tion. J Bone Joint Surg 67A:257–262
46. Kohn D, Beusche T, Caris J (1998) Drill hole position in
endoscopic anterior cruciate ligament reconstruction.
Results on an advanced arthroscopy course. Knee Surg
Sports Traumatol Arthrosc 6:13–15
47. Klos TVS, Habets RJE, Banks AZ, et al. (1998) Computer
assistance in arthroscopic anterior cruciate ligament
reconstruction. Clin Orthop 354:65–69
48. Hiraoka H, Kuribayashi S, Fukuda A, et al. (2006) Endo-
scopic anterior cruciate ligament reconstruction using
a computer-assisted fluoroscopic navigation system. J
Orthop Sci 11:159–166
49. Burkart A, Debski RE, McMahon PJ, et al. (2001) Precision
of ACL tunnel placement using traditional and robotic
techniques. Comp Aid Surg 6:270–278
50. Messerli G, Ménétrey J (2007) Reconstruction du liga-
ment croisé antérieur assistée par ordinateur: Etude
prospective non randomisée avec résultats à 12 mois
des 30 premiers cas. Thèse n 10503, Université de
Genève
51. Chouteau J, Benareau I, Testa R, et al. (2007) Compara-
tive study of knee anterior cruciate ligament reconstruc-
tion with or without fluoroscopic assistance: a prospective
study of 73 cases. Arch Orthop Trauma Surg (Epub ahead
of print)
52. Hart R, Krejzla J, Svab P, et al. (2008) Outcomes after con-
ventional versus computer-navigated anterior cruciate
ligament reconstruction. Arthroscopy 24:569–578
53. Kodali P, Yang S, Koh J (2008) Computer-assisted Surgery
for anterior cruciate ligament reconstruction. Sports Med
Arthrosc Rev 16:67–76
54. Picard F, DiGioia AM, Moody J, et al. (2001) Accuracy in
tunnel placement for ACL reconstruction. Comparison of
traditional arthroscopic and computer-assisted navigation
techniques. Comp Aid Surg 6:279–289
55. Plaweski S, Cazal J, Rosell Ph, Merloz Ph (2006) Ante-
rior cruciate ligament reconstruction using navigation.
A comparative study on 60 patients. Am J Sports Med
34:542–552
56. Eichhorn J (1998) Three years of experience with com-
puter navigation-assisted positioning of drilling tunnels
in anterior cruciate ligament replacements (S67), Arthros-
copy 20:31–32
57. Julliard R, Lavallée S, Dessenne V (1998) Computer
assisted reconstruction of the nterior cruciate ligament.
Clin Orthop Relat Res 354:57–64
58. Mauch F, Apic G, Becker U, Bauer G (2007) Differences
ff
in the placement of the tibial tunnel during reconstruc-
tion of the anterior cruciate ligament with and with-
out computer-assisted navigation. Am J Sports Med
35:1824–1832
59. Ishibashi Y, Tsuda E, Fukuda A, et al. (2008) Stability eval-
uation of single-bundle and double-bundle reconstruc-
tion during navigated ACL reconstruction. Sports Med
Arthrosc Rev 16:77–83
60. 60.Monaco E, Labianca L, Conteduca F, et al. (2007)
Double bundle or single bundle plus extraarticular teno-
desis in ACL reconstruction? Knee Surg Sports Traumatol
Arthrosc 15:1168–1174
61. Stindel E, Briard JL, Lavallee S, et al. (2004) Bone mor-
phing: 3-D reconstruction without pre or intraoperative
imaging – concept and application. In: Stiehl JB, Kiner-
mann WH, Haaker RG, editors. Navigation and robotics in
total joint and spine surgery. Berlin: Springer: 39–45

B. Sonnery-Cottet Single or double bundle?
Introduction
S
ignifi
ficant progress has been achieved in knee
ligament surgery over the past 30 years due
to an improved quality of the ancillary mate-
rial and a better knowledge of the pathophysiology
of the anterior cruciate ligament (ACL). Three
Th dis-
tinct periods may be outlined in the evolution of
ACL reconstruction over the years: while the 1980s
were marked by the development of arthroscopy
(1) and standardization of postoperative reha-
bilitation, the 1990s saw the development of
graft fixation techniques and the introduction of
resorbable implants. These years were also marked
by discussions about the most appropriate graft
for ligament reconstruction, i.e., patellar tendon,
hamstring tendon, quadriceps tendon, or allograft.
From 2000 onward, a turning point was observed
in this evolution: given the sufficient
ffi clinical per-
spective and the numerous studies carried out
(7600 studies found as a result of a search engine
query about ACL in 2007), surgeons were able to
obtain answers to their questions. Arthroscopic
ACL reconstruction has now become a routine
procedure. In the United States, 75,000–100,000
ligament reconstruction procedures are being
performed each year (2); around 35,000 are per-
formed in France. Although a return to pre-injury
level of sports activity is most frequently observed,
the long-term failure rate, irrespective of the graft
used, remains a concern and ranges from 10% to
30%, depending on the series (3–5). A 15% resid-
ual pivot shift rate has been reported (6). This Th
poor control of internal rotation would partly be
responsible for the occurrence of secondary menis-
cal and cartilaginous lesions, and particularly for
the degradation of intra-articular single-bundle
reconstruction results over time. The development
of combined procedures, associating intra-artic-
ular and extra-articular reconstruction (7), may
partly be explained by this poor control of rotatory
laxity. More recently, “anatomic” double-bundle
ACL reconstruction techniques emerged under the
impulsion of teams in Japan (8–16). Th These isolated
intra-articular reconstruction procedures with two
distinct bundles would result in improved knee
Chapitre 20
kinematics and, in particular, more efficient
ffi rota-
tory control (17–20). The
Th purpose of this chapter is
to consider the scientifi
fic basis of these two major
principles of ACL reconstruction, i.e., single- and
double-bundle reconstruction, in 2010.
Historical background
Although originally described on an Egyptian papy-
rus scroll dating back to 3000 BC, the ACL was first
fi
named ligamenta genu cruciale by the Greek phy-
sician Claudius Galen (129–199 BC) (2). The Th first
biomechanical study of the ACL was described by
W. Weber in 1836, while the first description of the
injury mechanisms was made as early as 1850 by
Amédée Bonnet, Lyon, France. In 1875, Georges
K. Noulis, Greece, described the first
fi clinical test
of the ACL with an anterior drawer at full exten-
sion, in his thesis entitled “Knee sprains.” One of
John Lachman’s students presented the test, now
known as the “Lachman test,” during the AAOS
congress held in New Orleans in 1976.
The first surgical suture of the ACL was performed
in 1895 by A.W. Mayo Robson, England, although
the description of this procedure was made in 1898
by W.H. Battle, another English physician. ThThe first
patellar tendon autologous graft was performed
on a cadaver by V. Nicoletti, Italy, in 1913 and was
surgically performed on a patient by the Russian
surgeon Grekow in 1914. In 1917, Ernest W. Hey
Groves, England, performed a fascia lata graft,
and in 1935, the American Willis C. Campbell pre-
sented a technique using the medial one-third of
the patellar tendon, the prepatellar retinaculum,
and the quadriceps tendon, later reintroduced by
Macintosh, Canada. TheTh first semitendinosus graft
dates back to 1939 and was performed by Harry B.
Macey, USA. This technique was later reintroduced
by K.O. Cho. In 1988, M.J. Friedman pioneered the
use of the four-stranded hamstring autograft.
In 1963, Kenneth G. Jones, USA, described his
surgical technique consisting of a patellar tendon
graft attached to the tibia. In 1969, Kurt Franke,
Germany, pioneered the free patellar tendon graft,
228 The Traumatic Knee
a technique similar to those currently used. In
1981, D.J. Dandy, England, was the fi
first to perform
an arthroscopy-assisted ACL substitute graft. ThThis
led the way to autograft and allograft arthroscopic
ACL reconstruction. Although double-bundle ACL
reconstruction was initially described as early as
1983 (21,22), T. Muneta, Japan, published in 1999
the preliminary results of a study on a series of
patients operated on using this technique (9). This
Th
article later inspired numerous authors into devel-
oping these “anatomical” double-bundle recon-
struction techniques.
Anatomy
Basic knowledge of the anatomy of the ACL is
essential in order to approach this type of ligament
reconstruction. The studies carried out on the anat-
omy of the ACL became increasingly refined fi over
the years and served as a basis for the evolution
of reconstruction techniques. It is still on the basis
of this anatomical knowledge that several teams
are now developing double-bundle reconstruction
techniques.
The ACL connects the tibia and the femur and
plays a major part in knee kinematics and stabil-
ity. As it is enveloped in synovial membrane, it
may be defi fined as intra-articular yet extra-syn-
ovial. Generally speaking, the ACL is splay shaped,
with large bone insertions and a narrower medial
portion. At the level of these bone insertions, the
ACL sections are three times as large as on its
medial one-third (23).
At femoral level, the ACL is fully inserted in the
posterior part of the medial surface of the lateral
condyle. According to Girgis, the insertion surface
is a segment of a circle, with a straight anterior line
and a convex posterior line, following the cartilagi-
nous limit of the inferior wall of the lateral condyle
(24). For other authors, this insertion is rather
oval in shape, with the long axis of femoral inser-
tion tilted in an angle of about 26° with the femoral
diaphyseal axis. This
Th ovoid insertion surface has a
mean length of 18 mm and a width of 11 mm (25).
In a recent study, the dimensions of these inser-
tions were examined using a different
ff approach.
For these authors, a large part of the ACL bone
insertion is made of several superficial,
fi fibrous lay-
ers. Dissection of this fibrous envelope revealed
that the “functional” femoral insertions of the ACL
presented a flatter shape, with a mean length of 15
mm for a mean width of 5 mm only (26).
At tibial level, the ACL is inserted in a fossa located
forward and just outside of the medial tibial spine.
The insertion surface is in the shape of an oval, the
long axis of which is orientated in an anteropos-
terior direction. The tibial insertion has a mean
length of 17 mm for a mean width of 11 mm (25).
For most authors, this insertion is larger and more
solid that the femoral insertion (23,24,27). In their
distal portions, the anterior fibers
fi of the ACL are
not in a straight line, but rather concave at this
level, giving the tibial insertion a characteristic
tent-shaped aspect. This collagen fascicle arrange-
ment allows the insertion of fibers forward of the
anterior edge of the notch roof when the knee is in
extension, without any conflict
fl with this structure.
Although ACL femoral and tibial insertions have
been known for a while, the number of bundles
remains a controversial issue among anato-
mists, and was the subject of numerous studies
(23,26,27). The names of the bundles correspond
to their tibial insertion. Girgis (24) found two dis-
tinct bundles (anteromedial, AM, and posterolat-
eral, PL), whereas this distinction is questionable
for Odensten (25). Norwood described the exis-
tence of a third bundle, the intermediary bundle
(28), while Sapega (29) also described a fourth
bundle. The general idea behind these descrip-
tions is to understand that the ACL is composed of
several bundles with various functions secondary
to varying length and tension during flexion
fl and
extension.
More recently, the number of anatomical stud-
ies describing the existence of two bundles sig-
nifi
ficantly increased, and nowadays, it is possible
to describe the topography of their bone inser-
tions.
From a general viewpoint, the PL bundle is shorter
than the AM bundle, with a mean length of 22.5 mm
and 34 mm, respectively. Th Their insertion surfaces
are quite similar, with insertions of 47 mm2 on the
femur and 56 mm2 on the tibia for the AM bun-
dle, and insertions of 49 mm2 on the femur and
53 mm2 on the tibia for the PL bundle (23). At fem-
oral level, the AM bundle is located in the proximal
portion of the ACL insertion, while the PL bundle
is located in the distal portion. For some authors,
the two bundles are inserted on either side of a lat-
eral bone edge (30). At tibial level, the AM bundle
is located in the AM portion of the ACL insertion,
just forward and slightly medial to the PL bundle
insertion (Fig. 1).
Fig. 1 – Femoral and tibial insertion of the anteromedial and posterolateral
bundles of the ACL.

Embryology
The ACL starts its formation around the 8th week
of gestation and is fully differentiated
ff from the 9th
week of gestation. Little change is observed in form
after week 20. Histologically, the ACL is composed
of numerous immature fibroblasts and is highly
vascularized (31). In a recent study on fetal ACL
development, Ferretti et al. (32) identified
fi two dif-
ferentiated bundles as AM and PL bundles in the
40 fetuses included in their study (Fig. 2). For the
authors, the ACL is very similar in fetuses and in
adults and is composed of two bundles, separated
by a vascular septum containing a branch of the
medial geniculate artery.
Fig. 2 – Anatomy of ACL.
Functional anatomy of the ACL
The ACL is composed of two bundles: the AM bun-
dle and the PL bundle. The AM bundle is slightly
medial and therefore close to the medial tibial
spine, whereas the PL bundle is posterior to the
AM bundle and positioned more laterally.
In full extension, the PL femoral insertion is distal
and posterior to the AM femoral insertion. During
flexion, the PL femoral insertion describes an arc
fl
around the AM femoral insertion to appear from
30° to 40° of flexion forward of the AM bundle
femoral insertion. Its femoral insertion gives the
AM bundle a more isometric behavior compared
to the PL bundle during flexion
fl and extension.
This pseudo-isometry enables the AM bundle to
remain relatively tight from extension to flexion.
fl
According to Amis and Dawkins, the AM bundle
slightly loosens up from 0° to 30° of fl flexion, and
then progressively tightens until maximum flex- fl
ion is reached. The PL bundle, on the other hand,
is predominantly stretched in extension, and then
loosens up when flexion begins, before tightening
again in the last degrees of flexion (33). Such obser-
Single or double bundle? 229
Fig. 3 – From extension (A) to 90° of flexion (B), the femoral attachment
of the PL bundle describes an arc around the AM femoral attachment. In
extension, the two bundles are parallel. Flexion puts the PL femoral attach-
ment forward the AM femoral attachment. From an anterior view at 90° of
flexion corresponding to the arthroscopic visualization (C); the PL bundle
can be observed at its femoral insertion located just inferior and shallow to
the AM femoral attachment.
vations suggest that the two bundles play distinct
roles: the PL bundle seems mostly efficient
ffi in two
limited sectors, i.e., the last 30° of extension and
to a more limited extend, when close to full fl flex-
ion. The AM bundle, with a more isometric behav-
ior, seems to present a broader scope of effi fficiency,
enabling the control of the anterior drawer in the
first degrees of flexion until full flexion is reached,
with a predominant role after 30° of fl flexion. How-
ever, its role in the control of tibial rotations is lim-
ited since it runs a vertical, central course in the
notch. Oppositely, the markedly distal, posterior
femoral insertion of the PL bundle enables a satis-
factory control of tibial rotations (Fig. 3).
Biomechanics
The ACL is the main restraint of anterior tibial
translation, but the mechanical role of this liga-
ment cannot be limited to only this function. Th The
biomechanical consequences of a ruptured ACL are
increasingly well understood, more particularly
the rotatory component (19). In the intact knee,
the axis of rotation is central and close to the tibial
spines. Around this axis, the medial and lateral tib-
ial plateaux present a certain degree of symmetric
rotation. In a ruptured ACL, this axis of rotation is
medializing, leading to an increased anterior tibial
translation as well as an increased internal rota-
tion of the lateral tibial plateau (Fig. 4).
The objective of ACL reconstruction procedures
is to reduce this anterior tibial translation and to
control excessive internal rotation of the lateral
tibial plateau. Various types of ACL reconstruc-
230 The Traumatic Knee
Fig. 4 – ACL biomechanics.
tion were performed and studied in order to evalu-
ate their effi
fficiency on the control of the anterior
and rotatory instability of the knee. In 2002, the
cadaveric studies by Woo SL et al. (34) and then
Yagi et al. (17) demonstrated that although single-
bundle reconstruction allowed for an appropriate
control of the anterior drawer, a satisfactory con-
trol of rotatory laxity cannot be reached through
this procedure. This hypothesis was confi firmed
by the recent clinical studies carried out using a
walking platform (35–37). It therefore appears
that, a pivot shift phenomenon may persist after
single-bundle reconstruction (38). According to
some authors (39,40), this residual rotatory lax-
ity could be responsible for osteoarthritis in ACL-
reconstructed patients. Single-bundle reconstruc-
tion with a femoral tunnel placed more laterally
and closer to the insertion of the PL bundle seems
to induce a signifi ficant increase in rotatory laxity
control, although failing to reproduce the kinemat-
ics of an intact knee (41,42).
Two major types of surgical options currently aim
at compensating this relative ineffectiveness
ff of
single-bundle reconstruction techniques to ensure
rotatory control:
– Combined procedures, associating lateral tenod-
esis with intra-articular reconstruction
– A new concept of double-bundle reconstruction
aiming at reconstructing the AM and PL bundles
of the ACL
From a biomechanical point of view, the advan-
tages of combined procedures are controversial.
For some authors, the combination of lateral teno-
desis with intra-articular reconstruction results
in decreased constraints on the intra-articular
graft (43,44). For others, like Amis (45), the com-
bination of lateral tenodesis with intra-articular
reconstruction does not allow for a better control
of anterior and rotatory laxity compared to intra-
articular reconstruction alone. A study by Samuel-
son demonstrated the benefi fits of combined proce-
dures exclusively in lesions of the ACL associated
with anterolateral lesions (46).
What should be kept in mind is that the mechani-
cal benefi
fit of combined procedures remains uncer-
tain and limited to some specific fi clinical situations:
although these combined procedures are likely to
be benefificial in terms of laxity control, they also
imply a significant
fi risk of perturbation of the knee
kinematics by blocking the tibia in external rota-
tion.
The mechanical studies on double-bundle recon-
struction techniques are more recent and ben-
efi
fited from new technologies enabling a finer eval-
uation. As early as 1990, Radford and Amis (47)
noted that “a double-bundle repair approximates
in function to the intact anterior cruciate ligament
and merits further investigation.” In their cadav-
eric study carried out in 1997, Sakane et al. (48)
demonstrated that ACL fibers were not submitted
to the same constraints during fl flexion. In 2004,
the cadaveric study performed by Gabriel et al.
(18) confirmed
fi that the two ACL bundles do have
distinct functions. A recent study by Zantop et al.
(49) confifirmed these data: during a selective sec-
tion of the AM bundle on a cadaver, an increased
anterior translation between 60° and 90° was
observed, whereas a selective section of the PL
bundle led to an increased anterior translation at
30° and an increased internal rotation between 0°
and 30°. These studies confi firm the biomechanical
importance of the PL bundle and its predominant
role in rotatory control. Double-bundle reconstruc-
tion techniques are the closest to the biomechan-
ics and kinematics of the intact knee (12,17,35–
37,39–42).
 Single or double bundle? 231

Discussion to evolve back to toward what should never have

Arthroscopic ACL reconstruction is performed
with good results in 80–90% of the cases, although
poorer evaluation scores are observed over time.
Thirty percent of the patients having undergone
ACL reconstruction would require a secondary
intervention for meniscal or cartilage damage,
or graft rupture. These
Th figures are signifi
ficant and
should encourage us to improve our techniques.
Additionally, a 15% rate of residual pivot shift has
been reported (6). This rate is probably signifi ficantly
underestimated, as no objective method of evalua-
tion is available, and is the indicator of a functional
instability at a greater extent than differential
ff lax-
ity measures at 20° (50).
Over 30 years ago, knee surgeons tried to use
extra-articular reconstruction techniques in order
to manage rotatory issues. This is how the concept
of combined procedure was developed in the 1960s
(Macintosh, Lemaire), associating intra- and extra-
articular reconstruction techniques. A review of the
literature yielded mitigated results with regards to
these procedures. Some authors no longer recom-
mend these techniques (51–53), while others use
them specifi fically for complex cases (54–56). This
invasive procedure requires an additional skin inci-
sion and complicates postoperative management.
Additionally, going under the lateral collateral
ligament would be responsible for decoaptation
of the lateral component over time. Although the
pre-eminence of extra-articular reconstruction
could not be established, this technique should
not be discarded from our therapeutic arsenal and
improvements ought to be aimed at, in an attempt
to make this technique less invasive, more iso-
metric and effifficient, irrespective of the degree of
flexion. Above all, it should restore physiological
internal rotation, which seems difficult
ffi to obtain
through surgical procedures.
The mitigated results of combined procedure and
their potential pitfalls as well as the progresses
made in the knowledge of the ACL biomechanics
and anatomy have encouraged some teams to work
on double-bundle reconstruction. Things seem
been forgotten, i.e., the anatomy. The
Th biomechani-
cal studies on double-bundle reconstruction have
demonstrated the benefi fits of these techniques,
particularly with regards to controlling rotatory
laxity. Four recent prospective comparative studies
confi
firmed these results (20,57–59) with a statisti-
cal improvement at the pivot shift evaluation with
the double-bundle reconstructions (Table 1). How-
ever, clinical evaluation remains diffi fficult as long
as the evaluation of rotational stability is still an
issue. Objective measurement methods of rotatory
laxity are in development (60) and will certainly be
helpful for clinical evaluation of ACL reconstruc-
tion procedures (57).
The evolution and the biologic integration of a
two-bundle graft can potentially be more chal-
lenging for a two-bundle graft than for a sin-
gle-bundle graft. Reassuring results have been
reported recently. The viability and the aspect of
the two-graft bundles have been evaluated in 136
of 178 consecutive patients with “second-look
arthroscopic evaluation” between 11 months and
2 years after anatomic double-bundle reconstruc-
tion (61). In this study, the arthroscopic aspect of
the AM bundle was quoted as excellent in 79.5%,
fair in 16.7%, and poor in 3.8%. The Th PL bundle
was evaluated as excellent in 75.8%, fair in 21.2%,
and poor in 3%. These
Th diff
fferent categories of graft
aspect were correlated with anterior laxity and
pivot shift test.
Double-bundle reconstruction techniques seem
promising, although we should remain cautious
before generalizing them. Th The number of tech-
niques described in the literature reflects
fl the lack of
standardization of this procedure. We have to keep
in mind that arthroscopic ACL single-bundle recon-
struction remains a technically delicate procedure.
The increased number of technical diffi fficulties leads
to increased risk of errors, particularly as one of the
reasons for failure of the current techniques is due
to inappropriate positioning of bone tunnels. Sev-
eral studies clearly demonstrated that, during sin-
gle-bundle reconstruction, the positioning of the
femoral tunnel is fundamental for laxity control.

Table 1 – Prospective comparative studies: Single versus Double Bundle reconstruction.

Group 1 Group 2 Group 3 Follow-up ATT Pivot shift
Yasuda n = 24. SB Study n =24. DB 2 years 3,2 >1 3,2 > 1
Level 2 Trans-tib Anatomic
Yagi n = 20. SB: AM bundle n = 20 n =20. DB 1 year Ns 3 > 1,2
Level 2 SB:PL bundle Anatomic instrumented
Aglietti n = 25 n =25. DB n =25. DB 2 years 3>1 3>1
Level 2 Trans-tib SB Single incision trans-tib 2 incision
Jarvela n =25. SB n =27. SB n =25. DB Absorbable 2 years Ns 3>1,2
Level 1 Metallic inter. screw Absorbable interf. screw interf. screw
Note: SB, single bundle; DB, double bundle.
232 The Traumatic Knee
Like for any new technique, the potential long-
term complications remain unknown. The pres-
ence of multiple tunnels may complicate revi-
sion and may be responsible for tibial or femoral
fractures. Postoperative tunnel enlargement may
result in important bone defects by making tun-
nels communicate. The presence of two intra-artic-
ular bundles may be responsible for stiffness
ff of the
knee, in extension due to a confl flict with the notch,
in flexion due to conflflict with the posterior cruci-
ate ligament.
Finally, should this type of reconstruction be rec-
ommended to all patients or exclusively for a cer-
tain type of laxity? In this context, we are entitled
to hope for improved ACL reconstruction tech-
niques in the future, through the development
of computer-assisted surgery. This type of tool
should allow us to perform more anatomically
precise reconstruction procedures and, fi first and
foremost, to identify the type of laxity concerned
by a specifi
fic procedure for the control of rotatory
laxity.
Nevertheless, few surgical concepts have been
the subject of so many preclinical evaluations.
The results of these studies still do not allow us to
demonstrate the clinical pre-eminence of double-
bundle reconstruction techniques; their clinical
evaluation, however, is fully justified.
fi
Conclusions
Intra-articular, single-bundle ACL reconstruction
techniques grew increasingly reliable and have
become standard procedures over the past few
years. These techniques have allowed us to obtain
a generally satisfactory stabilization. However, it
is a known fact that these single-bundle recon-
struction procedures do not allow for control of
all types of ACL injury-induced laxity. Alternative
solutions aiming at controlling excessive tibial
rotation have been introduced, such as lateral
tenodesis; their biomechanical and clinical results,
however, remain controversial. Under the impul-
sion of Japanese teams, some of the anatomical
and biomechanical features of the ACL have been
updated. Th The PL bundle was rediscovered, and
its specifi
fic, mechanical role was defi
fined in more
details:
– Involvement in the control of anterior tibial
translation, when the knee is close to full exten-
sion, in combination with the AM bundle
– Control of internal tibial rotation
These fundamental, highly documented data
led several surgical teams to develop “anatomic”
reconstruction procedures, aiming to achieve
reconstruction of both ACL bundles. Rigorous
long-term clinical studies will have to confirm fi
the results obtained in already promising in vivo
studies. The expected benefi
fits of these reconstruc-
tion techniques should be confi firmed in the light
of the clinical results obtained, and should lead
to a better knowledge of preferential indications.
The double bundle reconstructions have led to sig-
nifi
ficant advances in knowledge of anatomy and
biomechanics of the ACL. The future seems to be
moving towards taking into account the biological
environment of our reconstructions (62).
References
1. Dandy DJ (1981) Arthroscopic surgery of the knee. Lon-
don, Churchill Livingstone: 67–68
2. Petersen W, Zantop T. (2007) Anatomy of the anterior cru-
ciate ligament with regard to its two bundles. Clin Orthop
Relat Res. 454:35–47
3. Bach BR, Jr., Tradonsky S, Bojchuk J, et al. (1998)
Arthroscopically-assisted anterior cruciate ligament recon-
struction using patellar tendon autograft. Five- to nine-
year follow-up evaluation. Am J Sports Medd 26:20–29
4. Daniel DM, Stone ML, Dobson BE, et al. (1994) Fate of the
ACL-injured patient. A prospective outcome study. Am J
Sports Medd 22:632–644
5. Johma NM, Pinczewski LA, Clingeleffer ff A, Otto DD
(1999) Arthroscopic reconstruction of the anterior cruci-
ate ligament with patellar-tendon autograft and interfer-
ence screw fi
fixation. The results at seven years. J Bone Joint
Surg Brr 81:775–779.
6. Nedeffff DD, Bach BR, Jr. (2001) Arthroscopic anterior
cruciate ligament reconstruction using patellar tendon
autografts: A comprehensive review of contemporary lit-
erature. Knee Surgg 14:243–258
7. Galway RD, Beaupre A, Macintosh DL (1972) Pivot shift:
a clinical sign of symptomatic anterior cruciate insuffi- ffi
ciency. J Bone Joint Surg Brr 54B:763–764
8. Rosenberg T, Brown G (1997) Anterior cruciate liga-
ment reconstruction with a quadrupled semitendinosus
autograft. Sports Med Arthrosc Rev 5:51–58
9. Muneta T, Sekiya I, Yagishita K, et al. (1999) Two-bundle
reconstruction of the anterior cruciate ligament using
semitendinosus tendon with EndoButtons: operative tech-
nique and preliminary results. Arthroscopy 15:618–624
10. Hara K, Kubo T, Suginoshita T, et al. (2000) Reconstruc-
tion of the anterior cruciate ligament using a double bun-
dle. Arthroscopy 16:860–864
11. Pederzini, L, Adriani E, Botticella C, Tosi M (2000) Double
tibial tunnel using quadriceps tendon in anterior cruciate
ligament reconstruction. Arthroscopy 16:E9
12. Mae T, Shino K, Miyama T, et al. (2001) Single- versus two-
femoral socket anterior cruciate ligament reconstruction
technique: Biomechanical analysis using a robotic simula-
tor. Arthroscopy 17:708–716
13. Hamada M, Shino K, Horibe S, et al. (2001) Single- ver-
sus bi-socket anterior cruciate ligament reconstruction
using autogenous multiple-stranded hamstring tendons
with EndoButton femoral fixation: A prospective study.
Arthroscopy 17:801–807
14. Franceschi JP, Sbihi A, Champsaur P (2002) Dual
arthroscopic reconstruction of the anterior cruciate liga-
ment using anteromedial and posterolateral bundles. Rev
Chir Orthop 88:691–697
15. Bellier G, Christel P, Colombet P, et al. (2004) Double-
stranded hamstring graft for anterior cruciate ligament
reconstruction. Arthroscopy 20:890–894

16. Aglietti P, Giron F, Cuomo P, Losco M, Mondanelli N.
(2007) Single-and double-incision double-bundle ACL
reconstruction. Clin Orthop Relat Res. 454:108–13
17. Yagi M, Wong EK, Kanamori A, et al. (2002) Biomechani-
cal analysis of an anatomic anterior cruciate ligament
reconstruction. Am J Sports Medd 30:660–666
18. Gabriel MT, Wong EK, Woo SL, et al. (2004) Distribu-
tion of in situ forces in the anterior cruciate ligament in
response to rotatory loads. J Orthop Res 22:85–89
19. Lie DT, Bull AM, Amis AA. (2007) Persistence of the mini
pivot shift after anatomically placed anterior cruciate liga-
ment reconstruction. Clin Orthop Relat Res. 457:203–9
20. Yasuda K, Kondo E, Ichiyama H, et al. (2006) Clinical eval-
uation of anatomic double-bundle anterior cruciate liga-
ment reconstruction procedure using hamstring tendon
grafts: Comparisons among three different ff procedures.
Arthroscopy 22:240–251
21. Mott HW (1983) Semitendinosus anatomic reconstruction
for cruciate ligament insuffi
fficiency. Clin Orthop 172:90–92
22. Zaricznyj B (1987) Reconstruction of the anterior cruciate
ligament of the knee using a doubled tendon graft. Clin
Orthop 220:162–175
23. Harner. CD, Baek GH, Vogrin TM, et al. (1999) Quanti-
tative analysis of human cruciate ligament insertions.
Arthroscopy 15:741–749
24. Girgis FG, Marshall JL, Mojanen A (1975) The Th cruciate
ligaments of the knee joint. Anatomical, functional and
experimental analysis. Clin Orthop 106:216–231
25. Odentsen M, Gillquist J (1985) Functional anatomy of the
anterior cruciate ligament and a rationale for reconstruc-
tion. J Bone Joint Surgg 67A:257–262
26. Mochizuki T, Muneta T, Nagase T, et al. (2006) Cadaveric
knee observation study for describing anatomic femoral
tunnel placement for two bundle anterior cruciate liga-
ment reconstruction. Arthroscopy 22:356–361
27. Arnoczky SP (1983) Anatomy of the anterior cruciate liga-
ment. Clin Orthop 172:19–25
28. Norwood LA, Cross MJ (1979) Anterior cruciate ligament:
functional anatomy of its bundles in rotatory instabilities.
Am J Sports Medd 7:23–26
29. Sapega AA, Moyer RA, Schneck C, Komalahiranya N
(1990) Testing for isometry during reconstruction of the
anterior cruciate ligament. Anatomical and biomechanical
consideration. J Bone Joint Surgg 72:259–267
30. Shen W, Jordan S, Fu F (2007) Review article: Anatomic
double bundle anterior cruciate ligament reconstruction.
J of Orthop Surgg 15(2):216–221
31. Merida-Velasco JA, Rodriguez-Vasquez JF, Jimenez-Col-
lado J (1997) Development of the human knee joint liga-
ments. Anat Rec 248:259–268
32. Ferretti M, Levicoffff EA, Macpherson TA, et al. (2007) The
Th
fetal anterior cruciate ligament: an anatomic and histo-
logic study. Arthroscopy 23:278–283
33. Amis AA, Dawkins GPC (1991) Functional anatomy of the
anterior cruciate ligament. Fibre bundle action related to
ligament replacements and injuries. J Bone Joint Surg Br
73(B):260–267
34. Woo SL, Kamamori A, Zeminski J, et al. (2002) The Th eff
ffec-
tiveness of reconstruction of the anterior cruciate liga-
ment with hamstrings and patellar tendon. A cadaveric
study comparing anterior tibial and rotational loads.
J Bone Joint Surg Am 84-A(6):907–914
35. Ristanis S, Giakos G, Papageorgiu CD, et al. (2003) The Th
eff
ffects of anterior cruciate ligament reconstruction on
tibial rotation during pivoting after descending stairs.
Knee Surg Sports Traumatol Arthrosc 11(6):360–365
36. Tashman S, Collon D, Anderson K, et al. (2004) Abnor-
mal rotational knee motion during running after ante-
rior cruciate ligament reconstruction. Am J Sports Med
32(4):975–983
Single or double bundle? 233
37. Ch
Chouliaras
l V, Ristanis S, Moraiti C, et al. (2007) Effective-
ff
ness of reconstruction of the anterior cruciate ligament
with quadrupled hamstrings and bone-patellar tendon-
bone autografts: an in vivo study comparing tibial inter-
nal-external rotation. Am J Sports Medd 35(2):189–196
38. Lie DTT, Bull AMJ, Amis AA (2007) Persistence of the mini
pivot shift after anatomically placed anterior cruciate liga-
ment reconstruction. Clin Orthop Relat Res 457:203–209
39. Tashman S, Kollowich P, Collon D, et al. (2007) Dynamic
function of the ACL-reconstructed knee during running.
Clin Orthop Relat Res 454:66–73
40. Stergiou N, Ristanis S, Moraiti C, Georgoulis AD (2007)
Tibial rotation in anterior cruciate ligament (ACL)-defi- fi
cient and ACL-reconstructed knees: a theoretical propo-
sition for the development of osteoarthritis. Sports Med
37(7):601–613. Review
41. Loh JC, Fukuda Y, Tsuda E, et al. (2003) Knee stability and
graft function following anterior cruciate ligament recon-
struction: Comparison between 11 o'clock and 10 o'clock
femoral tunnel placement. 2002 Richard O'Connor Award
paper. Arthroscopy 19(3):297–304
42.Yamamoto Y, Hsu WH, Woo SL, et al. (2004) Knee stability
and graft function after anterior cruciate ligament recon-
struction: a comparison of a lateral and an anatomical fem-
oral tunnel placement. Am J Sports Medd 32(8):1825–1832
43. Draganich LF, Reider B, Ling M, Samuelson M (1990) An
in vitro study of an intraarticular and extraarticular recon-
struction in the anterior cruciate ligament deficient
fi knee.
Am J Sports Medd 18:262–266
44. Engebretsen L, Lew WD, Lewis JL, Hunter RE (1990) Th The
eff
ffect of an iliotibial tenodesis on intraarticular graft forces
and joint knee motion. Am J Sports Medd 18:169–176
45. Amis AA, Scammell BE (1993) Biomechanics of intra-ar-
ticular and extra-articular reconstruction of the anterior
cruciate ligament. J Bone Joint Surg Brr 75-B:812–817
46. Samuelson M, Draganich LF, Zhou X, et al. (1996) The Th
eff
ffects of knee reconstruction on combined anterior cruci-
ate ligament and anterolateral capsular deficiencies.
fi Am J
Sports Medd 24:492–497
47. Radford WJP, Amis AA (1990) Biomechanics of a double
prosthetic ligament in the anterior cruciate deficient
fi knee.
J Bone Joint Surg Brr 72(6):1038–1043
48. Sakane M, Fox RJ, Woo SL, et al. (1997) In situ forces in
the anterior cruciate ligament and its bundles in response
to anterior tibial loads. J Orthop Res 15(2):285–293
49. Zantop T, Herbort M, Raschke MJ, et al. (2007) The Th role of
the anteromedial and posterolateral bundles of the ante-
rior cruciate ligament in anterior tibial translation and
internal rotation. Am J Sports Medd 35(2):223–227
50. Kocher MS, Steadman JR, Briggs KK, et al. (2004) Rela-
tionships between objective assessment of ligament sta-
bility and subjective assessment of symptoms and func-
tion after anterior cruciate ligament reconstruction. Am J
Sports Medd 32(3):629–634
51. Anderson AF, Snyder RB, Lipscomb AB, Jr. (2001) Anterior
cruciate ligament reconstruction. A prospective random-
ized study of three surgical methods. Am J Sports Med
29:272–279
52. Barett GR, Richardson KJ (1995) The Th eff
ffect of added extra-
articular procedure on results of ACL reconstruction. Am
J Knee Surgg 8:1–6
53. Strum GM, Fox JM, Ferkel RD, et al. (1989) Intraarticular
versus intraarticular and extraarticular reconstruction for
chronic anterior cruciate ligament instability. Clin Orthop
Relat Res 245:188–198
54. Acquitter Y, Hulet C, Locker B, et al. (2003) Patellar ten-
don-bone autograft reconstruction of the anterior cruciate
ligament for advanced-stage chronic anterior laxity: is an
extra-articular plasty necessary? A prospective random-
ized study of 100 patients with five year follow-up. Rev
Chir Orthop Reparatrice Appar Mot 89(5):413–422. French
234 The Traumatic Knee
55. Dejour H, Dejour D, Ait Si Selmi T (1999) Chronic anterior
laxity of the knee treated with free patellar graft and extra-
articular lateral plasty: 10-year follow-up of 148 cases. Rev
Chir Orthop Reparatrice Appar Mot 85(8):777–789. Review.
French
56. Jonhston DR, Baker A, Rose C, et al. (2003) Long term
outcome of MacIntosh reconstruction of chronic anterior
cruciate ligament insuffifficiency using fascia lata. J Orthop
Sci 8:789–795
57. Yagi M, Kuroda R, Nagamsune K, et al. (2007) Double-
bundle ACL reconstruction can improve rotational stabil-
ity. Clin Orthop Relat Res 454:100–107
58. Aglietti P, Giron F, Cuomo P, et al. (2007) Single- and
double-incision double-bundla ACL reconstruction. Clin
Orthop Relat Res 454:108–113
59. Järvela T, Moisala AS, Sihvonen R, et al. (2008) Double-
bundle anterior cruciate ligament reconstruction using
hamstring autografts and bioabsorbable interference
screw fixation.
fi Am J Sports Medd 36:290–297
60. Musahl V, Bell KM, Tsai AG, et al. (2007) Development
of a simple device for measurement of rotational knee
laxity. Knee Surg Sports Traumatol Arthrosc 15(8):1009–
1012
61. Kondo E, Yasuda K (2007) Second look arthroscopic
evaluations of anatomic double-bundle anterior cruciate
ligament reconstruction: relation with postoperative knee
stability. Arthroscopy 23(11):1198–1209
62. Löcherbach C, Zayni R, Chambat P, Sonnery-Cottet B.
(2010) Biologically enhanced ACL reconstruction. Orthop
Traumatol Surg Res. Oct 8. [Epub ahead of print]

K.
C. Yasuda
Pelluchon Anatomic double-bundle ACL
reconstruction: how I do it?
History of double-bundle ACL reconstruction
T
he anterior cruciate ligament (ACL) is func-
tionally composed of two bundles: the anter-
omedial (AM) bundle (AMB) and posterolat-
eral (PL) bundle (PMB). An idea of double-bundle
ACL reconstruction with two tunnels in the femur
and the tibia, respectively, was first described by
Mott in 1983 (1). In this early technical paper, no
explanation concerning each tunnel location was
made. In 1987, Zaricznyj (2) reported on a double-
bundle procedure in which two tibial tunnels and
one femoral tunnel were created. In 1994, a tech-
nical manual produced under the advice of Rosen-
berg and Graf (3) displayed a few schematic draw-
ings on an arthroscopically assisted double-bundle
procedure using two femoral tunnels and one tibial
tunnel. These drawings provided an impact to sur-
geons, although the manual was rarely cited as a
scientifi
fic paper. In 1999, Muneta et al. (4) improved
this procedure by creating two tunnels in the tibia.
However, because they described that two femo-
ral tunnels were created at the 10:30 and 11:30
(or 12:30 and 1:30) orientations, respectively,
their procedure was diff fferent from the currently
performed “anatomic” double-bundle procedures.
Hereafter, several technical papers for double-bun-
dle ACL reconstruction procedures were published
(5–11). However, only a few clinical trials had been
conducted to evaluate the double-bundle proce-
dures. Recently, Hamada et al. (12) and Adachi et
al. (13) compared the clinical results between their
single- and double-bundle procedures, and showed
that there were no statistically significant
fi diff
ffer-
ences in subjective results or measured knee stabil-
ity between the two procedures. However, because
the authors described that the PLB was created at
the 1:30–3:00 (or 9:00–11:30) o’clock orientation,
there was a strong possibility that the tunnel posi-
tion for the PLB reconstruction appeared not to be
located at the best anatomic position according to
the following current knowledge (14–16).
In the 1980s and 1990s, the concept of double-bun-
dle ACL reconstruction appeared not to include ana-
tomic reconstruction of the PLB. This was because no
studies were conducted to clarify where the normal
Chapitre 21
attachment of the PLB was on the lateral femoral con-
dyle in a surgical visual field.
fi Thus, any a procedure
in which a femoral tunnel was intentionally created
through the center of the anatomical attachment
of the PLB has not been reported until the 2000 s.
In 2003, Yasuda et al. (16,17) reported a 2-year
follow-up study on the first
fi double-bundle procedure
in which four independent tunnels were intention-
ally created through the center of the four anatomi-
cal attachments of the PLB and AMB, respectively,
and they named this procedure “anatomic double-
bundle reconstruction.” Their procedure included a
newly developed method to clinically identify the
attachment of the PLB on the lateral femoral con-
dyle in an arthroscopic visual field (Fig. 1). This paper
advanced the previous concept of double-bundle
reconstruction to the current concept of “anatomic”
double-bundle reconstruction. Hereafter, several
technical papers on the anatomic double-bundle ACL
reconstruction have been reported to date (18–24).
Their tunnel creation techniques are classifi fied into a
few types: the trans-tibial tunnel technique, the so-
called far-anteromedial portal technique, the double-
incision outside-in technique, and so on. However,
the essence of the anatomic double-bundle proce-
dure, which is to create four independent tunnels
at the center of the four anatomical attachments of
the AMB and PLB, respectively, should be the same
over the technical difffferences. In this chapter, the
Fig. 1 – A method to clinically identify the attachment of the PLB on the lat-
eral femoral condyle in an arthroscopic visual field. When the surgeon holds
the tibia at 90° of knee flexion, keeping the femur horizontal, a surgeon
can imagine drawing a vertical line through the contact point between the
posterior condyle and the tibia. The center of the attachment of the PLB is
located approximately at the crossing point between this vertical line and
the long axis of the ACL attachment. Commonly, this point is 5–8 mm ante-
rior to the edge of the joint cartilage on the imaginary drawn vertical line.
236 The Traumatic Knee
author will explain the trans-tibial tunnel procedure
(16,25). However, the above-described essence and
some critical points are common among all anatomic
double-bundle procedures.
How I do it (my procedure)
Preparation of arthroscopic surgery
Surgery is performed with an air tourniquet in the
standard supine position. A surgeon sits on a chair
beside the operating table. An edge of a surgical
drape is attached to the waist area of the surgeon so
that the patient’s leg and foot can be hung beside the
table and can be put on the surgeon’s knee for easy
manipulation in a sterile condition (16,25). This setup
allows the surgeon to keep appropriate position of
the patient’s femur and tibia, which will be explained
latter, by using the surgeon’s knee. The positioning of
the patient’s femur and tibia is one of the most criti-
cal points to identify the anatomic PL attachment.
An arthroscope is inserted through the lateral infra-
patellar portal. After a routine arthroscopic examina-
tion, an approximately 3-cm-long oblique incision is
made in the AM portion of the proximal tibia. The Th
semitendinosus and gracilis tendons are harvested
using a tendon stripper in the figure-four knee posi-
tion. When the semitendinosus tendon is thick and
long enough, the gracilis tendon is not harvested.
Creation of tibial tunnels
A remnant of the torn ACL is sharply resected,
leaving a 1-mm-long ligament tissue at the femoral
and tibial insertions, which can be used as land-
Fig. 2 – Wire-navigator is composed of a Navi-tip (NT) and a Wire-sleeve
(WS). The Navi-tip consists of sharp tibial and femoral indicators (TI and FI).
The axis of the Wire-sleeve shown as a dotted line passes through the tip of
the tibial indicator.
marks for inserting guide wires. In ACL recon-
struction procedures with the trans-tibial tunnel
technique, it is the greatest key for success to cre-
ate a tibial tunnel having an appropriate three-
dimensional direction. Namely, a guide wire to
create a tibial tunnel should be inserted so that
the guide wire passes through the center of each
bundle attachment on the tibia and aims at that on
the lateral femoral condyle. To insert a tibial guide
wire, we use a specially designed guide, Wire-navi-
gator (Fig. 2), which was developed in our previous
study (26,27) and commercially available currently
(Wire-navigator, Smith & Nephew, Inc, Andover,
MA, USA). This device is composed of a Navi-tip
and a Wire-sleeve. The Navi-tip consists of sharp
tibial and femoral indicators. TheTh axis of the Wire-
sleeve passes through the tip of the tibial indica-
tor. First, a tibial tunnel for the PLB is created. The
Th
Navi-tip is introduced into the joint cavity through
the medial infra-patellar portal.
The surgeon holds the tibia at 90° of knee flexion,
keeping the femur horizontal. The Th tibial indicator
of the Navi-tip is placed at the center of the PLB
footprint on the tibia, which is located at the most
posterior aspect of the area between the tibial
eminences, and 5 mm anterior to the posterior
cruciate ligament (Fig. 3). Keeping the tibial indi-
cator on this point, we aim the femoral indicator
at the center of the PLB footprint on the femur
(Fig. 4A), which is precisely explained in the next
section, and the proximal end of the extra-articu-
larly located Wire-sleeve is fifixed on the AM aspect
of the tibia through the skin incision made for
the graft harvest. Th The proximal end and the direc-
tion of the Wire-sleeve are automatically decided,
depending on the direction of the intra-articular
Navi-tip (Fig. 4B). A Kirschner wire of 2 mm in
diameter is drilled through the sleeve in the tibia.
According to our basic studies, this tunnel does not
injure the medial collateral ligament, because the
Fig. 3 – A tibial tunnel outlet for PLB reconstruction is located at the most
posterior aspect of the area between the tibial eminences, and 5 mm ante-
rior to the posterior cruciate ligament. That for AMB reconstruction is located
at a point approximately 7 mm anterior to the center of the first tunnel.
 Anatomic double-bundle ACL reconstruction: how I do it? 237

A
Fig. 4 – How to use the Wire-navigator. Keeping the tibial indicator on this point, we aim the femoral
B
indicator at the center of the PLB footprint on the femur (A), and the Wire-sleeve ve is fixed
fixed on the
tibia. The proximal end and the direction of the Wire-sleeve are automatically decided, depending
on the direction of the intra-articular Navi-tip (B). Thus, a guide wire for the PLB reconstruction is
appropriately inserted.

Fig. 5 – Appropriate tunnel positions in the tibia (transparent computed tomogram). Note that the tibia tunnel angle for the PLB reconstruction averaged
40.7° to the tibial axis in the anterior-posterior view.

insertion point of the wire on the AM aspect of the
tibia is located several millimeters anterior to the
ligament (16).
Although the usage of the Wire-navigator easily
allows for appropriate insertion of a guide wire for
the PLB reconstruction, beginner surgeons should
check the guide wire location using an x-ray image
before over-drilling the tibial tunnel, because mal-
position of this wire causes not only diffi fficulty
of inserting a guide wire to the femur but also
destruction of the medial joint surface of the tibia.
In my clinical experience, the tibial tunnel angle
for the PLB reconstruction averaged 40.7° to the
Fig. 6 – A guide wire for the AMB reconstruction is appropriately inserted.
Note the difference in the wire direction between this and a guide wire for
the PLB reconstruction.
tibial axis in the anterior-posterior view and 35.4°
in the lateral view (28). After checking the guide
wire position, the first
fi tunnel is made with an
approximately 6-mm cannulated drill correspond-
ing to the measured diameter of the prepared sub-
stitute.
Second, a Kirschner wire for the AMB reconstruc-
tion is drilled using the same Wire-navigator. TheTh
tibial indicator is placed at the center of the tibial
footprint of the AMB, which is located at a point
approximately 7 mm anterior to the center of the
first tunnel (Fig. 3). Keeping the tibial indicator
on this point, we then aim the femoral indicator
at the center of the femoral footprint of the AMB.
The Wire-sleeve is fixed on the AM cortex of the
tibia. A Kirschner wire is drilled through the sleeve
in the tibia (Fig. 6). The
Th knee should be extended
to ensure that the tip of the second wire is located
at the point 5 mm posterior to the anterior edge
of the roof in the intercondylar notch. ThThe second
tunnel is drilled with an approximately 7-mm can-
nulated drill corresponding to the measured diam-
eter of the prepared substitute. Subsequently, two
intra-articular outlets are aligned in the sagittal
plane (Fig. 7). Although the edges of the intra-ar-
ticular tunnel outlets appear to be combined, such
a tibial tunnel outlet coalition will not provide any
problems to the clinical results, because the two
238 The Traumatic Knee
tunnels are completely independent each other in
the tibia except for the extremely limited portion
(Fig. 5).
Method to identify a targeted point for femur tunnel
creation
Previous anatomical studies reported that both
the normal AMB and the normal PLB have broad
attachment on the medial surface of the lateral
femoral condyle (29–31), because the membra-
nous soft tissues surrounding the main fibersfi of
the ACL spread on the lateral condyle (14). How-
ever, the authors (16) reported that the femoral
footprint of the main ACL fibers
fi that should be
clinically reconstructed in ACL reconstruction is
oval shaped with its long axis inclined toward the
posterior direction by 30° to the long axis of the
femur (Fig. 8). Recent anatomical studies have sup-
ported this observation (14,15).
It is diffi
fficult to identify a center of the anatomi-
cal attachment of the PLB on the femur in an
arthroscopic visual field,
fi because there are no defi
fi-
nite landmarks on the femur, although it is easy
in the cadaver knee. At the present time, only an
arthroscopic method to reproducibly identify the
targeted point on the femur was proposed by the
authors (16). Namely, the surgeon holds the tibia
at 90° of knee flexion, keeping the femur hori-
zontal. An imaginary circle can be drawn on the
Fig. 7 – Two intra-articular outlets are aligned in the sagittal plane.
margin of the posterior femoral condyle in the
arthroscopic visual field.
fi Then an imaginary verti-
cal line through the contact point between the pos-
terior femoral condyle and tibial cartilage surface,
which means a vertical diameter of the circle, can
be drawn (Fig. 8). ThThe center of the attachment of
the PLB is located approximately at the crossing
point between this vertical line and the long axis
of the ACL attachment. Because the remnant of
the ACL is commonly observed on the lateral con-
dyle, this point can be easily determined using this
method. If the remnant of the ACL is not identi-
fied on the lateral condyle, the center of the attach-
ment of the PLB can be determined as the point
5–8 mm anterior to the edge of the joint cartilage
on an imaginary drawn vertical line (Fig. 1).
Creation of femoral tunnels
First, a Kirschner wire is drilled at the center of
the femoral footprint of the AMB through the sec-
ond tibial tunnel, using the off ffset guide system
(Transtibial Femoral ACL Drill Guide, Arthrex,
Inc., Naples, FL, USA). This point is located at the
point 5–6 mm distal from the back of the femur.
This point is consistent with the “1:30” (or “10:30”)
orientation for the left (or right) knee. Using this
wire as a guide, a tunnel is made with a 4.5-mm
cannulated drill. The length of the tunnel is mea-
sured with a scaled probe (Fig. 9).
Then, to precisely observe the lateral condyle in
the arthroscopic visual field, a portal for an arthro-
scope is changed to the medial infra-patellar one.
When the surgeon holds the tibia at 90° of knee
flexion, keeping the femur horizontal, we can
identify the center of the attachment of the PLB
using the above-described method (Figs. 1 and 8).
The first femoral tunnel for the AMB reconstruc-
tion that has been already created can be used as
one of landmarks to determine the center of the
attachment of the PLB. To insert a guide wire at
this point, the surgeon manually holds a Kirschner
wire and aims it at the center of the attachment
Fig. 8 – When the surgeon holds the
tibia at 90° of knee flexion, keeping the
femur horizontal, a surgeon can imagine a
superimposed circle on the margin of the
posterior femoral condyle that contacts
the tibial surface in the arthroscopic visual
field. A surgeon also can imagine draw-
ing a vertical line, which means a vertical
diameter of the circle, through the contact
point. The center of the attachment of the
PLB is located approximately at the cross-
ing point between this vertical line and
the long axis of the ACL attachment.

Fig. 9 – After a femoral tunnel for AMB reconstruction was created at the
“1:30” (or “10:30”) orientation, the tunnel length is measured with a scaled
probe.
Fig. 11 – A socket for the PLB reconstruction is created with cannulated
drill.
of the PLB on the femur through the tibial tunnel,
keeping the femur horizontal at 90° of knee fl
flexion
(Fig. 10). Then, the surgeon lightly hammers the
wire into this point and, then, drills it. Surgeons
should avoid coalition of the intra-articular tun-
nel outlets specifi
fically on the femur. Therefore, in
a case with a relatively small size of the posterior
condyle, a targeted point is moved by 1–2 mm
posteriorly and distally from the above-described
original targeted point. The
Th 6-mm tibial tunnel
commonly has an enough space in which the wire
is moved to aim at the targeted point.
The guide wire position should be strictly con-
firmed, at least, before over-drilling. It may be
better for beginner surgeons to check the targeted
point using a lateral x-ray image at 90° of knee fl
flex-
ion. The above-described identifification method is
useful for this check. When it is difficult
ffi to aim a
Kirschner wire at the center of the attachment of
the PLB on the femur through the tibial tunnel,
the most common reason is that the tibial tunnel
was created in an inappropriate position. In the
case, the surgeon should give up the trans-tibial
tunnel technique and create the femoral tunnel
using the far-anteromedial portal technique or the
outside-in technique. Then,
Th a 4.5-mm-diameter
tunnel is drilled using this wire as a guide. Th The
tunnel length is measured in the same manner.
Anatomic double-bundle ACL reconstruction: how I do it? 239
Fig. 10 – Keeping the femur horizontal at 90° of knee flexion, a surgeon
manually aims a Kirschner wire at the center of the attachment of the PLB
on the femur through the tibial tunnel, and then inserts the wire into this
point.
Fig. 12 – Two sockets are created for the AMB and PLB reconstruction. Care
should be taken to avoid tunnel outlet coalition.
Finally, two sockets are created for the AMB and
PLB reconstruction with cannulated drills in the
Endobutton fixation system (Smith & Nephew,
Inc, Andover, MA, USA), the diameter of which is
matched to the two grafts prepared with the tech-
nique described below (Fig. 11). Thus,
Th two tunnels
are created inside the ACL remnant on the lateral
condyle (Fig. 12).
Graft fashioning
The harvested semitendinosus tendon is cut in
half. Regarding the gracilis tendon, both ends are
resected so that the thickest portion is utilized for
the graft and the length is matched to half the length
of the semitendinosus tendon. One half of the
semitendinosus tendon and the resected gracilis
tendon are doubled and used for AMB reconstruc-
tion. The remaining half of the semitendino-
sus tendon is also doubled and used for the PLB
reconstruction. Using these tendon materials, the
hybrid grafts (16,26,27) are fashioned (Fig. 13).
Namely, at the looped end of each doubled ten-
don graft, an Endobutton-CL (Acufex Microsurgi-
cal, Mansfifield, MA) is attached. The length of the
Endobutton-CL is decided so that 15- to 20-mm-
long tendon portion will be placed within the bone
240 The Traumatic Knee

Fig. 13 – Using semitendinosus and gra-

cilis tendons, the hybrid grafts are fash-
ioned. Namely, at the looped end of each
doubled tendon graft, an Endobutton-CL
is attached. A polyester tape is mechani-
cally connected in series with the other
end of the doubled tendons, using the
original technique.

tunnel. A commercially available polyester tape
(Leeds-Keio Artifi
ficial Ligament, Neoligament Inc.,
UK) is mechanically connected in series with the
other end of the doubled tendons, using the origi-
nal technique (Fig. 13). This tape is strong, soft,
meshed, 10 mm wide, and 15 cm long. In our expe-
rience, the diameter of the tendon portion ranged
from 6 to 8 mm for the AMB graft and from 5 to
6 mm for the PLB graft. TheTh first advantage of the
hybrid graft is that it is stronger and stiffer
ff than
the tendon-suture composite (32,33). Th The second
one is that the tape portions of the two grafts can
be simultaneously fixed to the tibia, being applied
an initial tension. The latter feature is specifi
fically
important for anatomic double-bundle recon-
struction.
Graft tensioning and fifixation
The graft for the PLB reconstruction is introduced
through the tibial tunnel to the femoral tun-
nel using a passing pin and is fixed
fi on the femur
by an Endobutton (Fig. 14A). Then, the graft for
the AMB is placed in the same manner. Thus,
Th the
two bundles having different
ff directions are intra-
articularly grafted (Fig. 14B). The grafts rarely
impinge to the femur. Notch plasty is performed
only in knees with an extremely narrow notch due
to osteochondral spur formation, and so forth.
For graft fixation, the knee is extended to approxi-
mately 10° on the operating table. A spring tensi-
ometer (Meira Co., Nagoya, Japan) is attached at
each end of the polyester tape portion of the graft.
An assistant surgeon simultaneously applied ten-
sion of 30 N to each graft for 2 min at 10° of knee
flexion, and a surgeon simultaneously secured the
two tape portions onto the AM aspect of the tibia
using two spiked staples in the turn-buckle fash-
ion (25).
The biomechanical theory of our tensioning tech-
nique is explained as follows: According to our in
vivo measurement studies, when we applied the
same initial tension on each bundle at 10° of knee
flexion, each tension pattern was similar to that
of the normal bundle (34). From the viewpoint to
easily avoid flexion contracture of the knee or graft
breakage after surgery, the fully extended position
may be safer as a knee angle for graft tensioning
than 10° of flexion. However, we should remember
that the initial graft tension in the hamstring ten-
don graft is dramatically reduced in the early phase

A B
Fig. 14 – After the graft for the PLB reconstruction is placed (A), the graft for the AMB is placed (B). Note that the intra-articularly grafted two bundles have
different directions.

after surgery (33,35). ThThus, we recommended the
knee position of 10° of knee flexion for graft ten-
sioning to restore the ACL function close to the
normal one immediately after surgery (25), taking
the postoperative graft relaxation into account.
Another important question on graft tensioning is
whether we should separately fix the two grafts at
diff
fferent flexion angles. According to our in vivo
measurement studies, if we apply a tension to
the AMB after we fixedfi the PLB at the extension
position, the initial tension applied to the PLB is
reduced to an unknown degree. Namely, a surgeon
fficiently control the graft tension in this
cannot suffi
technique. Th Therefore, in anatomic double-bundle
ACL reconstruction, it is important to simultane-
ously fix the two bundles, applying appropriate ini-
tial tensions to the two grafts.
Advantages and disadvantages of my procedure
Once appropriate tibial tunnels are created, the
trans-tibial tunnel technique has some advan-
tages, including easy femoral tunnel creation, easy
passage of the graft, easy flip
fl of an Endobutton,
and less invasive procedure. However, a disadvan-
tage of this technique is that high surgical skills or
useful devices such as Wire-navigator are needed
to create appropriate tibial tunnels. In our clini-
cal practice, we have not experienced any serious
complications in our anatomic double-bundle pro-
cedure (36,37). Commonly speaking, however, all
anatomic double-bundle procedures are not easy
to perform for beginner surgeons. Surgeons who
hope to follow one of these procedures should
obtain suffi
fficient surgical skills for arthroscopic
surgery before they attempt the procedures.
Clinical results
Our second-look arthroscopy study demonstrated
that, after the above-described anatomic double-
bundle procedure, the AMB showed “excellent” in
79.5% of the knees, “fair” in 16.7%, and “poor” in
3.8%, and the PLB showed “excellent” in 75.8%,
“fair” in 21.2%, and “poor” in 3.0% (38). However,
the greatest criticism to anatomic double-bundle
procedures has been summarized in the follow-
ing question: are the clinical results of anatomic
double-bundle reconstruction better than the
results of single-bundle reconstruction? Recently,
five prospective clinical studies (Level II) that
compared single- and anatomic double-bundle
reconstruction procedures have been available for
review (36,37,39–41), since the authors reported
the first 2-year comparative results (37). Regard-
Anatomic double-bundle ACL reconstruction: how I do it? 241
ing the postoperative knee stability, their ana-
tomic double-bundle reconstruction procedures
were better than their single-bundle reconstruc-
tion procedures, specifi fically in the result of the
pivot-shift test. To note, Yagi et al. (41) quantified
fi
the superiority in the pivot-shift test using a mag-
netic sensor system. Concerning the anterior lax-
ity measured with KT-2000, three out of the five fi
papers (36,37,39) reported that their anatomic
double-bundle reconstruction procedures were
better than their single-bundle reconstruction
procedures. Recently, we compared our single- and
double-bundle procedures using consecutive 328
patients (36). The anterior laxity was signifi ficantly
less in the double-bundle reconstruction (average
1.2 mm) than in the single-bundle reconstruc-
tion (average 2.5 mm). In the pivot-shift test, the
former was signifi ficantly better than the latter. In
the five studies, there were no signifi ficant diff
ffer-
ences concerning complication rate, range of knee
motion, muscle strength, and return to sports. Th The
better stability of the knee may be an advantage
from a viewpoint of the fundamental goal of ACL
reconstruction. The degree of improvement in the
knee stability looks small, but important because
the history of ACL reconstruction implies that
such small improvement may advance ACL recon-
struction in the future.
Conclusion
Recent basic studies have shown that the ana-
tomic double-bundle ACL reconstruction pro-
cedures have biomechanical benefi fits, at least,
immediately after surgery (42–45). From a clini-
cal viewpoint, however, the utility of anatomic
double-bundle reconstruction remains contro-
versial, although the recent Level II studies have
reported better knee stability after anatomic dou-
ble-bundle reconstruction (36,37,39–41). Further
clinical studies of Level I are needed to evaluate
the utility of anatomic double-bundle reconstruc-
tion. In addition, we should understand that we
have not established a perfect system to evalu-
ate the clinical results after ACL reconstruction
as of yet. For example, the measurement of the
knee stability using KT-2000 as well as the IKDC
evaluation criteria show only a part of the whole
clinical results after ACL reconstruction. We can
say that the development of anatomic double-
bundle ACL reconstruction procedures has indi-
cated the insuffi
fficiency in the evaluation system
for ACL reconstruction. For example, to precisely
compare the clinical results between single- and
double-bundle procedures, it is needed to develop
quantitative measurement tools for the pivot-
242 The Traumatic Knee
shift test, clinically available devices to measure
in vivo kinematics during athletic activities, clini-
cal evaluation criteria for secondary injuries of
the meniscus and the cartilage that occur within
10 years after ACL reconstruction, and so on.
Eff
fforts to establish a better evaluation system
will advance ACL reconstruction surgeries in the
near future.
References
1. Mott HW (1983) Semitendinosus anatomic reconstruc-
tion for cruciate ligament insuffi
fficiency. Clin Orthop Relat
Res 172:90–92
2. Zaricznyj B (1987) Reconstruction of the anterior cruciate
ligament of the knee using a doubled tendon graft. Clin
Orthop Relat Res 220:162–175
3. Rosenberg TD, Graf B (1994) Techniques for ACL recon-
struction with Multi-Trac drill guide. Mansfield, fi MA:
Acufex Microsurgical Inc
4. Muneta T, Sekiya I, Yagishita K, et al. (1999) Two-bundle
reconstruction of the anterior cruciate ligament using
semitendinosus tendon with endobuttons: operative tech-
nique and preliminary results. Arthroscopy 15(6):618–
624
5. Bellier G, Christel P, Colombet P, et al. (2004) Double-
stranded hamstring graft for anterior cruciate ligament
reconstruction. Arthroscopy 20(8):890–894
6. Caborn DN, Chang HC (2005) Single femoral socket
double-bundle anterior cruciate ligament reconstruction
using tibialis anterior tendon: description of a new tech-
nique. Arthroscopy 21(10):1273e1–1273e8
7. Franceschi J-P, Sbihi A, Champsaur P (2002) Dual
arthroscopic reconstruction of the anterior cruciate liga-
ment using anteromedial and posterolateral bundles.
Revue de Chirurgie orthopedique et Reparatrice de
L’appareil Moteur 88(7):691–697
8. Hara K, Kubo T, Suginoshita T, et al. (2000) Reconstruc-
tion of the anterior cruciate ligament using a double bun-
dle Arthroscopy 16(8):860–864
9. Hara K, Arai Y, Ohta M, et al. (2005) A new double-bundle
anterior cruciate ligament reconstruction using the poste-
rolateral portal technique with hamstrings. Arthroscopy
21(10):1274e1–1274e6
10. Marcacci M, Molgora AP, Zaffagnini S, et al. (2003) Ana-
tomic double-bundle anterior cruciate ligament recon-
struction with hamstrings. Arthroscopy 19(5):540–546
11. Takeuchi R, Saito T, Mituhashi S, et al. (2002) Double-bun-
dle anatomic anterior cruciate ligament reconstruction
using bone-hamstring-bone composite graft. Arthroscopy
18(5):550–555
12. Hamada M, Shino K, Horibe S, et al. (2001) Single- ver-
sus bi-socket anterior cruciate ligament reconstruction
using autogenous multiple-stranded hamstring tendons
with EndoButton femoral fixation: a prospective study.
Arthroscopy 17:801–807
13. Adachi N, Ochi M, Uchio Y, et al. (2004) Reconstruction
of the anterior cruciate ligament. Single- versus double-
bundle multistranded hamstring tendons. J Bone Joint
Surg 86-B:515–520
14. Mochizuki T, Muneta T, Nagase T, et al. (2006) Cadaveric
knee observation study for describing anatomic femoral
tunnel placement for two-bundle anterior cruciate liga-
ment reconstruction. Arthroscopy 22(4):356–361
15. Takahashi M, Doi M, Abe M, et al. (2006) Anatomical
study of the femoral and tibial insertions of the anterome-
dial and posterolateral bundles of human anterior cruciate
ligament. Am J Sports Med 34(5):787–792
16. Yasuda K, Kondo E, Ichiyama H, et al. (2004) Anatomi-
cal reconstruction of the anteromedial and posterolateral
bundles of the anterior cruciate ligament using hamstring
tendon grafts. Arthroscopy 20:1015–1025
17. Yasuda K, Kondo E, Ichiyama H, et al. (2003) Anatomical
reconstruction procedure for the anteromedial and poste-
rolateral bundles of the anterior cruciate ligament. Kan-
setsukyo (J Jpn Arthroscopy Ass) 28:17–23
18. Aglietti P, Cuomo P, Giron F, et al. (2005) Double-bundle
anterior cruciate ligament reconstruction: surgical tech-
nique. Oper Tech Orthop 15(2):111–115
19. Brucker PU, Lorenz S, Imhoff ff AB (2006) Aperture fixation
in arthroscopic anterior cruciate ligament double-bundle
reconstruction. Arthroscopy 22(11):1250
20. Cha PS, Brucker PU, West RV, et al. (2005) Arthroscopic
double-bundle anterior cruciate ligament recosntruction:
an anatomic approach. Arthroscopy 21(10):1275
21. Christel P, Franceschi JP, Sbihi A, et al. (2005) Anatomic
anterior cruciate ligament reconstruction: the French
experience. Oper Tech Orthop 15(2):103–110
22. Colombet P, Robinson J, Jambou S, et al. (2006) Two-bun-
dle, four-tunnel anterior cruciate ligament reconstruction.
Knee Surg Sports Traumatol Arthrosc 14(7):629–636
23. Kim SJ, Jung KA, Song DH (2006) Arthroscopic double-
bundle anterior cruciate ligament reconstruction using
autogenous quadriceps tendon. Arthroscopy 22(7):797e1–
797e5
24. Vidal AF, Brucker PU, Fu FH (2005) Anatomic double-
bundle anterior cruciate ligament reconstruction using
tibialis anterior tendon allografts. Oper Tech Orthop
15(2):140–145
25. Yasuda, K, Kondo E, Ichiyama H, et al. (2005) Surgical and
biomechanical concept of anatomic anterior cruciate liga-
ment reconstruction. Oper Tech Orthop 25:96–102
26. Yasuda K, Tsujino J, Ohkoshi Y, et al. (1995) Graft site
morbidity with autogenous semitendinosus and gracilis
tendons. Am J Sports Med 23:706–714
27. Yasuda K, Tsujino J, Tanabe Y, et al. (1997) Effects
ff of ini-
tial graft tension on clinical outcome after anterior cru-
ciate ligament reconstruction. Autogenous doubled ham-
string tendons connected in series with polyester tapes.
Am J Sports Med 25:99–106
28. Kondo E, Yasuda K, Ichiyama H, et al. (2007) Radiologic
evaluation of femoral and tibial tunnels created with the
transtibial tunnel technique for anatomic double-bundle
anterior cruciate ligament reconstruction. Arthroscopy
23:869–876
29. Dodds JA, Arnoczky SP (1994) Anatomy of the anterior
cruciate ligament: a blueprint for repair and reconstruc-
tion. Arthroscopy 10:132–139
30. Girgis FG, Marshall JL, Monajem ARS (1975) The Th cruciate
ligaments of the knee joint. Anatomical, functional and
experimental analysis. Clin Orthop Relat Res 106:216–
231
31. Harner CD, Baek GH, Vogrin TM, et al. (1999) Quanti-
tative analysis of human cruciate ligament insertions.
Arthroscopy 15:741–749
32. Miyata K, Yasuda K, Kondo E, et al. (2000) Biomechani-
cal comparisons of anterior cruciate ligament reconstruc-
tion procedures with flexor tendon graft. J Orthop Sci
5:585–592
33. Yamanaka M, Yasuda K, Nakano H, et al. (1999) The Th effffect
of cyclic displacement upon the biomechanical character-
istics of anterior cruciate ligament reconstructions. Am J
Sports Med 27:772–777
34. Yasuda K, Ichiyama H, Kondo E, et al. (2008) An in vivo
biomechanical study on the tension-versus-knee flexionfl
angle curves of 2 grafts in anatomic double-bundle ante-
rior cruciate ligament reconstruction: effects
ff of initial ten-
sion and internal tibial rotation. Arthroscopy 24:276–84

35. Numazaki H, Tohyama H, Yasuda K, et al. (2002) The Th
eff
ffect of initial graft tension on mechanical behaviors of
the femur-graft-tibia complex with anterior cruciate liga-
ment reconstruction during cyclic loading. Am J Sports
Med 30:800–805
36. Kondo E, Yasuda K, Azuma H, et al. (2008) Prospective
clinical comparisons of anatomic double-bundle versus
single-bundle anterior cruciate ligament reconstruction
procedures in 328 consecutive patients. Am J Sports Med
36(9):1675–87.
37. Yasuda K, Kondo E, Ichiyama H, et al. (2006) Clinical
evaluation of anatomic double-bundle anterior cruciate
ligament reconstruction procedure using hamstring ten-
don grafts: comparisons among 3 different
ff procedures.
Arthroscopy 22:240–251
38. Kondo E, Yasuda K (2007) Second-look arthroscopic eval-
uations of anatomic double-bundle anterior cruciate liga-
ment reconstruction: relationship with the postoperative
knee stability. Arthorscopy 23 (11):1198–1209
39. Aglietti P, Giron F, Cuomo P, et al. (2007) Single-and
Double-incision Double-bundle ACL Reconstruction. Clin
Orthop Relat Res 454:108–113
Anatomic double-bundle ACL reconstruction: how I do it? 243
40. Jarvela T (2007) Double-bundle versus single-bundle
anterior cruciate ligament reconstruction: a prospective,
randomize clinical study. Knee Surg Sports Traumatol
Arthrosc 15:500–507
41. Yagi M, Kuroda R, Nagamune K, et al. (2007) Double-bun-
dle ACL reconstruction can improve rotational stability.
Clin Orthop Relat Res 454:100–107
42. Mae T, Shino K, Miyama T, et al. (2001) Single- versus two-
femoral socket anterior cruciate ligament reconstruction
technique: biomechanical analysis using a robotic simula-
tor. Arthroscopy 17:708–716
43.Petersen W, Tretow H, Weimann A, et al. (2007) Biomechani-
cal evaluation of two techniques for double-bundle anterior
cruciate ligament reconstruction: one tibial tunnel versus
two tibial tunnels. Am J Sports Med 35(2):228–234
44. Yagi M, Wong EK, Kanamori A, et al. (2002) Biomechani-
cal analysis of an anatomic anterior cruciate ligament
reconstruction. Am J Sports Med 30(5):660–666
45.Yamamoto Y, Hsu WH, Woo SL, et al. (2004) Knee stability
and graft function after anterior cruciate ligament recon-
struction. A comparison of a lateral and an anatomical fem-
oral tunnel placement. Am J Sports Med 32(8):1825–1832

J. Iwasa, Y. Shima,
L. Engebretsen
Results of ACL reconstruction
Introduction
A
nterior cruciate ligament (ACL) injuries are
common among athletes, and although their
true natural history remains unclear, these
injuries are functionally disabling; they predispose
the knee to subsequent injuries and the early onset
of osteoarthritis (OA) (1). The ultimate goal of ACL
reconstruction should be, primarily, to have injured
patients return to previous leisure, sports, and
working and, secondarily, to prevent secondary knee
OA. ACL reconstruction is one of the most common
orthopaedic procedures performed in orthopae-
dic surgery today. Within the United States, the
occurrence of ACL injuries is estimated 95,000 inju-
ries annually, with roughly 50,000 requiring ACL
reconstruction (2,3). According to the Norwegian
National Knee Ligament Registry (NKLR), which
is a prospective surveillance system for monitoring
the outcome of cruciate ligament surgery, a total of
2714 primary ACL reconstruction surgeries were
performed by 57 diff fferent hospitals in Norway in
2006. This corresponds to an annual population inci-
dence of primary ACL reconstruction surgeries of 34
per 100,000 citizens (85 per 100,000 citizens in the
main at-risk 16–39 year age group) in Norway (4).
Over the years, various ACL reconstruction pro-
cedures have been described. Hey Groves (5) pre-
sented the first report of a procedure to recon-
struct torn ACL by using a tethered fascia lata
graft through anatomically placed drill holes in
the femur and tibia. The surgical methods have
improved for the past decade, from open tech-
niques with primary repair of the ACL with and
without augmentation to arthroscopy-assisted
technique with bone-patellar tendon-bone (BPTB)
or hamstring grafts, and finally to all-inside
arthroscopy-assisted technique. The majority of
scientifi
fic reports on ACL reconstruction are con-
cerned with the selection of graft and its fixa-fi
tion today. Despite the growing and widespread
use of ACL reconstruction and the many studies
of diff
fferent operative treatment options for the
reconstruction of ruptured ACL, the benefit fi of
ACL reconstruction still needs to be established,
as do the relative benefits
fi of the difffferent meth-
Chapitre 22
ods used. Numerous studies are carried out every
year to assess the quality of ACL reconstruction.
The authors use various parameters. Clinical
parameters such as subjective clinical laxity (Lach-
man grade, pivot-shift grade), as well as objective
measurements of knee laxity as obtained with
KT-1000 or KT-2000 arthrometer (MEDmetric
Corporation, San Diego, CA, USA), are measured.
Scoring systems such as the International Knee
Documentation Committee (IKDC) Subjective
Knee Form, Lysholm, Tegner, Cincinnati, Knee
Injury and Osteoarthritis Outcome Score (KOOS),
and Noyes sports activity score are also used. In
addition, functional tests such as the single hop
test, the triple hop test, and the vertical jump test
to provide assessment of functional strength and
stability of the involved leg are carried out.
ACL injury is one of the most common risk factors
for knee OA development in young adults (6), and the
severity of knee OA increases often with time from the
ACL injury. The incidence of knee OA after ACL injury
is reported to increase by meniscus and other ligament
injuries (1,7,8). However, the reported incidences
of knee OA development range from 10% to 90%
(1,9,10). There
Th is so far no consensus on the results
regarding incidence of secondary knee OA and risk
factors for knee OA development in the literature.
This chapter looks at the evidence from studies on
the outcome of ACL reconstruction and incidence
of knee OA. For the non-OA outcomes, we focused
on prospective,randomized, controlled trials (RCTs)
with a follow-up time of at least 2 years after ACL
surgery. For the OA outcomes, we studied prospec-
tive and retrospective studies with a follow-up time
of at least 10 years after ACL injury or surgery.
Methods
Identifification and selection of studies
on ACL reconstruction
In this chapter, we identified
fi and studied ran-
domized control studies (evidence level I or II) for
246 The Traumatic Knee
ACL reconstruction techniques with a minimum
follow-up of 24 months. Our intention was to per-
form a comprehensive review of the results of these
studies, including surgical protocols and objective
and subjective outcome measurements. Our litera-
ture search began with a MEDLINE search from
August 1997 to August 2007. The following search
terms were entered and modifi fied according to the
requirement of the database: (anterior cruciate
ligament) AND (surgery OR operate OR transplant
OR graft OR autograft OR allograft OR reconstruc-
tion). The
Th results were then limited to randomized
control studies, human subjects, and English lan-
guage articles only. All resulting articles were then
reviewed to determine whether they fi fit the inclu-
sion or exclusion criteria as previously established.
To ensure that no relevant studies were missed by
the MEDLINE search, we then performed a manual
cross-reference review of the citations of each rel-
evant article to determine whether there were any
further studies that might fitfi our search criteria.
Several studies were excluded for marginal viola-
tions of the inclusion criteria, such as the inclu-
sion of data from patients with 23 months or less
of follow-up, despite an overall mean follow-up of
greater than 24 months.
We collected demographic data, such as the fi final
number of subjects evaluated and the mean and
range of follow-up interval. The surgical proto-
cols, including surgical approach and femoral and
tibial fixation methods, were noted. The time to
return to unrestricted sports activity was identi-
fied in each study. The outcome measurements
evaluated from each study included arthrometer
side-to-side diff
fferences in laxity, the results of
pivot-shift test and Lachman test, IKDC score,
Lysholm score, Cincinnati knee score, KOOS,
Tegner activity score, and one-leg hop test. Addi-
tional information was collected from each study
when appropriate, such as preinjury Tegner activ-
ity score, another type of subjective knee score
and functional test.
Search for studies on knee OA development after ACL
injury
Our inclusion criteria for studies on knee OA
development were prospective or retrospective
studies with a follow-up time of at least 10 years
after ACL injury or surgery, which involved radio-
logical assessment. The methodological quality of
included studies, derived from Guyatt and Rennie
(11), was also assessed. These
Th assessment con-
tained questions regarding control group, descrip-
tion of the population, study design, validity and
reliability of the measurements of the exposure
and the outcomes, number of subjects lost to fol-
low-up, dropout analysis, regression analysis, con-
founding factors, and assessor blinding.
Stability after ACL reconstruction
Thirty-four studies were included in this system-
atic review based on the inclusion criteria (Table 1).
These studies were concerned with current top-
ics of debate including choice of graft and graft
fixation. Of these, 20 studies have been published
including BPTB or hamstring graft (12–31). Th Three
studies have looked at the outcome of ACL recon-
struction with hamstring graft including double-
bundle technique (32–34). ThreeTh studies have
looked at the outcome with the BPTB graft includ-
ing some synthetic graft augmentation (36,37,45).
Seven studies have looked at the outcome on graft
fixation, including graft tensioning technique
or bioabsorbable screw, etc. (35,38–42,46). The Th
remaining study has been published on navigation
technique (44).
Sixteen of the 34 papers gave information on the
postoperative Lachman test, and 18 papers gave
information on the postoperative pivot-shift test.
All used the standard grading system and could
be combined. All 34 papers gave postoperative
arthrometer findings. Twenty-one used KT-1000,
seven used KT-2000, three used the OSI CA-4000
arthrometer (Orthopaedic System Inc., Hayward,
CA, USA), two used a Telos system (Telos, Marburg,
Germany), and the remaining one used a Stryker
arthrometer (OSI Stryker, Kalamazoo, Michigan).
The force applied varied between studies. Some
studies gave data for more than one applied force.
Data were analyzed for fixed force (89 N, 134 N,
150 N, 200 N, 250 N, 9.08kg, or 18.16kg) or maxi-
mum manual force.
Subjective outcome and functional assessment
after ACL reconstruction
As a subjective outcome measurement, IKDC was
used in 25 of the 34 papers, Lysholm score and
Tegner activity score in 18 papers, Cincinnati
knee score in 7 papers, and KOOS and visual ana-
logue scale (VAS) in 2 papers (Table 2). ThThe scor-
ing system of patellofemoral disorders was used
in three papers (Kujala score in one and modified
fi
patellofemoral pain score in two (48)). There
Th are
respectively one paper using SF-36 short form
from health survey, Marx scale (knee activity rat-
ing scale), Hospital for Special Surgery (HSS) knee
score, and Subjective Assessment Numeric Evalu-
ation (SANE).
Table 1
Arthrometer Lachman test Pivot-shift test
Authors Graft choice, etc. Graft fixation N Follow-up Return to sports
(mm) (0,%) (0,%)
Single-bundle technique (BPTB or hamstring)
Liden et al. BPTB BPTB: femur-IS, tibia-IS ST: femur-RCI, 32 7Y 6M 2.3(-3.5-9) vs. 8 (27) vs. -
(12) ST tibia- RCI 36 (68–114M) 2.7(-4.5-9.5): NS (KT-1000, 7(22): NS
134N)
Maletis et al. BPTB Femur: bioabsorbable IS Tibia: 46 2Y 12M 2.3 vs. - 42 (91) vs.
(13) STG bioabsorbable IS×2 53 2.8: NS 39 (74): NS
(KT-1000, manual max)
Sajovic et al. BPTB Femur: RCI, Tibia: bioabsorbable IS 26 5Y 6M 1.9±2.0 vs. 22 (85) vs. 21 (81) vs.
(14) STG 28 1.6±2.4: NS 22 (79): NS 23 (83): NS
(KT-2000, 134N)
Gobbi et al. BPTB No details 50 2Y Not shown <3 mm:total 90: NS - -
(15) Hamstring 50 (CA4000, 200-N force)
Matsumoto et BPTB BPTB: femur-IS, tibia- IS BHB: femur- 40 5Y 6–10M 1.2±2.1 vs. - -
al. (16) BHB IS, tibia- IS 39 1.7±1.4: NS
(KT-1000, manual max)
Zaffagnini et BPTB BPTB: femur-IS, tibia-IS STG: femur- 25 5Y 4M 3 mm:15(60%) vs. 23(92) vs. 22(88) vs.
al. (17) STG (4 strand) EndoButton, 25 9(36%) vs. 19(72) vs. 16(64) vs.
STG(2 strand with tibia- bioabsorbable IS Extra-articular 25 16(64%) 23(92) 23(92)
extra-articular plasty) plasty: femur-2 staples, Gerdy's BPTB, STG(ext.) BPTB, STG (ext.), BPTB, STG(ext.),
tubercle-1 staple (KT-2000, quadriceps (P= 0.095) (P= 0.03)
activity test, 30P,
P P=0.0492)
Harilainen et BPTB BPTB: femur-IS, tibia- IS STG: femur- 37 5Y 6M 1.5±3.0 vs. 29(78) vs. 33(89) vs.
al. (18) STG Endobutton, tibia- AO spiked washer 37 1.2±3.9: NS 31(84): NS 33(89): NS
and screw (CA4000, 200-N force)
Ibrahim et al. BPTB BPTB: femur-IS, tibia- IS STG: femur- 40 6.5Y 8M <3 mm:35(87.5%) vs. 35(87.5) vs. 35(87.5) vs.
(19) STG Endobutton, tibia- spiked washer and 45 38(84.4%): NS 39(86.6): NS 37(84.2): NS
screw, or small plate, 2 screws and staple (KT-1000, manual max)
Gobbi et al. ST STG ST: femur- EndButton, tibia -FastLok 50 47 36M Not shown <3 mm:44(88%) vs. - -
(20) staple + polyester tape (24–52M) 42(89%): NS
STG: femur- EndButton, (CA4000, 200-N force)
tibia- 2 staples
Aglietti et al. BPTB BPTB: femur-Tunneloc screw, tibia-soft 60 2Y 6M 1.95(-1-5) vs. - 1+: 10(17) vs.
(21) STG threaded IS 60 2.2(0-5): NS 11(18): NS
STG: femur-BoneMulch screw, tibia- (KT-1000, 134 N)
WasherLoc device
Results of ACL reconstruction 247
 Arthrometer Lachman test Pivot-shift test
Authors Graft choice, etc. Graft fixation N Follow-up Return to sports
(mm) (0,%) (0,%)
Single-bundle technique (BPTB or hamstring)
Ejerhed et al. BPTB BPTB: femur-silk IS, tibia-silk IS ST: 32 2Y 6M 2.0(-5-11.5) vs. 18(56) vs. -
(22) ST femur-soft threaded RCI, 34 2.25(-4-10.5): NS 18(47): NS
248 The Traumatic Knee

tibia- soft threaded RCI (KT-1000, 89 N)

Feller and BPTB BPTB: femur-EndoButton, tibia- silk IS 21 27 3Y 9M 0.5±1.5 vs. - +: 0 vs.
Webster (23) STG STG: femur-EndoButton, tibia- Acufex 1.6±1.3: BPTB 5
fixation post (KT-1000, 134 N, P<0.05)
Otsuka et al. BPTB with non- Femur: IS 20 2Y 6–9M 1.9±1.0 vs. - -
(24) anatomic Tibia: IS 20 1.4±1.4 vs.
Anatomic 20 1.8±1.5: NS
All-inside anatomic (KT-1000, manual max)
Shaieb et al. BPTB Femur: RCI, Tibia: RCI 33 37 2Y 5–6M 1.8 vs. 0.35 vs. 1+: 5 vs.
(25) STG 2.8: NS 0.48 4
(KT-1000, 134 N)
Beynnon et al. BPTB BPTB: femur-IS, tibia- IS STG: femur- 28 28 39M 6M 1.1 vs. 10 (45.5) vs. 19 (86) vs.
(26) STG staple, tibia- staple (36–57) 4.4: BPTB 3 (14): 13(59):
(KT-1000, 133 N, P=0.004) BPTB BPTB (P=0.024)
(P=0.001)
O'Neill (27) STG (2 incision) STG: femur-2 staples, tibia-2 staples 75 102M 6M * from JBJS ≤2 mm: 56(75%) vs. - -
BPTB (2 incision) BPTB: femur-IS, tibia- IS 75 (Am)1996;78(6):803- 61(81%) vs.
BPTB (1 incision) 75 813 60(80%): NS
(KT-2000)
Aune et al. BPTB BPTB: femur-IS, tibia-IS STG: femur- 35 37 2Y 6M 2.7±2.2 vs. - -
(28) STG EndoButton, 2.7±2.1: NS
tibia- RCI+ 2 staples (KT-1000, manual max)
Eriksson et al. BPTB BPTB: femur-IS, tibia-IS STG: femur- 80 74 31M 6M <3 mm:39(49%) vs. 40/80(50%) vs. 56/80(70%) vs.
(29) ST EndoButton, 32(43%): NS 34/74(46%): NS 50/74(68%): NS
tibia- screw (OSI Stryker, 18.16 kg)
Webster et al. BPTB BPTB: femur-EndoButton, tibia-IS STG: 23 31 2Y 9M 1.1(-1-3.5) vs. - -
(30) STG femur-EndoButton, 1.7(0-3.5): NS
tibia-Acufex fixation post (KT-1000, 134 N)
Anderson et BPTB BPTB: femur-IS, tibia-2 staples 35 3Y 6–7M 2.1±2.0 vs. - 26 (74) vs.
al. (31) STG(extra-articular) STG: femur-staples, tibia-suture 35 2.6±2.2 vs. 23 (66) vs.
STG Extra-articular: Losee extra-articular 35 3.1±2.3: BPTB 20 (57)
reconstruction (KT-1000, manual max, P<0.05)
 Arthrometer Lachman test Pivot-shift test
Authors Graft choice, etc. Graft fixation N Follow-up Return to sports
(mm) (0,%) (0,%)
Double-bundle technique
Yasuda et al. Single- bundle Femur: EndoButton, tibia: 2 staples 24 2Y 9M 2.8 vs. - 1+: Single vs.
(32) Double-bundle 24 2.2 vs. Anatomic double
Anatomic double- 24 1.1: Anatomic double-bundle 9(36) vs.3(12):
bundle (STG) (KT-2000, 133 N, P=0.006) Anatomic double-
bundle (P=0.025)
Adachi et al. Single- bundle Femur: EndoButton CL, tibia: 55 32M 9M 1.2±2.5 vs. - -
(33) Double-bundle EndoButton tape + 2 staples 53 (24–36M) 1.3±2.5: NS
(KT-2000, 133 N)

Zhao et al. ST (4 strand) Femur: mini plate (Aesculap) Tibia: 33 2Y Not shown 2.8±0.5 vs. - 0: 29(87.9) vs.
(34) STG (8 strand) mini button (Aesculap) 35 1.3±0.4: 8 STG 34(97.1): NS
(Double-bundle) (KT-1000, 30 lb, P=0.0003)
Synthetic ligament
Drogset et al. Repair Repair: multiple loop sutures Repair 28 16Y Not shown 1.9 vs. 2+: 5(18%) vs. 2+: 5(18%) vs.
(35) LAD with LAD: femur-staples, 29 2.3 vs. 10(34%) vs. 5(17%) vs.
BPTB tibia-sutures Repair with BPTB: femur- 35 1.4: NS 4(11%): 2(6%) : NS (P=0.088)
IS, tibia-IS + screw +washer (KT-1000, 89 N (20 lb)) BPTB
(P=0.026)
Muren et al. BPTB LAD BPTB: femur-endbutton, tibia- 20 7Y 12M 1.1±1.2 vs. - 0 vs.
(36) insertion left intact BPTB with LAD: 20 1.8±1.6: NS 1
femur- screw and washer, tibia- (KT-1000, manual max)
insertion left intact
Nau et al. (37) BPTB LARS BPTB: femur-endbutton, tibia- staple 27 2Y Not shown 2.38 ±1.80 vs. - -
LARS: femur and tibia- interference-fit 26 4.86 ±3.80: NS
titanium screw (Telos system, 250 N)
Graft tension
Yoshiya et al. BPTB Femur: IS (25 N vs. 50 N) Tibia: IS (25 22 2Y 9–12M >3 mm: 2 vs. - +: 2 vs.
(38) N vs. 50 N) 21 3: NS 3: NS
(KT-1000, 89 N (20 lb))
Ejerhed et al. BPTB with Femur: IS, Tibia: IS 25 2Y 6M 2.5(-1.5-8.5) vs. 0: 16 vs. -
(39) preconditioning * Preconditioning: passive stretching 28 3.0(-7-6.5): NS 16: NS
No preconditioning at a constant load of 39 N for 10 min (KT-1000, 89 N)
immediately prior to implantation
Results of ACL reconstruction 249
 Arthrometer Lachman test Pivot-shift test
Authors Graft choice, etc. Graft fixation N Follow-up Return to sports
(mm) (0,%) (0,%)
Bioabsorbable screw, etc.
Laxdal et al. STG Femur: PLLA screw or RCI, Tibia: PLLA 32 2Y 6M 1.5(-3-10) vs. - -
(40) screw or RCI 36 0.75(-1-5): NS
250 The Traumatic Knee

(KT-1000, 89 N)

Drogset et al. BPTB Femur: metal IS or PLLA screw Tibia: 20 2Y 6M 0.3 vs. 0: 12(63) vs. 0: 17(89) vs.
(35) metal IS or PLLA screw 21 0.9: NS 10(56): NS 14(78): NS
(KT-1000, manual max)

Kaeding et al. BPTB Femur: PLLA screw or metal IS, Tibia: 31 2Y Not shown 1.0 ±3.0 vs. - -
(41) PLLA screw or metal IS 34 0.7 ±2.9: NS
(KT-1000)

Hill et al. (42) STG Femur: RCI, Tibia: RCI with or without 27 2Y 6M 1.8(1.4-2.1) vs. 0: 17(62.9) vs. 0: 24(88.9) vs.
supplementary staple 21 1.1(0.4-1.8): Supplementary 18(85.7): Supple- 20(95.2): NS
tibial fixation mentary tibial
(KT-1000, manual max, P=0.05) fixation (P=0.04)
Mariani et al. BPTB with IS Femur: metal IS or transcondylar IS 24 29M 6M 3.68 ±1.71 vs. 1+: 17(70.8) vs. 1+: 15(62.5) vs.
(43) With transcondylar IS Tibia: metal IS 31 (24-39M) 1.64±2.05: transcondylar 21(67.7): NS 20(64.5): NS
IS (KT-2000, manual max,
P<0.0001)
Navigation technique
Plaweski et al. STG with navigation Femur: BioRCI + Endoloop fixation 30 2Y Not shown 0.9 ±0.8 vs. 1.1 ±1.2: With 0: 26(87) vs. 0: 26(87) vs.
(44) Without navigation device 30 Navigation (Telos system, 150 23(76.7): NS 22(73.3): NS
Tibia: BioRCI N, P=0.0003)

Note: NS, nothing statistically significant difference.

Table 2
Cincinnati knee
Author IKDC Lysholm KOOS Tegner activity score One-leg hop Others
score
Single-bundle technique (BPTB or hamstring)
Liden et al. Normal or nearly normal 48% vs. 81(25-100) vs. 90(50-100): NS - - 5(0-7) vs. 6(2-9): NS 96%(0-119) vs. 92%(0- Knee-walking: NS Kneeling:
(12) 50%: NS 110): NS NS
Maletis et al. Normal or nearly normal 91% vs. 97 vs. 98: NS - - 5.9 vs. 5.7: NS *preinjury: - SF-36 short form from health
(13) 92%: NS 6.8 vs. 7.2 (P=0.03) survey 1Y: BPTB health
(P=0.036), vitality (P=0.021)
2Y: NS
Sajovic et al. Normal 38% vs. 50%: NS 92(74-100) vs. 92(62-100): NS - - - Grade A hop: equal or 88% vs. 82% returned to their
(14) greater than 90% of preinjury activity level: NS
contralateral limb 92% vs. Anterior knee pain or kneeling
93%: NS pain 19% vs. 17%: NS
Gobbi et al. Normal or nearly normal 88% vs. * No details about the differences * No details about the - * No details about the - Marx scale Psychovitality
(15) 90%: NS between 2 groups differences between differences between 2 questionnaire * No details
2 groups groups about the differences between
2 groups
Matsumoto et Normal or nearly normal 73% vs. - - - - - Return to the preinjury
al. (16) 86%: NS Subjective score 84.3 vs. activity level after the surgery:
86.8: NS 75.7% vs. 68.6%: NS Anterior
kneeling pain BHB < BPTB
(P=0.056, NS)
Zaffagnini et Normal or nearly normal 76% vs. - - - 7.8(2-8) vs. 7.1(2-8) vs. NS * No details Kneeling pain BPTB
al. (17) 72% vs. 84%: NS Subjective score 8.5(1-9): NS (P=0.0001). The time to return
82* vs. 76 vs. 89* BPTB, STG to sport was significantly
(ext.) (P=0.04) shorter for the STG (ext.)
(P=0.05).
Harilainen et Normal or nearly normal 84% vs. 95(34-100) vs. 95(34-100): NS - - 6(1-10) vs. 6(3-9): NS - Kujala PF: 96.5(47-100) vs.
al. (18) 84%: NS * Either group did not 98(54-100): NS
reach their preinjury
median Tegner activity
level of 7.
Ibrahim et al. Grade A or B 87.5% vs. 84.5%: NS 92.7(81-97) vs. 91.6(79-96): NS - - 7.9 vs. 7.8: NS * preinjury - Patellofemoral pain or crepitus:
(19) 8.9 vs. 8.9: NS 24% vs. 5%
* Return to activity: NS Anterior knee pain: 25%
vs. 6.6% BPTB > STG (no
statistical details)
Results of ACL reconstruction 251
 Cincinnati knee
Author IKDC Lysholm KOOS Tegner activity score One-leg hop Others
score
Single-bundle technique (BPTB or hamstring)
Gobbi et al. Normal or nearly normal 96% vs. 92.2 vs. 93.6: NS 84.5 vs. 82.3: NS - 5.6 vs. 6.0: NS *preinjury: 6M: 90% vs. 89%: NS SANE: 88.6% vs. 86.3%:
(20) 91%: NS 6.2 vs. 6.2: NS Final evaluation 95% vs. NS One-leg vertical jump:
252 The Traumatic Knee

94%: NS 6M- 89% vs. 91%: NS Final

evaluation- 93% vs. 93%: NS
Aglietti et al. Normal 63% vs. 57%: NS - - 92-88- - - Mean VAS: 8 vs. 9, Activity level
(21) Subjective score 82 vs. 85: NS 97-84- 1: preinjury: 87% vs. 88%,
79 vs. 2Y: 45% vs. 48% Modified
95-90- patellofemoral pain scoreb
97-87- 47(35-50) vs. 48(34-50): NS
83: NSa
Ejerhed et al. Normal or nearly normal 53% vs. 95(46-100) vs. 90(51-100): NS - - 6(1-9) vs. 6.5(3-9): NS 92(0-123) vs. 93(0-122): Knee-walking test was
(22) 59%: NS *preinjury 9(3-9) vs. NS significantly worse in the BPTB
9(5-9): NS than ST (P=0.01)
Feller and Normal or nearly normal (1Y- - 1Y-2Y-3Y: mean - - - Kneeling pain (%) (2Y-3Y): 65-
Webster (23) 2Y-3Y) 45%-65%-71% vs. 55%- 84.4-90.9-92.7 vs. 67 vs. 35-26 BPTB (P<0.01)
66%-93%: NS 87.7-91.9-93.7: NS
Otsuka et al. - 97 vs. 98 vs. 97: NS - - 5.0 vs. 5.0 vs. 4.8: NS - -
(24)

Shaieb et al. - 91.2 vs. 92.3: NS Good or excellent 91% - - - Hard cuts and pivots: normal
(25) vs. 95% 61.3% vs. 62.9%, Reducing
activity level compared with
preinjury level: 45% vs. 37%
Beynnon et al. Activity grade I 59% vs. 45%: NS - - - 6(4-9) vs. 5(3-9): NS Difference between the Climb stairs, duck walk, squat
(26) distances (cm): 7.4 ±10.7 et al.: NS Satisfaction scale
vs. 10.6 ±9.9: NS (1-10) 8.6 vs. 7.9: NS

O'Neill (27) Normal or nearly normal 89% vs. - - - - - The time required for return to
95% vs. 93%: NS the preinjury level of athletic
activity: NS (no details)

Aune et al. - - 6M-1Y-2Y: mean - - 6M-1Y-2Y: mean %loss Stairs hopple test: NS Kneeling
(28) 79-82.4-85.9 vs. 81.4- 12.3-7.9-4.3 vs. 3.9*-3.1*- problem (VAS) 35.5 vs. 18.9:
87.1-87.8: NS 0.7: * STG (P<0.05) BPTB (P<0.05)
 Cincinnati knee
Author IKDC Lysholm KOOS Tegner activity score One-leg hop Others
score
Single-bundle technique (BPTB or hamstring)
Eriksson et al. Normal or nearly normal 60% vs. 85(46-100) vs. 86(45-100): NS - - 6(1-10) vs. 6(1-10): NS 97% (72-114) vs. 96% VAS (How does your knee
(29) 55.4%: NS (59-113): NS * Triple-jump function?): 81(0-100) vs.
test 98% (73-121) vs. 99% 81(100), (How does your
(86-110): NS knee affect level of activity?):
82(0-100) vs. 80(0-100): NS
Modified patellofemoral pain
scoreb 43(22-55) vs. 43(14-55):
NS
Webster et al. Normal or nearly normal 61% vs. - Good or excellent: - - - -
(30) 61%: NS 90% vs. 88%: NS

Anderson et Normal or nearly normal 97% vs. - - - - - HSS 77.4 vs. 75.8 vs. 80: NS
al. (31) 67.6% vs. 78.8%: BPTB (P=0.02) Return to preinjury activity
Subjective score 100% vs. 94% vs. level 82.9% vs. 73.5% vs.
88%: NS 87.9%: NS
Double-bundle technique
Yasuda et al. Normal 67% vs. - - - - - All patients in each group
(32) 46% vs. were able to return to their
42%: NS chosen sport between 9M-2Y
postoperatively without any
reoperation.
Adachi et al. - - - - - - No subjective and functional
(33) data
Zhao et al. Subjective score 86.4 vs. 96.3: 89.6 vs. 96.5: 8STG (P=0.0006) - - 5.9 vs. 6.7: 8STG Normal or nearly normal -
(34) 8STG (P=0.0007) (P=0.002) 85% vs. 100%: NS
Synthetic ligament
Drogset et al. - Repair: 88.3-88, LAD: 91.4-85, BPTB: - - Repair:(6.7)-5.0-5.1, - Subjective knee function:
(35) 93.3-90: NS * At 5-Y follow up, BPTB LAD:(6.2)-5.0-5.2, excellent or good LAD< BPTB
significantly higher than Repair BPTB:(6.5)-5.3-5.6: NS (P=0.0038), Repair vs.LAD
or Repair vs. BPTB: NS OA:
Repair 17% LAD 3% BPTB 13%,
involved knee 11% vs.
contralateral knee 4% (P=0.001)
Results of ACL reconstruction 253
 Cincinnati knee
Author IKDC Lysholm KOOS Tegner activity score One-leg hop Others
score
Synthetic ligament
Muren et al. (36) - 99(91-100) vs. 98(88-100): NS - - 5 vs. 6: NS - -
Nau et al. (37) Subjective score (median) - - 6M: SA, NS * No details - No significant differences between
254 The Traumatic Knee

6M: B vs. B: NS 12M: B vs. B: NS 24M: QOL - the groups with respect to any of
A vs. A: NS LARS the IKDC categories
12M:
ADL, SA,
QOL -
LARS
24M:
NSa
Graft tension
Yoshiya et al. - - - - - - No subjective and functional data
(38)
Ejerhed et al. Normal or nearly normal 68% vs. 86(47-100) vs. 94(44-100): NS - - 7(3-9) vs. 6(2-9): NS 94%(68-132) vs. 94%(0-126): Knee-walking test: OK or not
67%: NS NS pleasant 60% vs. 53%: NS
Bioabsorbable screw etc.
Laxdal et al. Normal or nearly normal 77% vs. 90(60-100) vs. 94(41-100): NS - - 7(3-9) vs. 6(3-9): NS 100(76-120) vs. 94(79- -
(40) 60%: PLLA (P=0.03) *preinjury 8(4-10) vs. 106): PLLA (P=0.007)
8(5-10): NS
Drogset et al. - 6M - NS 1Y - NS 2Y - metal Mean pain score at - - 6M - NS 1Y - NS 2Y - Subjective knee function:
(35) rest: 1Y - 0.27 vs. metal 6M - NS 1Y - metal (P=0.03)
0.84: metal 2Y - 0.04 2Y - metal (P=0.03)
vs. 0.81: metal
Kaeding et al. 1Y: pain with activity - PLLA - - - - - -
(41) (P=0.031) 2Y: activity level - PLLA
(P=0.015) Swelling, giving way,
effusion 1Y and 2Y: NS
Hill et al. (42) Normal or nearly normal 85.2% vs. 95(81-100) vs. 95(86-100): NS - - - - Participating in level 1 and 2
85.7%: NS activities: 44.4% vs. 52.4%:
NS Incidence of kneeling
pain: 7.4% vs. 28.6%:
Supplementary tibial
fixation (P=0.05)
 Cincinnati knee
Author IKDC Lysholm KOOS Tegner activity score One-leg hop Others
score
Bioabsorbable screw etc.
Mariani et al. Normal or nearly normal 62.5% vs. 94.7(83-100) vs. 96.7(81-100): - - 6.2(2-9) vs. 6.4(2-9): NS - -
(43) 83.9%: transcondylar IS NS * preinjury 6.7(4-9) vs.
7(5-9): NS
Navigation technique

Plaweski et al. - - - - - - No subjective and functional

(44) data
Note: NS, nothing statistically significant differences.
†: Pain (P), – symptoms (S) – ADL – sports activity (SA) – QOL
‡: Werner et al. (46).
Results of ACL reconstruction 255
256 The Traumatic Knee
As a functional measurement, one-leg hop test was
used in 12 papers, kneeling test in 6 papers, and
knee-walking test in 3 papers. Some papers had
the data of one-leg hop test included in the overall
IKDC data. There are respectively one paper using
one-leg vertical jump test, triple-jump test, stair
hopple test, and others (climb stairs, duck walk,
and squat).
As a time to return to sports activity, 17 of the
34 papers (50%) set their postoperative protocol
to return to unrestricted sports activity at 6–9
months after ACL reconstruction, 6 papers at 9–12
months (17.6%), 2 papers at 4–6 months (5.9%), 2
after 12 months (5.9%), and 7 papers not clearly
shown (20.6%).
Graft option
BPTB vs. Hamstring
BPTB and hamstring tendon grafts are by far the
most common grafts used, and considerable debate
continues as to whether one or the other graft is
preferable. BPTB graft has been the most popular
graft choice because of their strength characteris-
tics, ease of harvest, rigid fixation,
fi bone-to-bone
healing, and clinical outcome. However, in recent
years, use of hamstring tendon grafts appears to
have increased, perhaps related to an increased
range of fixation option as well as to a perception
that hamstring tendon grafts are associated with
lower postoperative morbidity compared with
BPTB grafts.
Fourteen of 18 studies comparing the two tech-
niques showed little or no difference
ff in terms of
knee stability for either objective arthrometer
measurements, Lachman test, or pivot-shift test
(12–16,18,19,21,22,25,27–30,).Their Th studies con-
firm that BPTB and hamstring can be equivalent
options for ACL reconstruction. However, the
remaining four studies (17,23,26,31) found sig-
nificantly
fi better stability in the BPTB groups com-
pared to the hamstring groups. According to the
four studies with a 2- to 5-year follow-up, the knee
stability evaluation with the KT-1000 or KT-2000
arthrometer revealed signifi ficant better stability in
the BPTB group compared to the hamstring group.
Further, two of these studies, by Beynnon et al.
(26) and Zaffffagnini et al. (38), had more patients
in the BPTB graft group with a pivot-shift test +1
and with Lachman test +1.
Concerning both subjective and functional data,
12 of 18 studies comparing the two techniques
showed no diff fference (12–16,18,21,25–27,29,30).
However, the other five studies (17,19,22,23,28)
found the patients in the BPTB group had greater
kneeling pain or worse results in the knee-walking
test compared to the hamstring group. Further,
Aune et al. (28) found the hamstring group showed
signifi
ficantly less mean percent loss of one-leg hop
test compared to the BPTB group at 6 months and
1 year after operation; however, there were no sig-
ficant diff
nifi fferences at 2 years after operation. The
final IKDC rating from the study of Anderson et
al. (31) revealed a signifi
ficantly higher incidence of
normal or nearly normal results in the BPTB group
compared to the other groups; however, there were
no signifificant diff
fferences in the IKDC subjective
assessment or symptoms. They also showed that
an extra-articular procedure did not improve the
result of intra-articular hamstring reconstruction
increasing the incidence of patellofemoral crepita-
tion and loss of motion. On the other hand, Zaf-
fagnini et al. (17) found the two-strand STG tech-
nique with extra-articular procedure showed a
ficantly better subjective evaluation, a faster
signifi
return to sport, and less kneeling pain.
These difffferences between studies could have been
due to diff
fferent intensity of rehabilitation or diff
ffer-
ent graft fixation. After a review of the most recent
studies concerning BPTB vs. hamstring grafts for
ACL reconstruction, it is clear that the controver-
sial debate is far from over.
Double- vs. single-bundle technique
Double-bundle ACL reconstruction has been pro-
posed as an alternative to compensate for the
incompleteness of the conventional procedures.
Recent basic studies have showed that the double-
bundle technique has several theoretical advan-
tages such as a better knee stability by closer imita-
tion of the anatomic structure of the ACL (48–50).
However, the double-bundle technique has not
been clinically proven to be a superior ACL recon-
struction technique. Yasuda et al. (32) compared
the clinical outcome of anatomic double-bundle
ACL reconstruction with that of non-anatomic sin-
gle- and double-bundle reconstructions with ham-
string graft. In their 2-year follow-up study, they
showed that anatomic double-bundle reconstruc-
tion was signifificantly superior to single-bundle
reconstruction concerning restoration of the ante-
rior and rotational knee stability measured with
KT-2000 and pivot-shift examinations, although
they found no significant
fi diff
fferences in the over-
all IKDC assessment between three groups. In the
meantime, Adachi et al. (33) did not find a signifi fi-
cant diff
fference between the single- and double-
bundle group with regard to anterior laxity with
KT-2000. Owing to the fact that there are currently
only two prospective, randomized studies with a
follow-up of at least 2 years, it is obvious that there
is a need for more studies comparing double-bun-
dle technique with single-bundle technique.

Concerning the strength of the graft used for
double-bundle technique, Zhao et al. (34) found
that double-bundle ACL reconstruction with eight-
strand hamstring graft yields signifi
ficantly better
results than double-bundle ACL reconstruction
with four-strand hamstring graft on the basis of
KT-1000 examination and the subjective data
(IKDC subjective assessment, Lysholm score, and
Tegner activity score).
Synthetic ligaments
The use of synthetic material for ligament replace-
ment was proposed in the 1980s. Poor results and
high rates of failure were reported, and the concept
became less popular. Muren et al. (36) compared
the results of ACL reconstruction using the con-
ventional BPTB graft with the Kennedy ligament-
augmentation device (LAD) over-the-top augmen-
tation technique. At 7-year follow-up, they found
no statistical difffference in stability tests, Lysholm
score, or Tegner activity score. No advantages were
associated with the use of the Kennedy LAD. Drog-
set et al. (45) compared three surgical procedures:
acute primary repair, acute repair augmented with
a synthetic LAD, and acute repair augmented with
BPTB graft. At long-term (16-year) follow-up, the
rate of revision ACL surgery was 10 times higher
following primary repair than after primary repair
augmented by a BPTB graft. In the remaining
patients, those who had repair with a LAD had
signifi
ficantly less stable knees than those who had
repair with a BPTB graft. They found, at 5-year
follow-up, that Lysholm scores of the patients in
the acute repair augmented with BPTB graft group
were signifi ficantly higher than those of the patients
in acute primary repair group; however, there were
no signifificant difffferences among three groups at
16-year follow-up. They showed signifi ficantly bet-
ter results of the subjective knee functional assess-
ment in the acute repair augmented with BPTB
group compared to acute repair augmented with
a synthetic LAD graft group as well. They do not
support the use of LAD in ACL reconstruction on
the basis of no positive long-term effect. ff So far,
no current indications seem to exist for synthetic
ligaments.
Nau et al. (37) evaluated and compared the BPTB
autograft and the LARS artifi ficial ligament (Liga-
ment Advanced Reinforcement System; Surgical
Implants and Devices, Arc-sur-Tille, France) in
terms of clinical outcome. Instrument-tested lax-
ity (Telos, Marburg, Germany) was greater in the
LARS group at all stages of follow-up, but the dif-
ferences were not signifi ficant at 24 months. KOOS
was signifi ficantly better in the LARS group at 6
months (in the subscale of sports activity and
Results of ACL reconstruction 257
quality of life) and 12 months (in the subscale of
activity of daily living, sports activity, and quality
of life) of follow-up, but the differences
ff were not
signifi
ficant at 24 months.Th They suggest that the
LARS ligament seems to be a satisfactory treat-
ment option, especially when an early return to
high levels of activity is demanded.
Graft fixation technique
Graft tensioning
In most surgical techniques used for ACL recon-
struction, a firm traction or, in other words, a
manual preload is applied to the graft just prior
to the final fixation. The preload could theoreti-
cally counteract the early loss of tension in the
graft (51,52). In primates it has been demon-
strated that preconditioning the patellar tendon
by passive stretching for 10 min reduces the
loss of tension due to relaxation, an effectff that
lasts for at least 30 min after the removal of the
load (53). Theoretically, this eff
ffect could be ben-
efi
ficial when the middle-third patellar tendon is
implanted during ACL reconstruction in humans.
Ejerhed et al. (39) compared the group of patients
with BPTB autograft preconditioned by passive
stretching at a constant load of 39 N for 10 min
immediately prior to implantation with the other
group that underwent no preconditioning before
the implantation of the graft. Their
Th finding was
that preconditioning BPTB autografts during ACL
reconstruction did not produce any advantages in
terms of the restoration of laxity, subjective out-
come, or functional outcome at 2-year follow-up
examination. The preconditioning procedure
appears to be of minor importance for the long-
term outcome.
Initial tension applied to the graft is considered
to be among the important factors that influence
fl
the result of ACL reconstruction. The amount of
tension applied to the graft determines postop-
erative knee laxity and kinematics. Th There have
been several reports examining the effectff of the
initial graft tension on resultant knee kinemat-
ics (54,55). However, the optimal graft tension to
achieve a satisfactory outcome is still controversial
(56–58). Yoshiya et al. (38) investigated the effect
ff
of the graft tension applied at surgery on the out-
come of ACL reconstruction with BPTB graft. Th The
diff
fferent amounts of tension (25 and 50 N) did
not lead to any detectable differences
ff in KT-1000
arthrometer laxity measurements at 3, 6, 12, or
24 months after ACL reconstruction. In the study
by Lewis et al. (55), the ligament tension after 6
weeks in goats was similar even when the tension
was high or low.
258 The Traumatic Knee
Bioabsorbable interference screw, etc.
During the past decade, bioabsorbable interference
screws have become increasingly popular in ACL
reconstruction. With these screws, there is no need
for a second operation for removal and no compli-
cating factor if later revision surgery is necessary.
Several biomechanical studies have shown similar
results between metal and bioabsorbable screws
(59,60). However, there are only a few studies in
terms of the clinical outcome. Kaeding et al. (41)
found no difffferences between the poly-L-lactic acid
(PLLA) interference screw and a titanium metal
interference screw with respect to KT-1000 side-
to-side diff
fference at 2 years after ACL reconstruc-
tion with BPTB graft. In some subscales of IKDC,
the patients in the PLLA group had signifi ficantly
better result during the follow-up period, although
there are no other subjective or functional mea-
surements in their article. The authors conclude
that use of a PLLA interference screw can provide
clinical results equal to that of a metal interference
screw for fixation of BPTB graft in ACL reconstruc-
tion. Drogset et al. (35) also found no statistically
signifi
ficant diff
fference between the metal screw
group and the PLLA screws in stability measured
by KT-1000 arthrometer, Lachman test, or piv-
ot-shift test. However, the patients in the metal
screw group had signifi ficantly better results either
in the subjective data (Lysholm score, Cincinnati
knee score, and subjective knee function) or in the
functional data (one-leg hop test) at 2 years after
ACL reconstruction with BPTB graft. Th Therefore,
they do not recommend the use of bioabsorbable
screws. Even in ACL reconstruction using ham-
string tendons, no significantfi diff
fferences were
found between the metal and PLLA groups in
KT-1000 arthrometer laxity measurements, but
the PLLA group showed signifi ficantly better results
in the overall IKDC and one-leg hop test at 2-year
follow-up (40).
Mariani et al. (43) found better stability and sub-
jective outcome (overall IKDC) in transcondyler
fixation, although this prospective study could
not provide signifi ficant data suggesting that one
method of fixation is superior to the other. Accord-
ing to Hill et al. (42), supplementary tibial staple
fixation in female patients undergoing ACL recon-
struction with hamstring graft in addition to a
single size screw signifificantly improved the laxity
measurement but had signifi ficantly more incidence
of kneeling pain at 2 years after surgery.
Navigation technique
The use of computer-aided surgical navigation
systems in knee surgery is becoming more wide-
spread, off
ffering exciting and more practical pos-
sibilities in the clinical setting. The technology
is being increasingly used to assist ACL recon-
struction surgery to improve the accuracy of
bone tunnel placement and to improve control
of anterior laxity. Plaweski et al. (44) compared
the clinical and radiographic results of patients
undergoing ACL reconstruction with hamstring
tendon graft using a conventional technique and
an image-free navigation system, based on anato-
mometric criteria. They have demonstrated that
using navigation to assist in ACL reconstruction
leads to greater accuracy in tunnel placement and
signifi
ficantly less variation in radiologic laxity
measurements. Whether this enhanced precision
will lead to better long-term results is uncertain
at this stage, and further long-term follow-up is
required to determine whether this is truly the
case.
Knee OA development after ACL injury
Twenty-four studies with mean follow-up time
of 13.8 (10–27) years were included in this sys-
tematic review based on the inclusion criteria
(45,46,61–82). However, all in all the method-
ological quality in these studies seemed to be rela-
tively low (83). The included studies involved only
one prospective randomized control study (46).
The methodological weaknesses most frequently
identifi
fied in the included studies were no blinding
of the radiological assessment, lack of regression
analysis and dropout analysis, and low follow-up
rate for radiological assessment, and most studies
had a retrospective study design. We need prospec-
tive high-quality studies using regression analysis,
to identify incidence and risk factors for knee OA
development after ACL injury or surgery.
Incidence of knee OA
A varying frequency of OA has been reported after
both surgical and conservative treatment. The Th
incidence of knee OA development in the differ- ff
ent groups varied between 10% and 100%. It has
not been shown that surgical treatment reduces
the risk for OA in several studies (35,43,64,67,81).
According to Drogset et al. (35), who compared
acute primary repair, acute repair augmented with
a synthetic LAD, and acute repair augmented with
autologous BPTB graft, knee OA was reported for
11% of the 85 patients prospectively followed up
after ACL reconstruction (cut offff 1 on Ahlbäck clas-
sifi
fication). No signifi
ficant diff
fference between the
diff
fferent surgical methods regarding the incidence
of OA development was found. In a prospective
randomized study, Meunier et al. (43) compared

patient groups of primary repair with and without
augmentation and non-operated. This study found
30% knee OA in both groups, and 10% severe
knee OA in both groups using grade 3 Ahlbäck
and Fairbank classifi fication system. There were no
signifi
ficant diff
fferences between the operated and
non-operated groups regarding radiological signs
of OA using Ahlbäck and Fairbank grade 1–3 as OA
criterion. On the contrary, Daniel et al. (10) found
more OA in patients after ACL reconstruction than
in those who were treated non-surgically, which he
explained by a higher frequency of meniscal sur-
gery and a higher activity level of surgically treated
patients, but even the surgical trauma by itself
is proposed to influence
fl OA. The OA frequency
seems to be independent of initial ACL treatment.
However, primary stabilization of the ACL by sur-
gical treatment may reduce the risk for secondary
meniscus injuries.
In any case, all of the studies are heterogeneous
regarding treatment (operated or non-operated),
graft type, unilateral ACL tear or ACL tear with addi-
tional injuries, revisions or re-injuries, and level of
activity (high-level athletes or normal active). Also
different
ff radiological classifi
fication systems both
within and between groups were used.
Risk factors for the development of knee OA
Meniscus injuries are commonly encountered in
association with ACL injuries and are proposed to
partially explain poor results after treatment. Most
of the studies conclude that meniscus injury and
meniscectomy are the most important risk factors
for the development of knee OA after ACL injury
(43,61–68,72–79,81,82). Dividing the studies in
terms of meniscal status, there was clear differ- ff
ences: <15% knee OA for those with intact menisci
and >40% knee OA for those meniscectomied
(62,77,79,82). It is well established that the menis-
cus has an important role in transmitting forces
across the knee joint, and that the loss of a meniscus
often leads to degenerative changes. Other identi-
fied risk factors were chondral lesions (68,77), laxity
(70,75,77), advanced age at injury (76,78,80), level
of sports activity (61,71,76), soccer (81), obesity
(67,72,76), increased time from injury to surgery
(71,78), and OA of contralateral knee (76).
Conclusion
As stated above, the ultimate goal of ACL recon-
struction is, primarily, to improve knee function
and, secondarily, to prevent secondary knee OA.
The surgical methods have improved in the last
Results of ACL reconstruction 259
decades, and the altered surgical techniques will
probably infl fluence the long-term results clini-
cally and functionally as well as radiologically. So
far, about 20–95% of patients in these papers had
good anterior and rotational knee stability. Most
of these papers addressed preinjury or postinjury
activity level and returning to the preinjury activ-
ity level after ACL reconstruction ranged from 55%
to 100%. Considering all these factors, such as sta-
bility of the knee, subjective outcome, functional
outcome, and return to sports activity, we could
not find the signifificant advantage suggesting that
one method (graft type or fixation
fi technique) is
superior to the other. Unfortunately, even with the
present techniques in ACL reconstruction, success-
ful return to sports cannot be guaranteed because
of a variety of factors, such as lifestyle changes
(out of school, no longer competing), fear of recur-
rent knee injury, instability, and pain. Although
restoration of mechanical restraints is the initial
step in achieving knee functional recovery, factors
including the patient’s motivation and willingness
to complete the prescribed rehabilitation program
may also play a role in inflfluencing outcome.
In the long-term outcome, ACL surgery does not
necessarily reduce the risk for OA, and the most
important risk factors for OA development in ACL
injured knees reported seem to be meniscus injury
and meniscectomy. The only randomized study
that compared operated and non-operated sub-
jects reported no significant
fi diff
fferences between
the groups in knee OA development. Owing to the
lack of studies with high methodological quality, we
need to determine the results on the basis of the dif-
ferent samples and radiological methods used, and
there are needs for validity and reliability studies of
the diff
fferent radiological classifi
fication systems.
References
1. Gillquist J, Messner K (1999) Anterior cruciate ligament
reconstruction and the long-term incidence of gonarthro-
sis. Sports Med 27:143–156
2. Johnson DL, Fu FH (1995) Anterior cruciate ligament
reconstruction: why do failures occur? In: AAOS Instruc-
tional Course Lectures. Rosemont, Illinois: Th
The American
Academy of Orthopaedic Surgeons, 44:391–406
3. Miyasaka KC, Daniel DM, Stone ML, Hirshman P (1991)
The incidence of knee ligament injuries in the general pop-
ulation. Am J Knee Surg 4:3–8
4. Granan LP, Bahr R, Steindal K, et al. (in press) Develop-
ment of a national cruciate ligament surgery registry – the
Norwegian National Knee Ligament Registry. Am J Sports
Med 2008 Feb; 36(2):308–15
5. Hey Groves EW (1917) Operation for the repair of cruciate
ligaments. Lancet 2:674–675
6. Roos EM (2005) Joint injury causes knee osteoarthritis in
young adults. Curr Opin Rheumatol 17:195–200
7. Fithian DC, Paxton LW, Goltz DH (2002) Fate of the ante-
rior cruciate ligament-injured knee. Orthop Clin North
Am 33:621–636
260 The Traumatic Knee
8. Myklebust G, Bahr R (2005) Return to play guidelines
after anterior cruciate ligament surgery. Br J Sports Med
39:127–131
9. Clatworthy M, Amendola A (1999) The Th anterior cruciate
ligament and arthritis. Clin Sports Med 18:173–198
10. Daniel DM, Stone ML, Dobson BE, et al. (1994) Fate of the
ACL-injured patient. A prospective outcome study. Am J
Sports Med 22:632–644
11. Guyatt GRD (2002) Users’ guides to the medical literature:
essentials of evidence-based clinical practice / the Evi-
dence-Based Medicine Working Group. JAMA & archives
journals
12. Liden M, Ejerhed L, Sernert N, et al. (2007) Patellar tendon
or semitendinosus tendon autografts for anterior cruciate
ligament reconstruction: a prospective, randomized study
with a 7-year follow-up. Am J Sports Med 35:740–748
13. Maletis GB, Cameron SL, Tengan JJ, Burchette RJ (2007)
A prospective randomized study of anterior cruciate liga-
ment reconstruction: a comparison of patellar tendon and
quadruple-strand semitendinosus/gracilis tendons fixed fi
with bioabsorbable interference screws. Am J Sports Med
35:384–394
14. Sajovic M, Strahovnik A, Komadina R, Dernovsek MZ
(2007) The
Th effffect of graft choice on functional outcome in
anterior cruciate ligament reconstruction. Int Orthop 13
15. Gobbi A, Francisco R (2006) Factors aff ffecting return to
sports after anterior cruciate ligament reconstruction
with patellar tendon and hamstring graft: a prospec-
tive clinical investigation. Knee Surg Sports Traumatol
Arthrosc 14:1021–1028
16. Matsumoto A, Yoshiya S, Muratsu H, et al. (2006) A com-
parison of bone-patellar tendon-bone and bone-hamstring
tendon-bone autografts for anterior cruciate ligament
reconstruction. Am J Sports Med 34:213–219
17. Zaff
ffagnini S, Marcacci M, Lo Presti M, et al. (2006) Pro-
spective and randomized evaluation of ACL reconstruc-
tion with three techniques: a clinical and radiographic
evaluation at 5 years follow-up. Knee Surg Sports Trauma-
tol Arthrosc 14:1060–1069
18. Harilainen A, Linko E, Sandelin J (2006) Randomized
prospective study of ACL reconstruction with interference
screw fixation in patellar tendon autografts versus femo-
ral metal plate suspension and tibial post fifixation in ham-
string tendon autografts: 5-year clinical and radiological
follow-up results. Knee Surg Sports Traumatol Arthrosc
14:517–528
19. Ibrahim SA, Al-Kussary IM, Al-Misfer AR, et al. (2005) Clin-
ical evaluation of arthroscopically assisted anterior cruciate
ligament reconstruction: patellar tendon versus gracilis and
semitendinosus autograft. Arthroscopy 21:412–417
20. Gobbi A, Domzalski M, Pascual J, Zanazzo M (2005)
Hamstring anterior cruciate ligament reconstruction:
is it necessary to sacrifi fice the gracilis? Arthroscopy
21:275–280
21. Aglietti P, Giron F, Buzzi R, et al. (2004) Anterior cruci-
ate ligament reconstruction: bone-patellar tendon-bone
compared with double semitendinosus and gracilis ten-
don grafts. A prospective, randomized clinical trial. J Bone
Joint Surg Am 86:2143–2155
22. Ejerhed L, Kartus J, Sernert N, et al. (2003) Patellar tendon
or semitendinosus tendon autografts for anterior cruciate
ligament reconstruction? A prospective randomized study
with a two-year follow-up. Am J Sports Med 31:19–25
23. Feller JA, Webster KE (2003) A randomized comparison
of patellar tendon and hamstring tendon anterior cruciate
ligament reconstruction. Am J Sports Med 31:564–573
24. Otsuka H, Ishibashi Y, Tsuda E, et al. (2003) Comparison of
three techniques of anterior cruciate ligament reconstruc-
tion with bone-patellar tendon-bone graft. Differences
ff in
anterior tibial translation and tunnel enlargement with
each technique. Am J Sports Med 31:282–288
25. Shaieb MD, Kan DM, Chang SK, et al. (2002) A prospec-
tive randomized comparison of patellar tendon versus
semitendinosus and gracilis tendon autografts for ante-
rior cruciate ligament reconstruction. Am J Sports Med
30:214–220
26. Beynnon BD, Johnson RJ, Fleming BC, et al. (2002) Ante-
rior cruciate ligament replacement: comparison of bone-
patellar tendon-bone grafts with two-strand hamstring
grafts. A prospective, randomized study. J Bone Joint
Surg Am 84:1503–1513
27. O’Neill DB (2001) Arthroscopically assisted reconstruc-
tion of the anterior cruciate ligament. A follow-up report.
J Bone Joint Surg Am 83-A:1329–1332
28. Aune AK, Holm I, Risberg MA, et al. (2001) Four-strand
hamstring tendon autograft compared with patellar ten-
don-bone autograft for anterior cruciate ligament recon-
struction. A randomized study with two-year follow-up.
Am J Sports Med 29:722–728
29. Eriksson K, Anderberg P, Hamberg P, et al. (2001) A com-
parison of quadruple semitendinosus and patellar tendon
grafts in reconstruction of the anterior cruciate ligament.
J Bone Joint Surg Br 83:348–354
30. Webster KE, Feller JA, Hameister KA (2001) Bone tunnel
enlargement following anterior cruciate ligament recon-
struction: a randomised comparison of hamstring and
patellar tendon grafts with 2-year follow-up. Knee Surg
Sports Traumatol Arthrosc 9:86–91
31. Anderson AF, Snyder RB, Lipscomb AB, Jr. (2001) Anterior
cruciate ligament reconstruction. A prospective random-
ized study of three surgical methods. Am J Sports Med
29:272–279
32. Yasuda K, Kondo E, Ichiyama H, et al. (2006) Clinical
evaluation of anatomic double-bundle anterior cruciate
ligament reconstruction procedure using hamstring ten-
don grafts: comparisons among 3 differentff procedures.
Arthroscopy 22:240–251
33. Adachi N, Ochi M, Uchio Y, et al. (2004) Reconstruction
of the anterior cruciate ligament. Single- versus double-
bundle multistranded hamstring tendons. J Bone Joint
Surg Br 86:515–520
34. Zhao J, He Y, Wang J (2007) Double-bundle anterior cruci-
ate ligament reconstruction: four versus eight strands of
hamstring tendon graft. Arthroscopy 23(7):766–770
35. Drogset JO, Grontvedt T, Tegnander A (2005) Endoscopic
reconstruction of the anterior cruciate ligament using bone-
patellar tendon-bone grafts fixed
fi with bioabsorbable or
metal interference screws: a prospective randomized study
of the clinical outcome. Am J Sports Med 33:1160–1165
36. Muren O, Dahlstedt L, Dalén N (2003) Reconstruction of
acute anterior cruciate ligament injuries: a prospective,
randomised study of 40 patients with 7-year follow-up.
No advantage of synthetic augmentation compared to a
traditional patellar tendon graft. Arch Orthop Trauma
Surg 123:144–147
37. Nau T, Lavoie P, Duval N (2002) A new generation of arti-
ficial ligaments in reconstruction of the anterior cruciate
ligament. Two-year follow-up of a randomised trial. J
Bone Joint Surg Br 84:356–360
38. Yoshiya S, Kurosaka M, Ouchi K, et al. (2002) Graft ten-
sion and knee stability after anterior cruciate ligament
reconstruction. Clin Orthop 394:154–160
39. Ejerhed L, Kartus J, Kohler K, et al. (2001) Precondition-
ing patellar tendon autografts in arthroscopic anterior
cruciate ligament reconstruction: a prospective random-
ized study. Knee Surg Sports Traumatol Arthrosc 9:6–11
40. Laxdal G, Kartus J, Eriksson BI, et al. (2006) Biodegrad-
able and metallic interference screws in anterior cruciate
ligament reconstruction surgery using hamstring tendon
grafts: prospective randomized study of radiographic
results and clinical outcome. Am J Sports Med 34:1574–
1580

41. Kaeding C, Farr J, Kavanaugh T, Pedroza A (2005) A pro-
spective randomized comparison of bioabsorbable and
titanium anterior cruciate ligament interference screws.
Arthroscopy 21:147–151
42. Hill PF, Russell VJ, Salmon LJ, Pinczewski LA (2005) The Th
infl
fluence of supplementary tibial fixation on laxity mea-
surements after anterior cruciate ligament reconstruction
with hamstring tendons in female patients. Am J Sports
Med 33:94–101
43. Mariani PP, Camillieri G, Margheritini F (2001) Transcon-
dylar screw fixation in anterior cruciate ligament recon-
struction. Arthroscopy 17:717–723
44. Plaweski S, Cazal J, Rosell P, Merloz P (2006) Anterior cru-
ciate ligament reconstruction using navigation: a compar-
ative study on 60 patients. Am J Sports Med 34:542–552
45. Drogset JO, Grontvedt T, Robak OR, et al. (2006) A six-
teen-year follow-up of three operative techniques for the
treatment of acute ruptures of the anterior cruciate liga-
ment. J Bone Joint Surg Am 88:944–952
46. Meunier A, Odensten M, Good L (2007) Long-term
results after primary repair or non-surgical treatment
of anterior cruciate ligament rupture: a randomized
study with a 15-year follow-up. Scand J Med Sci Sports
17:230–237
47. Werner S, Arvidsson H, Arvidsson I, Eriksson E (1993)
Electrical stimulation of vastus medialis and stretching of
lateral thigh muscles in patients with patello-femoral symp-
toms. Knee Surg Sports Traumatol Arthrosc.1:85–92.
48. Radford WJ,, Amis AA (1990) Biomechanics of a double
prosthetic ligament in the anterior cruciate deficient
fi knee.
J Bone Joint Surg Br 72-B:1038–1043
49. Sakane M, Fox RJ, Woo SL, et al. (1997) In situ forces in
the anterior cruciate ligament and its bundles in response
to anterior tibial loads. J Orthop Res 15:285–293
50. Yagi M, Wong EK, Kanamori A, et al. (2002) Biomechani-
cal analysis of an anatomic anterior cruciate ligament
reconstruction. Am J Sports Med 30:660–666
51. Burks RT, Daniel D (1984) Anterior cruciate graft preload
and knee stability. Orthop Trans 8:1–52
52. Burks RT, Leland R (1988) Determination of graft tension
before fixation in anterior cruciate ligament reconstruc-
tion. Arthroscopy 4:260–266
53. Graf BK, Vanderby R, Jr., Ulm MJ, et al. (1994) Effect ff of
preconditioning on the viscoelastic response of primate
patellar tendon. Arthroscopy 10:90–96
54. Bylski-Austrow DI, Grood ES, Hefzy MS, et al. (1990) Ante-
rior cruciate ligament replacements: a mechanical study of
femoral attachment location, flexion angle at tensioning,
and initial tension. J Orthop Res 8:522–531
55. Lewis JL, Lew WD, Engebretsen L, et al. (1990) Factors
aff
ffecting graft force in surgical reconstruction of the ante-
rior cruciate ligament. J Orthop Res 8:514–521
56. Nabors ED, Richmond JC, Vannah WM, McConville OR
(1995) Anterior cruciate ligament graft tensioning in full
extension. Am J Sports Med 23:488–492
57. van Kampen A, Wymenga AB, van der Heide HJ, Bakens
HJ (1998) TheTh eff
ffect of diff
fferent graft tensioning in ante-
rior cruciate ligament reconstruction: a prospective ran-
domized study. Arthroscopy 14:845–850
58. Yasuda K,, Tsujino
j J,, Tanabe Y,, Kaneda K (1997) Eff
ffects of
initial graft tension on clinical outcome after anterior cru-
ciate ligament reconstruction. Autogenous doubled ham-
string tendons connected in series with polyester tapes.
Am J Sports Med 25:99–106
59. Johnson LL, vanDyk GE (1996) Metal and biodegrad-
able interference screws: comparison of failure strength.
Arthroscopy 12:452–456
60. Nakano H, Yasuda K, Tohyama H, et al. (2000) Interference
screw fixation of doubled flexor tendon graft in anterior
cruciate ligament reconstruction – biomechanical evalua-
tion with cyclic elongation. Clin Biomech 15:188–195
Results of ACL reconstruction 261
61. Fink C, Hoser C, Hackl W, et al. (2001) Long-term out-
come of operative or nonoperative treatment of anterior
cruciate ligament rupture--is sports activity a determining
variable? Int J Sports Med 22:304–309
62. Hart AJ, Buscombe J, Malone A, Dowd GS (2005) Assess-
ment of osteoarthritis after reconstruction of the anterior
cruciate ligament: a study using single-photon emission
computed tomography at ten years. J Bone Joint Surg Br
87:1483–1487
63. Hertel P, Behrend H, Cierpinski T, et al. (2005) ACL recon-
struction using bone-patellar tendon-bone press-fit fi fixa-
tion: 10-year clinical results. Knee Surg Sports Traumatol
Arthrosc 13:248–255
64. Lohmander LS, Ostenberg A, Englund M, Roos H (2004)
High prevalence of knee osteoarthritis, pain, and func-
tional limitations in female soccer players twelve years
after anterior cruciate ligament injury. Arthritis Rheum
50:3145–3152
65. Maletius W, Messner K (1999) Eighteen- to twenty-four-
year follow-up after complete rupture of the anterior cru-
ciate ligament. Am J Sports Med 27:711–717
66. McDaniel WJ, Jr, Dameron TB, Jr (1980) Untreated rup-
tures of the anterior cruciate ligament. A follow-up study.
J Bone Joint Surg Am 62:696–705
67. McDaniel WJ, Jr., Dameron TB, Jr. (1983) The Th untreated
anterior cruciate ligament rupture. Clin Orthop Relat Res
172:158–163
68. Meystre JL, Vallotton J, Benvenuti JF (1998) Double sem-
itendinosus anterior cruciate ligament reconstruction:
10-year results. Knee Surg Sports Traumatol Arthrosc
6:76–81
69. Murray AW, Macnicol MF (2004) 10-16 year results of
Leeds-Keio anterior cruciate ligament reconstruction.
Knee 11:9–14
70. Neyret P, Donell ST, Dejour H (1993) Results of partial
meniscectomy related to the state of the anterior cruciate
ligament. Review at 20 to 35 years. J Bone Joint Surg Br
75:36–40
71. Noyes FR, Matthews DS, Mooar PA, Grood ES (1983)
The symptomatic anterior cruciate-defi ficient knee. Part
II: the results of rehabilitation, activity modification,
fi and
counseling on functional disability. J Bone Joint Surg Am
65:163–174
72. O’Brien W (1993) Degenerative arthritis of the knee
following anterior Cruciate ligament injury: role of the
meniscus. Sports Med Arthrosc Rev 1:114–118
73. Pritchard JC, Drez D, Jr., Moss M, Heck S (1995) Long-
term followup of anterior cruciate ligament reconstruc-
tion using freeze-dried fascia lata allografts. Am J Sports
Med 23:593–596
74. Reid JS, Hanks GA, Kalenak A, et al. (1992) The Th Ellison
iliotibial-band transfer for a torn anterior cruciate liga-
ment of the knee. Long-term follow-up. J Bone Joint Surg
Am 74:1392–1402
75. Salmon LJ, Russell VJ, Refshauge K, et al. (2006) Long-
term outcome of endoscopic anterior cruciate ligament
reconstruction with patellar tendon autograft: minimum
13-year review Am J Sports Med 34:721–732
76. Segawa H, Omori G, Koga Y (2001) Long-term results of
non-operative treatment of anterior cruciate ligament
injury. Knee 8:5–11
77. Selmi T, Fithian D, Neyret P (2006) The Th evolution of
osteoarthritis in 103 patients with ACL reconstruction at
17 years follow-up. Knee 13:353–358
78. Seon JK, Song EK, Park SJ (2006) Osteoarthritis after
anterior cruciate ligament reconstruction using a patellar
tendon autograft. Int Orthop 30:94–98
79. Sommerlath K, Lysholm J, Gillquist J (1991) The long-
term course after treatment of acute anterior cruciate
ligament ruptures. A 9 to 16 year followup. Am J Sports
Med 19:156–162
262 The Traumatic Knee
80. Strand T, Molster A, Hordvik M, Krukhaug Y (2005) Long-
term follow-up after primary repair of the anterior cruciate
ligament: clinical and radiological evaluation 15-23 years
postoperatively. Arch Orthop Trauma Surg 125:217–221
81. von Porat A., Roos EM, Roos H (2004) High prevalence
of osteoarthritis 14 years after an anterior cruciate liga-
ment tear in male soccer players: a study of radiographic
and patient relevant outcomes. Ann Rheum Dis 63:269–
273
82. Wu WH, Hackett T, Richmond JC (2002) Effectsff of menis-
cal and articular surface status on knee stability, function,
and symptoms after anterior cruciate ligament recon-
struction: a long-term prospective study. Am J Sports
Med 30:845–850
83. Øiestad BE, Engebretsen L (in press) The
Th incidence of knee
OA development more than 10 years after anterior cruci-
ate ligament injury: a systematic review. J Bone Joint Surg
Am (in press)

P. Chambat, R. Vargas,
J. Desnoyer
Arthrofibrosis after anterior cruciate
ligament reconstruction
Introduction
T
he reconstruction of the anterior cruciate lig-
ament (ACL) is a common procedure carried
out in orthopaedic surgery. It aff
ffects mainly
young sportsmen and women. In 2005, 32,000
surgical procedures concerning the ACL were per-
formed in France. If surgery itself is important,
so is the preoperative condition of the knee and
the postoperative period. The result is very often
favorable, but complications are not exceptional,
especially with regard to the recuperation of joint
motion. It is a problem that occurs in the short-
and long-term postoperative phase.
The problem
It concerns patients who have had an ACL opera-
tion using whatever technique and who are slower
in regaining joint motion in the different
ff postop-
erative phases of rehabilitation. This problem is
always associated with pain.
Loss of mobility
The slow recuperation of joint motion may quickly
be obvious during the first weeks after surgery or
later when the protocol and work load are more
demanding. The alert signs are diff fferent depend-
ing upon the time of surgery. Lack of extension
of 10–15° and a limited flexion of 100° after three
weeks do not constitute a catastrophe because a
readjustment in the rehabilitation protocol can
still solve the problem.
On the other hand, a flexumfl of 5–10° with a
limited flexion of 120° after about 5 months are
cause for concern. Chances of spontaneous recu-
peration even after rehabilitation modification
fi
are slim.
The more time passes after surgical reconstruction,
Th
the less the chances of recuperation. It is impor-
tant to know if there is a possibility of non-surgical
recuperation in the opinion of the physiotherapist.
Chapter 23
There might be a lack of extension or flexion or
both (flexion
fl and extension).
In 1996 (1) a classification
fi of four diff
fferent types
was suggested:
Type 1: Less than 10° extension loss with normal
flexion
Type 2: More than 10° extension loss with normal
flexion
Type 3: More than 10° extension loss and more
than 25° flexion loss with a tight patella
Type 4: More than 10° extension loss, 30° or more
flexion loss, patella infera and marked
patellar tightness
This objective classifi fication suggests that an exten-
sion loss of a few degrees is not as well tolerated as
a flexion loss and that full recuperation of exten-
sion or better still of physiological recurvatum are
paramount for a good functional result. Th The two
most serious types involve patella abnormalities.
In fact, the patella is the “thermometer” or mea-
sure of good health of the operated knee.
The meta-analyses published keep us informed
about the percentage of patients operated for ACL
resulting with a reduction in joint motion. With
regards to flexion,
fl the loss aff
ffects about 15% of
patients (2). The Th difffference in technique – using
either the hamstrings or the patellar tendon – does
not show statistical diff fferences. Concerning the loss
of extension of more than 5°, the percentages vary
according to the study (0.7% hamstrings and 1.9%
PT) (3) (6% hamstrings and 9% PT) (4), but nei-
ther study signifi ficantly suggests which technique
is superior, even if a paper (5) points out that most
patients aff ffected by loss of flexion come from the
ischios group and the extension loss comes mainly
from the patellar tendon one.
Pain
Pain is often a problem in this delayed postoperative
recuperation. It makes it diffi
fficult to analyze because it
may be impossible to differentiate
ff if pain is the cause
of delay or a consequence of aggressive rehabilitation.
One has to be worried if pain lasts through the night
as opposed to decreasing with rest. Pain is most often
264 The Traumatic Knee
located anteriorly but can, at times, be diffuse
ff or even
be felt at some distance from the joint space.
Etiology
Arthrofi
fibrosis and loss of joint motion can have many
causes, some of which arising from technical prob-
lems during surgery, some in a postoperative period.
All these may often be interrelated, having thus a
negative eff
ffect with joint motion recuperation.
Problems with the surgical techniques
The causes might be iatrogenic in nature. They
might be one of the following:
– Intra-articular metallic interference or resorb-
able screw, most often in the tibial tunnel may
cause a confl flict with the anterior edge of the
inter-condylar notch.
– Bone mass which appears at the pre-spinal
surface, if the bone-tendon-bone was used for
reconstruction.
– Incorrect positioning of the tunnels may create
a diffi
fficulty with flexion if the femoral tunnel is
too anterior and a tight or difficult
ffi extension if
the tibial tunnel is too anterior, thus creating a
confl
flict in the notch.
– Unusually, a meniscal problem or a bucket handle
may occur after surgery, or a remnant of the native
ACL that is ripped and doubled over in the ante-
rior part of the joint may have been missed and not
resected during surgery. This
Th can cause the equiva-
lent of a cyclop, thus limiting full extension.
These problems are to be evaluated systematically
Th
with simple x-rays, which will visualize screws or bone
fragments and tunnel positioning with the help of
their sclerotic edges. MRI on the other hand will show
non-resorbable screws and soft tissue impingement.
Infection
A low-grade infection is not always easy to identify,
and one has to not only look for a swollen knee but
also investigate thoroughly.
We must be aggressive with joint aspiration in order
to identify the germ responsible for the infection.
Any delay can have catastrophic consequences for
joint motion and cartilage.
Quadriceps insuffi
fficiency
Insuffi
fficiency of the quadriceps may also be a reason
for the delay in recuperation, above all, with regards
to extension. A true paralysis due to nerve suffer-
ff
ing caused by a faulty tourniquet or because of local
regional anesthesia complication is rare. On the
other hand, a weakness of the muscle is relatively
frequent, which corresponds to an abnormality of
contraction in the last degrees of extension. ThisTh
defi
ficiency is often in relation to anterior pain that
impedes the active recuperation of extension and
favors the postoperative flexums. An EMG may be
useful in the case of severe dysfunction.
Fibrous formation at the foot of the ACL
This was described in 1996 (6) as the cyclop syn-
drome. This fibrous interposition prevents exten-
sion and may have one of two anatomical forms
due to either a true nodule or a simple increase in
width of the foot of the neo-ligament.
The cyclop
The nodule is more or less large and often ecchy-
motic and distinct from the ACL. This neo-forma-
tion can easily be seen during arthroscopy with the
knee in extension. It might be pedunculated on the
anterior part of the foot or on the ligament itself, or
it might also be suspended to the roof of the notch.
Intra-nodular ecchymotic lesions occur when it is
being crushed between the tibial plate and the roof
of the notch while the knee is in extension. Th This
can evolve according to physical activity that causes
intra-nodular bleeding, increasing its volume and
size and thus the flexum. Histologically, this cyclop
is formed of fibrocytes, an anarchic vascularization
of mature or immature bone residue in formation.
Cyclopoid formation
This widening of the foot of the ACL (7) is respon-
sible for the conflflict with the anterior part of the
notch roof when the knee is in extension. Th This
is observable, above all, in extension with a real
chunk of tissue interposed between the tibia and
the femur. The symptomatology is often not very
precise, with discomfort in extension or anterior
pain. It is often a late diagnosis.
Such an evolution of a cyclop or cyclopoid forma-
tion is often related to a transplant that is too
large, an anterior notch too narrow, a tibial tunnel
too anterior, or osteocartilagenous debris near the
opening of the tibial tunnel.
Anterior pain
Anterior pain is not unusual after ACL recon-
struction (8,9) but may be a true obstacle to joint
motion recuperation. The origin is multifactorial

and may be proximal due to patellar tendinitis or
in the anterior tibial tuberosity area if a big bone
plug was taken at this site, by cartilaginous lesions
in the patello-femoral joint surface by neuropathic
problems caused by lesion of the infra-patellar
branches of the medial saphenous nerve.
All cases of anterior pain are not necessarily linked
to problems of joint motion, but they must be
taken into account, even more so when we know
that they are present in 22% of patients oper-
ated on with a patellar tendon in comparison with
13% of patients operated on with ischios (4). Th This
pain, however, can occur whatever the choice of
transplant and may have negative feedback to the
extensive mechanism and quadriceps muscle and
tendon. Weakness, pain, and flexion
fl contracture
increase patello-femoral stress, and thereafter,
possible cartilaginous lesions may occur.
Complex regional pain syndrome (CRPS)
It is defi
fined (10) as being an exaggerated reaction to a
surgical or non-surgical trauma often accompanied by
prolonged, intense pain, even distant from the joint
space, also with a delay in functional recuperation,
vasomotor, and trophic problems. The Th occurrence
of such symptoms and signs is problematic in the
postoperative rehabilitation phase because this may
increase pain. A precise diagnosis is necessary. It must
be based (11) on clinical findings and sometimes with
technetium bone scanning, which is very sensitive
but poorly specifific. It may typically show an increas-
ing uptake of the isotope in each of the three phases
of the bone scan but could also be negative. Initially,
x-rays are of no use for diagnosis, but after 3 months,
a patchy subchondral ostopenia is usually present,
principally on the patella and the condyles. In the late
stages, profound bone demineralization occurs.
Patellar entrapment
It was described by L. Paulos (12) as a pathological
entity, but for us it seems most likely to be the final
fi
consequence of one or more of the causes previ-
ously described.
This syndrome has been described as evolving in
Th
three stages, each one more alarming:
The prodromal stage shows diffffuse edema in the peri-
articular soft tissues, particularly in the area of the
patellar tendon and fat pad with a clinically painful
active range of motion showing no improvement
and tenderness along the patellar tendon and also
a quadriceps extension lag.
The active stage corresponds to a restriction in both
active and passive knee flexion and extension, sig-
nificant
fi quadriceps atrophy and patellar crepitus,
Arthrofibrosis after anterior cruciate ligament reconstruction 265
and decreased patellar mobility with limitation of
glide and tilt. These
Th first two stages do not diff ffer
from a true CRPS with relationship to the differ- ff
ent causes of stiffffness previously described, such
as weakness of the quadriceps and anterior pain if
a CRPS syndrome was not attended to initially.
The residual stage: The final evolution, shows a fixed
and lowered patella (13) due to retraction of the
patellar tendon and peri-patellar soft tissues. Th The
lower patella represents the specifi ficity of this syn-
drome. This will also again be referred to in the
classifi
fication of joint motion loss (1). In each stage
of the evolution, there may be a negative impact
over joint motion with stiffness
ff and weakness of
the quadriceps at first,
fi which aff
ffects extension, fol-
lowed by a fixed
fi patella, which aff
ffects both flexion
and extension. Once again, the earliest possible
diagnosis with adapted patient care could reverse
the process.
Prevention of problems causing joint motion
recuperation
Post-traumatic or preoperative period
In order for the knee to be operated safely, it needs
to have recuperated fully from the accident and
this usually takes 6–8 weeks, ideally with phys-
iotherapy (14,15,16). In fact, what counts is how
the knee is at the time of surgery. It is important
to operate a pain-free knee that has recuperated
full range of motion. It should not be aff ffected by
a quadriceps or extension lag (17,18,19 ). When
a grade 1 or 2 peripheral lesion does not require
surgery, recuperation might be long because of
the time necessary for the knee to reconstitute
the layers. In such conditions, the knee is tension
free, but there is diff
ffuse swelling and subcutaneus
ecchymotic lesions due to capsular injury.
On the other hand, an isolated ACL rupture with a
tense knee and an intact capsule should recuperate in
a few days following drainage of the hemarthrosis. It
is important to reexamine the patient preoperatively
to be sure that the following have been obtained: nor-
mal pain-free joint motion and good control of the
quadriceps. It is also important to know what the
knee was like before the accident because conditions
such as arthrosis or cartilaginous lesions may present
an obstacle to full postoperative recuperation.
Per-operative period
Even though ACL reconstruction has become a rou-
tine operation, it is important to avoid any errors
that may refer to:
266 The Traumatic Knee
– the positioning of the tunnels;
– the intra-osseous positioning of the bone block
and the interference screws;
– the stability of the meniscus.
One should also look for subcutaneus undermin-
ing and prominent or metallic fixation
fi device,
which is often not well tolerated, and above all try
to control bleeding to avoid any hemarthrosis or
secondary hematomas.
Postoperative period
Pain should be controlled, and immediate full exten-
sion is the key (20). This does not have any repercus-
sions regarding stability (21,22). It is done passively
and actively with immediate activation of the quad-
riceps and locking of the knee in extension.
Mobilization of the patella is part of the basic exer-
cise. This should be done in both vertical and hori-
zontal directions. This mobilization is accompanied
by a “loosening and softening” of the sub-quadricip-
ital cul de sac. In general, being careful is the rule,
being attentive to any accessory pain (excess work,
the beginning of an inflflammatory phenomenon ...).
A pain-free peri-operative period, in general, is key to
minimize problems with joint motion recuperation.
Diagnosis of joint motion restriction
The diagnosis is supported by clinical and para-
clinical examinations.
Clinical examination
Clinically, it is important to analyze:
– the lack of extension and flexion compared to the
contralateral side;
– height and mobility of the patella in the frontal
and sagittal planes;
– performance of the extensor system (strength of
the quadriceps and active control of the patella).
Para-clinical evaluation
(a) Plain x-rays will show:
– the position of the femoral and tibial tunnels,
which can easily be recognizable by looking at
their sclerotic edges;
– malpositioning of intra-articular prominent
interference screw of tibial bone block;
– the abnormal aspect of a diff
ffuse bony radiologi-
cal image predominating in the anterior aspect of
the knee, indicating a global or localized CRPS;
– The height of the patella based on the patellar
indices (13) with a patella labeled “infera” if the
index, as compared to the non-operated side, is
clearly diminished.
(b) MRI may demonstrate:
– the existence of a cyclop lesion at the foot of
the ACL causing impingement;
– absorbable material beyond the joint line;
– edema of the subchondral bone;
– fibrosis of the fat pad sometimes associated to
a thickened patellar tendon;
– a thickening of the posterior capsule.
(c) Technetium bone-scan may show diffused ff or
localized infl
flammatory signs.
(d) An EMG could be helpful to investigate a severe
muscular loss.
Treatment
Mobilization under general anesthesia
This type of treatment is very controversial as it
is may damage the tissues. Its use is minimal. It
should only be reserved to very limited indications
corresponding to a flexion of less than 90°, 45 days
after surgery with almost full extension. Manipula-
tion should be gentle, just allowing flexion
fl of a little
more than 90°, which corresponds to a cap, and will
be followed by aggressive rehabilitation. Hyperflex-
fl
ion, thereby hyperpression, should be avoided at all
cost at the expense of weakness or stretching the
neo-ligament and causing more pain and maybe
patello-femoral cartilaginous damage.
Arthrolysis
It is well documented (23–25) and should be pre-
ceded by treatment of all probable causes (intra-
articular screw, etc.).
Loss of flexion only
The pathology is to be found in the quadricipital
pouch. The adherences are progressively liber-
ated arthroscopically through the antero-medial
and lateral portals and subsequently through two
supero-medial and supero-lateral accessory por-
tals. If the patella is fixed laterally, it is desirable to
liberate the collateral gutters, followed by a gentle
manipulation to be able to recuperate a normal
flexion. With regards to the positioning of the neo-
ligament, it may have been damaged or become
detached at the site of the femur insertion. It is
always important to conclude with an arthroscopic
evaluation of the inter-condylar notch.

Loss of extension only
Th pathology lies in the anterior compartment of
The
the knee with soft tissue scar preventing extension.
The ideal hypothesis is that of a cyclop that only
Th
needs resection. The other similar condition that
is the cyclopoid aspect of the foot of the ACL, with
diff
ffuse fibrosis in the pre-spinal surface, is more dif-
ficult to diff
fferentiate and also more diffi
fficult to treat.
Only with the knee in full extension can one appre-
ciate the quality of the arthrolysis, and if the small-
est doubt remains with regards to impingement of
the ACL, an inter-condylar notch plasty should be
done. The postoperative gain in extension will cor-
respond to the gain obtained without strain when
the heel is raised above the operating table.
Loss of flexion and extension
It is important to begin treating successively the
loss in extension and then the loss in flexion.
Supplementary steps sometimes necessary
In the case of a fixed patella infera with retro ten-
dinous fibrosis, a progressive anterior release of
the scar tissue between the fat pad and the patellar
tendon in the pre-epiphyseal surface might help
regain a few degrees of fl
flexion.
If there is no gain in extension despite complete
release of the anterior space of the knee eventu-
ally associated with a notch plasty, then posterior
medial and lateral surgical approaches are recom-
mended to access and detach the superior inser-
tions of the retracted posterior capsule. Th This is
most often seen in the chronic phase.
The combined step that should never be done
Even though a low patella causes stiff
ffness, it is danger-
ous to treat that condition at the same time as doing
an arthrolysis whatever technique one is using. Besides
the increased surgical aggression, it will also antago-
nize rehabilitation. Arthrolysis should be followed by
aggressive range of motion, whereas surgery to release
the patella requires a slow and gentle follow-up.
Surgical timing
It is not always easy to evaluate the time to do sur-
gery. It is important at first to identify the problem
and modify rehabilitation if possible, and we have
already discussed the possibility to manipulate the
knee under general anesthesia within the fi first 6
weeks after surgery.
Certainly after the 3rd month, if there has been
no progression in the range of motion, a surgical
solution can be discussed. If a simple mechanical
problem, such as a well-defi fined cyclop, is identi-
fied, there is no need to wait. One has to remember
that the result will also depend on the time elapsed
Arthrofibrosis after anterior cruciate ligament reconstruction 267
between the reconstructive surgery and the surgi-
cal release. If an infl
flammatory problem or a CRPS
is discovered, it is usually best not to operate.
This will have some serious drawbacks because,
in eff
ffect, it creates two problems. The first and
obvious one is no gain in the range of motion and
delay to obtain it, and the second is rehabilitation,
which increases pain in CRPS. These are problem-
atic knees that are best treated medically at fifirst.
Only when that situation is under control should
the mechanical part of it be addressed.
Rehabilitation
Physiotherapy should begin immediately and should
be aggressive. The goal is to concentrate all the eff
fforts
toward regaining the few degrees of extension miss-
ing, which are often difficult
ffi to recuperate.
1. With regards to an extension deficit,fi rehabilita-
tion should ideally last from 60 to 90 min depend-
ing on the pain, this being done every 3 h, alter-
nating sessions to address extension only with
active quadriceps exercises and gentle continuous
passive motion (CPM). Ideally four sessions a day
are to be considered, the night being the period of
the day without stress and overstimulation.
2. When it comes to a flexion problem, exercises
stimulating the hamstrings with active fl flexion
exercises are the best. These also followed by a
gentle range of motion on a CPM machine.
3. In a mixed loss of both extension and flexion,
an aggressive program is being done every 2 h,
one concentrating on flexion and the other on
extension, both again ideally ending with the
CPM machine.
Results
The results in the literature show that this problem
is not benign as compared with the control groups.
ACL reconstruction is followed by a non-negligible
number of complications. Harner (16) says patients
affl
fflicted by this problem remain with a joint motion
loss of 5° in extension and 21° in flexion, and no
problem with patello-femoral joint or residual lax-
ity. In this study, 67% of the patients having under-
gone an arthrolysis had excellent or good results as
opposed to 79% in the control group.
Agglietti (26) found that 58% of 31 patients who had
an arthrolysis were satisfi fied with regards to their
symptoms and 71% regarding joint motion, but the
final result was only satisfactory in 37% of the cases.
His opinion is that the result is better if surgery is
done early. Tayot (27) says that 75% of 52 patients
268 The Traumatic Knee
who were operated on regained normal range of
motion. Hassan (28) reports an incomplete correc-
tion of flexum that remained on average at 3°.
In summary, we note that despite arthrolysis, some
loss of joint motion often persists. An extension
defi
ficit of even a few degrees is more detrimental
than a lack of 10–20° of flexion. The overall result
regarding stability remains good, but the global
result is clearly inferior as compared to a non-com-
plicated ACL reconstruction.
Conclusions
Stiff
ffness of the knee following reconstruction of
the ACL is not an exceptional complication. The Th
best treatment is prevention.
– Preoperatively, the knee should recuperate a com-
plete pain-free range of motion with a good con-
trol of the quadriceps and no lag of extension.
– During surgery, one should use the least aggres-
sive possible technique.
– Postoperatively, good pain control and immedi-
ate full extension should be the goal.
If a complication occurs in spite of all these precau-
tions, the decision to proceed to surgery should be
made early before all the anatomical structures of
the knee stiffffen. The later surgery if being done,
the less predictable the result will be.
References
1. Shelbourne KD, Patel DV, Martini DJ (1996) Classification
fi
and management of arthrofibrosis
fi of the knee after ante-
rior cruciate ligament reconstruction. Am J Sports Med
24:857–862
2. Yunes M, Richmond JC, Engels EA, Pinczewski LA (2001)
Patellar versus hamstring tendons in anterior cruciate
ligament reconstruction: a meta-analysis. Arthroscopy
17(3):706–714
3. Freedman KB, D’Amato MJ, Nedeff ff DD, et al. (2003)
Arthroscopic anterior cruciate ligament reconstruction:
a metaanalysis comparing patellar tendon and hamstring
tendon autografts. Am J Sports Med 31(1):2–11
4. Biau DJ, Tournoux C, Kasahian S, et al. (2007) ACL
reconstruction: a meta-analysis of functional scores. Clin
Orthop Relat Res 458:180–187
5. Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC
(2005) Reconstruction of the anterior cruciate ligament:
meta-analysis of patellar tendon versus hamstring tendon
autograft. Arthroscopy 21(7):791–803
6. Jackson DW, Schaefer RK (1990) Cyclops syndrome: loss
of extension following intra articular anterior cruciate
ligament reconstruction. Arthroscopy 6:171–178
7. Muellner T, Kdolsky R, Groosschmidt K, (1999) Cyclops
and cyclopoid formation after anterior cruciate ligament
reconstruction: clinical and histomorphological differ-ff
ences. Knee Surg Sports Traumatol Arthrosc 7(5):284–
289
8. Sachs RA, Daniel DM, Stone ML, Garfein RF (1989) Patel-
lofemoral problems after anterior cruciate ligament recon-
struction. Am J Sports med 17:760–765
9. Burwell JMR, Davies AJ, Allum RL (1998) Anterior knee
symptoms afterreconstruction of the anterior cruciate lig-
ament using patellar tendon as a graft. Knee 5:245–248
10. Schutzer SF, Gossling HR (1984) Th The treatment of refl
flex
sympathetic dystrophy syndrome. J Bone Joint Surg Am
66-A:625–629
11. Dowd GS, Hussein R, Khanduja V, Ordman A (2007) com-
plex regional pain syndrome with special emphasis on the
knee. J Bone Joint Surg Br 89-B:285–290
12. Paulos LE, Rosenberg TD, Drawbert J, et al. (1987) Infra-
patellar contracture syndrome. An unrecognized cause of
knee stiff
ffness with patella entrapment and patella infera.
Am J Sports Med 15:331–341
13. Caton J, Deschamps G, Chambat P, et al. (1982) Les rot-
ules basses a propos de 128 observation. Rev Chir Orthop
68:317–325, 82
14. Schelbourne KD, Wilckens JH, Mollabashy A, De Carlo M
(1991) arthrofi fibrosis in acute anterior cruciate ligament
reconstruction. The eff ffect of timing of reconstruction and
rehabilitation. Am J Sports Med 19(4):332–336
15. Mohtadi NG, Webster-bogaert S, Fowler PJ (1991) Limi-
tation of motion following anterior cruciate ligament
reconstruction. A case control study. Am J Sports Med
19(6):620–624
16. Harner CD, Irrgang JJ, Paul J, et al. (1992) Loss of motion
after anterior cruciate ligament reconstruction. Am J
Sports Med 20(5):499–506
17. Cosgarea AJ, Sebastanelli WJ, De Haven KE (1995) Pre-
vention of arthrofi fibrosis after anterior cruciate ligament
reconstruction using the central third patellar tendon
autograft. Am J Sports Med 23(1):87–92
18. Sterett WI, Hutton KS,Briggs KK, Steadman Jr (2003)
Decreased range of motion following acute versus chronic
anterior cruciate ligament reconstruction. Orthopedics
26(2):151–154
19. Mayr HO, Weig TG, Plitz W (2004) Arthrofibrosis fi fol-
lowing ACL reconstruction-reasons and outcome. Arch
Orthop trauma Surg 124(8):518–522
20. Dandy DJ, Edwards DJ (1994) Problems in regaining full
extension of the knee after anterior cruciate ligament
reconstruction: does arthrofi fibrosis exist? Knee Surg
Sports Traumatol Arthrosc 2(2):76–79
21. Majors RA, Woodfi fin B (1996) Achieving full range of
motion after anterior cruciate ligament reconstruction.
Am J Sports Med 24(3):350–355
22. Isberg J, Faxén E, Brandsson S, et al. (2006) early active
extension after anterior cruciate ligament reconstruction
does not result in increased laxity of the knee. Knee Surg
Sports Traumatol Arthrosc 14(11):1108–1115
23. Fisher SE, Shelbourne KD (1993) Arthroscopic treat-
ment of symptomatic extension block complicating ante-
rior cruciate ligament reconstruction. Am J Sports Med
21(4):558–564
24. Reider B, Belniak RM, Preiskorn D (1996) Arthroscopic
arthrolysis for flexion contracture following intraarticular
reconstruction of the anterior cruciate ligament. Arthros-
copy 12(2):165–173
25. Shelbourne KD, Patel DV (1999) Treatment of limited
motion after anterior cruciate ligament reconstruction.
Knee Surg Sports Traumatol Arthrosc 7(2):85–92
26. Aglietti P, Buzzi R, De Felice R, (1995) Results of surgi-
cal treatment of arthrofi fibrosis after ACL reconstruction.
Knee Surg Sports Traumatol Arthrosc 3(2):83–88
27. Tayot O, Ait Si Selmi T, Dejour D (2007) A retrospective
analysis of 62 arthrolysis performed for knee stiffness ff
after grafts of the anterior cruciate ligament. J Bone Joint
Surg Br 79B:39–40
28. Hasan SS, Saleem A, Bach BR, (2000) Results of
arthroscopic treatment of symptomatic loss of extension
following anterior cruciate ligament reconstruction. Knee
Surg Sports Traumatol Arthrosc 13(4):201–209

M.A.
C. Pelluchon
Shaffer, G.N. Williams ACL rehabilitation
Overview
I
t has been estimated there are 100,000 new
anterior cruciate ligament (ACL) injuries each
year in the United States, an incidence of
1/3000 people (1). Young women, particularly those
involved in the sports of soccer and basketball, are
most at risk for ACL injury. A recent meta-analysis
indicated young women were nearly 3 times more
likely to suff
ffer an ACL injury when compared to a
male cohort group. The authors concluded a young
female who participated in sport year round had
a 5% risk for tearing her ACL (2). In the United
States, the standard of care for athletes involved in
cutting, pivoting sports who have suffered
ff a torn
ACL is season-ending surgical reconstruction fol-
lowed by a lengthy period of postoperative reha-
bilitation (3). Older athletes or those willing to
limit their activities to straight, linear movements
may not require ACL reconstruction (ACLR). In
addition, there is a small percentage of the popula-
tion who is able to maintain dynamic knee stability
through coordinated, well-timed contractions of
the musculature surrounding their knee. If these
athletes are able to return to high level cutting and
pivoting sports for 1 year without repeat giving way
episodes, they are termed “copers” (4). However, in
all likelihood, true “copers” represent no more than
15–30% of an ACL-defi ficient population (4,5).
Rehabilitation of the ACL-defificient individual
In the United States, the standard of care for high-
level athletes who have torn their ACL is surgical
reconstruction (3,6). But surgical reconstruction
necessitates a lengthy period of postoperative reha-
bilitation that forces athletes to miss the remain-
der of their competitive season and signifi ficantly
alters the lives of non-athletes. Therefore, there
are instances where conservative care is appropri-
ate. Older athletes and those individuals willing to
eliminate cutting and twisting activities may be
successful with conservative management alone.
In addition, non-operative care may be attempted
Chapitre 24
for athletes who have sufferedff an isolated ACL
injury, are near the end of their respective season,
and/or must delay their reconstruction for other
reasons.
It is important to remember, no more than 15–30%
of ACL-defi ficient individuals typically return to
running, jumping, and pivoting activities without
experiencing subsequent episodes of knee insta-
bility (4,5). Criteria have been established to assist
with the identifi fication of these potential “copers”
(5). After 4 weeks of rehabilitation following
their acute injury, ACL-deficient
fi individuals were
tested with a combination of hop tests, quadriceps
strength testing, patient outcome scales, and a
global knee rating. Of 93 patients tested, 39 (42%)
were deemed good candidates for non-operative
care. Following 4 additional weeks of progressive
strength training, agility drills, and functional
sport training (8 weeks since the initial injury),
24% of the original sample were able to success-
fully return to their sport without subsequent giv-
ing way episodes, additional injury, or a decrease in
their performance (5).
The long-term results of this algorithm for con-
servative treatment have recently been analyzed
(3).Over the 10-year duration of this study, 832
ACL injured patients presented to a single ortho-
pedic surgeon. Approximately 10% of the original
sample declined to participate and approximately
40% were eliminated due to the presence of associ-
ated knee injuries. Of the remaining 432 patients,
87 were eliminated because they were unable
to fully regain their preinjury status in terms of
pain, range of motion (ROM) and strength after
the initial postinjury physical therapy program.
The remaining 345 patients completed the Uni-
versity of Delaware screening examination (5)
approximately 6 weeks after index injury that
eliminated another 199 patients as non-copers.
Of the 146 potential copers who remained, 60%
chose to undergo ACLR before returning to their
recreational activities. Therefore, of the initial
group of 832 patients, only 88 attempted return
to sport without surgical reconstruction. Of those
88 patients, 72% were able to successfully return
to their sport and none sustained an additional
270 The Traumatic Knee

A B

C D
Fig. 1 – A typical progression of hamstring strengthening exercises that might be utilized in rehabilitation of an ACL-deficient individual. (A) Seated curls
allow the ROM to be adjusted to patient tolerance. (B) Prone curls are generally more challenging and allow for a more complete ROM. (C) Stool scoots are
more dynamic and start to mimic the function of the hamstring muscles during gait. (D) Supine ball series are the most challenging of the series and add a
motor control component due to the unstable surface.

knee injury. At the time of follow-up, 36 of the 63
patients who successfully returned to sport even-
tually went on to have their ACL’s reconstructed,
presumably at a time more convenient for them.
In summary, out of 832 original patients only 29
demonstrated the ability to return to a similar
level of activity without undergoing ACLR recon-
struction (3). This chapter clearly demonstrates
the diffi
fficulty returning to high-level sports with-
out a functioning ACL and the arduous process to
identify true copers of ACL defificiency
Following ACL injury, initial rehabilitation is
focused on eliminating swelling and restoring
preinjury ROM and strength. Early rehabilitation
interventions are very similar to those employed
following ACLR and will be more thoroughly
described in upcoming sections. However, com-
pared to standard postoperative rehabilitation,
rehabilitation of the ACL-deficient
fi individual is
unique in several important ways.
Often rehabilitation specialists will promote a
hamstring dominant program when working with
an ACL-defi ficient patient. Contraction of the ham-
strings resists anterior displacement of the tibia
thereby serving as a possible agonist for the ACL.
Hamstring strengthening can be accomplished using
a variety of methods, but seated isotonic curls can be
an easy entry point for recently injured individuals
as this exercise can be performed through a limited
ROM. As patients regain ROM, they can be advanced
to prone hamstring curls, and as patients regain
hamstring strength, they can be advanced to “stool
scoots,” or other more challenging hamstring exer-
cises (Fig. 1).
Simply increasing strength of the hamstrings is
insuffi
fficient to develop the coordinated neuromus-
cular control necessary for higher speed activities.
The Pivot Shift Control Program was developed to
promote coordinated, well-timed contractions of
the hamstrings to prevent a pivot shift in ACL-
defi
ficient individuals (7). In the first stage of pivot
shift training, the athlete is asked to relax and
experience a pivot shift as induced by the rehabili-
tation professional. The
Th athlete is then instructed
to prevent the occurrence of the pivot shift using
their musculature. Verbal and tactile cueing of the
hamstrings is added as needed. As patients gain
profi
ficiency, training progresses to include vari-
 ACL rehabilitation 271

A B
Fig. 2 – Clinician applied perturbations to (A) rocker board and (B) roller board.

able speeds, force levels, and knee positions. Pivot mass and retain quadriceps control may serve as
shift control training is just one component of one of the most important determinants of the
an overall program for ACL-deficient
fi individuals ability to cope with ACL defi ficiency.
and is always combined with other neuromuscu- Perturbation training provides one method to
lar training techniques. As such, ACL-deficient
fi address neuromuscular control of ACL-defi ficient
athletes may complete only 10 minutes of pivot individuals. Perturbations may involve the rehabil-
shift training per a 60–90 minute rehabilitation itation clinician physically displacing the patient’s
session. center or mass or altering the position of the sup-
Although the hamstrings may serve an agonistic port surface (Fig. 2). However, perturbations may
role with the ACL, recent research has highlighted also be applied by simply having the athlete stand
the importance of the quadriceps muscle group on an unstable surface. In theory, perturbation
for ACL-defi ficient individuals. Quadriceps struc- training results in greater anticipatory muscular
ture and function are profoundly altered after ACL control and/or an enhanced response to firing of
injury. A differential
ff response in those individuals proprioceptive receptors around the knee.
able to cope with ACL defi ficiency and those who The addition of 5 minutes of clinician-generated
cannot can be measured soon after ACL injury. perturbations to the rehabilitation sessions of ACL-
The quadriceps in general and the vastus lateralis defi
ficient individuals has demonstrated superior
in particular demonstrate greater atrophy in non- results when compared to standard rehabilitation
copers than in individuals who can successfully alone. Ninety two percent (92%) of ACL-deficient fi
cope with their ACL defi ficiency (8). Furthermore, individuals who underwent perturbation training
non-copers demonstrate a loss of control of their were able to successfully return to their sport with-
quadriceps when assessed via a target matching out a subsequent episode of giving way compared
protocol (9,10). ACL-deficientfi individuals dem- to 50% of potential copers who were treated with
onstrate less specifificity of their quadriceps when standard rehabilitation alone, 10 visits of strength-
compared to uninjured, control subjects (10). The Th ening and sport specifi fic rehabilitation (11).
quadriceps of ACL-deficient
fi individuals remained Finally, functional knee braces are regularly pre-
active even when the subject was performing knee scribed for ACL-deficient
fi individuals who wish to
flexion trials indicating a knee stiff
fl ffening strategy. return to sport. Although the exact mechanism for
Similar to the analysis of muscle morphology, the any beneficial
fi eff
ffect of functional bracing remains
vastus lateralis appeared to suff ffer a preferential unknown, ACL-defi ficient athletes commonly report
loss of control when compared to the other mus- improved confidence
fi with use of a functional knee
cles of the quadriceps group (9,10). In summary, brace. The use of functional braces will be more
quadriceps function is signifi ficantly altered after thoroughly evaluated in a later section of this
ACL injury and the ability to preserve quadriceps chapter.
272 The Traumatic Knee

Table I – Overview of rehabilitation following ACL reconstruction.

Phase Goals
(To be achieved by the end of this phase)
Phase I • Knee effusion well controlled
Immediately post–surgery • Adequate quadriceps control ability to do a hip flexion straight leg raise without extensor lag
(0–2 weeks) • Normal gait pattern without assistive devices
• Knee ROM of at least 0–90°
Phase II • Full knee ROM (0–135°)
Early rehabilitation activities • Able to ascend and descend stairs normally
(2–6 weeks) • Tolerating regular exercise program without increase in pain or swelling
Phase III • Regularly completing isotonic strengthening program in supervised physical therapy
Advanced rehabilitation activities • Starting to transition strengthening activities to local gym or athletic team’s weight room
(6–10 weeks) • Approximately 70–80% strength versus contralateral (uninvolved) lower extremity
• Appropriate control of knee during neuromuscular retraining exercises in the physical therapy clinic
Phase IV • Regularly completing isotonic strengthening program
Advanced functional activities • Running at least 85% of preinjury speed
(10 weeks–6 months) • Cutting and jumping without hesitation or obvious limitation
Phase V • No complaints of pain or knee instability
Return to sport (6–12 months) • Full ROM
• No new effusion
• Lower extremity strength/function at least 85% versus uninvolved LE
• Adequate performance in physical therapy or with sport specific drills that simulate the intensity, frequency,
and duration of the sport to which the athlete will return
• Athlete demonstrates a psychological readiness to return to sport, either verbally or with SANE score > 80/100

Rehabilitation following ACL reconstruction Controlling inflammation

Although there are slight variations based upon age,
patient history, activity level, graft source (bone-pa-
tellar tendon-bone (BTB), semitendinosus–gracilis
(STG), or allograft) and the presence of associated
injuries, rehabilitation programs following ACLR are
more similar than dissimilar. Owing to some of sub-
tleties mentioned above, no rehabilitation guideline
applies to every patient and the sample included
with this chapter should be used as a guide only.
Although we strongly advocate criteria-based reha-
bilitation progression, we acknowledge patients
achieve important milestones, particularly early in
the rehabilitative process, at roughly the same time
points. Therefore, for simplicity, we have divided
rehabilitation following ACLR into five fi phases:
Phase I – immediately post-surgery (0–2 weeks);
Phase II – early rehabilitation activities (2–6 weeks);
Phase III – advanced rehabilitation activities (6–10
weeks); Phase IV – advanced functional activities
(10 weeks–6 months); and Phase V – return to sport
(6–12 months) (Table 1, Appendix).
Phase I – Immediately post-surgery
(postoperative weeks 0–2)
The goals of the early rehabilitation period are to
control pain and postoperative swelling, and begin
to restore ROM.
Although the advent of arthroscopically assisted
reconstruction techniques and pain control meth-
ods such as perioperative nerve blocks may sug-
gest otherwise, patients should be reminded they
underwent a major surgical procedure. Although
cryotherapy, elevation, and compression all play
a role, limitation of activities is the most impor-
tant factor for control of postoperative inflamma-
fl
tion. As a result, patients need to slowly increase
their level of activity limiting their time in grav-
ity dependent positions for at least the fifirst 2–5
days following reconstruction. Commercial devices
now allow for the combination of cryotherapy and
compression (Fig. 3), but if a commercial device
is not available, patients should regularly apply
an ice pack with an elastic bandage while they lie
with their leg elevated. Elastic bandages or tubig-
rip sleeves are used around the knee in an effort
ff
to maintain compression to prevent edema forma-
tion as patients start to become active again. Th
These
methods serve as adjuncts to the analgesics and
non-steroidal anti-infl
flammatory medications that
are routinely prescribed by the medical team in the
early postoperative period.
Restoring knee joint ROM
Although the ROM goals for Phase I seem rather
modest (0–90°), restoration of knee extension
ROM of motion is of vital importance. Inabil-

Fig. 3 – Commercially available cryotherapy device, which allows simulta-
neous application of cold and compression for management of edema and
pain.
ity to regain full knee hyperextension has long-
term consequences on patellofemoral pain and
ability to regain full quadriceps strength (12).
The most reproducible method to regain full
knee extension ROM is to delay ACLR until
the patient has regained full motion preopera-
tively (13), but more recent reports question
whether ACLR when performed with hamstring
autograft needs to be delayed to achieve accept-
able results (14). We wish to highlight the poten-
tially important difference in autologous graft
sources (ipsilateral BTB or autologous STG)
when interpreting the contradicting results of
these two papers.
In many respects, the onus of restoring full ROM
after surgery has shifted to the therapist and
patient. Previously, patients were immobilized in a
postoperative knee brace locked in 0° of extension.
As postoperative care has evolved, many surgeons
have discontinued use of postoperative braces as
an unjustifi
fied cost Therefore, it has become para-
mount to ensure patients understand both the
importance and the methods for regaining full
A B
Fig. 4 – Exercises such as (A) prone hangs and (B) extension bridges promote full knee extension through application of a low load, prolonged stretch.
ACL rehabilitation 273
knee extension. Patients are commonly taught
extension bridges (Fig. 4) and prone hangs as
methods to regain knee extension ROM. Because
they can be performed in sitting or supine posi-
tions, extension bridges are easier to perform
in the early postoperative period, while patients
often report they are better able to relax in the
prone hang position. Regardless of the method,
the patient is encouraged to relax and maintain
the position for approximately 5 minutes. Addi-
tional periods of 5 minutes duration can be added
until full knee extension has been achieved or until
no further progress is made during that particu-
lar exercise session. Because regaining full knee
extension can be a painful undertaking in the early
postoperative period, patients are encouraged to
perform these activities more often throughout
the day as opposed to adding extra weight to these
stretches. If the patient is not progressing, the
rehabilitation specialist should perform hamstring
stretching and reassess knee extension ROM. If
hamstring stretching signifi ficantly improves knee
extension ROM, then hamstring muscle activity
is limiting knee extension ROM and hamstring
stretching should be added to the patient’s home
exercise program. Once patients have repeatedly
demonstrated they can achieve symmetric knee
extension, the frequency of these exercises can be
reduced.
The goal for the initial postoperative period is knee
extension ROM to at least 0º. However, the long-
term goal is for symmetric knee extension ROM.
Eradication of a flexion contracture is a very dif-
ficult rehabilitation problem. Therefore, the best
treatment is prevention of the problem by regain-
ing full knee extension ROM as soon as possible
after surgery. If a knee flexion
fl contracture does
occur, manual stretches by the therapist are added
to the knee extension stretches that are part of the
patient’s home exercise program. Low load, pro-
longed stretching with commercial devices can also
274 The Traumatic Knee

be added to the patient’s physical therapy sessions
and home programs (Fig. 5).
In contrast to knee extension, the primary dif-
ficulty with regard to knee flexion ROM is over
aggressiveness on the part of patients as they try to
restore full range. Generalized knee inflammation
fl
is often the result of overly aggressive home exer-
cises. For this reason, patients are given general
guidelines on the amount of ROM that is expected
(0–90º by 2 weeks; 0–120° by 4 weeks; full range
by 6 weeks). ROM beyond these targets is allowed
only if there is no residual pain, warmth, or edema
following exercise performance. A non-weight-
bearing exercise such as seated flexion (Fig. 6) is
easy for patients to perform and allows patients
to visually gauge their progress. Assistance can
be provided by use of the upper extremities or
contralateral lower extremity if patients are not
achieving their ROM goals. “Heel slides” (Fig. 6)
are often prescribed to improve knee flexion
fl ROM
following other knee procedures, but this exercise
often causes posterior knee pain in patients fol-
lowing ACLR, particularly those in which a STG
graft was chosen.
Retarding muscle atrophy/restoring muscle strength
Atrophy of the quadriceps muscle group is profound
and begins soon after ACL injury (15). Practically
speaking, if atrophy is minimized, strength is bet-
ter maintained. Preserving muscle size and post-
operative function actually begins before surgery
by enrolling athletes in a preoperative strengthen-
ing program (16). All conventional techniques of
standard open and closed chain strengthening can
be utilized preoperatively with progression deter-
mined by patient symptoms and ability to control
their knee.
The early stages of postoperative strengthening
typically consist of isometric quadriceps contrac-
tions in full extension (“quad sets”). Straight leg
raises are added once the athlete is able to com-
plete the exercise without pain or an extensor lag.
An extensor lag describes the inability to maintain
a fully extended knee when lifting the limb against
gravity. An extensor lag is indicative of quadriceps
weakness (Fig. 7) and generally speaking, most
patients have diffifficulty progressing to weight
bearing, closed chain activities with this degree

A B
Fig. 5 – Commercially available devices for treatment of a knee flexion contracture. The emphasis should remain on low loads applied over a longer period of time.

A B
Fig. 6 – Active assisted flexion ROM. (A) Seated flexion rarely causes the posterior knee pain often experienced by postsurgical patients when they perform
the more common heel slides (B).

Fig. 7 – Example of an “extensor lag” indicating weakness of the quadriceps
muscles as the patient tries to perform a hip flexion straight leg raise.
of weakness. Therefore, instead of progressing to
weight bearing exercises that will result in prefer-
ential loading of the uninvolved lower extremity,
interventions such as electrical stimulation or bio-
feedback can be used to try to maximize quadri-
ceps function of the recently operated extremity.
Electrical stimulation/biofeedback
Quadriceps inhibition is common after ACL injury
(15,17) and biofeedback or electrical stimulation
may be useful rehabilitation tools to maximize
muscle performance. Electrical stimulation is rec-
ommended for athletes who have diffi fficulty gener-
ating a volitional contraction of their quadriceps,
while biofeedback is more appropriate for patients
who can produce a fused, albeit weak contraction.
Electrodes for electrical stimulation are generally
placed on the muscle bellies of the vastus media-
lis and vastus lateralis as demonstrated in Fig. 8.
Early studies often demonstrated no additional
benefit
fi from the use of electrical stimulation when
compared to standard rehabilitation approach
post ACLR. In 1995, the results of a prospective
randomized trial were published that compared
high intensity electrical stimulation, low intensity
electrical stimulation, and high intensity volitional
exercises. The author’s hypothesis was that early
studies failed to utilize a suffi
fficiently high intensity
of electrical stimulation to generate a therapeutic
eff
ffect. Indeed, high intensity electrical stimula-
tion improved quadriceps strength (70% strength
when compared to the contralateral limb) greater
than low intensity electrical stimulation (51%) or
volitional exercise alone (57%). In addition to an
improvement in isokinetic quadriceps strength,
patients receiving high intensity electrical stimu-
lation demonstrated knee movement patterns
more similar to the gait pattern of uninjured sub-
jects. High intensity electrical stimulation was
performed with a triangular wave at 2500 Hz.
ACL rehabilitation 275
Fig. 8 – Typical set up for the application of electrical stimulation. Initially
the athlete will be asked to volitionally contract with the stimulation. As
they recover the ability to volitionally contract, then high intensity stimula-
tion is applied without the addition of an active contraction.
Electrical stimulation was broken into 75 PPS of
11 seconds on and 120 seconds off ff. Fifteen (18)
contractions were completed three times per week
(19). Patients are strongly encouraged to tolerate
as much stimulation intensity as possible. Addi-
tional intensity promotes the recruitment of addi-
tional motor units.
More recently, similar electrical parameters have
been applied with the knee in a fully extended
position (20). Similar to the earlier paradigm, in
which electrical stimulation produced knee exten-
sion against a fixed isokinetic dynamometer, high
intensity electrical stimulation again demonstrated
greater quadriceps strength gains when compared
to a standard rehabilitation program. Although
the magnitude of the eff ffect was not as great as the
flexed knee model, this more recent work dem-
onstrated the beneficial
fi eff
ffects of supplemental
electrical stimulation in an extended knee posi-
tion. This finding was important as the flexed knee
position can be uncomfortable for patients’ status
post ACLR particularly for those in whom the graft
source was autologous bone tendon bone.
As patients become more proficient
fi with volitional
activation of their quadriceps, a biofeedback unit
may be used in lieu of electrical stimulation. Bio-
feedback measures the electrical potentials within
the quadriceps muscle group and provides the
patient with visual and auditory feedback. Owing
to fluctuations in conductivity and alterations as a
result of length tension changes, electrical activity
within the muscle is only partially correlated with
force output. As a result, biofeedback can’t be used
as a measure of strength but is recommended to
ensure a consistently high patient eff ffort during
performance of early postoperative rehabilitation
exercises such as quadriceps sets and straight leg
raises.
276 The Traumatic Knee

Ambulation One of the most common gait deviations following

ACLR is termed a “quadriceps avoidance” gait pat-
Following isolated ACLR, patients are taught to
tern. Patients who have diffi
fficulty regaining eccen-
utilize standard axillary crutches immediately
tric control of their quadriceps in the early postop-
bearing weight as tolerated through their involved
erative period may keep their knee fully extended
lower extremity. Most patients do not utilize
throughout the stance phase to avoid using their
postoperative bracing. Therefore,
Th knee motion
quadriceps Targeted exercises such as standing
is generally unencumbered after reconstruction.
terminal knee extension (Fig. 9) can be utilized
However, there is one caveat. With the advent of
to regain eccentric quadriceps control. It is also
ambulatory surgery (no overnight hospital stay)
helpful to practice the gait cycle, encouraging the
and peripheral nerve blocks as a means of pain
athlete to utilize a more normal flexion extension
control, many patients now leave the hospital uti-
cycle. Ambulating in a pool or walking over cones
lizing a knee immobilizer until their quadriceps
on the ground during the land-based portions of
function returns (24–48 hours after discontinu-
the rehabilitation program encourages active con-
ing the peripheral nerve block). Full weight bear-
trol of the knee and helps the patient regain con-
ing may be delayed and a postoperative knee brace
fidence.
may be used if a patient undergoes an osteotomy
or concomitant meniscal repair at the time of their
ACLR. Our modifi fied protocol calls for a postopera-
tive brace with the knee locked in full extension
for ambulation following repair of larger menis-
cal tears. The brace is unlocked at postoperative
week 4 and eventually discontinued during the 6th
postoperative week. In contrast to patients who
have an undergone an isolated ACLR, patients
who have undergone repair of a large meniscal tear
at the time of their ACLR begin full weight bear-
ing 6 weeks after surgery (Table 2). Irrespective
of the type of surgery, the criteria to discontinue
use of crutches and progress to full weight bearing
include a normal gait pattern, protective quadri-
ceps strength and no complaints of pain. Depend-
ing upon their individual situation, patients Fig. 9 – Terminal knee extension versus elastic resistance. This is a helpful
with isolated reconstruction of the ACL may use exercise to encourage knee extension ROM at initial ground contact during
crutches up to 2 weeks postoperatively. the gait cycle.

Table II – Changes to standard postsurgical rehabilitation protocol.

Procedure Weight bearing Brace ROM
ACLR + meniscectomy No changes No changes No changes
ACLR + meniscal repair No changes No changes No changes
ACLR + large meniscal repair WBAT × 6 weeks Locked in full extension for ambulation × 4 ROM 0–90° × 4 weeks.
weeks.
ROM 0–120° from 4 to 6 weeks.
Unlocked for ambulation from 4 to 6 weeks.

Brace discontinued at 6 weeks postoperatively.

ACLR + osteotomy (tibial or
femoral)
ACL revision
Multiple ligament injury
NWB × 6 weeks Brace set at 0–90° × 4 weeks. ROM 0–90° × 4 weeks.
WBAT × 6–8 weeks
Brace set at 0–120° × 4–6 weeks. ROM 0–120° from 4 to 6 weeks.
No changes No changes No changes
WBAT × 4 weeks Locked in full extension for ambulation × 4 ROM 0–90° × 4 weeks
weeks.
ROM 0–120° from 4 to 6 weeks.
Unlocked for ambulation from 4 to 6 weeks.

Brace discontinued at 6 weeks post–operatively.

Note: NWB, non-weight bearing; WBAT, weight-bearing as tolerated; ROM, range of motion.

Criteria to progress to Phase II
• Knee eff
ffusion well controlled
• Adequate quadriceps control demonstrated by
the ability to do a hip flexion straight leg raise
without extensor lag
• Normal gait pattern without use of assistive devices
• Knee ROM at least 0–90°.
Phase II – early rehabilitation exercises
(postoperative weeks 2–6)
The focus of Phase II rehabilitation is to restore
full knee ROM and advance early strengthening
exercises. In this phase the rehabilitation special-
ist will begin to challenge the patient’s neuromus-
cular system by including more dynamic strength-
ening exercises. Progression of the strengthening
program from fixed foot, single plane activities to
more dynamic movement patterns sets the stage
for higher level neuromuscular control exercises
that will follow in the later stages of rehabilitation
Restoring full knee range of motion
Because of the potential of arthrofibrosis,
fi if there
is any remaining flexion contracture, restoring
full knee extension ROM is the paramount goal of
Phase II. Prone hangs (Fig. 4) can be added to the
extension bridges that were previously described.
Lightweights can be added as needed to the ankle
or knee, respectively, with these exercises. Reha-
bilitation clinicians are cautioned to remember
the biological principle of creep whereby low load
prolonged stretches yield a permanent increase in
length. Higher loads with these exercises may be
counterproductive if they cause pain and subse-
quent muscle guarding rendering the stretch inef-
fective. Finally, manual overpressure into extension
or commercial devices (Fig. 5) may be utilized for
A B
Fig. 10 – More advanced techniques to address knee flexion ROM that is not improving as expected, (A) lunge stretch, (B) kneeling stretch.
ACL rehabilitation 277
more recalcitrant cases. Again the principles of low
load and prolonged duration are emphasized. More
frequent rather than more aggressive stretching
is suggested is often more effective.
ff Patients are
asked to use their commercial device for 2–3 bouts
of five minutes duration 3 or 4 times per day.
Once full extension ROM has been achieved, atten-
tion can be turned to knee flexion.
fl To increase knee
flexion ROM, active assisted ROM exercises on a
stationary bicycle is often helpful during Phase II.
The patient completes a “half moon” utilizing the
contralateral lower extremity to generate the impe-
tus for the stretch. End range is maintained for 5–10
seconds and then the patient “pedals” in the oppo-
site direction until end range is reached again. ThThis
technique continues until the patient is able to make
full, pain free revolutions on the bicycle. Clinicians
are encouraged to remember that due to ability to
compensate at the ankle and hip, patients are often
able to complete full revolutions going backwards
on the bicycle prior to forward. In all patients, but
particularly for those whom have undergone recon-
struction with patellar tendon autograft, adequate
patellar mobility must be ensured. Manual mobili-
zations of the patella are added as needed.
Restoration of full knee flexion ROM is usually
straightforward for patients following isolated
ACLR. Manual stretches into flexion, lunging for-
ward onto a stair step, and having a patient try to sit
on their heels from a kneeling position are all exam-
ples of more aggressive techniques that can be added
as needed if knee flexion ROM is not improving as
expected (Fig. 10). The goal is to achieve knee flexion
ROM of at least 0–135° by the end of Phase II.
Open vs. closed chain strengthening exercises
The early stages of strengthening following ACLR
typically consist of isometric quadriceps contrac-
tions in full extension (“quad sets”) and straight leg
raises completed while lying on a treatment table.
These exercises are called “open chain” exercises
278 The Traumatic Knee
and are in contrast to closed chain exercises that
occur when the athlete is moving his body over a
fixed foot position. In the most general of terms,
fi
open chain exercises are generally thought to bet-
ter isolate activity of a single muscle group. By
contrast, closed chain exercises, with their empha-
sis on multijoint motions, are theorized to more
directly carry over to functional activities.
Squatting exercises through a limited arc of motion
(“mini-squats”) or leg press maneuvers are examples
of early closed chain exercises that can be added to
the postoperative rehabilitation regimen during
Phase II. The rehabilitation specialist must ensure
that the patient is not preferentially loading their
Fig. 11 – Standard minisquat exercise with the patient demonstrating
preferential loading of his uninvolved lower extremity.
uninvolved lower extremity (Fig. 11). If cueing does
not improve the athlete’s performance, another
closed chain exercise may be more appropriate. In
this situation, aquatic exercise offers
ff a mechanism
to reduce loading of the knee joint so that forces
may be balanced across both lower extremities.
Stresses to the knee can be finely controlled with
subtle increases in ROM, resistance levels, or levels
of submersion in the water (Fig. 12).
As the athlete’s strength and functional movement
patterns improve, progressive challenges are added
to the rehabilitation program. Additional resistance
in the form of body weight can be added by having
patients complete exercises that are more unilat-
eral in nature such as step ups/downs, lunges, and
single leg squats. Th
These exercises serve as important
vehicles to improve lower extremity strength, knee
control, and patient confidence.
fi The rehabilitation
specialist must closely monitor the patient’s form
with these exercises to ensure that proper form is
utilized. Valgus knee positioning and “dropping” the
hip complex are common compensations to avoid
loading the quadriceps muscle group with unilat-
eral exercises (Fig. 13). Unilateral exercises are an
important progression towards the goal of normal
management of stairs by the end of Phase II.
Attention should also be given to muscles such as
the hip abductors and adductors. Frontal plane
muscles are important for maintaining proper
knee mechanics. Hip abductor/adductor and other
“lateral” muscles can be progressively challenged
with activities such as side stepping against resis-
tance, lateral lunges, or lateral squats (Fig. 14).
One of the controversies regarding ACL rehabilita-
tion is the appropriate use of open kinetic chain
knee extension (21). As this exercise is confined
fi to
simple knee joint extension it elicits significant
fi elec-
tromyographic activity of the quadriceps (22,23).
Quadriceps function has been well correlated to gait
(19), ability to climb stairs (16), and eventual return
to play. However, isolated contractions of the quadri-
ceps particularly near the end ranges of knee exten-
Fig. 12 – Levels of submersion
and percent body weight for
aquatic exercises.

Fig. 13 – Valgus knee positioning and “dropping” the hip complex are com-
mon compensations to avoid loading the quadriceps muscle group during
performance of unilateral lower extremity exercises such as step-downs.
Fig. 14 – Examples of coronal plane activities that aim to target muscle groups
such as the hip abductors and adductors, (A) lateral squatting, (B) lateral step-
ping against elastic resistance.
sion place an anterior shear stress on the ACL (24).
Theoretically, if applied repetitively, this stress could
cause progressive lengthening of the ACL graft.
However, some authors have noted the amount of
strain on the ACL during open chain knee extension
is no greater than typically experienced with a squat
or Lachman’s test (25). Furthermore, recent reports
have indicated open chain knee extension could be
applied without “stretching out” the postsurgical
graft (26,27) or producing anterior tibial translation
in patients with ACL defi ficiency (28). Furthermore,
the addition of open chain knee extension exercises
resulted in improved quadriceps torque (26,28),
jump performance, and patient self-report score
(28) and increased the likelihood of return to sport
at preinjury levels (26). Although open chain exten-
sion exercises can be utilized safely in the early stages
following BTB reconstruction (29), we would like to
caution rehabilitation clinicians to closely monitor
any patient complaints of anterior knee pain. Com-
ACL rehabilitation 279
B
plaints of infrapatellar pain are frequent in the early
stages following BTB reconstruction and have been
cited as a complication of programs that emphasized
open kinetic chain exercises (30). Finally, clinicians
should understand, in contrast to closed kinetic chain
exercises that provide some protection to the ACL as
a result of joint compression, ACL strain increases in
proportion to load for open kinetic chain knee exten-
sion (21). Therefore, open chain knee extension can
be utilized safely to increase quadriceps function, but
loads should be manageable and the patient should
be regularly questioned regarding the presence of
anterior knee pain.
Supervised rehabilitation vs. home exercise program
Because of the long-term nature of ACL rehabilita-
tion and the fact many patients undergo ACLR at
a tertiary medical center far from their home, it is
tempting to consider whether rehabilitation follow-
280 The Traumatic Knee
ing ACLR can be completed independently by the
patient. Prospective randomized controlled trials
(18,31–33) as well as retrospective review (34) have
examined this question. Dependent variables such as
ROM, isokinetic torque data, self-report scores, and
measures of functional activities such as hop tests
have all been compared. Little difference
ff has been
noted in these variables between patients who regu-
larly attend supervised therapy sessions and those
patients who have only intermittent contact with
rehabilitation professionals following their ACLR.
However, when analyzing the results of these stud-
ies, it is important to remember patients completing
home-based rehabilitation intermittently return to
the tertiary center for instruction while patients who
complete supervised rehabilitation typically select a
local provider. Potentially important variables such
as the education and experience levels of the rehabili-
tation professionals have not been analyzed in these
studies. In addition, adolescents were eliminated
as potential patients in two studies as the authors
felt young patients did not possess the maturity to
assume responsibility for their own rehabilitation
(18,35). Finally, the studies analyzing the potential for
home-based rehabilitation did not stratify the results
based upon the activity level of the patient. High-
level athletes may require more advanced, regular
rehabilitation to safely and eff
ffectively return to their
sport. Nonetheless, the aggregate results of studies
comparing regular, supervised therapy to intermit-
tent exercise instruction indicate many patients can
have a successful outcome after ACLR with regular
completion of a home exercise program updated at
regular intervals by a rehabilitation professional. Elite
athletes, adolescents, and those patients without easy
access to exercise equipment may all serve as exam-
ples of patients who require more regular follow-up.
If the number of rehabilitation visits must be lim-
ited, we suggest “front loading” those visits, that is,
utilizing more visits during the early postoperative
period (i.e., the first 6 weeks). Regular follow-up
rehabilitation sessions are recommended to ensure
crucial rehabilitation goals are being met after sur-
gery. As the athlete achieves important milestones
such as control of knee infl flammation, full knee
ROM, adequate quadriceps strength for normal
daily activities, and appropriate knee stability, regu-
lar visits may be curtailed in lieu of intermittent ses-
sions. Intermittent contact with the rehabilitation
professional is still important and serves to answer
patient questions and advance the patient’s home
and gym exercise programs. We feel that a mini-
mum of 6 visits with a rehabilitation professional is
necessary for successful outcome following ACLR.
Criteria to advance to Phase III
• Full knee ROM
• Able to ascend and descend stairs normally
• Successfully completing regular exercise program
of Phase II activities.
Phase III – advanced rehabilitation exercises
(postoperative weeks 6–10)
Phase III rehabilitation strives to build on the limb
strength gained in Phase II with well-timed, well–
proportioned muscle contractions. In Phase III,
traditional strengthening exercises are combined
with additional challenges to the nervous system
such as pertubations, mental distraction tasks
such as catching a ball, or other activities that pro-
gressively force the center of gravity away from the
base of support.
Restoring neuromuscular control
The restoration of neuromuscular control of the
knee may be the most important but least under-
stood component of ACL rehabilitation. It has been
known for some time the native ACL contains spe-
cialized mechanoreceptors (35). Ruffi ffini endings
and Pacinian corpuscles have been identifi fied (36).
Despite their presence, the relative importance of
intrinsic mechanoreceptors in the greater scope of
dynamic knee control remains unknown. A correla-
tion between joint position sense and the number
of mechanoreceptors found in the ACL remnant at
the time of reconstructive surgery has been dem-
onstrated (37). However, other authors feel that
mechanoreceptors within the joint capsule and
to a greater extent the muscle spindles, serve a
more vital role (38). Theoretically, when the ACL
is ruptured, athletes are no longer able to make
use of the feedback from the intrinsic mechanore-
ceptors housed within the ACL. Instead, informa-
tion obtained from sensory receptors in the cap-
sule, skin, or muscle spindle must be maximized.
Repopulation of mechanoreceptors within the ACL
occurs in a similar manner to revascularization. As
with revascularization, mechanoreceptor repopu-
lation is most active between 2 and 8 weeks post-
operatively (39). The
Th number of mechanoreceptors
in reconstructed knees has been shown to equal
the number in uninjured knees by 8 weeks post
reconstruction (39).
Simply repopulating mechanoreceptors in the
reconstructed ACL may not guarantee limb con-
trol. The goal of this third phase of rehabilitation
is to maximize control of the limb by fine-tuning
the responses to the stimulation of mechanore-
ceptors within the skin, joint capsule, and muscle
spindle as well as the repopulated mechanorecep-
tors within the ACL graft of reconstructed patients.
Although ensuring appropriate movement pat-
terns of the knee is a key criterion for progression
of the Phase II strengthening program, in terms of

post reconstruction rehabilitation, exercises that
target dynamic stability are most appropriately
employed in the third phase of rehabilitation. By
this point, athletes have regained much if not all of
their ROM. Therefore, the confounding variable of
passive stiff
ffness is removed from the equation of
dynamic knee stability. In addition, to progress to
the third phase of rehabilitation, athletes must be
regularly completing a strengthening program. Pro-
gressive strengthening provides the building blocks
on which coordinated muscle function is built.
Exercises that target knee stability take many
forms. Single limb stance activities are simple to
perform and can be easily progressed with use of
an unstable surface or ball toss drill. Ball tosses
produce displacement of the athlete’s body weight
over their center of gravity and the act of catching
the ball forces the athlete to concentrate on some-
thing other than maintaining their balance. As the
athlete demonstrates mastery of static stabiliza-
tion tasks, dynamic stability tasks such as lunging
or stepping onto on an unstable surface are gradu-
ally introduced.
Maintaining dynamic knee stability while focus-
ing on a progressively more complicated task is a
theme often repeated throughout the rehabilita-
tion process. The culmination of the neuromuscu-
lar program results in a successful return to sport.
Successful postoperative rehabilitation allows the
athlete to maintain control of their knee while
completing a basketball lay up, a soccer kick, or
landing from a jump after a volleyball spike.
Randomized controlled trials have consistently
demonstrated the superiority of neuromuscular
retraining when compared to standard strength
training for ACL-reconstructed patients. Improved
functional outcome scores as well as decreased
latency time of refl flexive hamstring contractions
have been demonstrated following 12 weeks of
“proprioceptive enhancement techniques.” The Th
control group completed standard isotonic train-
ing while the experimental group completed sin-
gle limb stance activities on wobble boards, mini
trampolines, and perturbation training (40). Simi-
larly, 34 reconstructed individuals who completed
neuromuscular training activities demonstrated
greater improvements in functional outcome
scores versus a group who completed strength
training alone (41). In this study, neuromuscular
training consisted of plyometrics exercises, single
limb stance on unstable surfaces and standing
reach activities that perturbed the subjects’ bal-
ance. Supervised rehabilitation was carried out on
a two time per week basis for 6 months; the norma-
tive protocol for ACL-reconstructed individuals in
Norway, the country of origin of this study. Inter-
estingly, diff
fferences between the groups were not
apparent at the 3-week testing point, only at the
ACL rehabilitation 281
end of the study. The similarities between groups
at 3 weeks indicate that the process of learning
to make use of sensory information in a recently
reconstructed knee is slow and diffifficult. Finally, 12
weeks of “proprioceptive training” techniques that
include balance, agility, and perturbation train-
ing resulted in signifificantly greater gains in peak
torque of the hamstrings and quadriceps when
compared to a standard isotonic, strength training
for individuals’ post-ACLR (42).
Perturbation training is a significant
fi component of
each of the neuromuscular training programs high-
lighted above. Perturbations typically take one of two
forms, either intrinsically generated perturbations
or clinician-induced perturbations. Intrinsically gen-
erated perturbations would include the “wobble” of
the athlete while standing on one leg single on an
unstable surface. A clinician-induced perturbation
occurs when a clinician disturbs the standing bal-
ance of a patient either by manually pushing the ath-
lete or perturbing the support surface.
In theory, perturbation training results in either
greater anticipatory muscular control or improved
refl
flexive and volitional muscle activation in
response to mechanoreceptor stimulation. Given
the role of the hamstrings as ACL agonists in the
control of anterior tibial shear, an increase in
refl
flexive activation would theoretically unload the
ACL. Therefore, an increase in hamstring activity
from the perturbation component of an ACL injury
prevention program has a protective effect ff on the
ACL. By contrast, ill-timed activation of the quad-
riceps, particularly with the knee near full exten-
sion in an internally rotated, valgus position would
place the ACL at risk for injury as the quadriceps
produces an anterior shear force on the tibia.
Clincian generated perturbations were first rigor-
ously studied by comparing two groups of patients
following ACLR. The experimental group com-
pleted perturbation training in addition to a stan-
dard rehabilitation program. Perturbation train-
ing included clinician-generated perturbations of
a rocker or roller board on which the subject was
standing. Subjects in the experimental group com-
pleted 10 sessions of rehabilitation on a 2–3 time
per week basis. The control group was treated at
the same frequency, but completed only a standard
stretching and strengthening program without the
addition of perturbation training. The Th perturba-
tion group demonstrated improved subjective and
objective outcomes. Patient self-report scores for
activities of daily living, return to sport, global
knee rating, as well as objective measures such as
the time for single leg crossover hop testing were all
superior for the experimental group. Finally, with
“success” defifined as the absence of “giving way”
episodes, subjects who completed the perturba-
tion training program were 5 times more likely to
282 The Traumatic Knee
successfully return to high level sports when com-
pared to the standard rehabilitation group (11).
The exact mechanism of perturbation training is
unknown. There appear to be two primary changes
within the neuromuscular control system that
could possibly explain the beneficial
fi eff
ffects of per-
turbation training. The
Th first is modulation of spinal
and supraspinal refl flexes in response to repeated
perturbations. Perturbation training may also
result in a change in anticipatory motor control
as subjects devise a motor plan to guard against
perturbations. In an attempt to answer this cen-
tral question, researchers developed a special plat-
form that was programmed to give way when the
subject’s heel initially made contact during the
gait cycle. Uninjured subjects as well as a group of
ACL-defi ficient individuals identifi fied as potential
copers by the University of Delaware algorithm
completed perturbation training according to
the protocol described above (43). ACL-deficient fi
subjects who had undergone perturbation train-
ing more closely resembled uninjured subjects in
terms of EMG and kinematic variables. Trained
subjects demonstrated more coordinated ham-
string and quadriceps muscle activity at termi-
nal swing and just before initial contact with the
support surface. Therefore, perturbation training
resulted in normalization of neuromuscular con-
trol in anticipation of the perturbation rather than
in response to the perturbation (43). Using a simi-
lar research paradigm, athletic women served as
subjects in a follow-up study. Consistent with an
often-theorized mechanism for non-contact ACL
injuries in athletic women, these female athletes
demonstrated refl flexive activation of their quadri-
ceps in response to sudden giving way of the sup-
port surface. Peak hamstring activity occurred only
after initial contact, that is, too late to prevent the
perturbation or the potentially injurious quadri-
ceps activation that followed. After completing the
perturbation-training program, uninjured athletic
women instead demonstrated peak hamstring
activity prior to heel strike. Th Therefore, as in the
earlier study with ACL-deficient
fi individuals, per-
turbation training resulted in feed forward control
as athletes anticipated the perturbation that was
to occur during gait and preemptively altered their
neuromuscular program.
Postoperative and functional knee bracing
Because of the importance of regaining full exten-
sion, there is apparent justification
fi for use of a
postoperative brace locked in full extension early in
the postoperative period. Under this paradigm, the
brace may be removed or unlocked for performance
of therapeutic exercises, dressing and bathing, but
is worn in locked fashion for all other activities of
daily living. Despite the rationale, most studies
find no signifificant diff
fference in knee extension
ROM with use of a postoperative brace (44,45). In
fact, patients were better able to regain full exten-
sion with use of a simple neoprene knee sleeve
when compared to a postoperative brace (46). In
addition, the use of a postoperative brace has been
associated with decrements of strength and func-
tion when comparing patients under braced and
unbraced conditions (46). In summary, there is lit-
tle evidence to support the use of a postoperative
brace following isolated reconstruction of the ACL.
In contrast to “post operative” bracing that is used
early in the postoperative process, “functional”
knee braces are typically utilized as an athlete read-
ies himself for return to sport. In theory, functional
knee bracing stimulates cutaneous mechanorecep-
tors perhaps partially offffsetting the loss of proprio-
ceptive information from a recently reconstructed
ACL. There have been few studies analyzing the use
of functional braces after ACLR. In a multicenter,
prospective, randomized trial, no differences
ff were
found in isokinetic strength, single leg hop values,
KT 1000 values, and patient self-report measures
in patients who used a functional brace for the first
fi
year after surgery (47). Patients reported subjec-
tive improvements in confi fidence while wearing
the functional knee brace but also reported prob-
lems with brace migration and negative impact on
sport performance. Twenty one percent (21%) of
subjects admitted to discontinuing use of the brace
before the end of the 1-year study period. Aver-
age length of brace use for this subgroup was 8
months. Given the expense of functional bracing,
the lack of proven effi
fficacy, and the feeling that an
elastic bandage/brace may actually provide better
proprioceptive feedback (48), the use of functional
bracing should perhaps be reserved for return to
sport following revision surgery or in athletes who
have suff
ffered a multiple ligament injury.
Criteria to advance to Phase IV
• Regularly completing isotonic strengthening pro-
gram in supervised physical therapy
• Starting to transition strengthening activities to
local gym or athletic team’s weight room
• Approximately 70–80% strength versus contral-
ateral (uninvolved) lower extremity
• Demonstrates appropriate control of knee with
neuromuscular retraining exercises in the physi-
cal therapy clinic.
Phase IV – advanced functional activities
(10 weeks–6 months)
The primary goal of the fourth phase of rehabilita-
tion is to prepare the athlete for return to sport.
Running, cutting, and jumping are near universal

requirements of the sports in which athletes most
often tear their ACL’s. Therefore, these tasks are of
primary importance during this phase. However,
the rehabilitation professional should also be cog-
nizant of other tasks that are important parts of
the sport to which the athlete hopes to return. It
may seem obvious, but the athlete who intends to
return to soccer, should practice kicking a ball dur-
ing rehabilitation sessions or practice back hand-
springs in the rehabilitation clinic if the athlete
hopes to return to women’s gymnastics.
With simple changes in the rehabilitation pro-
gram, such as the substitution of the elliptical
stair climber for a stationary bicycle, the progres-
sion to running can safely begin before 10 weeks
postoperatively “Running” in non-weight- bear-
ing fashion in the pool is another activity that can
safely be completed prior to 10 weeks and that may
help ease the transition to running later. Approxi-
mately 10 weeks postoperatively, ladder drills or
other simulated running tasks that encourage the
athlete to “stay up on their toes” are helpful tech-
niques to begin motions similar to running yet
help to absorb ground reaction forces at the ankle
joint. After the athlete demonstrates satisfactory
performance with these introductory tasks, typi-
cally 12 weeks postoperatively, interval jogging
can begin. The
Th rehabilitation clinician must ensure
the athlete can run without limping. Most often, a
limp in the stance phase of gait indicates either the
athlete is having pain with load acceptance and/or
the athlete doesn’t possess the requisite quadri-
ceps strength necessary to begin interval jogging.
Selecting a soft, flat running surface such as grass,
a running track, or a treadmill may help to amelio-
rate small pains. Given the limits of the athlete’s
cardiovascular fitness and local muscle endurance
it is most appropriate to begin with interval versus
sustained jogging. Bouts of 30–60 second jogging
are interspersed with similarly timed rest periods.
As the athlete progresses, intervals can be length-
ened and rest periods gradually removed. Once the
athlete can jog at approximately 70–80% of their
preinjury speed, cutting drills can begin. Cutting
drills should initially begin with preprogrammed
cuts. That is, the athlete is told when and where
to make their cut. Increasing the speed, number,
and angle of the cuts are initial progressions until
eventually, athletes start to cut at random times
and directions according to commands given by
the rehabilitation clinician. Jumping drills can
begin once the athlete can successfully run at
approximately 85% of their preinjury speed. As
with the transition to jogging, if the rehabilitation
clinician is mindful of avoiding ground reaction
forces, activities that simulate jumping can begin
prior to the 85% threshold. Tasks such as jump-
ing while partially submerged in the pool or jump-
ACL rehabilitation 283
ing on a “shuttle” (athlete lies in supine, “jumps”
against elastic resistance that can be adjusted to
less than the athlete’s body weight) are techniques
that can be employed to minimize forces across
the knee. Once land-based jumping begins, the
rehabilitation clinician can continue to minimize
ground reaction forces by jumping up to a box and/
or completing all plyometrics activities by landing
on two legs. As the athlete is better able to absorb
the ground reaction forces, level surface jumping
and finally jumping down from an elevation can be
added. Landing on one leg, completing multiple,
sequential jumps, and/or jumping while changing
direction are more advanced progressions of the
jumping program and should be added according
to the needs of the athlete.
Criteria for progression to Phase V
• Regularly completing isotonic strengthening pro-
gram
• Running at least 85% of preinjury speed
• Cutting and jumping without hesitation or obvi-
ous limitation.
Phase V – return to sport (6–12 months)
Determining the readiness of an athlete to return to
sport can be a diffi
fficult prognostication for the sports
medicine team. Both subjective and objective infor-
mation must be considered. First and foremost, the
athlete should be pain free during performance of
tasks at least as stressful as what he will encounter
when he returns to play. ThThe athlete should not dem-
onstrate any limp or other guarding of the extremity
during performance of these functional tasks. Any
eff
ffusion after performance of rehabilitation or func-
tional testing should be viewed as a stark indication
that the neuromuscular system is not adequately
countering the high stresses experienced within the
joint. Furthermore, the athlete should feel confi- fi
dent about their return to sport. Use of patient self-
report measures can be very helpful in this regard.
Alternatively, a global knee rating such as the SANE
(Single Assessment Numeric Evaluation) score,
where the athlete is asked to rate the overall func-
tion of their knee on a 100-point scale, can quickly
provide very meaningful information (49).
Objective measures of muscle function such as
isokinetic assessment provide additional informa-
tion to guide the clinician with regard to return to
sport. Historically, authors advocate for no more
than 10% asymmetry in terms of isokinetic vari-
ables between the involved and uninvolved lower
extremity. However, isokinetic data should only be
used as part of the criteria to judge readiness to
return. Owing to test position, it is not uncommon
for athletes to perform better during functional
284 The Traumatic Knee
testing than during isolated assessments of muscle
performance particularly if a BTB served as their
graft source. Furthermore, a significant
fi portion
of the quadriceps defi ficit observed during isolated
testing may in fact be concomitant activity of the
antagonistic hamstring muscles (50).
The athlete’s performance during simulated sport
tasks in therapy is perhaps the most important fac-
tor for judging readiness for return to sport. How-
ever, relying on observation alone makes it difficult
ffi
to truly quantify small decrements in performance.
As a result, single leg hop tests may be utilized as
an objective measure of knee joint function. These
Th
tests have proven reliable and valid for use with
patients following ACLR (51) and have been thor-
oughly described elsewhere (52). It may be most
useful to employ a battery of tests including such
single leg vertical jump, single leg hop for distance,
and single leg timed hop to globally assess the ath-
lete’s postoperative weakness, landing mechanics,
and knee stability. Height, distance, and time are
then compared to the respective variables for the
uninvolved lower extremity.
Although we measure ligamentous knee laxity with
KT-1000 at regular intervals following surgery, we
do not typically utilize this information in gaug-
ing readiness to return to sport. We feel passive
measures of laxity pale in comparison to the more
important markers of neuromuscular function and
patient self-report outcome scores.
Criteria to return to sport
• No complaints of pain or knee instability
• Full ROM
• No new effusion
ff
• Lower extremity strength/function at least 85%
versus uninvolved LE
• Adequate performance in physical therapy or with
sport specifi
fic drills that simulate the intensity,
frequency, and duration of the sport to which the
athlete hopes to return
• Athlete demonstrates a psychological readiness
to return to sport, either verbally or with SANE
score > 80/100.
Avoiding postoperative complications
In our experience, residual strength loss, arthrofibro-
fi
sis, anterior knee pain (BTB), and hamstring strains
(STG) are the most common rehabilitation complica-
tions after ACLR. We will briefl
fly review each of these
complications hopeful that with a better understand-
ing of the origin of the complication, problems dur-
ing the rehabilitation process can be avoided.
Loss of knee extension ROM, anterior knee
pain, and inability to regain quadriceps strength
are interrelated. The best way to avoid residual
strength loss after reconstruction is to ensure
that the patient regains full knee extension ROM.
Patients unable to fully extend their knees have
diffi
fficulty returning their quadriceps strength to
preinjury levels and as such often experience per-
sistent anterior knee pain.
It has been well documented that arthrofi fibrosis
can largely be avoided by delaying reconstruction
until full knee ROM has been obtained preopera-
tively (13). However, there are many valid reasons
why reconstruction can’t be delayed. If fl flexion
contractures arise, they must be addressed during
the early postoperative period. Low-level activity
of the hamstrings, that is, “guarding,” is an often-
overlooked cause of a pseudo-flexion
fl contracture.
In this instance, hamstring stretching, particularly
contract relax/PNF stretching, should be utilized.
If accessory motions of the knee joint are limited,
light joint mobilizations are a manual technique
that can be used in a comprehensive scheme to
improve ROM. In addition, more aggressive tech-
niques such as manual overpressure into extension
and use of commercial extension assist devices
should all be employed as necessary. Th These devices
provide a prolonged, low-level stretch that is often
very effffective for addressing recalcitrant flexion
contractures.
Clinicians must, to the extent possible, prevent
undue muscle atrophy in the pre and immediate
postsurgical periods. Electrical stimulation should
be used as needed to assist with quadriceps muscle
activation (19,20). A recent randomized controlled
trial has demonstrated the superiority of eccentric
exercises in terms of maintaining muscle volume
and restoring quadriceps strength in the early
postoperative period following ACLR (53). To this
point, however, the recumbent stepper ergometer
utilized as the mode of eccentric exercise is not
commercially available. It is unknown whether
concentrating rehabilitation efforts
ff on the eccen-
tric components of more traditional rehabilitation
methods can produce a similar eff ffect. Irrespective
of the method, in order to maximize quadriceps
strength, it is imperative patients continue with
strengthening exercises after discharge from for-
mal physical therapy. TheTh rehabilitation profes-
sional should recommend regular performance of
a strengthening program for at least 1 year after
reconstruction.
Pain around the infrapatellar donor site is one of
the primary complications of ACLR with a BTB
graft. Prevention of anterior knee pain begins
with ensuring adequate patellar mobility. For
reconstructions with autologous BTB grafts,
manual mobilizations of the patellofemoral joint
should begin early in the postoperative period
(Phase II – 2–6 weeks postoperative). Because

patellar mobility and quadriceps flexibility are
intrinsically linked, it is vitally important to
restore quadriceps flexibility as well. Passive
stretching in prone or Th Thomas test positions
allows the rehabilitation clinician to increase
the amount of hip extension as needed to cre-
ate a stretch on the rectus femoris. Manipulat-
ing quadriceps length at the hip is important, for
instances, such as postoperative ACL rehabilita-
tion where patients lack knee fl flexion ROM. Ade-
quate core stability and Gluteal muscle function
is also very important in the prevention of ante-
rior knee pain. Weakness in these areas can lead
to overuse of the quadriceps as a hip and pelvic
stabilizer. Finally, the rehabilitation professional
should judiciously increase the frequency and
intensity of quadriceps loading activities such as
squats, lunges, and step-downs. If anterior knee
pain does occur, and inevitably it will at some
point following reconstruction with BTB, the
rehabilitation clinician should reexamine knee
extension ROM, patellar mobility, Gluteal muscle
function, and quadriceps flexibility. Redoubling
eff
fforts to address these defificits as well as tempo-
rarily focusing on techniques such as a leg press
machine for quadriceps strengthening often helps
to alleviate the problem. Loads can be reduced on
the leg press machine to still allow quadriceps
strengthening with less than full body weight.
But the leg press carries the additional advan-
tage of maintaining the angle of the shin more
perpendicular to the foot as opposed to the more
oblique angle often produced during a standard
squat or lunge maneuver. The Th result is a reduc-
tion in load to the anterior knee. In summary,
although anterior knee pain occurs frequently
during rehabilitation of the ACL-reconstructed
patient with BTB graft, it tends to resolve early
in the rehabilitation process and only very rarely
produces residual disability (54).
Just as anterior knee pain is a common complica-
tion of the use of BTB grafts, hamstring strains
are common following STG grafts. After removal
of the semitendinosus tendon, the muscle belly is
left with only a fascial attachment to the under-
lying semimembranosus. As the demand on the
hamstring muscles is progressively increased
during the rehabilitation program, there is a risk
of straining that fascial attachment. In general,
postoperative strains tend to be minor but require
short-term modifi fication of resisted hamstring
activities. The incidence of hamstring strains can
be reduced with due attention to hamstring fl flex-
ibility and gradual progression of hamstring load-
ing. Prone hamstring curls on an isotonic weight
machine should be delayed until 1 month post-
surgery in patients for whom an STG graft has
been chosen.
ACL rehabilitation 285
Rehabilitation after ACL revision
Approximately 5–10% of all ACLRs rerupture. Sim-
ilar to primary ACL injury, in the United States,
rerupture is most often followed by surgical recon-
struction. An allograft is most often chosen as the
graft source for revision surgery as the athlete
most likely received an autograft initially.
If rerupture occurs during the fi
first 12 weeks after
reconstruction, the most common explanations
are technical error during surgery, failure to recog-
nize concomitant pathology, or failure to address
knee malalignment. If, however, failure occurs
after 12 weeks, the rehabilitation clinician should
question whether the athlete achieved all post-
operative goals before being cleared for return
for sport. Although many authors recommend a
slower progression following revision surgery, the
prior experience of the athlete and the use of an
allograft versus autograft often allows for rela-
tively easier progression through the rehabilita-
tion stages. For that reason, the athlete should be
reminded to be cautious and mindful of postop-
erative restrictions. Following revision surgery, it
is particularly important that strength and neu-
romuscular control are restored before return to
competitive sports is allowed. In cases of revision
surgery, jogging is often delayed until 4 months
postoperatively. Return to sport typically isn’t
considered until at least 9 months postopera-
tively (55).
Rehabilitation following multiple ligament
injuries
Controversy exists regarding the management of
knee dislocations/multiple ligament injuries. Th The
controversy primarily centers on the timing and/
or staging of reconstructive procedures. After sur-
gery, the sports medicine team tries to balance the
need for protection of reconstructed ligaments
against the need for mobilization to prevent loss
of ROM. As there are many variables when reha-
bilitating patients following multiple ligament
injuries, it is difficult
ffi to outline a rehabilitation
protocol that applies to all patients. Oftentimes,
surgeons will tailor rehabilitation recommenda-
tions based upon the extent and severity of the
injury and intraoperative results. However, in gen-
eral, patients status post multiple ligament recon-
struction are immobilized in a postoperative brace
for all activities of daily living for a period up to
4 weeks. The brace may be unlocked/removed for
performance of ROM exercises. The surgeon often
recommends specifi fic ROM limits although 0–90°
is typically the most liberal ROM allowed during
286 The Traumatic Knee
the first 4 postoperative weeks. Because ROM and
thereby physiologic function of the knee is limited,
the patient and therapist must work diligently to
minimize atrophy and strength loss during this
early postoperative period. Electrical stimulation
in combination with regular performance of quad-
riceps sets and straight leg raises are the hallmarks
of the early strengthening program. The Th postop-
erative brace is generally unlocked between the
4th and 6th postoperative weeks and the patient
is allowed to start the progression to full weight
bearing. With achievement of these goals, the
rehabilitation options increase and patients gradu-
ally resume a more typical, if somewhat delayed,
rehabilitation program similar to isolated ACLR.
Return to sport is typically delayed until 9–12
months postoperatively and functional bracing is
recommended for patients following multiple liga-
ment reconstruction (56) (Table 2).
Additional caveats when rehabilitating the patient
with multiple ligament injuries include the neces-
sity to maintain passive dorsiflexion
fl ROM in
patients who have suff ffered common peroneal
nerve palsy, the elimination of valgus/varus forces
for MCL and LCL reconstructions, respectively,
the avoidance of resisted hamstring activities in
the acute postoperative period for reconstructions
involving the PCL, and judiciously regaining knee
extension ROM in individuals with posterolateral
corner reconstructions. Close communication with
the surgeon is always important but never more so
than when trying to balance knee mobility and sta-
bility following multiple ligament reconstruction.
References
1. Frank CB, Jackson DW (1997) Current Concepts Review:
the science of reconstruction of the anterior cruciate liga-
ment. J Bone Joint Surg 79A:1556–1576
2. Prodromos CC, Han Y, Rogowski J, et al. (2007) A meta-
analysis of the incidence of anterior cruciate ligament
tears as a function of gender, sport, and a knee injury
reduction regimen. Arthroscopy 23:1320–1325
3. Hurd WJ, Axe MJ, Snyder- Mackler L (2008) A 10 year
prospective trial of a patient management algorithm and
screening examination for highly active individuals with
anterior cruciate ligament injury: Part 1 Outcomes. Am J
Sports Med 36:40–47
4. Eastlack ME, Axe MJ, Snyder- Mackler L (1999) Laxity,
instability, and functional outcome after ACL injury: copers
versus noncopers. Med Sci Sports Exerc 31:210–215
5. Fitzgerald GK, Axe MJ, Snyder-Mackler L (2000) A deci-
sion- making scheme for returning patients to high-
level activity with nonoperative treatment after anterior
cruciate ligament rupture. Knee Surg Sports Traumatol
Arthrosc 8:76–82
6. Marx RG, Jones ED, Angel M, et al. (2003) Beliefs and atti-
tudes of members of the American Academy of Orthope-
dic Surgeons regarding the treatment of anterior cruciate
ligament injury. Arthroscopy 19:762–770
7. Walla DJ, Albright JP, McAuley E, et al. (1985) Hamstring
control and the unstable anterior cruciate ligament-defi- fi
cient knee. Am J Sports Med 13:34–39
8. Williams GN, Snyder-Mackler L, Barrance, PJ, Buchanan
TS (2005) Quadriceps femoris muscle morphology and
functional after ACL injury: a differential
ff response in
copers versus non-copers. J Biomech 38:685–693
9. Williams GN, Barrance PJ, Snyder- Mackler L, Buchanan
TS (2004) Altered quadriceps control in people with ante-
rior cruciate ligament defi ficiency. Med Sci Sport Exerc
36:1089–1097
10. Williams GN, Barrance PJ, Snyder- Mackler L, et al. (2003)
Specificity
fi of muscle action after anterior cruciate liga-
ment injury. J Orthop Res 21:1131–1137
11. Fitzgerald GK, Axe MJ, Snyder-Mackler L (2000) The Th effi
ffi-
cacy of perturbation training in nonoperative anterior
cruciate ligament rehabilitation programs for physically
active individuals. Phys Th
Ther 80:128–140
12. Sachs RA, Daniel DM, Stone ML, Garfein RF (1989) Patel-
lofemoral problems after anterior cruciate ligament recon-
struction. Am J Sports Med 17:760–765
13. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M
(1991) Arthrofifibrosis in acute anterior curcial ligament
reconsruction: the eff
ffect of timing on reconstruction and
rehabilitation. Am J Sports Med 19:332–336
14. Bottoni CR, Liddell TR, Trainor TJ, et al.(2008) Postopera-
tive range of motion following anterior cruciate ligament
reconstruction using autograft hamstrings: a prospective,
randomized clinical trial of early versus delayed recon-
structions. Am J Sports Med 36:656–62.
15. William GN, Buchanan TS, Barrance PJ, et al. (2005) Quad-
riceps weakness, atrophy, and activation failure in pre-
dicted noncopers after anterior cruciate ligament injury.
Am J Sports Med 33:402-407
16. Mizner RL, Petterson SC, Stevens JE, et al. (2005) Pre-
operative quadriceps strength predicts functionnal abil-
ity one year after total Knee arthroplasty J Rheumatol
32:1533–1539
17. Chmielewski TL, Stackhouse S, Axe MJ, Snyder- Mackler
L (2004) A prospective analysis of incidence and severity
of quadriceps inhibition in a consecutive sample of 100
patients with complete acute anterior cruciate ligament
rupture. J Orthop Res 22:925–930
18. Fischer DA, Tewes DP, Boyd JL, et al. (1998) Home based
rehabilitation for anterior cruciate ligament reconstruc-
tion. Clin Orthop Rel Res 347:194–199
19. Snyder- Mackler L, Delitto A, Bailey SL, Stralka SW
(1995) Strength of the quadriceps femoris muscle and
functional recovery after reconstruction of the ante-
rior cruciate ligament. A prospective, randomized clini-
cal trial of electrical stimulation. J Bone Joint Surg
Am.77:1166–1173
20. Fitzgerald GK, Piva SR, Irrgang JJ (2003) Stimulation pro-
tocol for quadriceps strength training following anterior
cruciate ligament reconstruction. J Orthop Sports Phys
Ther 33:492–500
21. Fleming BC, Oksendahl H, Beynnon BD (2005) Open- or
closed-kinetic chain exercises after anterior cruciate liga-
ment reconstruction? Exerc Sport Sci Rev 33:134–140
22. Lutz GE, Palmitier RA, An KN, Chao EY (1993) Compari-
son of tibiofemoral joint forces during open-kinetic-chain
and closed-kinetic-chain exercises. J Bone Joint Surg Am
75:732–739
23. Wilk KE, Escamilla RF, Fleisig GS, et al. (1996) A compari-
son of tibiofemoral joint forces and electromyographic
activity during open and closed kinetic chain exercises.
Am J Sports Med 24:518–527
24. Kvist J, Gillquist J (2001) Sagittal plane knee translation
and electromyographic activity during closed and open
kinetic chain exercises in anterior cruciate ligament-defi-
fi
cient patients and control subjects. Am Journal of Sports
Med 29:72–82
25. Beynnon BD, Johnson RJ, Fleming BC, et al. (1997) The
Th strain
behavior of the anterior cruciate ligament during squatting

and active flexion-extension. A comparison of an open and
close kinetic chain exercise. Am J Sports Med 25:823–829
26. Mikkelsen C, Werner S, Eriksson E (2000) Closed kinetic
chain alone compared to combined open and closed kinetic
chain exercises for quadriceps strengthening after anterior
cruciate ligament reconstruction with respect to return to
sports: a prospective study. Knee Surg Sports Traumatol
Arthrosc 8:337–342
27. Perry MC, Morrissey MC, King JB, et al. (2005) Effects
ff of
closed versus open kinetic chain knee extensor resistance
training on knee laxity and leg function in patients dur-
ing the 8- to 14- week post- operative period after anterior
cruciate ligament reconstruction. Knee Surg Sports Trau-
matol Arthrosc 13:357–369
28. Tagesson S, Oberg B, Good L, Kvist J (2008) A comprehen-
sive rehabilitation program with quadriceps strengthen-
ing in closed versus open kinetic chain exercise in patients
with anterior cruciate ligament defi ficiency: a randomized
clinical trial evaluating dynamic tibial translation and
muscle function. Am J Sports Med 36:298–307
29. Heijne A, Werner S (2007) Early versus late start of open
kinetic chain quadriceps exercises after ACL reconstruc-
tion with patellar tendon or hamstring grafts: a prospec-
tive randomized outcome study. Knee Surg Sports Trau-
matol Arthrosc 15:402–414
30. Bynum EB, Barrack RL, Alexander AH (1995) Open ver-
sus closed chain kinetic exercises after anterior cruciate
ligament reconstruction. A prospective randomized study.
Am J Sports Med 23:401–406
31. Beard DJ, Dodd CA (1998) Home of supervised rehabilita-
tion following anterior cruciate ligament reconstruction:
a randomized controlled trial. J Orthop Sports Phys Th Ther
27:134–143
32. Grant JA, Mohtadi NG, Maitland ME, Zernicke RF (2005)
Comparison of home versus physical therapy –supervised
rehabilitation programs after anterior cruciate ligament
reconstruction: a randomized clinical trial. Am J Sports
Med 33:1288–1297
33. Schenck RC, Jr., Blaschak MJ, Lance ED, et al. (1997) A
prospective outcome study of rehabilitation programs and
anterior cruciate ligament reconstruction.Arthroscopy
13:285–290
34. De Carlo MS, Sell KE (1997) Th The eff
ffects of the number
and frequency of physical therapy treatments on selected
outcomes of treatment in patients with anterior cruci-
ate ligament reconstruction. J Orthop Sports Phys Ther Th
26:332–339
35. Kennedy JC, Alexander IJ, Hayes KC (1982) Nerve supply
of the human knee and its functional importance. Am J
Sports Med 10:329–335
36. Zimny ML, Schutte M, Dabezies E (1986) Mechanorecep-
tors in the human anterior cruciate ligament. Anat Rec
214:204–209
37. Adachi N, Ochi M, Uchio Y, et al. (2002) Mechanoreceptors
in the anterior cruciate ligament contribute to the joint
position sense. Acta Orthop Scand 73:330–334
38. Williams GN, Chmielewski T, Rudolph KS, et al. (2001)
Dynamic knee stability: current theory and implications
for clinicians and scientists. J Orthop Sports Phys TherTh
31:546–566
39. Shimizu T, Takahashi T, Wada Y, et al. (1999) Regenera-
tion process of mechanoreceptors in the reconstructed
anterior cruciate ligament. Anch Orthop Trauma Sung
119:405–409
ACL rehabilitation 287
40. Beard DJ, Dodd CA, Trundle HR, et al. (1994) Proprio-
ception enhancement for anterior cruciate ligament defi- fi
ciency. A prospective randomised trial of two physiother-
apy regimes. J Bone Joint Surg (Br) 76-B:654–659
41.Risberg MA, Holm I, Mykleburst G, Engebretsen L (2007)
Neuromuscular training versus strength training during the
first 6 months after anterior cruciate ligament reconstruc-
tion: a randomized clinical trial. Phys Th
Ther 87:737–750
42.Liu-Ambrose T, Taunton JE, MacIntyre D, et al. (2003) The Th
eff
ffects of proprioceptive or strength training on the neu-
romuscular function of the ACL reconstructed knee: a ran-
domized clinical trial. Scand J Med Sci Sports13:115–123
43. Chmielewski TL, Hurd WJ, Rudolph KS, et al. (2005) Per-
turbation training improves knee kinematics and reduces
muscle co-contraction after complete unilateral anterior
cruciate ligament rupture. Phys Th Ther 85:740–749
44. Brandsson S, Faxen E, Kartus J, et al. (2001) Is a knee brace
advantageous after anterior cruciate ligament surgery? A
prospective, randomised study with two year follow-up.
Scand J Med Sci Sports 11:110–114.
45. Moller E, Forssblad M, Hansson L, et al. (2001) Bracing
versus nonbracing in rehabilitation after anterior cruci-
ate ligament reconstruction: a randomized prospective
study with 2 year follow up. Knee Surg Sports Traumatol
Arthrosc 9:102–108
46. Muellner T, Alacamlioglu Y, Nikolic A, Schabus R (1998)
No benefi fit of bracing on the early outcome after anterior
cruciate ligament reconstruction. Knee Surg Sports Trau-
matol Arthrosc 6:88–92
47. McDevitt ER, Taylor DC, Miller MD, et al. (2004) Func-
tional bracing after anterior cruciate ligament reconstruc-
tion: a prospective, randomized, multicenter study. Am J
Sports Med 32:1887–1892
48. Beynnon BD, Good L, Risberg MA (2002) The Th effffect of
bracing on proprioception of knees with anterior cruciate
ligament injury. J Orthop Sports Phys Th Ther 32:11–15
49.Williams GN, Taylor DC, Gangel TJ, et al. (2000) Comparison
of the single assessment numeric evaluation method and
the Lysholm score. Clin Orthop Rel Res 373:184–192
50. Krishnan C, Williams GN, Delaney F, et al. (2007) Antag-
onist muscle activity during maximal isometric knee
strength testing. J Orthop Sports Phys Ther
Th 37: A72–A73
51. Reid A, Birmingham TB, Stratford PW (2007) Hop test-
ing provides a reliable and valid outcome measure during
rehabilitation after anterior cruciate ligament reconstruc-
tion. Phys Ther
Th 87:337–349
52. Noyes FR, Barber SD, Mangine RE (1991) Abnormal lower
limb symmetry determining by function hop tests after
anterior cruciate ligament rupture. Am J Sports Med
19:513–518
53. Gerber JP, Marcus RL, Dibble LE, et al. (2009) Effects
ff of
early progressive eccentric exercise on muscle size and
functional after anterior cruciate ligament reconstruc-
tion: a 1-year follow-up study of a randomized clinical
trial. Phys Ther
Th 89:1–9
54. Feller JA, Webster KE, Gavin B (2001) Early post-opera-
tive morbidity following anterior cruciate ligament recon-
struction: patellar tendon versus hamstring graft. Knee
Surg Sports Traumatol Arthrosc 9:260-266
55. Allen CR, Griffiffin JR, Harner CD (2003) Revision anterior
cruciate ligament reconstruction. Orthop Clin North Am
34:79–98
56. Harner CD, Waltrip RL, Bennett CH, et al. (2004) Surgi-
cal management of knee dislocations. J Bone Joint Surg
86:262–273

ACL Reconstruction
Post-op Rehab
GENERAL REHABILITATION GUIDELINES AND
PRINCIPLES:
Rehabilitation exercises are essential to full recov-
ery from your knee injury and subsequent surgical
procedure. Following the guidelines and principles
described below will minimize your recovery time
and maximize return to full activity.
IMMEDIATE POSTOPERATIVE GOALS (within 2 weeks)
• Full knee extension ROM (equal to uninjured
knee)
• Active control of quadriceps muscle
• Swelling controlled
• Knee flexion ROM of at least 0–90°
EXPECTED RECOVERY:
• Anticipate approximately 24–36 postoperative
physical therapy appointments (3x/week for fi
first
month, 2x/week for second month, 1x–2x/week
thereafter)
• Walking without crutches by approximately 2
weeks after surgery
• Return to desk type work/school within 1 week
following surgery
• Manage stairs normally by approximately 6 weeks
after surgery
• Begin running approximately 12 weeks after sur-
gery
• Progress back to sports 6–12 months after sur-
gery if you have met the goals below.
WOUND CARE:
• Can shower initially as long as bandages are cov-
ered with waterproof covering
• Remove bandages 2 days after surgery
• May shower 2 days after surgery without covering
wounds. Make sure to dry wounds thoroughly. No
soaking of wound (i.e., bath) for 10–14 days.
Appendix
• Clean around wounds using hydrogen peroxide.
Pat dry
• Cover with fresh band-aids or gauze pads (if
needed)
• Reapply elastic bandage/compression stocking
until swelling is minimal
• Follow up with physician as scheduled at approxi-
mately 10–14 days after surgery.
PAIN/SWELLING CONTROL:
• Rest – Avoid long periods of standing/walking/
strenuous activity
• Ice – 3x/day for 20 minutes each following rehab/
activity/work as needed to control pain
• Compression – Apply ACE bandage to involved
knee (tighter at bottom)
• Elevation – Keep leg (knee) elevated as often as
possible
• Medication – Pain and anti-infl flammatory medi-
cations will be prescribed for a period of 7 days
after surgery. Refi
fills of this medication are NOT
permitted, however, over the counter medica-
tions such as Ibuprofen (Motrin) and Acetamino-
phen (Tylenol) are very effective.
ff
PROGRESSION CRITERIA:
General Principles:
1. Outside of rehabilitation sessions, try to limit
activity as much as possible for first 2–5 days
2. Progress slowly using any increase in pain and
swelling as an indication to slow the rate of prog-
ress in rehabilitation sessions
3. Add only 1–2 new exercises/activities to your
routine each day. Be particularly careful with exer-
cises that stress the front of your knee
4. Ice the involved knee for 20 minutes following
each rehabilitation session and after other strenu-
ous activities
5. If activities or exercises added to your routine
cause pain, swelling or recurrence of other symp-
toms, discontinue exercise and consult physician
and/or physical therapist immediately.
290 The Traumatic Knee

RETURN TO SPORT PROGRESSION 1. No complaints of pain

1. Progress from physical therapy exercises to car-
diovascular conditioning/strength training, and
then sport specificfi activities
2. Progress from straight ahead running to cutting
and changes of direction
3. Progress to jumping/plyometric exercises as
warranted by the sport
4. Progress from controlled to uncontrolled situations
5. Progress from participating in limited practice
(“safe” drills, limited repetitions), to full practice,
and finally to competition.
2. No swelling
3. Full ROM
4. Appropriate knee stability upon clinical exami-
nation
5. Adequate strength and performance on func-
tional performance tests
6. Running/Cutting without a “limp.”
In addition to accomplishing the above goals, you
should not return to sport until you feel that you
are “ready” to safely return at near your preinjury
level.

RETURN TO SPORT CRITERIA:

Your physician or physical therapist will “clear” you
to return to sport when you have accomplished the
following goals.

Weight bearing ROMa Therapeutic exercises

Immediately post- Weight bear as 0–90° Patellar Mobs: All directions
surgery (0–2 weeks) tolerated with ROM: Wall slides, heel slides, prone hangs, extension bridging
crutches. Expect Strengthening: Quad sets, SLR, toe raiseselectrical stimulation as needed
to d/c crutches Stretching: Calves, quads, hams, hip flexors
when able to walk Gait: Gait training
without a limp
Early rehabilitation Full weight bearing 0–135° ROM: PROM as needed. Stationary bike. Add weight to prone hangs/commercial
activities (2–6 weeks) without pain or devices if extension ROM not equal to opposite side
limp Strengthening: SLR’s x4 directions (add weight if no extensor lag), squats/wall
squats, leg press/shuttle, ham curls
Proprioceptive Ex: Single limb stance, wobble board
CV conditioning: Stationary bike (high seat/low resistance initially)
Aquatics: Address problem areas
Gait: On land or in pool as needed
Advanced rehabilitation Full ROM ROM: PROM or bike with low seat if not meeting flexion goals
activities (6–10 weeks) Strengthening: Advance as appropriate. Add unilateral leg press and/or Shuttle
if not doing so already. Step ups
Proprioceptive Ex: Progress as tolerated on gradually less stable surfaces, eyes
closed, perturbation
training, etc.
CV Conditioning: Stationary bike or in pool. Add slide board as appropriate
Advanced functional Jogging without Strengthening: Single leg wall squats, sport cord, open chain knee extension
activities pain or limp full ROM
(10 weeks–6 months) Proprioceptive Ex: Progress as tolerated
CV Conditioning: Increase times/workout intensity for bike or pool
Running: Begin with interval jogging- straight ahead on “soft level surface”
(12 weeks). Increase interval jogging speed. Gradually incorporate turns/cutting.
Plyometric Ex: Start with two leg jumping on level surface “Head up, Land soft,
flexed knees, knees pointing straight ahead”
Return to sport Running/cutting/ Strengthening: Continue regular strengthening ex
(6–12 months) jumping without Proprioceptive Ex., CV Conditioning: Patient now involved in partial practice
pain or limitation activities and/or rehabilitation sessions designed to mimic sport tasks
Running: Straight line sprinting. Unplanned cutting.
Plyometric Ex: Complex unilateral jumping
a
Minimum expected range of motion.
 Chapter 25

F. Chotel, J. Henry, J. Bérard ACL rupture in children: anatomical

and biological bases, outcome
of ACL deficient knee in childhood:
strategy, operative technique,
results, and complications.

Introduction metaphyseal fractures over ligamentous injuries

in young children.
During the last 20 years, huge progress has been The ACL inserts on the medial and posterior
made in knee ligament surgery in adults; more aspect of the lateral condyle and near the middle
than 7700 publications concern the anterior cru- of the tibial intercondylar surface. Large and
ciate ligament (ACL) on Pubmed. Paradoxally, few oval insertions have been studied by Shea (2):
interests were given to the traumatic ligament looking from the anterior margin of the tibia,
knee in children. ACL anterior boundary, center, and posterior
Publications on ACL in children are more recent. boundary were 27, 43, and 59% posterior respec-
This problem, borderline between adult and pedi- tively. Overall dimensions in younger subjects
atric orthopedic practice, is raising more interest. are smaller than in adults but the anatomical
Sports practice is now highly encouraged. Best def-
inition with magnetic resonance image (MRI), and
development of knee arthroscopic techniques for
children, did change the vision of knee menisco-
ligamentous injuries.
Specific particularities of children anatomy and
a better knowledge of biological basis help to
explain the physiopathology of different inju-
ries.
After dealing with ACL rupture, we will treat the
diffi
fficult question of the chronic instability.

Anatomical and biological bases

Anatomical basis
Medial and lateral collateral ligaments insert into
the epiphysis, with the exception of the inferior
insertion of the superficial medial collateral liga-
ment which inserts into the proximal tibial meta-
physis distal to the physeal plate. This epiphy- Fig. 1 – Anatomic relationship between growth plate and ligamentous,
capsular and meniscal insertions. Superficial layer with fibular collateral
seal link is reinforced with capsule, ACL and PCL
ligament (a) and tibial (b), medial capsular ligament (c), medial meniscus
ligaments (cf. Fig. 1) making a real and strong (d), and ACL (e). The distance “h” increases with age (Kim (1)). A tibial Salter
block. Physeal growth plates and tibial meta- I displaced physeal fracture implies at least a lesion of the superficial medial
physis are usually the “weak link in the chain.” collateral ligament (contrary to Salter II physeal fracture separation with
This explains the frequency of physeal and tibial medial metaphyseal fragment).
292 The Traumatic Knee

landmarks for the ACL are proportional and com- vascularization can also explain false positive
parable. The tibial epiphyseal height is 10 mm at meniscal lesions on MRI analysis in children (3)
the age of 7, 13 mm at the age of 13 and 15 mm (cf. Fig. 2).
at the age of 16 (3).
Roof inclinaison angle (angle between femoral
diaphysis and Blumensaat line) is about 35–40°;
this angle is useful when looking for growth dis-
turbances in the sagittal plane. Anatomic study
conducted by Behr show that the distance from
the ACL superior fibers to the physis was constant
around 2.5–3 mm during growth process (4). Th The
“over the top” position is at the level of the distal
femoral physis.
Bernard (5) and Bénareau (6) developed methods
to help positioning of ACL femoral attachment
in adults. These methods, based on proportions
(constant during growth), are applicable in chil-
dren. Anatomic reconstruction of ACL femoral
insertion on immature skeleton is possible with-
out crossing the growth plate but rather with
an epiphyseal tunnel parallel to the plate (cf.
page 307).
The primary function of ACL is to limited ante-
rior translation of the tibia under the femur in
any articular position. Multiple fibers
fi constitute Fig. 2 – Classical false-positive signal on the posterior horn of the medial
the ACL, it can be separated in two functional meniscus observed in children. This patient is asymptomatic.
bundles: an anteromedial bundle tensed when
the knee is in flexion and a posterolateral bundle
tensed in extension (7). The ligament is called Consequences on physiopathology of injuries
“isometric” due to the absence of length variation
during the flexion/extension
fl movement. There Traditional teaching had held that the physis is
is a direct relation between geometry of cruciate weaker and less resistant to stress than the liga-
ligaments and the aspect of femorotibial articular ment–bone interface. This phenomenon explains
surfaces. The terminology of “anatomo-isometry” the predominance of metaphyseal fractures and
has been used, showing that both notions are growth plate fractures compared to knee sprains.
closely linked. When adolescence occurs, growth plates are less
Moreover, the ACL controls rotation; it resists vulnerable than ligamentous structures.
tibial internal rotation under the femur. Lastly, it The frequency of sleeve lesion or osteochondral
prevents hyperextension and controls the lateral avulsion on the ligamentous insertion can be
stability, acting as a secondary brake to the varus explained by the microstructural aspect (cf. Fig. 3);
and valgus stress. during childhood, ligamentous collagen fi fibers are
The perichondral ringg is a peripheral and vulnerable
Th in continuity with the perichondrium of epiphy-
structure surrounding the physis. Th This structure seal cartilage. In adults, the ligamentous insertion
provides 50% of the resistance to shear stress. Any on the bone is a type direct.
injury to this structure (due to a traumatism or to The energy of the trauma is a determinant fac-
surgery) could result in axial growth disturbance. tor: small subjects, low corporal mass, and short
This is the main diffi
fficulty for ACL reconstruction limbs participate to decrease the kinetic energy
with a femoral tunnel. Perichondral ring can also of the trauma. Morever, young children practice
be damaged during ``over the top'' positioning of low energy sports that expose more to metaphy-
a graft (8). seal fractures rather than epiphyseal separation
At birth, meniscii have their definitive and (usually high energy trauma). The type of cruci-
adult shape, no transitory discoid shape had ate ligament lesion depends on the energy but
been observed during embryological develop- also of loading-rate and direction of the trauma
ment. The vascularization is initially very rich; as well (10). Injuries with low-energy, rapid-
it regresses during growth process to obtain a loading events resulted mainly in ACL midsub-
nearly adult conformation at the age of 10. This stance rupture, whereas ligament–bone junction
fact can explain the strong potential for heal- injuries occur with high-energy, slow-loading
ing of menisci lesions in children (9). This rich events (10).
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 293
The growing knee
In order to determine at what time an adult tech-
nique can be used for ACL reconstruction in chil-
dren or to determine the consequences after epi-
physiodesis, several important points concerning
limbs growth will be recalled.
How to determine residual growth?
The knee has the stronger growth potential in
the human body (“growth occurs toward the knee
and away from the elbow”). It allows a mean local
growth about 2 cm per year (60% for distal femur
and 40% for proximal tibia). The
Th Green and Ander-
son tables (11) gave the residual growth on each
physis according to the skeletal age (cf. Fig. 4).
These tables underline two fundamental notions:
the importance of using skeletal age and the 2
years diff
fference between maturation of boys com-
pared to girls.
Using skeletal age is more eff
ffective. Dimeglio (12)
observe during a study around the puberty period,
50% of the observations concourred between
chronological and skeletal age, 30% showed a
higher age, and 20% showed a lower age. The Th elite
athlete can display a higher percentage of discor-
dance (especially in dance or gymnastic).
The direct evaluation of knee skeletal age is diffiffi-
cult and inaccurate. The physiologic growth plate
closure occurs over a period of about 2 years and
is centrifugal. Th
This fact explains that the com-
plete fusion of the anterior tibial tuberosity is an
absolute criterium for maturity, but it occurs very
late (15–16 year old for girls and 18 years old for
boys).
The disappearence of the central high signal band
on T2-gradient-recalled echo MRI may suggest a
Fig. 3 – Multiple bony avulsions can reveal a
serious sprain: anterior eminence intercondylar
fracture, Segond’s fracture and femoral avulsion
of the lateral collateral ligament.
near closure of the growth plate and allow adult
type reconstruction with drill hole across the
growth plate (13). We recommend few TDM slices
on the growth plate center in order to look at the
beginning of physiological centrifugal closure. Th This
central closure does not led to any axial deformity
by peripheral injury and allows an adult type recon-
struction without any risk.
The skeletal age is evaluated on left hand X-ray
with anteroposterior view and left elbow X-ray
with AP and lateral views. Beginning of ossifica- fi
tion on the iliac crest (Risser 1 or more) means the
end of lower limb growth even if there is a residual
growth plate (cf. Fig. 5) (12). Whatever the method
of analysis used, the accuracy of prediction is about
6 months.
The skeletal growth includes three successive
pubertal peaks for the lower limb, the trunk and
the thoracic growth. Total height is a combination
of trunk and lower extremities lengths. We tradi-
tionally learn that the teenager will stop ``chang-
ing shoe size, then trousers length and later, shirt
and eventually jacket size.”
The puberty changes start at the age of 11 for girls
and 13 for boys. Menstruation is a good indica-
tor of growth slowing down for girls and it corre-
sponds to the closure of the knee growth plates.
There are less indicators for boys where secondary
sexual criteria used in Tanner scale can be useful:
pubis and axillary pilosity P4 is the equivalent of
menarche for boys (14).
In conclusion, waiting for knee-bone maturity does
not mean wait for the patient’s majority. When girls
have 13.5 years of skeletal age and have their periods,
the lower limb residual growth is nearly achieved
while it will be necessary to wait 15.5 years of skeletal
age for boys to achieve the same status.
294 The Traumatic Knee

Fig. 4 – Anderson and Green charts (11) established on 100 American children.

Fig. 5 – The puberty peak for girls is encountered at a mean age of 13 when the elbow physis are fused radiologically. A similar schema is used for boys but
with a 2-year delay (peak at 15 years of age).
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 295

Unfortunately, few authors make distinction of
sex during studies about ACL injuries in children.
Wessel classifi
fied children under 10 years, pre-ado-
lescents between 11 and 12, and adolescents over
13–16 years (15). Only more recent studies give
the pubertal status of children but segmentation
of period is variable. Aichroth (16) Guzzanti (17)
classifi
fies their groups using the pubertal Tanner
scale (pre-puberty or Tanner 1, puberty Tanner 2
and 3, and adolescent Tanner 4 and 5).
Growth disturbances and epiphysiodesis
The traumatic knee in children is exposed to
growth disturbance due to initial physeal injury or
to surgical treatment. A central epiphysiodesis will
cause leg discrepancy. A peripheral epiphysiodesis
will cause an angular deformity. This deformity is
predictable in Bowen tables (18) (cf. Fig. 6A).
A growth disturbance on posterolateral femo-
ral tunnel during ACL reconstruction will lead to
angular deviation with combine frontal and sagittal
plane deformity (cf. Fig. 6B). The sagittal compo-
nent of the deformity ``S” is frequently neglected:
it is manifested with an epiphyseal flexum
fl and ver-
ticalization of the Blumensaat line. It is essential
to locate accurately (with TDM or MRI) the epi-
physiodesis bridge in order to plan treatment.
Wester (19) developed prediction graphs giving
the shortening and angular deformity resulting
from growth disturbances after ACL reconstruc-
tion on immature skeleton. For example, a surgery
performed the year before maturity could lead to
5° femoral valgus and 1 cm shortening of the leg!
Consequences of epiphysiodesis in pre-adolescence
could be smaller than in a younger child. Paradox-
ally, the risk of pre-mature growth plate closure
could be much superior in adolescents. Seil (20)
reported, in an in vivo study on transphyseal ACL
replacement in sheep with open physis, that filling
the tunnels with tendon graft do not always pre-
vent the formation of a transphyseal bony bridge.
However, these bony bridges have no influence
fl on
longitudinal growth because of the force exerted
by residual growth potential (20). Many studies
showed that growth plate product strong force of
distraction able to break a small epiphysiodesis
bridge crossing the physis in young children. This
Th
force had been quantifified experimentally around
human proximal tibia and distal femur and this
force is comparable to the body weight (Bylski-
Austrow (21)). Growing process slows down close
to bone maturity (Anderson (11)). In clinical prac-
tice, growth disturbances reported in the literature
mainly aff
ffect adolescents when they approach the
end of growth around the knee (cf. page 313).
Joint laxity in paediatric population
Physiological laxity?
Laxity does not mean instability. On a seman-
tic point of view, laxity is a clinical sign elicited

Fig. 6 – (A) Trigonometric circle representing coronal deformity with “e” angle (according to Bowen (18)). The physis width is the radius r (adjacent side
CC); the remaining growth is the arc (opposite side). (B) Planification of combined axial changes on a coronal view of the growth plate (gray color). The
posterolateral epiphysiodesis bridge conduct to deformity in an elective plane with a sagittal component S and a coronal component C.
C C is the radius of the
trigonometric circle of valgus deformity and S is the radius of the trigonometric circle of femoral flexion deformity.
296 The Traumatic Knee
objectived by an examinator and is due to abnor-
mal movement between two articular surfaces.
On the other “instability” is a symptom felt and
reported by the patient.
Children have a general and physiological increase
in articular laxity: an important anterior laxity
and a physiological glide during pivot-shift test are
often observed bilaterally without any abnormal
symptom. During examination we can also note a
severe ligamental recurvatum (cf. Fig. 7).
Baxter (22) examined 232 patients aged between
7 and 14 years with Genucom Knee analysis Sys-
tem. The absolute value of both translation and
rotation laxity decreased as age increased. No sig-
nificant
fi diff
fference was seen between right and left
knees of the same patient and between boys and
girls’knees.
For others authors, girls have a signifi
ficantly greater
laxity compare to boys (23) (24). Th The meniscal
complex also presents a hyper-laxity that plays an
important role in shocks absorption.
All these observations underline the limits of clini-
cal diagnosis in children and the risk of progressive
elongation of transplant after ACL reconstruction
on knee with significant
fi recurvatum.
Diff
fferential diagnosis: congenital laxity
We only mention the congenital laxity as a dif-
ferential diagnosis for post-traumatic laxity. Liga-
mentous agenesis mainly concern the central pivot
and are associated with others malformations of
lower limb. The
Th malformation is sometimes evi-
dent (lateral longitudinal ectromely), and at times
very discret (slight fibular hypoplasia).
Roux and Carlioz (25) reported in this context, 95%
of ACL abnormalities and 60% of PCL abnormali-
ties. Despite a major laxity, the jerk test is positive
only in 23% of all knees: the jerk can be masked by
the lateral condyle hypoplasia and the valgus lax-
ity. Functionally, only 16% of children complain of
Fig. 7 – The knee recurvatum is a part of the physiologic constitutional laxity
observed in children. This recurvatum is an “enemy” to ACL reconstruction.
occasional symptoms and only 4% have significant
fi
restriction of their activity. This good tolerance
may also be explained by the relative low level of
activity of these children.
X-ray confi
firms the diagnosis showing classic hyp-
oplasia of the spinal process and sometimes of the
femoral intercondylar notch (26)(cf. Fig. 8).
Fig. 8 – Femoral hypoplasia of the lateral condyle, agenesia of the tibial
spinal process, and anterior subluxation of the tibia evoke a congenital dis-
ease (here revealed in a traumatic context).
High level of activity and bad compliance
Young children are “daily pivot-sport athletes!”; their
basic level of ligamentous stress is high. Out of the
sport practice, a child jump, leap, run, go down
stairs two by two steps. This
Th current mode of life is
equivalent to non-organized sports.
The young child cannot describe his discomfort
but during the pivot-shift test, he will recognize
this discomfort thus giving good ground to discuss
instability.
Adolescents tend to minimize their symptoms
and this increases the delay to see a doctor.
Moreover youngsters usually have difficulties
ffi to
project theirself in the future, and they do not
understand the necessity to reduce or adapt their
sporting practice. Adequate management needs
the understanding of this specifi fic psychology
that often results in a general bad observance to
treatment.
Limits to children’s evaluation
Laxity evaluation in children should be as pre-
cise and rigorous as in adults. However, pediatric
arrangement to the IKDC evaluation is a neces-
sity.
The measurement of AP laxity leads to diffi
fficulties.
Is it wise to evaluate with the same method, the
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 297
laxity in a young girl and that of a professional rug-
byman?
The measurement of the anterior tibial translation
should be given relative to the size of the condyle:
this notion conduct to concept of subluxation
index (Chouteau (27)). A 10 mm translation on a
7 cm condyle is a higher laxity (50%) than the same
translation on an 11 cm condyle. Of course the dif-
ferential laxity must be taken in account, compar-
ing the non-pathologic contralateral knee.
Radiologic methods are delicate in children assesse-
ment of anteroposterior laxity; posterior condyle
ossifi
fication is sometime irregular and partial.
TélosTM assessement of translation is minimized by
internal rotation phenomenon.
The use of standard KT 1000 TM is not adequate
for tibia with length less than 34 cm. However,
KT-1000/JRTM (Junior) (MEDmetric®) allows
evaluation on smaller sized tibia around 26 cm
(8 years old child). KT 1000 measurement in
children has been validated in the normal knee
(Flynn (28)) but not in pathologic knee. We have
observed that even in expert hands the KT-1000
assessment on pathological knees underesti-
mates the laxity. Measurements of the same knee
under general anesthesia (before reconstruction)
increase the values compared to the same mea-
surements without anesthesia. Such an objec-
tive evaluation of the ACL reconstruction results
could be really optimistic (cf. Results). Complete
passive systems must, however, be used to assess
laxity in children in order to avoid muscular inter-
ferences.
Anterior tibial intercondylar eminence fractures
The old terminology ``tibial spine fracture'' should
be abandoned; it corresponds to a radiologic
appearence but is inappropriate on the anatomic
point of view. The tibial ACL or PCL insertion in the
pre-spinal or the retrospinal area corresponds to the
intercondylar surface. The term of tibial intercondy-
lar eminence fracture is now routinely used.
Epidemiology
Th injury occurs usually in children between 8 and
This
13 years old. The anterior tibial intercondylar emi-
nence fractures (ATEFs) is the main type of ACL
lesion before 12 years old. In a recent french prospec-
tive multicenter-study, 82% of intercondylar emi-
nence fractures occured in immature patients (under
13 years of age for girls and 15 for boys) (29).
This lesion is not specifi fic from children and it is
also reported in adult series (half of the adult series
in Senekovic study (30) had ATEF avulsion). Age
and mechanism during injury can explain the low
incidence of associated initial lesions: only 6–8%
meniscal (31), and 14% of ligamentous lesions
(30).
Mechanism and physiopathology
Trauma on flexed knee is first in frequency: fall from
a bicycle with anteroposterior impact on a fixed fi
tibia; tackle during football practice increasing the
anterior tibial translation or injury during on land-
ing after a jump. The internal rotation of the tibia
under the femur has also been invocated. Th The anter-
omedial ACL bundle traction detaches an osteocar-
tilaginous fragment with chondral component from
adjacent joint surface, this lesion has an intact pos-
terior hinge (Stage 2 with anterior displacement).
On the other hand, uncommon traumatism in
hyperextension of the knee removes usually a small
fragment without lateral cartilaginous component.
In such a case, a close reduction is more uncertain.
Hyperextension is a severe traumatism that leads to
a lesion in all fibers or bundles (posterolateral bun-
dle as well) without a posterior hinge (Meyers and
Mac Keever Stage 3). Bony avulsion on the femoral
insertion is very rare but could be underestimated if
a stress view X-ray is not performed initialy.
X-ray and classifications
fi
Most of classifi fications are based on standard
X-rays. This is a cause of diffi
fficulty because:
– the ATEF is not seen on AP view,
– detection of Salter III lesions sometimes requires
oblique views,
– the avulsed fragment is sometime partially ossi-
fied, nearly invisible, with a “crisp aspect” on the
tibial ACL insertion (cf. Fig. 9), or completely
non-ossifified (diagnosis on MRI).
– Dynamic stress X-rays are not recommended for
non-displaced ATEF; it could increase the dis-
placement.
Meyers and Mac Keever (32) proposed a classification
fi
in three stages, based on the degree of displacement
on the lateral view. A fourth stage for comminution
component had been added (cf. Fig. 10). Th This clas-
sifi
fication with therapeutic implication is still exten-
sively used. Zifko (33) use a classifi fication according
to the avulsion area in the intercondylar eminence:
anterior (type A), anterior with extension into the
middle interconylar area (Type B). Others authors
added the type C in the posterior intercondylar area.
A Meyers’type I fracture can be A, B or C.
However, no classifi fication actually takes into
account the associated intraligamentous lesions.
298 The Traumatic Knee
Fig. 9 – Two examples of anterior tibial eminence fractures. The first one was neglected. The border line between ACL avulsion on the floor
and chondral anterior tibial eminence avulsion fracture is not well defined.
Fig. 10 – Classification of fractures of the anterior tibial eminence according
to Meyers and Mc Keever (32) (and frequency of lesions). Type I: no or minimal
displacement and no limitation of knee extension (14%). Type II: the anterior
one third to half of the fragment is lifted upward while the posterior border acts
as a hinge and still maintains in contact with the proximal surface of the tibia
(45%). Type III: completely separed fractures (III+: rotated fragment) (35%).
Type IV: displaced avulsion fractures with comminutive fragments (6%).
Treatment
Aims
Restoration of normal articular congruence and
complete extension without any anterior osseous
confl
flict. To restore ACL ligamentous integrity.
Principles and limitation of conservative management
As for all displaced articular fracture, a reduction
is recommended. During full extension, lateral
condyles push on the lateral cartilaginous expan-
sion of the avulsed fragment and bring the frag-
ment back in its notch. The intercondylar notch and
trochlea give an anterior pressure when full exten-
sion tends toward hyperextension (cf. Fig. 11).
Three limitations can be objected to conservative
management:
– Th
The first one is due to obstacle to reduction with
anterior soft tissue interposition: meniscal horn, or
the transverse meniscal ligament. These
Th interposi-
tions may be removed during closed manipulation.
– The second one is due to intraligamentous lesion
before avulsion fracture. ThThe fracture occur when
the elastic deformation become plastic deforma-
tion, around an elongation between 20 and 25%.
Noyes (34) shows experimentally in primates that
collagen architecture modifications
fi explained the
ACLs plastic deformation. A traumatism is able
to give 50% of ligament lenghtening without
macroscopic rupture. Ligamentous failure caused
by a tibial eminence fracture occurred in 57% of
the specimen at a slow loading rate and in 28% of
the specimen at a fast loading rate.
These deformities could explain bad objective
results even after good anatomical reduction
after conservative treatment. Some authors sug-
gested a more aggressive approach in which the
fragment must be countersunk in order to try to
compensate the ACL elongation (35, 36).
– The third one is that conservative management with
extended knee place the ACL in a constrained situ-
ation. This tension is not compatible with a good
healing process of the intraligamentous injury.
Indications
The choice method for type I ATEF is conserva-
tive treatment. A long cast with or without ankle
immobilization in slight flexion (between 10 and
20°) is the best option in children. Knee aspiration
to remove hemarthrosis can be used in painful and
swollen knees. After 4–6 weeks the cast is removed
and full weight-bearing is allowed.
Surgery is recommended for type III and IV ATEF.
A pre-operative testing with clinical and fluoro-
fl
scopic assessment can be helpful (cf. Fig. 12). An
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 299
Fig. 12 – AP view during stress X-rays of a knee with evidence of ATEF; a
Salter III physeal fracture is observed on the medial side. This injury is asso-
ciated with rupture of the medial collateral ligament.
asymmetry of laxity (compared to opposite side)
superior to 8 mm of medial joint opening during
Fig. 11 – Principle of non-operative
treatment in extension for ATEF. A
bad result was obtained in spite of
an anatomic reduction and fixation:
hyperextension is not recommended.
It supposes reduction with the top of
the notch but this hyepextension put
the ACL in tension (this fracture was a
type III and should have been treated
surgically).
valgus stress requires an MCL surgical treatment
and a meticulous medial meniscus exploration
looking for an “anteromedial triad.” The Th choice
between arthrotomy and arthroscopy is operator-
dependent but the “reduction should at least be
anatomical!”
The use of “countersinking” technique can be use-
ful in order to obtain an optimal ACL tension.
Arthroscopic management allows easy meniscal
exploration but is a highly demanding technique
for fracture fixation. A post-operative brace or cast
in a slight flexion
fl is needed for 6 weeks.
Multiples fixation techniques have been described:
absorbable sutures, kirshner wires, multiple pins,
wire suture, staple, direct or retro screwing. There
Th
is no clear biomechanical advantage in perform-
ing any particular fixation method in Mahar study
(37).
The transphyseal fixation is the best on a mechan-
ical point of view but may conduct to epiphysi-
odesis. Mylle (38) reported an anterior epiphysi-
odesis with a tibial recurvatum occuring 2 years
following transphyseal fi fixation for ATEF in an
11 years old girl. The author recommends early
implant removal (after 6 weeks) or to use epiphy-
seal fixation. Hallam (39) combined conservative
treatment with arthroscopically assisted reduc-
tion in order to reduce anterior interposition. A
cast in extension was used for 6 weeks to main-
tain the reduction.
We now routinely use all inside fixation
fi with
absorbable suture performed under arthroscopy
and including countersinking (cf. Figs. 13 and 14).
The advantages are:
300 The Traumatic Knee

Fig. 13 – Details of our technical procedure for arthroscopic treatment of intercondylar tibial eminence fractures. The patient is in supine position, standard
arthroscopic portals are used. Evacuation of the hemarthrosis and careful exposure of the fracture site. Reduction test is performed.
f Debridment of the tibial
fracture basis for allowing a countersinking effect after ACL exploration looking for partial ACL lesion. Use of ACL guide and a 1 cm incision is performed
medially to the anterior tibial tuberosity for exposure of the tibial metaphysis.
Details of thread fixation are given in Fig. 14. The fracture is reduced under fluoroscopic and arthroscopic control by pulling on both ends of the thread. Control
of joint congruity, absence of meniscal interposition and cruciate testing are performed. Both ends of the thread are tied through the metaphyseal approach.
After closure of the three short scars, a long cast is applied at 20° of flexion. Non-weight bearing is recommended for 5 weeks with crutches (for children over
7 years). From 5 to 7 weeks progression from partial to total weight bearing, active flexion and close-chain exercises are performed.
f

Fig. 14 – Schematic representation of resorbable thread

fixation during the procedure is resumed in Fig. 13.
One spade-tipped 2 mm pin is inserted through an
arthroscopic guide from the proximal tibia to reach the
prepared notch on its posteromedial border (1). A mono-
filament resorbable thread is passed through the ante-
rolateral portal and through the spade tipped guide (2)
and is pull out through the metaphyseal approach (3).
A Reverdin needle is introduced by the lateral portal
through the floor of the ACL fibers (4). This Reverdin
needle captures the intra-articular end of the thread and
pull it across the ACL and out of the joint through the
anterolateral portal (5).
A second spade-tipped 2 mm pin is introduced by the
same procedure to reach the notch on its anterolateral
border (6). This second pin is used to pull the lateral part
of the thread (7) down toward the proximal tibia (8).
The two extremities of the thread are then tied together
on the proximal tibia while a blunt hook holds the ACL
insertion downwards (9).
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 301
– single procedure: no further surgery to remove
fixation material,
– suture is passed through the ligament and not
through the avulsed bone: technically possible
even in comminutive fracture or small fragments
size,
– two small tunnels minimize the risk of epiphysi-
odesis (transphyseal fi
fixation),
– no complex instrumentation is required (spade-
tip guide and Reverdin needle),
– minimal morbidity due to an arthroscopic proce-
dure, and best cosmetically with three very short
scars.
There are more controverses about treatment of
type II ATEF:
Some authors still recommend a conservative
treatment if perfect reduction is achieved. No
study has found correlation between quality of
reduction and residual laxity in type II ATEF. We
recommend as many authors, a surgical approach:
this strategy allows a good control of ACL tension
in both flexion
fl and extension.
Results
Unfortunately an anatomical reduction does not
guarantee a perfect laxity control at follow-up.
Smith (40) reported an objective residual laxity
in nearly all patients and 50% of symptomatic
patients after only 7 years of mean follow-up.
Willis (41) found 74% of the patients had laxity
with KT-1000 arthrometer; 20% of the patients
had a positive pivot shift test but only 10% com-
plained of symptoms and none of them had insta-
bility after 4 years follow-up. In rare ATEF type I
fracture there was no side-to-side diff fference; the
mean arthrometric diff fference was 3.5 mm for
type II and 4.5 mm for grade III lesions. Wiley et
Baxter (42) found similar values with a Genucom
evaluation.
The rate of residual laxity seems smaller in recent
studies: 33% for Iborra after 7 years follow-up (43)
and 38% for Janarv (44).
These results show that long-term prognosis of
this injury must remain guarded, based on the
finding of persistent ACL laxity. The familly have
to be informed about this problem. Despite the
fact that no treatment is measurably superior to
another, we recommend to treat this lesion as
a ligamentous injury rather then a simple frac-
ture.
Complications
Healing in a wrong position (defined
fi as more than
2 mm) is mainly a complication of conservative
treatment (43). It can result in residual laxity with
or without extension limitation. In very rare cases
with isolated flexum, a simple notch plasty could
be suggested; of course an associated instability
requires a ligamentous reconstruction.
Non-union after ATEF is very uncommon, and
mainly due to missed diagnosis or neglected treat-
ment. The symptoms are pain during extension
with sometime lack of extension or instability.
Standard X-rays establish the diagnosis (cf. Fig. 15).
The treatment is surgical but no specifi fic publica-
tion reports result concerning treatment of such
non-unions.
The retraction occurring during the healing
process can be another difficulty and sometimes
bone grafting of the fracture notch can be use-
ful.
Fig. 15 – Non-union after neglected ATEF in an
adolescent. This patient suffers from giving way
and a painful fixed flexed deformity.
302 The Traumatic Knee

Other complications Prospective explorations of post-traumatic hemar-

Growth disturbance is mainly an iatrogenic
complication. Immobillization adverse effects
can be encountered: deep veinous thrombosis is
not seen before puberty and there is no need for
prophylactic anti-thrombotic treatment before
this period. Contractured knee due to algoneu-
rodystrophy (Sudeck’syndrome) should be con-
sidered if rehabilitation is getting very hard and
painful.
ACL midsubstance Rupture
ACL rupture on skeletally immature patient
accounts for roughly 3–4% of all ACL ruptures in
the 1980s (57/1722 – Mc Carroll (45) and 24/710-
Lipscomb (46)).
Epidemiology and pathological anatomy
Site and extent of ACL tear
Site of tear is equally divided among proximal, mid-
dle, and distal sites (Stanistski (47), Parker (48)).
According to Kellenberger (49) and Rochcongar
(31), femoral avulsion was 16% of ACL ruptures,
and distal avulsion on the tibial site was only 10%
of ruptures.
throsis allow diagnosis of partial ruptures, undere-
valuated for a long time because of good functional
tolerance. The absence of consensual defi finition of
the partial rupture could explain high variability of
this injury in the literature: 13% of ACL ruptures
for Kellenberger (49), 53% for Kocher, and more
than 60% for Stanitski (50), Saciri (34), and Angel
(51).
According to Stanitski, more than half of partial
ruptures are misdiagnosed clinically. MRI is less
accurate for partial tear than complete rupture;
the diagnosis is established during arthroscopic
exploration.
Partial tears could be more common in children
than adult population. According to Saciri, children
under 13 years of age are more commonly exposed
to partial rupture. This
Th notion is not confi firmed by
Stanitski.
A partial ACL rupture is associated with a smaller
rate of meniscal injuries compare to a complete
rupture (Angel (51)).
Associated lesions during ACL rupture
Management of ACL rupture must take into
account the associated lesions. Epidemiology of
associated meniscal and ligamentous lesions are
given in Table 1 (more than 100 patients investi-
gated acutely in seven difffferent studies). Parker
and Andrews’retrospective studies were excluded;
the rates of 83 and 100% of meniscal tears reported

Table 1 – Associated lesions with ACL midsubstance rupture in acute phase (inferior to 6 weeks following the accident). ACL rupture is associated with 48%
rate of meniscal tears, equally distributed between medial and lateral compartment.
No. of Type of ACL rupture Rate of menisc. Loc. of menisc. Peripheral lesions
Authors/date Age Acc.
knees (n = 64) tears (%) tears (n = 131) (n = 48)

8 15 Y (13–16) _ 50 3 mm 1 ML _
1988
Kallenberger 13 complete
15 14.8 Y (11–18) 46 4 mm 3 ML 6 MCL 2 LCL
1990 2 partial
14.5 Y 3 mm 3 ML 1 mm
Graf 1992 10 _ 70 _
(11.7–16.3) + ML

Patel 1993 33 12.5 Y (11–15) _ 42 8 mm 6 ML 9 MCL

4 mm 5 ML 2 mm
Mizuta 1995 16 12.8 Y (10–15) _ 68 _
+ ML
6 mm 6 ML 3 mm
Bracq 1996 33 13.8 Y (8–15) 22 complete 11 partial 45 _
+ ML
1 mm 3 ML 1 mm
Luhmman 2003 16 14.5 Y 12 complete 4 partial 31 _
+ ML

73% complete 27% 22% MM 21% ML

Total 131 _ 48 31 % MCL 4% LCL
partial 5% MM+ML
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 303
during surgery in emergency are probably due to
surgery selection bias.
About half of ACL ruptures in children are associ-
ated with meniscal tear. This is similar or slightly
less than adult observations (52). Pre-adolescents
could have less meniscal tears associated with ACL
rupture than adolescents (47).
Site of meniscal tear is equally divided among
medial and lateral compartments. In adult series,
lateral meniscus tears are more common (53). Sim-
ilar observation was seen in the pediatric series by
Millet (54): 47% of the lateral meniscus lesions and
11% of medial meniscus lesions. Th The lateral com-
partment of the knee is the mobile compartment;
during injury there is increased stress on that side
(Bone bruise are laterally located).
There are few reports in literature about the type
of meniscal tear. In our experience this is mainly
peripheral tears (Bucket-handle lesion) in both
compartments or horizontal tears on the lateral
side (Bergerault (55)). These lesions display a high
rate of spontaneous healing. Chondral tears are less
common than in adults; it was reported between 0
and 9% of ACL ruptures in children (54, 56).
Management in acute rupture
Diagnosis
Stress, pain, and fear are limiting factors in clini-
cal examination of an acutely traumatized child.
The presence of even a slight hemarthrosis must
suspect an intra-articular lesion. In Wessel study
(retrospective analysis of 1273 children treated in
emergency) 18% of traumatic knees display hemar-
throsis (15). Th
The hemarthrosis rate increases with
age: 5.7% in children less than10 years old, 19.7 %
in children between 11 and 12 years old, and 30%
in those between 13 to 16 years old.
In adult series, hemarthrosis revealed an ACL rup-
ture in 75% of cases (57). In children, the propor-
tion of ACL ruptures accompanying hemarthrosis
increases with age to reach around 45% of ACL
ruptures in post-traumatic hemarthrosis (58).
Others etiologies of hemarthrosis are meniscal
tears and femoropatellar dislocations. Luhmann in
a prospective study during 6 months (59) identi-
fied 55 lesions on 44 traumatic knees with a joint
eff
ffusion; 14 cases are due to femoropatellar insta-
bility, 16 cases to meniscal tears, and 21 cases to
ligamentous injuries (16 ACL, 3 LCM, 1 PCL, and 1
ATEF). The small proportion of ATEF in this study
is due to the age of the patients (mean age of 14
years and 8 months).
The epidemiology of hemarthrosis varies with the
gender of the children; joint eff ffusion in girls is
mainly due to femoropatellar dislocations (58% of
cases) and rarely due to ACL rupture (16% of cases).
On the contrary, joint eff
ffusion in boys is rarely due
to femoropatellar dislocation (12% of cases) but is
mainly due to ACL injury (52% of cases).
Clinical examination of knee with hemarthrosis is
diffi
fficult with lower sensibility of tests: Angel (60)
mentioned only 56 % of correct diagnosis after
clinical evaluation. Pivot shift test or anterior
translation on flexed knee is not possible on acute
assessment, but Lachman-Trillat test on extended
knee is still a sensible and specifi fic sign for ACL
rupture.
Radiological evaluation of knee hemarthrosis in
children needs four views: AP view, lateral view,
axial, and schuss X-rays.
Care must be taken when reading AP view looking
for ATEF (frequently misdiagnosed). Segond‘s frac-
ture is pathognomonic of ACL rupture in adults as
well as in children (cf. Fig. 3). Lateral views allow
the diagnosis of small avulsions ATEF (cf. Fig. 9).
Axial view is useful in diagnosing bony avulsion
after femoropatellar dislocation or subluxation.
The “schuss” view allows diagnosis of femoral avul-
sion of ACL or PCL (cf. Fig. 16). In ambiguous situa-
tion oblique or comparative views can be ordered.
In the eighties, knee examination under general
anesthesia was recommended for unexplained
hemarthrosis in children.
The development of arthroscopic techniques brings
paediatric surgeons to use it first as a diagnosis tool
(47) (61). However in the nineties, arthroscopic
exploration is no longer recommended even in
adults (62). MRI scans is actually the most suitable
diagnostic tool after conventional radiography,
for evaluating hemathrosis in knee joint during
Fig. 16 – Traumatic femoral avulsion of the ACL on schuss view X-ray.
(collection Pr C. Bonnard tours)
304 The Traumatic Knee
childhood (15). However, there are indications for
arthroscopic surgery if MRI cannot establish a def-
inite diagnosis or if arthroscopy allows a surgical
management at the same time.
MR images on ACL rupture identify direct primary
findings (abnormal signal intensity, abnormal Blu-
mensaat angle, and discontinuity) and indirect
secondary findings (bone bruise in lateral com-
partment, anterior tibial displacement, uncovering
of posterior horn of lateral meniscus or abnormal
posterior cruciate angle) (63) (cf. Fig. 17). Inverted
Blumensaat angle more than 10° could be the most
sensitive and specifi
fic primary sign. All ACL rup-
tures in this study had at least a positive primary
sign.
Fig. 17 – Major MRI signs for ACL rupture. (A): Discontinuity, (B): abnor-
mal intraligamentous signal intensity, (C): Blumensaat angle with normal
angle on the left (negative value when the apex is pointed upwards); and
pathological positive angle up to 10° due to ACL rupture on the right. (D):
PCL angle: normal on the left; pathological <115° due to ACL rupture on the
left. Morever the line tangential to the posterior margin of the distal PCL do
not intersect the medullary cavity of the distal femur. (E): Bone bruise with
high signal intensity on T2-sequence images.
Fig. 18 – MRI aspect of bone bruise with “kissing lesion”” of the lateral compartment with high signal during a Fat Sat T2 sequences. No ACL lesion was
observed for this patient; bone bruise sign is less sensitive and less specific of ACL ruptures in children than in adults.
Bone bruise is a very sensitive sign in adult prac-
tice of ACL injury (97–100%) but could have a
lower sensibility in children because of a sponta-
neous higher laxity (cf. Fig. 18). In Lee study, the
sensibility of bony bruise is only 68%. However,
25% of the patients have MRI more than 6 weeks
after the accident. The bone bruise specifi ficity
could also be lower in children compare to adults
(64).
Chondral exploration on acute knee is also a limi-
tation of MRI. In case of hemarthrosis, Fat sat 3D
SPGR sequences should be used (Spoiled Gradient
Echo) (3).
Management of ACL rupture
The direct and simple suture is not recommended;
it was the reference treatment in the 1970s. Enge-
bretsen (67) reported 63% of bad results after mid
follow-up term with a Plamer Marshall repair. This
Th
method, already abandoned for adult, must also be
abandoned for children.
Early ACL reconstruction has been abandoned; it
increases the risk of complications and hinders
rehabilitation.
The conservative treatment after acute isolated
ACL injury is preferred. It is a three-phase pro-
gram:
– Phase I includes use of knee immobilizer for com-
fort, cryotherapy to reduce swelling, early crutch
ambulation with progressive weight bearing as
tolerated, and early range motion exercices. Th
This
phase usually lasts from 7 to 14 days.
– Phase III is a supervised rehabilitation eff
ffort to
restore normal muscle balance and quadriceps-
harmstring strength ratio. This phase usually
lasts up to 6 weeks.
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 305
– Phase IIII is a gradual return to functional and
sports activities. This phase is possible only in
the absence of instability during basic and daily
activities. Non-pivot and low demanding sports
are allowed first: crawl swimming (and not breast-
stroke), jogging on flat surfaces, and cycling.
More demanding activities are allowed consid-
ering a symetrical muscular balance absence of
instabilty.
The use of functional braces in skeletally immature
athletes is controversial. There are no real rules
in using these braces. Moreover, the mechanism
of action is still unclear (proprioceptive feeback
ffect?). Most of braces in children are custom-
eff
made with a prohibitive cost and compliance is
low. Graf (68) showed that secondary lesions were
common despite bracing; this protection does not
allow at risk sports (pivot and contact sports).
Functional braces should just be considered as a
technical help in a good rehabilitation program; at
risk activities must be controlled in order to guide
the patient until skeletal maturity. In case of unfa-
vorable outcome with repeated giving-way, the
conservative treatment must be suspended for an
ACL reconstruction on a skeletally immature indi-
vidual.
More rarely, the conservative treatment can be
defi
finitive (partial tears, very good tolerance, and
real renunciation to at risk sport activities).
Treatment of associated meniscal tears
The worse complication of meniscal injury in a
child is meniscectomy. The meniscectomy is an
easy option, but is inadequate with a bad short-
term prognosis and future arthritis. Preserving
the meniscus should be a priority.
Meniscus preservation is not synonym of surgery.
In many cases the lesion had a good potential to
heal spontaneously. Abstention is an alternative
option as much frequent as suture (Millett (54),
Beaufifils (69)). In adult series Ihara (70) shows that
67% of meniscus injuries did heal spontaneously in
the 3 months. We presume that this favorable con-
dition is not worse in children. According to Noyes
(9), the tissue quality is more important than tear
location to decide meniscus preservation.
Principles of meniscus suture are the same than
for adults with vasculo-nervous protection (69).
Arthroscopic techniques allow a fi finest exploration
and a possible “all inside” suture.
Meniscus anchors can be used but are cost effec- ff
tive and require a learning curve. ThereTh is no evi-
dence of superiority of these sutures over classical
“inside-out'' suture under arthroscopy or through
a short and posterior arthrotomy. Because of
important variability in knee size, the position of
anchor in the deep soft tissue is not standardized
in children. This limitation exposes to the risk of
posterior vasculo-nervous injuries.
Noyes (9) recommends the use of a micropick to
penetrate the femoral notch three or four times
to introduce blood into the joint to potentially
increase fibrin clot formation at the meniscal
repair site. This clot decreases synovial fluid vis-
cosity and has a lubrification
fi eff
ffect. Of course
this action is non-useful in case of simultaneous
ACL reconstruction. The rehabilitation program
allows immediate knee motion. Range of motion
exercices from 0 to 90° of flexion are begun post-
operatively, with flexion advanced to 120° by the
6th post-operative week. At first, only toe-touch
weight-bearing was allowed, and weight-bearing
is gradually increased to full by the 6th post-
operative week. The meniscal healing process is
long and requires restriction of activities such as
squatting, jumping, running, and twisting for the
first 6 months post-operatively.
Results of meniscal sutures in children are good,
despite tears extending into the central avas-
cular region (where sutures are usually avoided
in adults). Near 90% of good clinical results are
reported after meniscal tear and ACL repair in 45
knees of patients less than 19 years old (Noyes
(9)).
The meniscal repair and ACL reconstruction are
ideally performed during a single procedure. Proce-
dures can also be chronologically dissociated, with
primary meniscal suture urgently and secondary
ACL reconstruction.
Management of associated ligamentous injuries
Complex ligamentous injuries (both cruciates
tears) and knee dislocations are very rare in chil-
dren. Knee dislocation with integrity of ACL had
been reported. The popliteal vascular risk of injury
of this lesion must be recalled.
Chronically ACL-deficient
fi knee
Traditionally and during many years, non-opera-
tive management has been the mainstay of treat-
ment of ACL midsubstance rupture in children. The
Th
skeletal maturity was the minimal requirement for
ACL reconstruction. This concept has changed.
What about conservative management?
Many studies have been published about conser-
vative management after ACL rupture in children.
These studies are retrospective, with a small num-
ber of patients and short follow-up, and with mul-
tiple biases (age, sex, sport level, etc.). However, all
concluded that the conservative management is
not able to control recurrent instability symptoms.
306 The Traumatic Knee
Despite activity modification,
fi rehabilitation and
bracing, the instability resulted in meniscal inju-
ries and capsulo ligamentous lesions, and after
long-term follow-up to degenerative changes
(Aichroth (16)).
In Graf study, instability was observed only 7
months following the ACL rupture (68). Mizuta
reported 60% of children with instability after 3
years follow-up from the rupture (71). The
Th propor-
tion of instability was 97% in sportman after 4
years follow-up (Mc Carroll (72)).
Instability episodes exposed the patient to second-
ary meniscal injuries, and do not allow going ahead
with sport practice: in Mizuta study, 95% patients
had stopped sports in the 3 years following the
rupture (71).
Secondary meniscal injuries are mainly seen in the
medial compartment (31, 68, 73). Millet distin-
guished acute reconstruction within 6 weeks fol-
lowing rupture and chronic ACL reconstruction;
the medial meniscal rate of tears increase from 11
to 36% between acute and chronic group (54). ThThe
lateral meniscal rate of tears was found unchanged
between the two groups. Our observations were
similar (73)(cf. Fig. 19).
The time to secondary meniscal lesions seems
shorter in children and adolescent studies than
in adults ones. Bracq and Menous reported that
60% of patients developed secondary meniscal
tears after only 10 months follow-up (31). Two
lesions occurred between 1 and 3 months, 5 cases
between 3 and 6 months, and 8 cases between 6 to
12 months. Graf reported 87% meniscal injuries at
15 months after the rupture (68).
The degenerative evolution was the ultimate step,
50% X-ray abnormalities were observed after only
5 years follow-up! (16, 71) (cf. Fig. 20).
Fig. 19 – Influence of time from injury to ACL recon-
struction on percentage of meniscal tears observed
during surgery (n = 56) (73).
Fig. 20 – Early degenerative knee in a
23-year old patient 10 years after ACL
rupture managed non-operatively (col-
lection Ph. Neyret-Lyon).
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 307
Th
These observations are a plea for early reconstruc-
tion between 3 and 9 months following the acci-
dent causing complete ACL rupture in children. No
study has, as far as we know, reported the rate of
instability and secondary meniscal tears in chil-
dren population who really give up sport activities
at risk or children with partial ACL rupture.
To conclude, conservative management is syn-
onym of natural history and is associated with
poor results.
Isolated extra-articular reconstruction
Mc Carroll (72) reported 10 extra-articular teno-
desis performed in skeletally immature patients;
nine of them had instability and four required an
intra-articular procedure secondary. Extra-articu-
lar reconstruction associated with meniscal suture
to protect the repairment is not a valid option, as
giving way and secondary meniscal tears appear
with time (68). Thus, the protection of the menis-
cus is only temporary.
ACL reconstruction on skeletally immature patients
The intra-articular reconstruction is the preferred
treatment. Strategies and surgical techniques
are still debated in the adult practice. In pediat-
ric practice, strategies are associated with one
more diffi
fficulty: do not interfere with the residual
growth.
Different techniques of reconstruction
Each type of procedure must take into account fi five
parameters: graft resistance (choice of graft tissue),
anatomo-isometry (location of tunnels), quality of
fixation, good tensioning, and no residual growth
disturbance (cf. Fig. 21)
Fig. 21 – Main techniques for ACL
reconstruction in children (74). Name
of author and year of publication are
noticed for each technique.
308 The Traumatic Knee
Choice of graft tissue
-Th
The bone patellar tendon bone autograft had
mechanical properties closed to the ACL; it is
more resistant than 2-string hamstring or 4-string
harmstring ligament (75). However, the anterior
tuberosity growth plate does not permit to har-
vest a bone tendon bone graft. The Th use of this
graft results in a bone recurvatum due to anterior
growth arrest and possible inverted tibial slope.
The Clocheville technique described by Robert and
Bonnard (76) (cf. Fig. 21) detaches distal patellar
tendon fibers on the perichondral ring (like gold-
twaith procedure) without bone. The graft length
is increased by the fibrous-osseous
fi surface of the
patella harvested 2 cm long and 2 cm wide and
rolled like a cigarette.
Hamstring tendons are extensively used in USA.
These grafts can be 2-strings (Lipscomb (46), Brief
(77), Bisson (78), Parker (48), Matava (79), Janarv
(44), Mc Intosh (80)) or 4-strings, the fixation
fi is
the weak point. Moreover wide anatomic varia-
tions in length and useful diameter can be a prob-
lem in child.
The iliotibial band distally attached on it tibial
insertion (Gerdy’s tubercle) is used as an extra
and intra-articular procedure by Nakhostine (81),
Micheli (82), and Jaeger and Poulhes (83). TheseTh
authors routed the band under the lateral collat-
eral ligament and over the top of the lateral femo-
ral condyle. The tibial passage was over the front
of the tibia (82), or through an epiphyseal tun-
nel (81, 83). This long graft tissue is more elastic
than short intraarticular graft. Jaeger increased
the graft diameter taking 3–4 cm wide of iliotibial
band and rolling it like a cigarette; the aponeurosis
was closed using the intermuscular septum.
Quadriceps tendon is used by Stäubli (84), Lo (85),
and Gebhard (86). We also used this transplant
since 2003 due to good mechanical properties,
possiblities to harvest a graft as wide as necessary,
and to have bone block on the patella side.
The use of allograft (dead donor) of Achilles ten-
don is promoted by Aronowitz (87), Andrews (88),
and Kim (1). Fuchs (89) used a allograft from patel-
lar tendon. The allograft ligamentization could be
slower with alteration of mechanical properties
during the first year post-operatively. This graft is
not widely used in Europe due to the immunologic
reaction produced and the risk of infectious dis-
ease transmission.
In adult practice, extra-articular plasty in com-
bination with intra-articular procedure is still a
controversy. According to the defenders of the
extra-articular reinforcement plasty, it is indicated
in major laxities, high level sport practice, and in
case of articular recurvatum. Because of the laxity,
daily pivot-sport athletes, children could have ben-
fit from it. The reinforcement can be in the con-
efi
tinuity of the same intra and extra-articular graft
(Nakhostine 78], Micheli (82), Jaeger (83)). It can
also be an independent procedure (Brief (77), Lip-
scomb (6)). Extra-articular plasty can be source of
growth disturbance without epiphysiodesis due to
the tenodesis eff
ffect (8) (cf. Fig. 24-C).
Location of tunnels and position of the graft (anatomo-
isometry)
Adult-type procedures applied to children use tun-
nels through growth plates. These Th methods are
called transphyseal (Matava (79), Aronowick (87),
Bellier (90)). The main risk of growth disturbance
is on the femoral side due to peripherical location.
Authors of these methods insist about few rules:
– Drill the growth plate by hand or with low rota-
tion motor to avoid thermal injury.
– Use small tunnels diameter about 7–8 mm.
Kocher (8) reported two cases of growth dis-
turbance due to big tunnels (12 mm). However,
limits in experimental studies are vague and con-
tradictory ((Guzzanti [91), Houles (92)]. During
canine experimentation, a semimembranous
tendon driven through a femoral tunnel around
11% of the growth plate did not cause growth
disturbance after 6 months follow-up (91).
– Have a tibial transphyseal tunnel as vertical as
possible (60° of minimal obliquity) in order to
limited the growth plate damage.
– Bend the knee into important flexion fl when drill-
ing the femoral tunnel from inside not to damage
posteriorly the growth plate in periphery and the
perichondral ring. Such a lesion could induce a
combined valgus and flexion deformity with ver-
ticalization of the Blumensaat line (due to ante-
rior residual growth) (cf. page 291).
– Do not place a bone block or a screw (even resorb-
able) though the growth plate, this would produce
an experimental growth arrest! Tendinous grafts
make a fibrous interposition which may prevent
any bone bridge through the growth plate and
allow residual growth. Stadelmayer (93) reported
in a canine ACL reconstruction model that his-
tologic evidence of an osseous bridge could not
be seen in specimens with interposed iliotibial
band. However, bridge formation was seen in
animals that did not have grafting but only drill-
ing across physis.
Transphyseal intra-articular ACL reconstructions
allow anatomic and isometric reconstruction.
However, most of the patients in these series were
adolescents or patients near skeletal maturity with
short residual growth. The Th eff ffect of such proce-
dures on young children is not known.
For fear of drilling the growth plate, numerous
authors proposed alternative methods without
crossing the physis called physeal sparingg tech-
niques:
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 309
– One option is to use no bone tunnels: the graft
crossed over the front of the tibia and is posi-
tioned over the top of the femoral lateral con-
dyle (Parker (48), Brief (77), Micheli (82)). Brief
describes a technique using a medial hamstring
brought in continuity under the coronary liga-
ment (cf. Fig. 21). Micheli uses a variation of the
Nakhostine technique (cf. Fig. 21) with a route of
iliotibial band over the front of the tibia.
These physeal sparing techniques are easy to per-
form with a short learning curve, but on the pre-
tex to respect growth process, add deliberately two
anatomic errors (too much anterior on the tibial
side and too posterior on the femoral side). The Th
absence of isometry facilitates the graft elongation
during extension and secondary ruptures with
“cigarecut effect.”
ff
In contrast with Brief‘s technique, Parker described
a more isometric procedure doing an epiphyseal
groove under the intermeniscal ligament and a
femoral attachement in a notch in the over the top
position. Even without groove or notch, the over
the top position is dangerous as the growth plate
is clearly located there; it is recommended in such
technique to avoid underperiosteal route, which is
at risk of epiphysiodesis (8).
In practice, techniques without tunnels are no lon-
ger used (only 6% of surgeons questioned in the
Kocher survey do not perform tibial tunnels).
– Anderson (94) used a transepiphyseal tech-
nique: the femoral and tibial tunnels went
through the epiphyses but avoided the physis
(Nashville evolution procedure). The princi-
ple of femoral epiphyseal tunnel is appealing
because it allows real anatomic reconstruc-
tion of the ACL. This procedure is technically
demanding and required the use of intra-op-
erative fluoroscopic imaging for a precise and
horizontal tunnel placement from outside to
inside. Lipscomb (46) already used this femo-
ral approach since 1977 (Nashville initial pro-
cedure). According to Behr study (4), the mar-
gin of maneuver is short for not injuring the
physis tangentially (germinative cells are on
the epiphyseal side). The tibial tunnel must be
very horizontal and short (to the opposite of
transphyseal techniques). The main problem
of Anderson technique using a quadruple ham-
string tendon graft is the graft fixation.
Clocheville technique is another physeal sparing
technique. Robert and Bonnard (76) perform a
femoral tunnel in metaphyseal location and sagittal
direction. They use an epiphyseal groove on the tib-
ial side (cf. Fig. 21). The
Th absence of femoral attache-
ment of the graft allows for a relative isometry but
is non-anatomic, and the control of the rotatory
laxity is not achieved. The metaphyseal attachement
produces a vertical ligament and increases the ante-
rior tibial translation during extension. The
Th femo-
ral tunnel migration during growth does not seem
to modify the isometry, as if the reflexion
fl point of
fibers had a neo-attachment.
– Janarv (44) avoided the physis with a 2-strings
semitendinosus tendon. The distal insertion
of the tendon was preserved and the graft was
driven through an epiphyseal tibial tunnel and
placed in over-the-top position on the femur.
Kim (1) described an original epiphyseal tibial
attachement with interference screw fixation
fi to a
bone plug of Achilles tendon allograft (cf. Fig. 21)
but minimal patient age for such procedure was
at least 8 years (because of thickness of the epi-
physis).
Between transphyseal and physeal sparing
techniques, some partial or mixed transphyseal
techniques had been described (Guzzanti (91),
Andrews (88), Bisson (78)). Tibial growth distur-
bances are very rare after ACL reconstruction in
skeletally immature patients even with transphy-
seal methods. To the opposite, authors concern
about femoral growth disturbance in valgus and
flexion deformity. Many of the mixed techniques
use a tibial transphyseal method and a femoral
physeal sparing method over the top (Andrews
(88), Bisson (78)). These techniques give a
compromise in term of inocuity and anatomo-
isometry.
Methods of graft fixation
The graft fixation is the main reason for growth
disturbance (8).
The use of staple to fix the graft outside a tun-
nel is a simple and common procedure. Staple can
be on the epiphyseal or metaphyseal side but it
should never cross the growth plate (In Kocher’s
survey (8) the tibial physis was stapled in three
patients).
When the fixation is metaphyseal, the remain-
ing growth made the attachment point migrate
toward the diaphysis (cf. Fig. 22). This
Th phenom-
enon testifi fies the absence of epiphysiodesis but
could have biomechanical eff ffect on the graft: is
there any collagenic fibers
fi relaxation? Does the
graft get thinner or does it sustain progressive
elongation?
The use of interference screws allows stabiliza-
tion of the graft inside the tunnel and closer to
the joint. One advantage is limitation of graft
movements and tunnel widening seen radiologi-
cally. However, tunnel widening is uncommon
with ACL reconstruction on skelatally immature
patients. Just as for bone block in a bone-tendon
graft, the interference screw must not be placed
through the physis (cf. Fig. 23). Kim (1) proposed
an allograft fi fixation on the tibial side with an
interference screw in a closed tunnel strictly epi-
310 The Traumatic Knee
Fig. 23 – Technical fault producing femoral valgus and tibial varus defor-
mities due to growth arrest after fixation by transphyseal screwing dur-
ing an “adult technique” (collection Robert/from the CD ESSKA 2000 Knee
anatomy for orthopedic surgeons). This patient has a clinically malaligned
limb by with an oblique joint.
physeal. The length of the screw is defi
fined with
an anatomic study of the tibial epiphyseal thick-
ness according to the age.
Fig. 22 – (A–P) X-rays after ACL reconstruction
with Nakhostine technique. The staple outside the
tibial tunnel moved toward the diaphyseal area
due to remaining growth. During growth the epi-
physo-metaphyseal tunnel becomes longer and
more vertical. Growth arrest lines (black arrows)
give an idea of how the growth process has
evolved since surgery. Parallelism of this line with
the physis eventually excludes epiphysiodesis.
The option to preserve the physiologic insertion of
a local graft (iliotibial band, hamstring) solves the
fixation diffi
fficulty; but such a graft presents a long
transplant with a distance fi fixation and results in a
high module of elasticity.
The weak point in techniques using hamstring ten-
dons is the fixation; Anderson (94) used a 4-strings
plasty. Because of short graft an Endo-button®
is used on the femoral side and tibial fixation
fi is
achieved with thread on a metaphyseal screw. Such
an elastic fixation procedure could allow secondary
graft elongation.
Graft tension
Edwards (95) highlights the adverse eff ffect of graft
tension across the physis in an experimental work
on canine model. The iliotibial band graft with a
tension of 80N produced signifi ficant shortening,
femoral valgus, and tibial varus deformities with-
out epiphysiodesis bridge. In Kocher’s survey (8),
two patients had tenoepiphysiodesis after extrar-
ticular plasty that could be attribuate to this mech-
anism.
None of the actual techniques (even pedicle graft
and sparing techniques) are able to avoid this spe-
cifi
fic risk. Both graft and fixation should not cross
the physis to avoid this risk.
Post-operative care
Younger is the child, less is the chance of post-
operative knee contracture or stiffness.
ff The early
rehabilitation is not a must as in adults. Some
authors still recommend cast immobilization
which is excluded in adult post-operative liga-
mentous surgery. Cast immobilization is a neces-
sity after bad primary stability; it allows better
observance in young children. None, partial, or full
weight-bearing is recommended according to the
technique used. The rehabilitation can be delayed;
it is progressive and as soft as done in female post-
operative rehabilitation programs. It is recom-
mended to avoid hyperextension.
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 311

When the physiologic recurvatum is important, an
anti-recurvatum orthosis can be useful. ThThis ortho-
sis do not have any stabilization intent, but it helps
ligamentization process of the graft. ThThe recurva-
tum could explain some bad results observed in
children. Organized sport restriction for children
and adolescent is a challenge because the limit
between play and sport is not very well demarcated.
It is important to limit child during the delicate
and graft fragility period between 3 and 6 months
post-operatively. Th
The complete return to full sport
practice is possible according to muscular trophicity
usually arround 8–10 months post-operatively.
Lower limb discrepancy, axial deformity, and
progressive change in passive range of motion,
can refl
flect a growth disturbance (increase knee
recurvatum for example). Comparative and pre-
operative X-rays will help to difffferentiate growth
disturbance due to the initial injury from those
due to the ACL reconstruction procedure. Surgeon
must look at growth arrest lines for an asymetry in
line migration. Growth disturbance can be due to
growth arrest or not; the Fig. 24 shows three dif-
ferent types of growth disturbance. Th The local vas-
cular eff
ffect secondary to injury or surgery can be a
source of overgrowth process and limb discrepancy
due to abnormal stimulation of the pathologic leg.
This overgrowth is rarely more than 2 cm. Such
prediction could be treated by percutaneous epi-
physiodesis after rigourous planning.
For an adequate management, early detection of
growth disturbance clinically and radiologically is
essential. Options can be only simple follow-up to
check a spontaneous bursting of a small bridge across
the physis, it can also be a desepiphysiodesis for larger
bridge in order to avoid progression of the growth
disturbance, more rarely it can be a physeal distrac-
tion in order to correct axial deformity and length.
Authors preferred method
Our experience with ACL reconstruction in chil-
dren started with a partial transphyseal technique
using the iliotibial band similar to Nakhostine’s
technique (81). A tibial transphyseal tunnel was
performed. The over the top position was a low
demanding technique and easily conducted under

Fig. 24 – Three types of growth disturbances after ACL reconstruction in children. “p”” represent physiologic growth process; the dotted line represent the
physiologic “growth arrest line”; The pathologic “growth arrest line” is represented by the continuous one.
– Type A: Absence of growth process (“a”) due to localized injury of the physis and result in a bone bridge across the physis (epiphysiodesis). This growth
disturbance evolves throughout the remaining growth process. The amount of deformity is proportional to the localization and the size of the initial growth
plate injury. Spontaneaous breakage of the bone bridges may occur in very young children whose growth plate can create large distraction forces. This
growth arrest can lead to axial deformities if located at the peripheral of the physis (femoral side) and symmetric leg length discrepancies if located in the
center of the physis (tibial side).
– Type B: Overgrowth process (p+ ( ) is probably caused by a local hypervascularization effect able to stimulate the physis which is still open. This growth
disturbance is temporary and usually becomes apparent in a limited period of 1 or 2 years following the surgery. It leads mainly to a leg length discrepancy.
Sometimes tibial valgus deformity can also occur due to asymmetrical overgrowth (similar to childrens’post-traumatic tibial valgus deformities)(cf. Fig.29).
– Type C: Undergrowth process (p-( ) due to a “tenoepiphysiodesis” effect. The graft tension across the physis causes this deformity with open physis (Edwards
(95), Kocher (8)).
312 The Traumatic Knee

arthroscopy (cf. Figs. 25 and 26). Six patients had
this type of reconstruction: all of them had good
stability and none had secondary meniscal tears.
However, the objective residual laxity assessed
with passive dynamic X-ray was disappointing.
Despite a similar follow-up, results reported by
Nakhostine (91) were much lower than results
reported by Poulhes and Jaeger (96).
In 2003, we started with a new and original pro-
cedure (74). Behr study (4) and Anderson results

Fig. 25 – Details of personnal technique for ACL reconstruction in children.

Fig. 26 – Technical details for femoral epiphyseal tunnel drilling during ACL reconstruction in children. A 2 cm incision is made centered on the lateral
epicondyle. The iliotibial tract is incised longitudinally and the lateral collateral ligament is visualized. C-arm fluoroscopic visualization of the knee in a
strictly lateral plane allows to put a guide pin. The point of the guide is introduced in the femoral epiphysis using the quadran method. The guide wire is
not angulated anteriorly or posteriorly but kept perpendicular to the femur in the coronal plane, until it became a point, and then driven across the femoral
epiphysis. Appropriate drill as used manually to ream over the guide pin.
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 313
(94) were a plea for anatomic reconstruction with
a femoral epiphyseal tunnel parallel to the physis.
Computer assisted surgery (6) was helpful during
the learning curve period in order to reproduce the
anatomic femoral insertion avoiding the growth
plate (cf. Fig. 27). On the tibial side, our transphy-
seal tunnel is near central and there are very rare
growth disturbances reported with this location.
These were all caused by fixation devices (stapling
for example (8)).
Otherwise, the weak point of Anderson’s technique
is the fixation on the femoral side, due to a short
hamstring graft. An alternative was the quadriceps
tendon, this graft has good mechanical properties,
its length and diameter are adaptable to needs (84).
Moreover, it can be harvested with a bone block on
the patella, and thus permits a bone–tendon graft
construct. The use of trapezoidal patella bone block
allows an excellent primary stability in the femoral
Fig. 27 – Femoral position of the tunnel according to the quadran method
of Bernard (5). The epiphyseal tunnel drilled under fluoroscopic control is
below the physis.
tunnel due to impaction and direct bone integra-
tion. The intrarticular passage is conducted under
arthroscopy and the tibial fixation
fi is achieved with
an interference screw strictly metaphyseal (metal-
lic mark) and a staple outside the tunnel or more
recently with a WasherLoc (highest ultimate fail-
ure strength (97)).
This procedure allows early rehabilitation and a
post-operative rehabilitation program is used as
described in adult women. Immediate weight-
bearing is encouraged in case of absence of menis-
cal repair. If an important recurvatum is noted
on the controlateral knee, the splint is quickly
changed for an orthotic brace with ability to
limit the recurvatum during the ligamentization
period. To date, 73 skeletally immature patients
have been operated with this procedure but only
46 have currently reached skeletal maturity (cf.
Fig. 28).
Results
Results of main ACL reconstructions in children are
analyzed in Table 2 but all series included a small
number and a short follow-up. This made compari-
son between techniques very difficult.
ffi Despite the
reported results, extraphyseal procedures without
tunnel are non-anatomic and non-isometric and
are no longer recommended.
Only two comparative studies have been reported:
– Gebhard compared results of 68 patients oper-
ated with four different
ff methods in four cen-
ters (86). None of the methods showed major
diff
fference in outcomes compared to the other.
No growth disturbance could be noted after 32
months of mean follow-up. However, only 40
patients out of 68 were skeletally immature at
time of reconstruction.
– We have recently reported a multicenter study of
102 skeletally immature patients at the time of
Fig. 28 – MRI assessment of the ACL reconstruc-
tion with our procedure: a graft with a normal MRI
signal on an asymptomatic child.
314 The Traumatic Knee

Table 2 – Results of different techniques of intra-articular ACL reconstruction in children.

Mean age
Delay/accident in Associated initial
Author (date) No. of patients
at reconstr Follow-up at revision
months meniscal tears
(range)
Intra-articular plasty without any bone tunnel

Brief (1991) 7 out of 9 17.2 Y (14–28) 4 acute/5 chr _ 3–6.5 Y

Parker (1994) 5 12.9 Y _ 3 ML and 2 ML and MM Mean 2.8 Y

Plasty with patellar tendon and bone tunnels

Mc Carroll (1994) 60 14.2 Y (13–17) _ _ Mean 4.2 Y (2–7)
Robert (1999) 2 ML and 1 mm/2 mm
18 out of 20 12.5 Y (8–14.5) 1 acute/7 chr (1999) Mean 4.5 Y
Bonnard(2000) and 2 ML
Plasty with hamstring tendons and bone tunnels
23/24 menisc tears
10 acute/8 subA
Lipscomb (1986) 24 13.9 Y (12–15) at time of surgery: 12 Mean 3 Y (2–5.5)
and 6 Chr.
ectomy Med and 7 Lat
14.3 Y
Janarv (1996) 15 Mean 12 months _ Minimal 3 Y (8 x >5 Y)
(10.7–16.4)

Matava (1997) 8 14.4 Y (12–15) 4 Acute/4 Chr. 2 MLet 1 mm+ML 2–3,7 Y

3 IJ et 2 Q
Lo (1997) 12.4 Y (8–14) Mean 6.8 m (1–14m) 2 ML + 2 mm Mean 7.4 Y (4.5–9.9)
(+renfort LAD)

Bisson (1998) 9 13 Y (10–15) 5 Acute/4 Chr 2 ML + 3 mm 2–6 Y

13.7 Y
Edwards (2001) 19 out of 20 _ _ Mean 34 Months (17–89 m)
(11.8–15.6)

Guzzanti (2003) 8 11 Y (10–12.5) _ 1 mm Mean 5.5 Y (4–7)

2 Acute 8 SubA and

Anderson (2003) 12 13.3 Y 8 ML + 2 mm Mean 4.1 Y (2–8.2)
2 Chr.

13.8 Y boys 13.3 Y 4 ML + 2 ML + 2 mm

Mc Intosh (2006) 16 _ Mean 41 Months (24–112)
girls (11.2–14.9) + ML
Plasty with allograft and bone tunnels
3 ML 2 mm+ML and
Andrews (1994) 8 13 Y (9–15) 7 Acute/1 Chr. 2–7.7 Y
3 mm
Mean 5.3 m with
Aronowitz (2000) 15 out of 19 13.4 Y (11–15) 12 Menisc tears/19 Mean 2 Y (1–5)
19 Chr

Fuchs (2002) 10 13.2 Y (9–15) _ 4 ML 3 mm 2 ML+MM Mean 3.3 Y

Intra- and extra-articular plasty with iliotibial band

3 ML 1 mm+ML and
Micheli (1999) 8 out of 17 11 Y (2–14) 2 Acute/6 Chr Mean 5.2 Y
1 mm

Nakhostine (1995) 5 14 Y (12–15) 3 Acute/2 Chr 1 ML Mean 4.4 Y (2–6)

Poulhes & Jaeger Mean 26 m 3

8 out of 10 11.4 Y (10–13) 2 mm Mean 4.5 Y (1–15)
(2001) Acute/5 Chr
Chr = Chronic; Sub A = Subacute; MM = medial meniscus ML = lateral meniscus; Second. men. tear = secondary meniscal tear; KT Max = anterior tibial translation during maximum
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 315

Return to sport Subjective Objective evaluation/differential Growth

Clinical result/ secondary menisc. tears
with same level evaluation KT000 disturbance

7 moderate instability 1 franc instability 0 but only 1 immature

6 time with orthesis _ 5 eval: Mean 3.4 mm (2/3/3/4/5 mm)
and all Lachman 1+ boy !
0 despite of groove on
5/5 2/5 moderate instability Lysholm 95.2 Mean (KT max) 3.6 mm ± 1.9
the femur (and tibia)

55/60 3/60 re-ruptures 1 Second. menisc tear _ 51x<3.5, 6x>4<5 et 3>5 mm 0

IKDC 10A 3B 3C 2D 1 Second. menisc. tear 1 Lysholm 12 Exc 5 Good 8 eval: Mean 1.5 mm 2x0 mm 3x1 mm 1/15 at maturity
8/8 (1999)
failure instab/20 et 1M and 3x3 mm (femoral valgus 5°)

1 LLD -20 mm
15/24 2x franc instability 9 patients with symptoms _ 5 eval: mean 2.4 mm (1/1/2/3/5 mm)
(technical fault)

12/15 1 Second. menisc tear Lysholm 92.6 (79–100) _ 0

3/8 (5/8 different Cincinatti score =

1x pivot Shift + 5x>3 mm and 8 mm 0
level) 90–100/10
Mean (KT max) 1 mm ± 1.6
4/5 IKDC 4A and 1C 0 instability or pivot shift + 4 normal knees 0
(-1/1/1/1/3 mm)
2/9 instability with 1 complete rerupture and 1 7 Lysholm 99 1 Lys76 & Mean 2.8 mm with 3x<3 mm 2x >3 and
7/9 0
partial 1Lys 70 <5 mm and 1>5 mm

19 2 reruptures Lysholm modif 93/95 16x<3 mm 2x 3to 6 mm and 2x>6 mm 0

Score OAK =
8 No instability or Second.menisc. tear 5 eval: Mean 1.8 mm (1.5/1.5/2/2/2 mm) 0
96–98/100
8 with no limits
IKDC obj 7A and 5B 2/12 instability during pivots IKDC Subj 96.5 (86 Mean 1.5 mm with only 1 >2.5 mm
and 4 limits with at 1 LLD +10 mm
activity ++ to 100) (3.75)
risk act.

10/16 1/16 Lachman 1+ and pivot-shift 1+ 2 reruptures IKDC subj 99 (94–100) _ 1LLD +15 mm

5/8 1 rerupture/3 pivot shifts + 6 Exc 1Good and 1M 5x<3 mm; 3x 3–5 mm 0

Mean 1.7 mm (10 x <2 mm and 5x >2

16/19 1 second. menisectomy /0 pivot shift + Lysholm 97 (94–100) 0
and <3 mm
IKDC 7A 2B et 1D 1 second. menisc. tear
9/10 Lysholm 95 8x <3 mm et 2x 3à 5 mm 0
(after RTA)

IKDC 7A 2B et 1D No instability or Second.

8/8 Lysholm 97.4 (93–100) 7 eval: Mean 0.6 mm (-2/-1/0/0/1/2/4) 0
menisc. tear/0 pivot shift + and 2 Lachman1+
No instability or Second. menisc.tear/1pivot shift ISKscore 4x195 and 1
5/5 Mean 2.8 mm (1/2/3/3/5) 1 LLD 15 mm
+ and 4 glides to 200
Lysholm 11 x >95
8/8 No instability or Second.menisc. tear 8x<2 mm 0
Tegner 6 to 10
manual stress and KT 1000 assessment; LLD = Lower Limb discrepancy.
316 The Traumatic Knee
reconstruction (98,99). Four different
ff methods
were used in six centers. The mean chronologi-
cal and skeletal ages at reconstruction were
12.3 years and 11.6 years respectively. Th The
mean delay accident-surgery was 10.4 months.
The indication for reconstruction was instabil-
ity three time out of four, and meniscal tear
one time out of four. Four complications were
noticed (one aspiration for joint effusion,
ff one
septic arthritis, one deficit
fi of flexion treated by
arthrolysis, and one fixed
fi flexed deformity due
to cyclops syndrome resected arthroscopically).
After 3.5 year follow-up (range 1–11), 11% of
patients decreased sport level or gave up sport,
18% increased level and 50% returned to same
sport level. The
Th IKDC score was 92 ± 13% with
86% in Class A or B. Thirteen per cent of patients
had a glide during pivot shift test. In this series,
five patients had recurrence of instability due
to technical failure (two cases), biological fail-
ure (one case), or new rupture (two cases after 2
and 9 years following the reconstruction). None
of the four procedures used was found superior
to another (Clocheville physeal sparing tech-
nique, partial transphyseal reconstruction with
quadriceps tendon (personnal method) or ili-
otibial band, and transphyseal reconstruction
with hamstrings).
Meniscal and cartilaginous protection effect
ff apophysis.
Secondary meniscal tears after ACL intra-articular
reconstruction in children are extremely uncom-
mon (cf. Table 2). The ACL reconstruction pre-
serves the medial meniscus at mid-and long-term;
we observed in an adult study that the number of
medial meniscal tear at 10-year follow-up following
ACL reconstruction was 10 times less than medial
meniscal tear in the pre-operative period (Chotel
(100), Millet (54)).
The chondral protection eff
Th ffect is diffi
fficult to esti-
mate because of the short follow-up of current
studies on ACL reconstruction. In children, there
is a lack of evidence to support a protective role of
ACL and meniscus reconstructive surgery on the
development of osteoarthritis. Variation in out-
come is reinforced by additional variables associ-
ated with individuals such as age, sex, genetics,
obesity, muscle strength, activity, and reinjury
(101). Adult series have clearly proven the rela-
tionship between meniscectomy and secondary
osteoarthritis (102).
Growth disturbances
Kocher (8) reported a survey performed at the
Herodicus Society and ACL Study Group about
ACL reconstruction in children. Eleven per cent
surgeons who answered had ever seen a growth
disturbance after ACL reconstrucion on skel-
etally immature patients. They were 15 reported
cases with growth disturbances: eight cases of
distal femoral valgus deformity with arrest of
the lateral distal femoral physis, three cases of
tibial recurvatum with arrest of the tibial tuber-
cule apophysis, two cases of genu valgum with-
out arrest due to a lateral extra-articular tenode-
sis, and two cases of leg length discrepancy (one
shortening and one overgrowth). Almost all cases
were associated with technical errors; deformity
with bony bar associated with implants (inter-
ference screw, staple, multiple transphyseal pin)
or bone plug of a patellar tendon graft across the
physis.
Parents have to be aware that even in experienced
hand, even with physeal sparing techniques, the
risk of growth disturbance is still present after ACL
reconstruction in skeletally immature patient.
We performed a similar survey in 2005 among
Sofcot (Société française de chirurgie otho-
pédique et traumatologique) and Sofop (Société
française d’orthopédie pédiatrique) (103). Nine
new growth disturbances after ACL reconstruc-
tion in skeletal immature patients were identified;
fi
six distal femoral valgus deformities with growth
arrest were reported after Kenneth Jones tech-
nique, transphyseal technique with hamstrings,
or Clocheville technique. Two patients had tibial
recurvatum due to arrest of the tibial tubercule
All these eight children were operated within the year
before closure of the growth plate, but for none
of them the skeletal age were taken into account
(cf. Fig. 29).
One boy (10 years old at surgery) had temporary
tibial valgus deformity secondary to a probable
asymetrical overgrowth by vascular phenomenon
(cf. Fig. 30). A spontaneous correction similar
to post-traumatic genu valgum deformity was
observed during remaining growth (cf. Fig. 31).
Iterative ruptures
The frequency of iterative rupture in children
is estimated around 10–20% (only 2% in adult
series). This could be explained by:
– Return to very intensive sport pratice without
modulation. Young age patients are often in the
middle of their sports progression, 18% patients
with ACL reconstruction return to higher sport
level compared to previous activity level (Cho-
tel 99)).
– A pre-disposition for ACL midsubtance rupture
could be due to the size of intercondylar notch.
Patients with midsubstance ACL injuries could
have a narrower notch index than those with
tibial spine fractures (104). This
Th factor is still
debated but prophylactic notchplasty is not yet
recommended (105).
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 317
Indications and algorithm of treatment (cf. Fig. 32)
The literature analysis shows that indications are
still unclear (cf. Table 2). All authors agree that
blind conservative treatment is a very dangerous
attitude. The classical strategy used by most of
orthopedists is to delay the reconstruction until
skeletal maturity (temporary or waiting conserva-
tive treatment). However, this dogmatic attitude is
no longer valid (73) and multiple factors should be
taken into account:
The skeletal maturity: This assessment must take
into account skeletal age, puberty stage, and clo-
sure of the growth plate on knee X-rays.
Some authors modulate the technique of recon-
struction according to the patient maturity: they
recommend extraphyseal reconstruction for
younger, transphyseal reconstruction for older,
and partial transphyseal procedure in between (Mc
Carrol (45), Micheli (82), Kocher (8), Guzzanti (17),
and Taskiran (106)). The background for this strat-
egy is based on the theoretical impact of growth
arrest according to the age. Older the patient will
be, less important the defomity will be after growth
arrest. However, we noticed in a recent survey
(Chotel (103)) that growth arrest occurs mainly in
adolescents during the last year before knee phy-
seal closure. Capacity of strong growing process to
break spontaneously small epiphyso metaphyseal
bridges is important in young but it slows down
with the maturity process. In others words, conse-
quence of growth arrest is minor in older child but
the risk of growth arrest could be much higher.
That’s why we believe there is a place for a delayed
reconstruction in adolescents close to maturity. Of
course, during the waiting period, the follow-up
must be close with restriction of sports at risk and
a meticulous medical management. Th This tempo-
rary conservative treatment for very young child
is subject to caution. More important the waiting
period is, less good is the observance. It seems
clearly unrealistic to try to restrict a 10 years old
boy for 5 years.
Fortunately, the large majority of ACL ruptures
occur in adolescents. The best indicator to manage
ACL tear in adolescent the same way you do it in
adults is growth plate closure on X-rays, but this
indicator comes late. When central physiologi-
cal closure of growth plate is starting, no angu-
lar deviation can be induced by surgery anymore.
This stage is usually obtained in a girl with 13.5
years of skeletal age (Puberty Tanner 4 and Ris-
ser 1) or a boy 15.5 years of skeletal age (Tanner
4 and Risser 1). The central closure of the growth
plate is sometime diffi
fficult to appreciate on stan-
dard X-rays. In case of difficulties
ffi or dissociation
between skeletal age and puberty, CT scanner will
help to assess the extent of the central physiolog-
ical physeal closure. MRI is not helpful as residual
signal is still present a long time after growth
plate closure.
Instability with repeated giving way in a child with
more than 1 year of residual growth before knee
maturity is necessary and sufficient
ffi condition for
ACL reconstruction without any delay. Instability
with giving way is necessary, because we believe
it is not easy to propose a surgery at risk for an
asymptomatic patient. Sometimes the giving way
is not clearly reported by children, it can also be
dissmissed; the patient must recognize a pivot
shift test as daily or regular symptoms generating
bad feeling (cf. page 295).
Suffi
fficient, because results of conservative treat-
ment in children have shown that medial meniscal
tears appear shortly on an unstable knee.
Timing and delay since the initial accident: Some
authors recommend an ACL reconstruction with-
out delay (only few weeks) after rupture in order
to preserve meniscii (54). This
Th attitude does not
allow a good recovery after the initial injury and
does not permit a good evaluation of the tolerance
to the ACL defificiency.
We recommend ACL reconstruction few months
after the rupture. This small delay allows for the
healing of many meniscal tears and for the evalua-
tion of the functional tolerance to ACL defi ficiency.
According to scholar imperative, the optimal period
for reconstruction is between 3 and 9 months fol-
lowing the initial accident (over this delay, second-
ary meniscal tear will increase).
Delayed reconstruction over 1 year is not recom-
mended unless the knee stability is corrected and
after sport activities at risk have been stopped. A
durable conservative management is a possible
option for uncommon partial ACL ruptures, but in
case of secondary giving way ACL reconstruction
will be required.
The presence of associated meniscal tears: We must
distinguish two situations:
– Meniscal tears that occur during the ACL rupture
have healing capacity and meniscal surgery is
rarely indicated in the acute phase. Only dislo-
cated and fixed bucket-handle tears will urgently
require reduction and suture. In these specific fi
cases, the ACL reconstruction can be delayed for
few weeks (between 6 and 12 weeks). Th This strat-
egy allows for a good preparation to surgery and
easier rehabilitation.
– Occurrence of a secondary meniscal tear means
the failure of conservative treatment and is a for-
mal criteria for ACL reconstruction and meniscal
repair on skeletally immature patient (48, 107).
The social context and the motivation to sport: The
elite-level athlete does not want to stop his career
because of instability; he will be a candidate for
non-delayed reconstruction. Th The uncontrolled child
318 The Traumatic Knee

Fig. 29 – An example of cumulative errors (italic characters) to be avoided during management of ACL rupture in children.
12.5 years old boy (chronological age) at time of ACL rupture of the right knee. The conservative management was pursued despite multiple giving ways and
inability to obtain sports restriction. 15 months later, the patient was admitted in emergency with hemarthrosis due to peripheral medial meniscal tear:
this secondary meniscal lesion has been repairedd without considering the ACL rupture. This suture on an unstable knee failed. Another repair was performed
9 months later and associated this time with an ACL reconstruction but with an adult type Kenneth Jones procedure on a patient now 14.5 years of chrono-
logical age. Unfortunately the skeletal maturation was not taken into accountt and the patient developed a progressive valgus deformity. X-rays performed
6 months following the Kenneth Jones procedure reveals an oblique joint line with femoral valgus and slight tibial varus (A). The lateral view reveals an
associated femoral epiphyseal flexed deformity (decrease in Blumenssat angle) and tibial epiphyseal recurvatum (decrease of tibial slop) (B). Both damages
were due to growth arrest with graft bone blocks in the tunnels. In order to limit progression of the deformity due to remaining growth, an epiphysiodesis
was proposed. But growth plate stapling was unreliable because being performed too late (15 months following ACL reconstruction!) (C and D). Morever and
unfortunately the ACL reconstruction conducted to a poor objective result (IKDC C) (the closed Blumensaat angle may have induced a “cigarecut effect” on
the ACL graft). At the age of 17, the patient is admitted for a new medial meniscal tear. A second Kenneth-Jones procedure was performed associated with a
medial meniscectomyy and the staples were removed ( E and F).
Revision at the age of 23 shows a stable knee with correct range of motion (135°-0-15°) and good subjective results, slight apparent valgus and 2.5 cm++
shortening of the right leg with a resected medial meniscus (G). This result was achieved after four procedures and is consecutive to four or five successive
errors during the management.
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 319

Fig. 30 – Example of overgrowth process secondary to ACL reconstruction

Fig. 31 – Evolution in the same patient reported in Fig. 29; spontaneous
of the left knee in a 10 years old boy (extra and intra-articular iliotibial
resolution of the asymetrical valgus deformity during remaining growth
band according to Nakhostine). “Growth arrest lines” are marked with white
was noticed, and no further epiphysiodesis procedure was required. A small
arrows. Symetrical overgrowth on the femoral side led to a minor leg dis-
residual lower limb discrepancy is noticed at skeletal maturity.
crepancy. Asymetrical overgrowth on the tibial side is probably due to sub-
periosteal approach for graft stapling (out of the transphyseal tunnel). Both
right and left lateral tibial lengths are equal (b). The medial tibial length is
1 cm longer (a + 1) on the left side compared to the right side (a).

Fig. 32 – Organigram for management of ACL rupture in

children. M+ refers to an acute meniscal tear that requires
a repair or to a secondary meniscal lesion. I+ refers to per-
sistent or secondary instability despite a well-conducted
rehabilitation program.
320 The Traumatic Knee
with bad compliance to conservative management
could have pediatric ACL reconstruction. In such
situations, post-operative program and dates have
to be clearly explained. Children or adolescents
can be asked to sign up a commitment contract
to respect the post-operative care and progressive
return to sport after ACL reconstruction.
Conclusions
Th
There are many specifific features in chidren’s ACL
rupture compared to adults. The remaining growth
potential is an important factor to consider. Th The
physis is a fragile structure that can be hurt during
the accident or during ACL reconstruction. How-
ever, immaturity is not only skeletal but also artic-
ular, ligamentous, and capsular. Morever children
motor development is changing. Studies in this
field allow for a better knowledge of physiopathol-
fi
ogy of ACL rupture in children.
The management of knee sprain in children and
Th
adolescents involves a good clinical assessment
adapted to the patient age, an appreciation of
the remaining growth (based on skeletal age and
pubertal stage) and specifi fic pediatric-imaging
techniques.
The exploration of unexplained post-traumatic
Th
hemarthrosis no longer refers to arhroscopy but
rather to MRI. The excellent reputation given to
anterior tibial eminence intercondylar fractures
must be reviewed. In fact, residual laxity is often
observed even after anatomic re-insertion.
Midsubstance ACL rupture on skeletally imma-
tured patients is increasing and it now shares the
same epidemiology than adults. Th The conservative
treatment is a dangerous option that can lead to
unfavorable issues at very short-term. Knowing
the outcome of untreated ACL ruptures, should
we propose a surgical management to all cases,
indistinctive of clinical tolerance? This question
is still debatable and needs to be proven in fur-
ther studies. Some authors prefer systematic
reconstruction. Our strategy is less dogmatic
and instability is our main concern. It seems
in fact diffi
fficult to impose a functional surgery
with its theorical risk of growth disturbances to
an asymptomatic patient, who moreover is not
motivated.
However, ACL reconstruction in children must
often be proposed. The intra-articular procedure is
the method of choice. So far, no technique exhibits
superior results compared to another. The Th theoret-
ical risk of growth disturbances is very low in expe-
rienced hands, but still justifies
fi a close post-opera-
tive follow-up. The meniscal preservation must be
a rule. The prevention of sports accidents should
be a real and permanent concern. An adequate and
systematic physical preparation is required.
References
1. Kim SH, Ha KI, Ahn JH, et al. (1999) Anterior cru-
ciate ligament reconstruction in the young patient
without violation of the epiphyseal plate. Arthroscopy
15(7):792–795
2. Shea KG, Apel PJ, Pfeiffer ff RP, et al. (2002) TheTh tibial
attachment of the anterior cruciate ligament in children
and adolescents: analysis of magnetic resonance imaging.
Knee Surg Sports Traumatol Arthrosc 10(2):102–108
3. King SJ (1997) Magnetic resonance imaging of knee inju-
ries in children. Eur Radiol 7(8):1245–1251
4. Behr CT, Potter HG, Paletta GA Jr (2001) The relationship
of the femoral origin of the anterior cruciate ligament and
the distal femoral physeal plate in the skeletally immature
knee. An anatomic study. Am J Sports Med 29(6):781–
787
5. Bernard M, Hertel P, Hornung H, et al. (1997) Femoral
insertion of the ACL. Radiographic quadrant method. Am
J Knee Surg 10(1):14–21 (discussion 21–22)
6. Benareau I, Testa R, Moyen B (2002) Computer-assisted
anterior cruciate ligament reconstruction: fluoroscopy-
based surgical navigation. Conférence d’enseignement,
Paris: Editions scientifi
fiques et médicales Elsevier SAS, pp
58–64
7. Amis AA, Dawkins GPC (1991) Functional anatomy of the
anterior cruciate ligament. J Bone Joint Surg Br 73:260–
267
8. Kocher MS, Saxon HS, Hovis WD, et al. (2002) Manage-
ment and complications of anterior cruciate ligament
injuries in skeletally immature patients: survey of the
Herodicus Society and The ACL Study Group. J Pediatr
Orthop 22(4):452–457
9. Noyes FR, Barber-Westin SD (2002) Arthroscopic repair
of meniscal tears extending into the avascular zone in
patients younger than twenty years of age. Am J Sports
Med 30(4):589–600
10. Skak SV, Jensen TT, Poulsen TD, et al. (1987) Epidemi-
ology of knee injuries in children. Acta Orthop Scand
58(1):78–81
11. Anderson M, Green WT, Messner MB (1963) Growth and
predictions of growth in the lower extremities. J Bone
Joint Surg Am 45:1–14
12. Dimeglio A (2001) Growth in pediatric orthopaedics. J
Pediatr Orthop 21(4):549–555
13. Sasaki T, Ishibashi Y, Okamura Y, et al. (2002) MRI evalu-
ation of the growth plate closure rate and pattern in the
normal knee joint. J Knee Surg 15:72–76
14. Tanner J (1962) The developement of the reproduc-
tive system. Growth at adolescence. Blackwell scientific, fi
Oxford, pp 28–39
15. Wessel LM, Scholz S, Rusch M, et al. (2001) Hemarthrosis
after trauma to the pediatric knee joint: what is the value
of magnetic resonance imaging in the diagnostic algo-
rithm? J Pediatr Orthop 21(3):338–342
16. Aichroth PM, Patel DV, Zorrilla P (2002) Th The natural his-
tory and treatment of rupture of the anterior cruciate liga-
ment in children and adolescents. A prospective review. J
Bone Joint Surg Br 84(1):38–41
17. Guzzanti V, Falciglia F, Stanitski CL (2003) Physeal-sparing
intraarticular anterior cruciate ligament reconstruction in
preadolescents. Am J Sports Med 31:949–953
18. Bowen (1985) Partial Epiphysiodesis at the knee to correct
angular deformity. Clin Orthop Relat Res 198:184–191
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 321
19. Wester W, Canale ST, Dutkowsky JP, et al. (1994) Predic-
tion of angular deformity and leg-length discrepancy
after anterior cruciate ligament reconstruction in skel-
etally immature patients. J Pediatr Orthop 14(4):516–
521
20. Seil R, Pape D, Adam F, et al. (2003) ACL replacement in
sheep with open physes: an evaluation of risk factors.
Arthroscopy 19(6); suppl 1:32
21. Bylski-Austrow DI, Wall EJ, Rupert MP, et al. (2001)
Growth plate forces in adolescent human knee: a radio-
graphic and mechanical study of epiphyseal staples. J
Pediatr Orthop 21(6):817–823
22. Baxter MP (1988) Assessment of normal pediatric knee
ligament laxity using the genucom. J Pediatr Orthop
8(5):546–550
23. Grana WA, Moretz JA (1978) Ligamentous laxity in sec-
ondary school athletes. Jama 240(18):1975–1976
24. Hinton RY, Rivera VR, Pautz MJ, Sponseller PD (2008).
Ligamentous laxity of the knee during chilhood and ado-
lescence. J Pediatr Orthop 28(2):184–187
25. Roux MO, Carlioz H (1999) Clinical examination and
investigation of the cruciate ligaments in children with
fibular hemimelia. J Pediatr Orthop 19(2):247–251
26. Manner HM, Radler C, Ganger R, et al. (2006) Dysplasia of
the cruciate ligaments: radiographic assessment and clas-
sifi
fication. J Bone Joint Surg Am 88(1):130–137
27. Chouteau J (2001) Index de subluxation: comparaison
entre radiographie dynamique et index KT1000. Mémoire
DIU arthroscopie Lyon
28. Flynn JM, Mackenzie W, Kolstad K, et al. (2000) Objec-
tive evaluation of knee laxity in children. J Pediatr Orthop
20(2):259–263
29. Chotel F, Bergerault F, Accadbled F, et al. (2007) Epidemiol-
ogie des entorses du genou de l’enfant: étude hospitalière
prospective multicentrique. In: Les lésions ligamentaires
et méniscales du genou de l’enfant et de l’adolescent. Rev
Chir Orthop Reparatrice Appar Mot 93(6 Suppl):112–116
30. Senekovic V, Veselko M (2003) Anterograde arthroscopic
fixation of avulsion fractures of the tibial eminence
with a cannulated screw: five-year results. Arthroscopy
19(1):54–61
31. Bracq H, Robert H, Bonnard C, et al. (1996) Lésion du
pivot central du genou de l’enfant et de l’adolescent. Ann
Orthop de l’Ouest 28:171–94
32. Meyers MH, McKeever FM (1970) Fracture of the inter-
condylar eminence of the tibia. J Bone Joint Surg Am
52(8):1677–1684
33. Zifko B, Gaudernak T (1984) Problems in the therapy of
avulsions of the intercondylar eminence in children and
adolescents. Treatment results based on a new classifica- fi
tion. Unfallheilkunde 87(6):267–272
34. Saciri V, Pavlovcic V, Zupanc O, et al. (2001) Knee arthros-
copy in children and adolescents. J Pediatr Orthop B
10(4):311–314
35. Grönkvist H, Hirsch G, Johansson L (1984) Fracture of
the anterior tibial spine in children. J Pediatr Orthop
4(4):465–468
36. McLennan JG (1995) Lessons learned after second-look
arthroscopy in type III fractures of the tibial spine. J Pedi-
atr Orthop 15(1):59–62
37. Mahar AT, Duncan D, Oka R, et al. (2008) Biomechanical
comparaison of four different
ff fixation techniques for pedi-
atric tibial eminence avulsion fracture. J Pediatr Orthop
28(2):159–162
38. Mylle J, Reynders P, Broos P (1993) Transepiphysial fixa-fi
tion of anterior cruciate avulsion in a child. Report of a
complication and review of the literature. Arch Orthop
Trauma Surg 112(2):101–103
39. Hallam PJ, Fazal MA, Ashwood N, et al. (2002) An alter-
native to fixation of displaced fractures of the anterior
intercondylar eminence in children. J Bone Joint Surg Br
84(4):579–582
40. Smith JB (1984) Knee instability after fractures of the
intercondylar eminence of the tibia. J Pediatr Orthop
4(4):462–464
41. Willis RB, Blokker C, Stoll TM, et al. (1993) Long-term
follow-up of anterior tibial eminence fractures. J Pediatr
Orthop 13(3):361–364
42. Wiley JJ, Baxter MP (1990) Tibial spine fractures in chil-
dren. Clin Orthop 255:54–60
43. Iborra JP, Mazeau P, Louahem D, et al. (1999) Fractures
of the intercondylar eminence of the tibia in children.
Apropos of 25 cases with a 1-20 year follow up. Rev Chir
Orthop Reparatrice Appar Mot 85(6):563–573
44. Janarv PM, Westblad P, Johansson C, et al. (1995) Long-
term follow-up of anterior tibial spine fractures in chil-
dren. J Pediatr Orthop 15(1):63–68
45. McCarroll JR, Shelbourne KD, Patel DV (1995) Anterior
cruciate ligament injuries in young athletes. Recommen-
dations for treatment and rehabilitation. Sports Med
20(2):117–127
46. Lipscomb AB, Anderson AF (1986) Tears of the anterior
cruciate ligament in adolescents. J Bone Joint Surg Am
68(1):19–28
47. Stanitski CL, Harvell JC, Fu F (1993) Observations on
acute knee hemarthrosis in children and adolescents. J
Pediatr Orthop13(4):506–510
48. Parker AW, Drez D Jr, Cooper JL (1994) Anterior cruci-
ate ligament injuries in patients with open physes. Am J
Sports Med 22(1):44–47
49. Kellenberger R, von Laer L (1990) Nonosseous lesions of
the anterior cruciate ligaments in childhood and adoles-
cence. Prog Pediatr Surg 25:123–131
50. Stanitski CL (1988) Anterior cruciate ligament injuries
in the young athlete with open physes. Am J Sports Med
16(4):424
51. Angel KR, Hall DJ (1989) Anterior cruciate ligament injury
in children and adolescents. Arthroscopy 5(3):197–200
52. Bellabarba C, Bush-Joseph C A, Bach BR Jr (1997) Patterns
of meniscal injury in the anterior cruciate-deficient
fi knee:
a review of the literature. Am J Orthop 26(1):18–23
53. Duncan JB, Hunter R, Purnell M, et al. (1995) Meniscal
injuries associated with acute anterior cruciate ligament
tears in alpine skiers. Am J Sports Med 23(2):170–172
54. Millett PJ, Willis AA, Warren RF (2002) Associated inju-
ries in pediatric and adolescent anterior cruciate ligament
tears: does a delay in treatment increase the risk of menis-
cal tear? Arthroscopy 18(9):955–959
55.Bergerault F, Accadbled F (2007) Etude prospective des
lésions méniscales de l’enfant. 1In: Les lésions ligamentaires
et méniscales du genou de l’enfant et de l’adolescent. Rev
Chir Orthop Reparatrice Appar Mot 93(6 Suppl):109–112
56. Patel DV, Aichroth PM, Al Duri ZA (1993) Th The natural his-
tory of anterior cruciate ligament in children and adoles-
cent. J Bone Joint Surg Br 75(Suppl 1):99–102
57. Noyes FR, Bassett RW, Grood ES, et al. (1980) Arthroscopy
in acute traumatic hemarthrosis of the knee. J Bone Joint
Surg Am 62:687–692
58. Eiskjaer S, Larsen ST (1987) Arthroscopy of the knee in
children. Acta Orthop Scand 58(3):273–236
59. Luhmann SJ (2003). Acute traumatic knee effusions
ff in chil-
dren and adolescents. J Pediatr Orthop 23(2):199–202
60. Angel KR, Hall DJ (1989) The role of arthroscopy in chil-
dren and adolescents. Arthroscopy 5(3):192–196
61. Matelic TM, Aronsson DD, Boyd DW Jr, et al. (1995) Acute
hemarthrosis of the knee in children. Am J Sports Med
23(6):668–671
62. Michaud A (1996) Quelle est la place de l’arthroscopie
devant un genou traumatique récent de l’adulte? Con-
férence de consensus sur l’arthroscopie du genou. Sau-
ramps médical, Montpellier, pp 203–207
322 The Traumatic Knee
63. Lee K, Siegel MJ, Lau DM, et al. (1999) Anterior cruciate
ligament tears: MR imaging-based diagnosis in a pediatric
population. Radiology 213(3):697–704
64. Snearly WN, Kaplan PA, Dussault RG (1996) Lateral-com-
partment bone contusions in adolescents with intact ante-
rior cruciate ligaments. Radiology 198(1):205–208
65. Stanitski CL (1998) Correlation of arthroscopic and clini-
cal examinations with magnetic resonance imaging fi find-
ings of injured knees in children and adolescents. Am J
Sports Med 26(1):2–6
66. Major NM, Beard LN Jr, Helms CA (2003) Accuracy of MR
imaging of the knee in adolescents. AJR Am J Roentgenol
180(1):17–19
67. Engebretsen L, Svenningsen S, Benum P (1988) Poor
results of anterior cruciate ligament repair in adolescence.
Acta Orthop Scand 59(6):684–686
68. Graf BK, Lange RH, Fujisaki CK, et al. (1992) Anterior
cruciate ligament tears in skeletally immature patients:
meniscal pathology at presentation and after attempted
conservative treatment. Arthroscopy 8(2):229–233
69. Beaufifils P (2003) Traitement moderne des lésions méniscales
– Reconstruction méniscale. In: Cahiers d’enseignement de
la Sofcot. Edited by Elsevier, Paris, pp 69–87
70. Ihara H, Miwa M, Takayanagi K, et al. (1994) Acute torn
meniscus combined with acute cruciate ligament injury.
Second look arthroscopy after 3-month conservative
treatment. Clin Orthop 307:146–154
71. Mizuta H, Kubota K, Shiraishi M, et al. (1995) The
Th conser-
vative treatment of complete tears of the anterior cruci-
ate ligament in skeletally immature patients. J Bone Joint
Surg Br 77(6):890–894
72. McCarroll JR, Rettig AC, Shelbourne KD (1988) Anterior
cruciate ligament injuries in the young athlete with open
physes. Am J Sports Med 16(1):44–47
73. Henry J, Chotel F, Chouteau J, et al. (2009) Rupture of
the anterior cruciate ligament in children: early recon-
struction with open physes or delayed reconstruction to
skeletal maturity? Knee Surg Sports Traumatol Arthrosc
17(7):748–755
74. Chotel F (2004) Les entorses du genou de l’enfant et de
l’adolescent. In: cahiers d’enseignement et conférences de
la SO.F.C.OT. Elsevier Ed, Paris, pp 209–240
75. Noyes FR, Butler DR, Grood ES, et al. (1984) Biomechani-
cal analysis of human ligament grafts used in knee liga-
ment repairs and reconstructions. J Bone Joint Surg Am
66:344–352
76. Robert H, Bonnard C (1999) The possibilities of using the
patellar tendon in the treatment of anterior cruciate liga-
ment tears in children. Arthroscopy 15(1):73–76
77. Brief LP (1991) Anterior cruciate ligament reconstruction
without drill holes. Arthroscopy 7(4):350–357
78. Bisson LJ, Wickiewicz T, Levinson, et al. (1998) ACL
reconstruction in children with open physes. Orthopedics
21(6):659–663
79. Matava MJ, Siegel MG (1997) Arthroscopic reconstruction of
the ACL with semitendinosus-gracilis autograft in skeletally
immature adolescent patients. Am J Knee Surg 10(2):60–69
80. Mc Intosh AL, Dahm DL, Stuart MJ (2006). Anterior
cruciate ligament reconstruction in skeletally immature
patient. Arthroscopy 22(12):1325–1330
81. Nakhostine M, Bollen SR, Cross MJ (1995) Reconstruc-
tion of mid-substance anterior cruciate rupture in adoles-
cents with open physes. J Pediatr Orthop15(3):286–287
82. Micheli LJ, Rask B, Gerberg L (1999) Anterior cruciate lig-
ament reconstruction in patients who are prepubescent.
Clin Orthop 364:40–47
83. Poulhes JC, Van Hille W, Lutz C, et al. (2000) Réparation
du ligament croisé antérieur de l’enfant. Technique de
Mac Intosh au facia Lata modifi fiée JH Jaeger. In: Jaeger
Ed. Ligamentoplastie du LCA: Mc IntoshFL Versus KJ et
DIDT. Strasbourg: Sauramps .p.169–174
84. Staubli HU, Schatzmann L, Brunner P, et al. (1999) Mechan-
ical tensile properties of the quadriceps tendon and patellar
ligament in young adults. Am J Sports Med 27(1):27–34
85. Lo IK, Kirkley A, Fowler PJ, et al. (1997) The Th outcome of
operatively treated anterior cruciate ligament disruptions in
the skeletally immature child. Arthroscopy 13(5):627–634
86. Gebhard F, Ellermann A, Hoff ffmann F, et al. (2006) Multi-
center-study of operative treatment of intraligamentous
tears of the anterior cruciate ligament in children and adoles-
cents. Knee Surg Sports Traumatol Arthrosc 14:797–803
87. Aronowitz ER, Ganley TJ, Goode JR et al. (2000) Anterior
cruciate ligament reconstruction in adolescents with open
physes. Am J Sports Med 28(2):168–175
88. Andrews M, Noyes FR, Barber-Westin SD (1994) Anterior
cruciate ligament allograft reconstruction in the skeletally
immature athlete. Am J Sports Med 22(1):48–54
89. Fuchs R, Wheatley W, Uribe JW, et al. (2002) Intra-articu-
lar anterior cruciate ligament reconstruction using patel-
lar tendon allograft in the skeletally immature patient.
Arthroscopy 18(8):824–828
90. Bellier G (2000) Rupture du ligament croisé antérieur chez
l'enfant – Indications, techniques et résultats. In: Lan-
dreau P, Christel P, Djian P (eds) Pathologie ligamentaire
du genou. pp 450–462 Springer, Paris, pp 450–462
91. Guzzanti V, Falciglia F, Gigante A, et al. (1994) The
Th eff
ffect of
intra-articular ACL reconstruction on the growth plates of
rabbits. J Bone Joint Surg Br 76(6):960–963
92. Houle JB, Letts M, Yang J (2001) Effects ff of a tensioned
tendon graft in a bone tunnel across the rabbit physis. Clin
Orthop 391:275–281
93. Stadelmayer DA, Arnoczky SP, Dodds J, Ross H (1995)
The effffect of drilling and soft tissue grafting across open
growth plates. Am J Sports Med 23:431–435
94. Anderson AF (2003) Transepiphyseal replacement of the
anterior cruciate ligament in skeletally immature patients. A
preliminary report. J Bone Joint Surg Am 85(7):1255–1263
95. Edwards PH, Grana WA (2001) Anterior cruciate liga-
ment reconstruction in the immature athlete: long-term
results of intra-articular reconstruction. Am J Knee Surg
14(4):232–237
96. Poulhes JC, Van Hille W, Lutz C, et al. (2001) Rupture
du LCA chez l’enfant: opération de Mac Intosh modifiée fi
au Fascia Lata (technique et résultats). Rev Chir Orthop
Reparatrice Appar Mot 87(Suppl 6):2S22
97. Coleridge SD, Amis AA (2004) A comparaison of fi five
tibial-fi
fixation systems in hamstring-graft anterior cruci-
ate ligament reconstruction. Knee Surg Sports traumatol
Arthrosc 12(5):391–397
98. Bonnard C, Chotel F (2007) Knee ligament and menis-
cal injury in children and adolescents. Rev Chir Orthop
Reparatrice Appar Mot. 93(6 Suppl):95–139
99. Chotel F, Bonnard C, Accadbled F, et al. (2007) Résultats
et facteurs pronostiques de la reconstruction du LCA sur
genou en croissance. A propos d’une série multicentrique
de 102 cas. In: Les lésions ligamentaires et méniscales
du genou de l’enfant et de l’adolescent. Rev Chir Orthop
Reparatrice Appar Mot 93(6 Suppl):131–138
100. Chotel F (1996) Résultats à long terme de la reconstruc-
tion du ligament croisé antérieur par le procédé de “Mac
InJones”. These med Lyon, Claude Bernard
101. Lohmander LS, Englund PM, Dahl LL, et al. (2007) The Th
long-term consequence of anterior cruciate ligament
and meniscus injuries: osteoarthritis. Am J Sports Med.
35(10):1756–1769
102. Neyret P, Donell ST, Dejour H (1993) Results of partial
meniscetomy related to the state of the anterior cruciate
ligament. J Bone Joint Surg Br 75:36–40
103. Chotel F, Mottier F, Bonnard C (2007) Enquête de pratique
sur la prise en charge de la rupture du LCA de l’enfant
par les chirurgiens orthopédistes français. In: Les lésions
ligamentaires et méniscales du genou de l’enfant et de
 ACL rupture in children: anatomical and biological bases, outcome of ACL deficient knee… 323
l’adolescent. Rev Chir Orthop Reparatrice Appar Mot 93(6
Suppl):117–120
104. Kocher MS, Mandiga R, Klingele K, et al. (2004) Anterior cru-
ciate ligament injury versus tibial spine fracture in the skel-
etally immature knee: a comparison of skeletal maturation
and notch width index. J Pediatr Orthop 24(2):185–188
105. LaPrade RF, Terry GC, Montgomery RD, et al. (1998) The Th
eff
ffects of agressive notchplasty on the normal knee in
dogs. Am J Sports Med 26(2):193–200
106. Taskiran E, Ergun M (2004) Anterior cruciate ligament
reconstruction in skeletally immature patients. Acta
Orthop Traumatol Turc 38(Suppl 1):101–107
107. Janarv PM, Nystrom A, Werner S, et al. (1996) Anterior
cruciate ligament injuries in skeletally immature patients.
J Pediatr Orthop 16(5):673–677
108. Bonnard C, Bergerault F, Robert H (2002). Reconstruction
du ligament croisé antérieur chez l'enfant: Ligamento-
plastie de Clocheville. In Jaeger, Ligamentoplastie du LCA:
Mc IntoshFL Versus KJ et DIDT. Strasbourg: Sauramps,
pp 175–181
109. Noyes FR, De Lucas JL, Torvik PJ (1974) Biomechanics
of anterior cruciate ligament failure: an analysis of strain-
rate sensivity and mechanisms of failure in primates.
J Bone Joint Surg Am 56:236–253

S.P.
C. Pelluchon
Robinson, W. Shen,
F.H. Fu
Combined injuries of the anterior
cruciate ligament and posterolateral
corner
Introduction
R
upture of the anterior cruciate ligament
(ACL) is a common injury seen by orthope-
dists. When diagnosing and treating ACL
injuries, it is important to carefully evaluate for
concomitant injuries to the knee. The stability and
kinematics of the knee depends on the successful
interaction of the knee ligaments, muscles, menisci,
and articular surfaces. Injury to additional struc-
tures may cause the normal kinematics and long-
term function may be further compromised (1).
The success of ACL reconstruction is dependent on
the surgeon’s ability to identify and address inju-
ries not only to the ACL, but also to the second-
ary stabilizers of the knee (2–4). Recent attention
has been directed toward associated injuries of the
ACL and the posterolateral corner (PLC).
Historically, injury to the PLC has been an elusive
diagnosis and difficult
ffi to treat. The diffi
fficulty in mak-
ing this diagnosis may be related to inconsistent ter-
minology about the PLC, the variation in both injury
pattern and clinical presentation, as well as the lack
of experience in diagnosing this injury. Even when
successfully diagnosed, a knee with a combined ACL
and PLC injury presents a challenging surgical prob-
lem to address. However, the results of ACL recon-
Fig. 1 – Illustration of the medial aspect of the lateral femoral condyle
showing the insertion sites of the AM and PL bundles of the ACL and their
associated osseous landmarks. (Reproduced with permission from Ferretti
et al., Arthroscopy,
y 2007.)
Chapitre 26
struction are consistently worse if the diagnosis is
missed and the PLC injury is not treated appropri-
ately. Th
The purpose of this chapter is to review the
anatomy, function, diagnosis, and treatment of
combined ACL and PLC injuries in hopes to provide
a better understanding of this combination of inju-
ries, increase the frequency of a successful diagno-
sis, and improve the results of their treatment.
Anatomy and function
Anterior cruciate ligament
Structure
The ACL attaches proximally on the posterior aspect
of the lateral femoral condyle and runs in an oblique
course distally through the intercondylar notch to
insert between the medial and lateral tibial spines.
It fans out extensively at its femoral origin and tib-
ial insertion sites such that these sites are approxi-
mately three times larger than the cross-sectional
area of the ligament’s mid-substance (5,6).
It is generally agreed that the ACL consists of two
bundles: the anteromedial (AM) bundle and the
slightly smaller posterolateral (PL) bundle. The Th
bundles derive their names from their relative
insertion positions on the tibia: the AM bundle
inserting anteromedially between the tibial spines
and the PL bundle insertion slightly posterior and
lateral to the AM bundle. A bony ridge runs proxi-
mal to distal through the entire ACL femoral inser-
tion, called the lateral intercondylar ridge. It marks
the anterior border of ACL femoral insertion site.
A second bony ridge, the lateral bifurcate ridge,
can be found in the anterior part of the femoral
footprint that runs anterior to posterior. Th The lat-
eral bifurcate ridge separates the femoral insertion
sites of the AM and PL bundles and may also be
observed by a change in slope of the femoral inser-
tion topography between the femoral insertions of
the AM and PL bundles (7) (Fig. 1).
326 The Traumatic Knee
The two-bundle anatomy of ACL has been dem-
onstrated in fetal specimen. The gross morphol-
ogy of the ACL in fetuses is very similar to the
ACL in adults, but with a more evident distinction
between AM and PL bundles. The histology of the
fetal specimens shows the presence of a septum
dividing the AM and PL bundles of the ACL (8).
Blood supply
A cadaveric study from Toy et al. (9) showed that
ACL vascularization arises from the middle genicu-
lar artery, the vessels of the infrapatellar fat pad,
and the adjacent synovium. The middle genicular
artery gives rise to a number of small peri-ligamen-
tous vessels that form a web-like network within
the synovial membrane. These vessels give rise to
penetrating branches that transversely cross the
ACL and anastomose with the longitudinally ori-
ented endo-ligamentous vessels. Terminal branches
of the inferior medial and lateral genicular arteries
supply the distal portion of the ACL directly. TheTh
insertions of the ACL seem to be better vascular-
ized than the middle portion, while the proximal
portion seems to have a greater vascular density
than the distal portion. The arteries at the ligamen-
tous–osseous junctions of the ACL do not signifi- fi
cantly contribute to the ligament’s vascularity.
Function
The AM and PL bundles are not isometric through
the full knee range of motion; rather, each has
varying contributions to knee stability at different
ff
flexion angles. The AM bundle maintains a more
constant level of tension throughout knee range of
motion, with some increased tension near 45–60°
of knee flexion. The PL bundle is generally more
taut near full extension (with the AM bundle more
lax), and slackens when past 30° of knee flexion.
fl
When near full extension, the PL bundle plays an
important role in limiting anterior tibial transla-
tion and controlling knee rotation (10–12).
Posterolateral corner
Structure
The PLC is composed of multiple anatomic struc-
tures that work together to provide additional
translational and rotational stability for the knee.
The static structures classically included in the
description of PLC injuries include the lateral col-
lateral ligament (LCL), popliteofi
fibular ligament,
PL capsule, lateral capsular ligaments, fabello-
fibular ligament (FFL), and arcuate ligament. The
fi
dynamic structures include the iliotibial band
(ITB), popliteal muscle complex, and the biceps
femoris tendon. There are several anatomic vari-
ants that make the classifi
fication and description of
the anatomy complicated (13–15). There Th has also
been signifi
ficant variation in the literature regard-
ing the nomenclature of these structures (16). We
will review the structures of the PL aspect of the
knee and their function.
Lateral collateral ligament
The LCL originates proximally on the lateral femo-
ral epicondyle and inserts on the lateral aspect of
the fibular head. It has been shown that the femo-
ral insertion of the LCL consistently lies 1.4 mm
proximal and 3.1 mm posterior to the lateral epi-
condyle (17). The
Th fibular insertion lies 8.2 mm
posterior to the anterior border of the fi
fibula, and
28.4 mm antero-inferior to the proximal tip of the
fibular styloid (18,19). The LCL is approximately
70 mm in length.
LCL is the primary static stabilizer to varus stress
of the knee in the initial 0–30° of knee flexion.
As the knee flexes beyond 30°, the LCL becomes
slightly lax. While near full extension, this liga-
ment also provides resistance to external rotation
of the tibia (20).
Popliteofibular ligament
The ligamentous insertion on the fibula is com-
prised of the anterior and posterior popliteofibular
fi
ligaments. They originate from the popliteus ten-
don at its musculotendinous junction and make a
“Y”-shaped confi figuration with anterior and poste-
rior divisions (17,21). The popliteofifibular ligament
is a static stabilizer of the lateral and PL knee by
resisting varus, external rotation, and posterior
tibial translation (17,22).
The popliteofifibular ligament has previously been
identifi
fied as the “short external lateral ligament”
(23), “popliteofibular
fi fascicles” (24), “fi
fibular origin
of the popliteus” (13), “popliteus muscle with ori-
gin from the fibular head” (14), and “popliteofi fibu-
lar fibers” (25).
Posterolateral capsule and capsular ligaments
The joint capsule can be divided into superfi ficial
and deep layers. The deep layer extends postero-
laterally and forms the coronary ligament and the
hiatus for the popliteus tendon. From anterior to
posterior, the joint capsule divides into anterior,
lateral, and posterior sections (15).
The mid-third lateral capsular ligament is formed
by the thickening of the lateral joint capsule of the
knee and it can be divided into the meniscofemoral
and meniscotibial components. Th The meniscofemo-
ral component extends from the femur down to the
meniscus, whereas the meniscotibial component
extends from the meniscus down to the tibia. Th This
ligament complex functions as a secondary stabilizer
 Combined injuries of the anterior cruciate ligament and posterolateral corner 327
to varus stress (20,22). Injury to the meniscotibial
component is relatively common and can be associ-
ated with a bony avulsion (Segond fracture) (26,27).
The coronary ligament of the lateral meniscus lies
Th
posterior to the mid-third lateral capsular liga-
ment. It is the meniscotibial portion of the pos-
terior joint capsule extending from the anterior
margin of the popliteal hiatus to the lateral aspect
of the posteroinferior popliteomeniscal fascicle. It
secures the posterior horn of the lateral meniscus
to the tibia and functions to resist hyperextension
and PL rotation of the tibia (22).
Fabellofibular ligament
Th FFL originates from the posterior aspect of the
The
supracondylar process of the femur blending with
the fibers of the lateral head of the gastrocnemius
muscle or from the lateral margin of the fabella
(when a fabella is present). From its origin, the FFL
descends distally and inserts into the fi fibular pro-
cess. Its attachment is on the posterior and lateral
edge of the styloid process, just posterior to the
attachment of the arcuate ligament and lateral to
the insertion of the poplitealfi
fibular ligament (28).
Arcuate ligament
Th arcuate ligament forms a triangular sheet of
The
fibers that diverge upward from the fibular styloid
and consists of two limbs. A stronger lateral limb
attaches to the posterior capsule and the femur
while a weaker medial limb blends with the oblique
popliteal ligament. Th The attachment of the lateral
limb of the arcuate ligament is just anterior to the
attachment of the FFL at the lateral edge of the
styloid process (28).
It is important to distinguish the arcuate ligament
from the arcuate complex. The arcuate complex
includes the arcuate ligament, LCL, popliteal tendon,
lateral head of the gastrocnemius, FFL, and poplit-
eofi
fibular ligament. Chronic PL rotatory instability
results from injury to the arcuate complex (29).
Signifificant variability has been found in the FFL
and arcuate ligament. Seebacher et al. (15) reported
that 13% specimens have only the arcuate liga-
ment, 20% have only the FFL, and 67% have both
structures. This variation in anatomy contributes
to the diffi
fficulty in identifying these structures in
the operating room.
Iliotibial band
Th ITB is a thick fascial sheath extending over the
The
tensor fasciae latae muscle along the lateral aspect
of the thigh and inserting onto the anterolateral
aspect of the lateral tibial plateau. It can be divided
into superfificial, deep, and capsulo-osseous layers.
The superfi
Th ficial layer is underneath the subcutane-
ous tissues on the lateral aspect of the leg. The
Th deep
and capsulo-osseous layers, commonly known as
“Kaplan fibers,” insert into the lateral supracondy-
lar tubercle of the femur and blend into the lateral
intramuscular septum. Distally, they also insert
onto the lateral aspect of the patella and the lat-
eral tibial tuberosity, just posterior and proximal
to Gerdy tubercle (22,30,31).
The ITB is an important stabilizer of the lateral
compartment and acts as an accessory anterolat-
eral ligament. When the knee fl flexes, the ITB exerts
an external rotational and posteriorly direct force
on the lateral tibia. When the knee extends, the
ITB serves as an important secondary restraint to
varus and PL rotation force (31). Since the super-
ficial layer of the ITB is rarely injured in PLC inju-
ries, it serves as a reliable anatomic landmark dur-
ing the dissection.
Popliteus complex
The popliteus musculotendinous unit and its mul-
tiple ligamentous connections to the fi fibula, tibia,
and meniscus are known as the popliteus complex.
The popliteus is an obliquely oriented muscle that
originates from the posteromedial aspect of the
proximal tibia. It gives rise to the popliteus tendon
at the lateral one-third of the popliteal fossa and
passes through the popliteal hiatus in the coro-
nary ligament of the lateral meniscus. Th The tendon
runs intra-articularly for part of its course before
inserting onto the lateral femoral condyle (22). TheTh
insertion site consistently lies anterior and inferior
to the LCL femoral insertion (14,17). The popliteus
is a dynamic internal rotator of the tibia and plays
a major role in dynamic and static stabilization of
the lateral tibia on the femur. The popliteus com-
plex restricts posterior tibial translation and exter-
nal tibial rotation, and resists varus stress of the
tibia, while providing dynamic stability to the lat-
eral meniscus (24,32).
As the popliteus tendon courses proximal and later-
ally, it gives off
ff three branches known as the popli-
teomeniscal fascicles. These branches contribute to
the dynamic stability of the lateral meniscus and
prevent its medial entrapment when varus force is
applied to the knees (20,24,33). The specifi fic role
of each individual fascicle is not completely under-
stood.
Biceps femoris
The biceps femoris is comprised of two heads, the
long head and the short head, each with fivefi distal
insertions (22,34). The three most important
branches of the long head are the direct arm (attaches
to the PL aspect of the fibular styloid), the anterior
arm (courses lateral to the LCL), and the lateral
aponeurotic arm (attaches to the PL portion of the
LCL). The capsular arm and the anterior arm are the
328 The Traumatic Knee

Fig. 2 – (A) Cross-section anatomy illustrating the layers of the posterolateral corner. (B) Illustration of the anatomy and layers of the posterolateral corner
from a posterolateral view. (Reproduced with permission from Seebacher et al., JBJS, 1982.)
 Combined injuries of the anterior cruciate ligament and posterolateral corner 329
most important branches of the short head of the
biceps femoris. The distal portion of the capsular
arm is the FFL and provides support for the PL
capsule. The
Th anterior arm of the short head blends
with the meniscotibial component of the mid-third
lateral capsular ligament as it attaches to the tibia.
Layers of the posterolateral corner
Seebacher et al. (15) studied the dissections of 35
cadaver knees and divided the structures of the PLC
into three distinct layers: superfi ficial (layer I) that
includes the lateral fascia, iliotibial tract, and biceps
femoris tendon; middle (layer II) that includes the
patellar retinaculum and patellofemoral ligaments;
and the deep (layer III) that includes the capsule,
LCL, arcuate ligament, FFL, popliteofi fibular liga-
ment, and the tendon of popliteus (Fig. 2).
Blood supply
The blood supply of the PLC is mainly composed
of branches from the popliteal artery: the lateral
superior genicular, lateral inferior genicular, mid-
dle genicular, posterior tibial recurrent, and several
unnamed branches. The LCL and the lateral region
of the knee are supplied by the articular branches
of the lateral superior genicular artery. Th
This branch
anastomoses with the ascending branch of the
lateral inferior genicular artery, which runs ante-
riorly, deep to the LCL, and supplies surround-
ing structures (34,35). The
Th posterior capsule and
associated structures are supplied primarily by the
middle genicular artery and other small branches
directly off
ff the popliteal artery (35,36). The pos-
terior tibial recurrent artery is the primary blood
supply for the popliteus (15,35).
Function
The primary functions of the PLC are to resist varus
stress, external rotation, and, to a lesser extent,
posterior tibial translation. The
Th biomechanical role
of each component of the PLC has been investigated
by selective ligament sectioning in cadaveric knees
(19,37–44). Veltri and Warren determined that the
main contributors to PL stability are the LCL, popli-
teus, and the popliteofi fibular ligament (45).
The LCL is the primary restraint to varus knee stress
at all flexion angles, whereas the posterior cruciate
ligament (PCL) is considered a secondary restraint.
When the PLC is defi ficient and the PCL is intact, the
PCL will provide some resistance to varus stress,
but it is not as effective
ff in this role as an intact PLC
(2,19,43). Selective sectioning of the PLC reveals
that both the PL capsule and the LCL contribute to
PL rotatory stability against external rotation (46).
The popliteus complex (popliteus tendon and
popliteofifibular ligament) is considered the primary
restraint to external rotation of the knee between
20° and 130° and varus angulation from 0° to 90°
(47,48). However, recent studies have shown that
this function is shared by the LCL, which is the
primary restraint to external rotation near full
extension. The PCL, which is most taut when the
knee is in flexion, also contributes to restraining
external rotation. Isolated injury to the PLC causes
increased external rotation, which can be seen
at 30° of knee flexion in the setting of an intact
PCL. Isolated sectioning of the PCL did not show
increase in rotation at any angle. However, when
both the PCL and the PLC are disrupted, there is
increased external rotation at both 30° and 90° of
knee flexion (19,40,49).
The PLC is also a secondary stabilizer to anterior and
posterior translation. While the primary restraint
to anterior tibial translation is the ACL, the PLC
does provide resistance to anterior tibial translation
in the ACL-defi ficient knee. The PCL is the primary
restraint to posterior tibial translation of the knee,
but the PL structures are important in resisting pos-
terior tibial translation at small flexion angles. With
the knee flexed to 90°, sectioning of the PLC results
in minimal posterior translation. If both PCL and
PLC are injured, sectioning results in a significant
fi
increase in posterior translation of the knee at all
flexion angles (19,45). In summary, the role of the
PLC in resistance to anterior translation seems to
be more prominent near full knee extension (50).
When examining the eff ffect of combined sectioning
of both the ACL and PLC, Veltri et al. (44) found
increased tibial anterior translation and posterior
translation between 30° and 45° as seen with iso-
lated ACL and PLC sectioning, respectively. Inter-
estingly, they also found increased coupled exter-
nal rotation at 30°, 45°, and 90° when compared to
isolated PLC sectioning, but no significant
fi increase
in primary external rotation of the tibia. LaPrade et
al. (51) studied the eff ffect of Grade III PLC injuries
on ACL reconstruction. They found increased ten-
sion on the PCL graft for varus and internal rota-
tion between 0° and 30°. As a result of this work,
most authors recommend concurrent treatment of
combined PLC and ACL reconstruction.
Diagnosis
History
Mechanism of injury
The first step in making the correct diagnosis of a
combined ACL and PLC injury is a thorough his-
tory. Paying close attention to the mechanism of
injury may help in directing the diagnostic algo-
330 The Traumatic Knee
rithm. The ACL is most often injured with a non-
contact twisting or deceleration mechanism. Th The
knee sustains a hyperextension force that may be
associated with internal rotation. Contact injuries
usually result from forced anterior tibial transla-
tion with respect to the femur.
The majority of PLC injuries occur as part of a com-
bined injury pattern with the ACL or PCL with iso-
lated PLC injuries being extremely rare (52). Typi-
cally, there are two types of injury mechanisms:
non-contact and contact. The non-contact injury
pattern typically involves a forceful hyperextension
of the knee or excessive varus stress with concur-
rent tibial external rotation (51,53–55). Alterna-
tive non-contact mechanisms have been described,
but all involved a combination of translation and
rotational forces (53,55–59). Contact injuries are
mainly due to sports, motor vehicle accidents, or
falls. A posterolaterally directed force strikes the
AM proximal tibia, causing hyperextension of the
knee with varus and external rotation during con-
tact injury (52,60).
Symptoms
The acute injury often presents with complaints
of pain and swelling of the knee. The symptoms
of PL instability are variable and depend on the
extent of the injury, the degree and type of laxity,
tibiofemoral alignment, and patient activity level
(45). Patients may have diffi
fficulty with stairs, twist-
ing and pivoting activities, and episodes of “giving
way.” Functional instability is often found when
the patient is in full extension, which limits their
activities (16). Depending on the specific
fi nature of
the injury, the findings in the setting of an acute
injury can be missed if the physician does not
maintain a high index of suspicion.
If the injury is not diagnosed, however, the
patient’s symptoms may progress slowly over sev-
eral months or years. A chronic injury will most
likely cause persistent instability. There may be
lateral joint line pain, paresthesias, and diffi
fficulty
with lateral movements, cutting, or pivoting
activities (45,61). Patients with a history of failed
ACL reconstruction should be carefully evaluated
for associated PLC injury that was not eff ffectively
managed at the time of initial injury.
Physical examination
A complete knee examination is essential to ade-
quately evaluate for potential injury. The
Th contral-
ateral limb, if uninjured, may serve as a baseline
for evaluation of the injured extremity. A careful
neurovascular examination is critical in com-
bined ACL and PLC injuries because the common
peroneal nerve is at particularly high risk. Sensa-
tion changes in the peroneal nerve distribution
and weakness with ankle dorsifl flexion and great
toe extension have been reported in 13–30% of
patients (55,61–63). Distal pulses should be mea-
sured and ankle–brachial indices (ABI) should be
evaluated since vascular injury also may be present
with multiligamentous knee injury.
Tibiofemoral and patellofemoral alignment and
stability need to be assessed. This begins with
inspection of the overall limb alignment, limb
length, and gait pattern. The injured limb usually
presents with edema, ecchymosis, and induration.
In a contact injury, these findings are often found
on the AM proximal tibia. Gait and stance should
be observed to evaluate for a static varus thrust,
dynamic varus thrust, or subluxation with weight
bearing. A varus thrust may be accentuated by hav-
ing the patient walk backwards or with their tibia
rotated externally. Patients may walk with fl flexed
knee to avoid pain and instability experienced with
full extension (54). On palpation, patients usually
have tenderness over PL joint, fi fibular head, and
lateral joint line (45,52).
The combined ACL and PLC injury results in
increased anterior translation, posterior transla-
tion, varus instability, PL rotational instability,
and anterolateral rotational instability. A number
of clinical physical exam tests are used to help
identify these findings. The patient should also
undergo a thorough evaluation of the entire knee
to rule out other associated structural injuries.
Anterior cruciate ligament examinations
Lachman test
With the knee in 30° of flexion, the tibia is trans-
lated anteriorly with respect to the femur. The Th
degree of anterior translation and the presence
or absence of an endpoint is compared to the con-
tralateral knee. The test is graded with respect to
both the amount of relative tibial translation and
the subjective quality of the endpoint (64). Grade
I is defi
fined as increased anterior translation of the
tibia with respect to the femur 0–5 mm greater
than the contralateral side. Grades II and III are
defi
fined as 6–10 and >10 mm, respectively. Grade
A is defi
fined as a firm endpoint while Grade B is a
soft endpoint.
Anterior drawer test
The anterior drawer is performed with the knee
flexed to 90° with the foot stabilized. An anterior
force is directed to the proximal tibia to attempt
anterior translation of the tibia with respect to the
femur. Increased anterior translation of the tibia
when compared to the contralateral knee is indica-
tive of ACL injury.
 Combined injuries of the anterior cruciate ligament and posterolateral corner 331
Pivot shift test
The knee is placed in full extension and slowly
flexed with a valgus force and an axial load. In an
ACL-defificient knee, the tibia will sublux anteri-
orly in extension. As the knee is flexed during the
maneuver, the shape of the lateral femoral condyle
and the inflfluence of the IT band cause the tibia to
reduce. Often, internal or external rotation can
be used to accentuate the reduction during the
maneuver.
Posterolateral corner examinations
Varus stress test
Varus and valgus laxity testing should be per-
formed in full extension and then at 30° of flexion
to isolate the collateral ligaments. An increase in
varus laxity indicates an injury to the LCL. Progres-
sively greater varus laxity is created with additional
injury to the popliteus tendon, meniscotibial por-
tion of the middle third lateral capsular ligament,
and ITB (55).
Posterolateral drawer
The PL drawer test is performed with the knee
flexed to 90° and the tibia is externally rotated
15°. The posteriorly directed force causes the lat-
eral tibia plateau to move while the medial plateau
does not translate (65). When performed at 90°
with the tibia in neutral rotation, posterior trans-
lation is primarily determined by the integrity of
the PCL. However, when performed with external
rotation, increased posterior translation is sugges-
tive of popliteal complex injury (65–67).
Posterolateral external rotation test
The PL external rotation test is performed with
a posterior force placed on the externally rotated
tibia when the knee is in 30° and 90° of fl flexion.
Positive results at 30° indicate a PLC injury while
positive results at 90° may be indicative of PCL
injury (55). When there is an isolated increase of
translation 30° when compared to 90°, the test is
suggestive of isolated PLC injury in the setting of
an intact PCL.
Dial test
The dial test, or PL rotation test, is performed with
the patient in either a supine or prone position.
The knee is tested at both 30° and 90° of flexion
and the relationship of the medial aspect of the
foot to the femoral axis is examined. The normal
values of external rotation at 30° fall between 10°
and 45° while at 90° of knee flexion, tibial external
rotation increases in normal subjects to between
15° and 70° (45). As the result of this test corre-
lates to the presence of ligamentous laxity, the
most useful application is a comparison between
the aff
ffected and contralateral extremities (68). An
isolated increase of 10° or more of external rota-
tion at 30° of flexion suggests an isolated PLC
injury. An increase at both 30° and 90° suggests an
injury of both the PLC and the PCL.
External rotation recurvatum test
The external rotation recurvatum test is used to
diagnose PL rotatory instability in full extension.
It is performed with the patient in a supine posi-
tion and lifting the lower extremity by the great
toe and comparing the position of the knee to the
contralateral side. A knee with a significant
fi PLC
injury should fall into hyperextension, varus, and
tibial external rotation (60). This
Th test is most com-
monly positive in the setting of a combined PLC
and ACL injury (66).
Reverse pivot shift test
The reverse pivot shift test is a dynamic test of the
PLC and the PCL (61). TheTh knee is flexed between
45° and 60° with an external rotation force applied
to the tibia and a valgus stress is applied. If the
PLC is injured, the knee will be subluxed in flexion
fl
by the IT band. The knee is slowly brought to full
extension. At 25–30° of flexion, the IT band will
cause the tibia to reduce. However, this test may
be positive in up to 35% of normal knees examined
under anesthesia (68).
Imaging
X-rays
Routine radiographs in all cases of suggested lat-
eral or PL instability should include flexion
fl and
extension weight-bearing views, a lateral view of
the involved knee, and patellofemoral views of
both knees (69). Avulsion of Gerdy’s tubercle, an
arcuate fracture (avulsion of the fibular head), and/
or increased lateral joint space widening may sug-
gest potential lateral or PL instability. Segond frac-
tures, an avulsion of the lateral aspect of the cap-
sule from the tibial plateau, are commonly thought
to indicate ACL injury but may be found in isolated
PLC injuries as well. Varus and valgus stress views
can be obtained to evaluate for dynamic injury
(24). Patients with chronic PLC injuries may have
radiographic evidence of osteoarthritis in the
medial, lateral, or patellofemoral compartments.
Full length standing films
fi of the bilateral extremi-
ties may be used to evaluate for alignment abnor-
malities.
Magnetic resonance imaging
Magnetic resonance imaging (MRI) can be very
useful in evaluating for injury to the structures
332 The Traumatic Knee
of the PLC (26). The use of standard imaging
sequences as well as a T2-weighted coronal oblique
series that includes the entire fibular head and sty-
loid is recommended for PL injury (20,70) (Fig. 3).
PL knee injuries often will show bone edema on
the AM aspect of the lateral femoral condyle. Ross
et al. showed that this pattern of edema was pres-
ent in all cases of combined PCL and PLC injuries
(71). The
Th size of the fibular styloid fracture and its
location may indicate the severity of injury. The Th
particular area of the fibular
fi head that is avulsed
may indicate which ligaments are injured. Small
avulsions with medial edema may suggest arcuate
or popliteofi
fibular ligament injury. Larger avulsions
with diffffuse proximal fibular edema may repre-
sent LCL and possibly biceps femoris injuries (72).
Juhng et al. found when a fibular avulsion fracture
is appreciated, it is always combined with intra-
articular pathology including cruciate ligament,
meniscus, and PL capsule (73).
Classifification
Ligamentous injuries to both the ACL and PLC
are generally classifi
fied depending on the sever-
ity of the structures. Grade I injuries are sprains
with minimal tearing of the structure of the liga-
ment and are without abnormal knee kinematics.
Grade II injuries have partial tearing with slight to
moderately abnormal joint motion. Grade III inju-
ries are associated with complete disruption of the
described structure with severely abnormal joint
motion. There are no natural history studies in
the literature that describe the results of isolated
injury to the various components of the PLC (16).
Fig. 3 – T2 coronal oblique proton-density-weighted magnetic resonance
image demonstrating the fabellofibular ligament (short arrows), which
extends from the fibular styloid process to fabella. (Reproduced with per-
mission from Yu et al., Radiology,
y 1996.)
Fanelli and Feldman proposed a PLC classifica- fi
tion with three types (A, B, and C) (74). Type A is
defi
fined as increased external rotation only, corre-
sponding to injury to the popliteofifibular ligament
and politeus tendon with an intact LCL. Type B is
defi
fined as increased external rotation with 5–10
mm of lateral joint line opening at 30° of flexion
fl
but a firm endpoint. This is usually attributed to
damage to the popliteofifibular ligament, popliteus
complex, and attenuation of the LCL. Type C is
defi
fined as increased external rotation with >10
mm of lateral joint line opening at 30° of flexion
fl
without a firm endpoint, indicating a complete dis-
ruption of the popliteofi
fibular ligament, popliteus
complex, and LCL.
Treatment
The key to successful treatment of any injury, includ-
ing combined anterior cruciate ligament and PLC
injuries, is patient selection. Each patient should
be evaluated individually and treatment should be
tailored appropriately. Some low-demand patients
may be best treated non-operatively. However, this
chapter will focus on treatment of young, active
patients that intend to return to active lifestyles
and minimize the risk of long-term complications.
Therefore, we will proceed with the assumption of
ACL reconstruction and focus on how to best man-
age the associated PLC injury.
Non-operative treatment
Not all injuries to the PLC require surgical inter-
vention to achieve a successful result. Grade I or
II PLC injuries, in which there is not complete
disruption of the anatomic structures, can have a
good clinical outcome if appropriate conservative
management is applied (63,75). Despite the good
clinical results in the Kannus study, many of these
patients exhibited residual laxity (63,75).
After routine ACL reconstruction the patient should
follow an appropriate ACL rehabilitation protocol
that includes early protected mobilization. It is
important to avoid excessive varus and hyperex-
tension stress with weight bearing while the asso-
ciated injured PLC structures heal, so restricted
weight bearing may be indicated for the fi first 3–4
weeks. Weight bearing is progressed gradually with
a brace locked in extension. After adequate range
of motion has been achieved, progressive strength-
ening and functional training is essential to limit
the risk of re-injury. Early quadriceps strengthen-
ing is performed with the knee in full extension.
Active hamstring activity is restricted for 8 weeks
 Combined injuries of the anterior cruciate ligament and posterolateral corner 333
after surgery. Closed chain exercises begin around
12 weeks and hamstring strengthening exercises
begin around 16 weeks. The progression through
this rehabilitation protocol may be longer than
that expected for an isolated ACL reconstruction.
Active patients with Grade III injuries to the PLC
may have poor results with conservative manage-
ment (75). Often these patients have significant
fi
quadriceps atrophy, gait abnormalities, hyperex-
tension, and a dramatic varus thrust. If untreated,
these abnormalities may lead to additional injury
to the knee and accelerated degenerative joint dis-
ease. Isolated ACL reconstructions performed in
the setting of untreated Grade III injuries to the
PLC are at risk for failure (2). Therefore, surgi-
cal treatment of Grade III PLC injuries is recom-
mended.
Surgical treatment
Surgical treatment of combined ACL and PLC inju-
ries must consist of careful consideration of the
timing of the surgery, assessment of the injury,
determination of a surgical plan, and proper recon-
struction technique for the ACL and PLC. There
Th are
a number of reconstruction techniques, includ-
ing primary repair, repair with augmentation,
advancement, and reconstruction.
Surgical timing
The timing of surgical intervention is a key issue
in the management of PLC injuries. Acute repair
of the PLC, within 3 weeks of injury, has been
shown to have better results than chronic repair
(52,53,56,58,63,76). TheTh best results occur when
the PLC is repaired within the fi
first 2–3 weeks after
injury (27,63,67,71,77–79). After 3 weeks, signifi-fi
cant scar formation and soft tissue attenuation
limits the success of a primary repair and makes
identifi
fication of the peroneal nerve more diffi
fficult.
Some authors recommend staging PLC and ACL
reconstruction to reduce the risk of arthrofi fibro-
sis. In most cases, however, the authors feel that
patients are best treated with combined ACL and
PLC surgery 2–3 weeks after the injury.
Assessment of injury
The first step in surgical intervention is to critically
assess the degree of injury. An examination under
anesthesia gives important clues regarding the
function and stability of the knee. When combined
with preoperative history, physical exam, and
imaging studies, the surgeon should have a good
understanding of the injury pattern and what will
be required for surgical reconstruction before the
first incision is made. This understanding allows
fi
for constructive preoperative planning and makes
the case smooth and time effi fficient. Since the main
contributors to PL stability are the LCL, popliteus,
and the popliteofifibular ligament, these structures
are the main focus of surgical procedures to restore
PL stability of the knee.
Diagnostic arthroscopy is then performed to
confi
firm the diagnosis and address intra-articu-
lar pathology. The cruciate ligaments, menisci,
popliteal hiatus, the popliteomeniscal fascicles,
and the capsular ligaments can be directly assessed.
More than 1 cm of opening of the lateral compart-
ment with varus stress, a positive “drive through
sign,” is suggestive of incompetent lateral struc-
tures. LaPrade found that diagnostic arthroscopy
at the time of open reconstruction assisted in the
diagnosis of Grade III PLC injuries (80). ThereTh is
some risk of fluid extravasation with arthroscopy
in the setting of acute capsular disruption. To
avoid this, the surgeon should be efficient
ffi with
the arthroscopic portion of the procedure and care
should be taken to monitor compartments postop-
eratively. At the time of arthroscopy, intra-articu-
lar meniscal and chondral pathology can be treated
appropriately.
Anterior cruciate ligament reconstruction technique
Careful consideration of the entire surgical plan
should guide decisions regarding the technique and
graft choice. Double-bundle ACL reconstruction is
an excellent option for acute PLC repairs that do
not require additional tunnel placement in the
lateral femoral condyle. When PLC repair or recon-
struction requires a femoral tunnel, it increases the
risk of osteonecrosis of the lateral femoral condyle.
In this situation, single-bundle reconstruction is a
safer option (81). Graft choice for ACL reconstruc-
tion should reflflect the experience of the surgeon,
the desire of an informed patient, and the realiza-
tion of the need for multiple grafts in the com-
pleted procedure.
When addressing combined ACL and PLC injuries,
it is important to prepare the associated cruciate
reconstruction first. Once the exposure for the
PLC portion of the procedure is performed, the
utility of arthroscopy may be limited. It is impor-
tant, however, to delay tensioning of the ACL graft
until the PLC portion of the procedure has been
completed (82).
Posterolateral corner reconstruction technique
Due to the variety of injury patterns included in
PLC injuries, surgical treatment must be tailored
to the specifi
fic injury pattern. The surgical approach
is through a lateral curvilinear incision, straight, or
hockey stick incision depending on surgeon pref-
erence. Terry and LaPrade described a series of
334 The Traumatic Knee
Fig. 4 – Surgical dissection for posterolateral corner as described by Terry
and LaPrade. (Reproduced with permission from Terry and LaPrade, AJSM,
1996.)
three fascial incisions that, when used together,
provide adequate exposure to the entire PLC (34)
(Fig. 4). Although exposing the peroneal nerve is
considered controversial, a safe dissection and
identifi
fication of the nerve from a known location
(either proximal or distal from the area of injury)
may limit the risk of incidental iatrogenic trauma.
A critical part of the dissection includes assessing
the integrity of structures along the way.
Primary repair, augmentation, and advancement
Injury patterns in which the PLC structures are
attenuated or avulsed, but are otherwise intact,
may be best addressed with primary repair. Th This
may be performed with a number of different
ff tech-
niques, including direct sutures, suture anchors,
tunnel soft tissue fixation, bone block LCL advance-
ment, or open reduction internal fixation of bony
fragments. Regardless of the fi fixation technique,
a layered repair should be performed from deep
to superfi
ficial. Tensioning should be performed at
60° of flexion and internal rotation to minimize
the stress across the PLC. A primary repair can be
augmented with allograft in cases with less consis-
tent healing such as intrasubstance tears and acute
injuries with compromised tissue.
Jakob and Warner described a technique to treat
mild cases of PLC instability due to an attenu-
ated, but intact, LCL and popliteal tendon (83).
The authors restored tension in both the popliteus
tendon and the LCL by advancement and re-at-
tachment of these structures into the lateral femo-
ral condyle. In cases in which the tissue was felt
to be insuffi
fficient, the repair was augmented with
additional tissue. With this technique, they re-
established PL stability and maintained anatomic
attachment sites.
Hughston and Jacobson performed an arcuate
advancement in which they made an incision near
Fig. 5 – Technique for advancement of the arcuate ligament complex for
anterolateral rotatory instability. (Reproduced with permission from Hugh-
ston et al., JBJS, 1985.)
the posterior boarder of the IT band, mobilized
and protected the peroneal nerve, lifted a bone
block with an osteotome, and advanced the LCL
anteriorly and proximally while internally rotat-
ing the tibia (76). In 96 knees followed for 4 years,
they reported 85% good objective outcomes, 78%
good subjective outcomes, and 80% good func-
tional outcomes. This technique does not repro-
duce an isometric LCL and, therefore, may stretch
out over time. It also does not address injury to
the popliteal-fi
fibular ligament or the musculoten-
dinous junction of the popliteus (76,84). Th
This tech-
nique is adequate for mild to moderate instability,
but not for severe injury to the PLC (Fig. 5).
Posterolateral corner reconstruction
Patients that have severe or chronic PLC defi ficiency
are best treated with PLC reconstruction, for which
there are many diff fferent techniques. Clancy and
Sutherland describe a non-anatomic technique in
which the biceps femoris tendon is tenodesed to
the lateral femoral epicondyle through a trough
and fixed with screws (85). This is felt to negate the
deforming force of the biceps femoris muscle and
create an approximation of the LCL. They reported
on 39 patients with combined cruciate ligament
and PLC injury. Their
Th findings included 77% of
patients returning to activity with no restrictions
and 54% of athletes returning to prior competitive
level. Veltri et al. pointed out, however, that this
technique does not reproduce the popliteofibularfi
ligament or the popliteus tendon attachment to
the tibia, which are both felt to be important sta-
bilizers (44).
Noyes and Barber-Westin describe a technique in
which they combined arcuate advance with recon-
 Combined injuries of the anterior cruciate ligament and posterolateral corner 335

Fig. 6 – Posterolateral corner reconstruction with Achilles allograft and hamstring autograft. (Reproduced with permission from Noyes et al., AJSM, 1996.)

Fig. 7 – Anterior extracapsular sling for anterolateral rotatory instability. (Reproduced with permission from Albright et al., ICL, 1998.)

struction of the LCL and popliteus tendon (86). In
their technique, the arcuate advancement is per-
formed with the knee in 30° of flexion, rather than
at 90° as previously described by Hughston and
Jacobson (76). Th
The LCL was reconstructed anatom-
ically using bone-patellar tendon-bone autograft
or Achilles allograft while the popliteus was recon-
structed using hamstring autograft (86). They
report on 21 patients with 42 months follow-up
and had 76% good to excellent functional results
with 10% failure rate of the reconstruction (Fig. 6).
Albright and Brown created a posterolateral corner
sling (PLCS) to reconstruct the LCL and the popli-
teus (87). They passed the central slip of the IT band
autograft or an Achilles allograft through a tunnel
in the proximal tibia and fixed
fi it on the femur near
the LCL insertion (87). They eliminated PL rota-
tory instability on physical examination in 87% of
the 30 patients in the study. Failures were defined
fi
by increased joint laxity and other joint pathology.
This technique, however, does not reproduce the
LCL or popliteal-fifibular ligament and may be best
indicated for patients with isolated PL rotational
instability (Fig. 7).
Veltri and Warren recommended an anatomic
reconstruction of all injured PL structures
(43–45,88). They reconstructed the LCL with the
central slip of the biceps femoris, autograft, or
allograft. They recommended that both the tibial
and fibular attachments of the popliteofi fibular
ligament should be addressed. Th The specifi
fics of
this reconstruction depend on the specifics
fi of the
injury. Isolated injury of the popliteus complex
at the tibia or fibula can be reconstructed with a
single graft fixed to the lateral femoral condyle
and secured within tunnels in the tibia or fibula.
336 The Traumatic Knee

Fig. 9 – Lateral collateral ligament reconstruction with bone-patellar

tendon-bone allograft. (Reproduced with permission from Latimer et al.,
AJSM, 1998.)

Fig. 8 – Posterolateral corner reconstruction of the LCL, popliteofibular lig-

ament, and the popliteus complex using a docking technique. (Reproduced
with permission from Verma et al., Arthroscopy,
y 2005.)

Combined injury to both the tibial and fi fibular

attachments can be reconstructed with a single
attachment to the femur and split reconstruction
to the tibia and fibula using a single split Achil-
les allograft, patellar tendon allograft, or patellar
tendon autograft. Later, Verma et al. used a dock-
ing technique to modify this reconstruction to
minimize the length of the femoral tunnel, need
for hardward, and length of the surgical procedure
(89) (Fig. 8).
Latimer et al. reconstructed the LCL with a 9-mm
bone-patellar tendon-bone allograft (90). In 10
patients with combined cruciate and PLC instabil-
ity followed on an average of 28 months, 9 patients
had decreased varus laxity and correction of exter-
nal rotation at 30° of knee flexion. Five of these
patients returned to pre-injury level of activity and
four returned to activity at one level lower. They
felt that use of a large graft served to functionally
replace the other structures of the PLC that were
not specifi
fically reconstructed (Fig. 9). Fig. 10 – Posterolateral corner reconstruction with preservation of the dis-
Santander and Iraporda described a technique tal insertion site of autograft semitendinosis. (Reproduced with permission
in which autologous semitendinosis was used to from Santander et al., Arthroscopy,y 2002.)
reconstruct the PLC (91). In this technique, the
graft is harvested proximally with preservation of an interference screw while the remainder of the
the distal insertion. A tibial tunnel is drilled from graft is brought through a drill hole in the fifibula
the tibial insertion of the semitendinosis to a point and secured to itself with a suture (Fig. 10).
on the lateral tibia close to the emergence of the Arciero uses a technique to reproduce the function
popliteal tendon. The midportion of the graft is of the LCL, the popliteofifibular ligament, and the
secured in the lateral epicondyle of the femur with popliteal complex by using two separate limbs of
 Combined injuries of the anterior cruciate ligament and posterolateral corner 337

Fig. 11 – Photograph of posterolateral corner reconstruction with two limbs of a soft tissue graft.
(Reproduced with permission from Arciero, Arthroscopy,y 2005.)

soft tissue graft (92). One graft is passed through

a transfi
fibular tunnel and an interference screw is
placed in the fibula with equal length of graft on
either side. The posterior limb is used to recon-
struct the popliteal complex and the popliteal-
fibular ligament while the anterior limb is used to
fi
reconstruct the LCL. Both limbs are secured to the
femur with interference screws. Using this tech-
nique in 14 patients with a combination of ACL,
PCL, and PLC injuries, they restored varus stabil-
ity and diminished abnormal pathologic external
rotation of the tibia in all knees (Fig. 11).
Hanypsiak and Parker modified fi a technique
described by LaPrade in which Achilles allograft
is used to reconstruct the popliteal complex and
the LCL (27,93). A single bone block is used as the
femoral attachment while the tendinous portion
of the graft is split into two bundles. ThThe anterior
bundle, reconstructing the popliteus complex, is
passed under the posterior bundle, through a tib- Fig. 12 – Illustration of Achilles tendon allograft and two soft tissue arms
ial tunnel drilled from the distal medial aspect of to reconstruct the posterolateral corner. (Reproduced with permission from
Gerdy’s tubercle to the popliteal tibial sulcus, and Hanypsiak and Parker, Chapter 48: surgical treatment of posterolateral cor-
secured with an interference screw. The posterior ner injuries. In: Surgical techniques in sports medicine. Lippincott Williams
and Wilkins, 2007.
bundle, reconstructing the LCL, is passed deep
to the superfi ficial layer of the ITB and the ante-
rior arm of the long head of the biceps, brought of the injury pattern and use of an appropriate
through the fibular head, and pulled through the reconstruction technique to address the associated
tibial tunnel. The graft is fixed in the fibular head instability will enable to best clinical outcomes.
with an interference screw with the knee flexed
fl to
30° to reconstruct the LCL while the remainder of Valgus osteotomy
the graft is fi
fixed in the tibial tunnel with the ante- In addition to the previously described soft tissue
rior bundle to reconstruct the popliteofi fibular liga- repairs and reconstructions, a valgus osteotomy
ment (Fig. 12). may be indicated to prevent excessive lateral-sided
The specifific soft tissue reconstruction technique loads. Correcting varus malalignment is critical
used must be tailored to the specific fi needs of the to protect soft tissue reconstruction procedures
patient and the injury pattern. Although many of (27,88,95). Patients should be evaluated for both
these techniques report good clinical results, an static malalignment and dynamic varus thrust.
anatomic reconstruction of the injured structures Static deformity is best determined with long
is always preferred (94). An accurate assessment cassette alignment films
fi that can assist in deter-
338 The Traumatic Knee
mining the alignment of the lower extremity with
regard to the mechanical axis. Dynamic deformity,
such as a varus thrust with weight bearing, should
be evaluated in the offiffice as part of the routine
physical examination. While there is some debate
whether re-alignment procedures should be per-
formed concurrently with soft tissue procedures,
most authors recommend ligament reconstruction
6–12 months after successful healing of valgus
osteotomy in order to minimize the risk of compli-
cations (66,95–97). The timing for surgical treat-
ment of acute PLC injury should follow the previ-
ously established guidelines.
Noyes et al. performed high tibial osteotomies
(HTO) in patients with ACL defi ficiency, lower limb
varus angulation, and varying amounts of PLC
fi
deficiency (97). Although they describe using both
medial opening and lateral closing osteotomies,
they prefer a lateral closing wedge tibial and fibu-
fi
lar osteotomy (proximal fibular
fi neck) that pre-
serves the proximal attachment of the tibiofibular
fi
joint. The authors feel this technique avoids the
need for iliac crest bone graft and enables more
rapid osseous union and rehabilitation. Of the 41
patients that underwent HTO, 34 underwent ACL
reconstruction and 18 underwent PLC reconstruc-
tion. At follow-up, 85% of knees had no episodes
of “giving way” and 71% of patients subjectively
felt their knee to be very good or good.
Complications
As with any ligament reconstruction procedure,
there is risk of standard complications such as
graft failure, hardware complications, loss of
motion, hematoma, and infection. With additional
procedures, there is increased risk of femoral con-
dyle fracture, femoral condyle osteonecrosis, graft
impingement, incorrect tunnel placement, tunnel
enlargement, tunnel convergence, and diffi fficulty
with revision surgery. The proximity of the per-
oneal nerve to the operative fifield in PLC recon-
struction makes neurologic complications more
concerning and appropriate care must be taken to
avoid iatrogenic injury. The
Th final treatment plan
should attempt to provide optimal knee stability
and kinematics while minimizing the risk of these
complications.
Rehabilitation
Depending on the extent of the surgical interven-
tion, the standard ACL rehabilitation protocol may
need to be adjusted. The
Th use of a continuous pas-
sive motion machine (CPM) may be implemented
immediately postoperatively through a range of
motion that does not stress the repair or recon-
struction. Since patients may have significant
fi post-
operative pain and swelling, proper management
should include cold therapy. Patients are placed
in a hinged articulated brace to prevent exces-
sive varus and hyperextension stress. They should
begin with early ROM, quadriceps strengthening,
and patellofemoral joint mobility within the first
fi
1–2 weeks. Quadriceps strengthening should be
performed with the knee in full extension during
the initial stages.
Non-weight bearing with the brace locked in full
extension may be indicated for the first
fi 2–4 weeks.
Weight bearing is gradually progressed with the
brace locked in extension until full weight bearing
without crutches is achieved 6–8 weeks postopera-
tively. Active hamstring activity is restricted for
8 weeks after surgery. Closed chain exercises and
hamstring strengthening exercises begin around
10 and 16 weeks postoperatively, respectively.
Return to full activity level without restriction is
usually allowed between 6 and 9 months postop-
eratively. The progression through this rehabilita-
tion protocol may be longer than that expected for
an isolated ACL reconstruction.
Conclusion
Combined injuries of the ACL and the PLC present
a challenging problem for the orthopedic surgeon.
With a clear understanding of the anatomy, a high
index of suspicion, careful clinical evaluation, and
appropriate imaging, these injuries can be appro-
priately diagnosed. Close attention to the specific
fi
nature of the anatomic injury and proper patient
selection will allow treatment to be tailored to the
individual patient. Most Grade I and II injuries of
the PLC can be treated non-operatively in associa-
tion with ACL reconstruction. Grade III injuries
of the PLC should be treated surgically. An ortho-
pedic surgeon treating these injuries should be
familiar with a number of treatment techniques
and principles in order to appropriately utilize the
techniques that best address the injuries. With the
appropriate evaluation and treatment, these inju-
ries can be successfully treated and patients may
obtain excellent results.
References
1. Zelle BA, et al. (2007) Double-bundle reconstruction of the
anterior cruciate ligament: anatomic and biomechanical ratio-
nale. J Am Acad Orthop Surg 15(2):87–96
2. Harner CD, et al. (2000) Biomechanical analysis of a poste-
rior cruciate ligament reconstruction. Defificiency of the poste-
rolateral structures as a cause of graft failure. Am J Sports
Med 28(1):32–39
3. Noyes FR, Barber-Westin SD, Roberts CS (1994) Use of
allografts after failed treatment of rupture of the anterior cru-
ciate ligament. J Bone Joint Surg Am 76(7):1019–1031
 Combined injuries of the anterior cruciate ligament and posterolateral corner 339
4. O'Brien SJ, et al. (1991) Reconstruction of the chronically
insuffi
fficient anterior cruciate ligament with the central third
of the patellar ligament. J Bone Joint Surg Am 73(2):278–
286
5. Odensten M, Gillquist J (1985) Functional anatomy of the
anterior cruciate ligament and a rationale for reconstruction.
J Bone Joint Surg Am 67(2):257–262
6. Harner CD, et al. (1999) Quantitative analysis of human cru-
ciate ligament insertions. Arthroscopy 15(7):741–749
7. Ferretti M, et al. (2007) Osseous landmarks of the femoral
attachment of the anterior cruciate ligament: an anatomical
study. Arthroscopy, in press; 23–11:1218–25
8. Ferretti M, et al. (2007) The fetal anterior cruciate ligament:
an anatomic and histologic study. Arthroscopy 23(3):278–
283
9. Toy BJ, et al. (1995) Arterial supply to the human anterior
cruciate ligament. J Athl Train 30(2):149–152
10. Sakane M, et al. (1997) In situ forces in the anterior cruciate
ligament and its bundles in response to anterior tibial loads. J
Orthop Res 15(2):285–293
11. Gabriel MT, et al. (2004) Distribution of in situ forces in the
anterior cruciate ligament in response to rotatory loads. J
Orthop Res 22(1):85–89
12. Buoncristiani AM, et al. (2006) Anatomic double-bundle
anterior cruciate ligament reconstruction. Arthroscopy
22(9):1000–1006
13. Sudasna S, Harnsiriwattanagit K (1990) The ligamentous
structures of the posterolateral aspect of the knee. Bull Hosp
Jt Dis Orthop Inst 50(1):35–40
14. Watanabe Y, et al. (1993)Functional anatomy of the postero-
lateral structures of the knee. Arthroscopy 9(1):57–62
15. Seebacher JR, et al. (1982) The structure of the posterolateral
aspect of the knee. J Bone Joint Surg Am 64(4):536–541
16. Covey DC (2001) Injuries of the posterolateral corner of the
knee. J Bone Joint Surg Am 83-A(1):106–118
17. LaPrade RF, et al. (2003) The posterolateral attachments of
the knee: a qualitative and quantitative morphologic analysis
of the fibular collateral ligament, popliteus tendon, poplit-
eofi
fibular ligament, and lateral gastrocnemius tendon. Am J
Sports Med 31(6):854–860
18. LaPrade RF, et al. (2005) Mechanical properties of the
posterolateral structures of the knee. Am J Sports Med
33(9):1386–1391
19. Grood ES, Stowers SF, Noyes FR (1988) Limits of movement
in the human knee. Eff ffect of sectioning the posterior cruciate
ligament and posterolateral structures. J Bone Joint Surg
Am 70(1):88–97
20. LaPrade RF, Wentorf F (2002) Diagnosis and treatment
of posterolateral knee injuries. Clin Orthop Relat Res
402:110–121
21. Maynard MJ, et al. (1996) The popliteofi fibular ligament.
Rediscovery of a key element in posterolateral stability. Am J
Sports Med 24(3):311–316
22. Terry GC, LaPrade RF (1996) The biceps femoris muscle com-
plex at the knee. Its anatomy and injury patterns associated
with acute anterolateral–anteromedial rotatory instability.
Am J Sports Med 24(1):2–8
23. Last R (1950) The popliteus muscle and lateral meniscus.
With a note on the attachment of the medial meniscus. J Bone
Jt Surg Br 32:93–99
24. Staubli HU, Birrer S (1990) The popliteus tendon and its
fascicles at the popliteal hiatus: gross anatomy and functional
arthroscopic evaluation with and without anterior cruciate
ligament defi ficiency. Arthroscopy 6(3):209–220
25. Fabbriciani C, Oransky M, Zoppi U (1982) The popliteal
muscle: an anatomical study. Arch Ital Anat Embryol
87(3):203–217
26. LaPrade RF, et al. (2000) The magnetic resonance imaging
appearance of individual structures of the posterolateral knee.
A prospective study of normal knees and knees with surgically
verifi
fied grade III injuries. Am J Sports Med 28(2):191–199
27. LaPrade RF, Hamilton CD, Engebretsen L (1997) Treat-
ment of acute and chronic combined anterior cruciate liga-
ment and posterolateral knee ligament injuries. Sports Med
Arthrosc Rev 5:91–99
28. Diamantopoulos A, et al. (2005) The posterolateral corner of
the knee: evaluation under microsurgical dissection. Arthros-
copy 21(7):826–833
29. Flandry F, Sinco SM (2006) Surgical treatment of chronic
posterolateral rotatory instability of the knee using capsular
procedures. Sports Med Arthrosc 14(1):44–50
30. Terry GC, Hughston JC, Norwood LA (1986) The anatomy
of the iliopatellar band and iliotibial tract. Am J Sports Med
14(1):39–45
31. Kaplan EB (1958) The iliotibial tract; clinical and morpholog-
ical significance.
fi J Bone Joint Surg Am 40-A(4):817–832
32. Noyes FR, Barber-Westin SD (1995) Surgical reconstruction
of severe chronic posterolateral complex injuries of the knee
using allograft tissues. Am J Sports Med 23(1):2–12
33. Simonian PT, et al. (1997) Popliteomeniscal fasciculi and lat-
eral meniscal stability. Am J Sports Med 25(6):849–853
34. Terry GC, LaPrade RF (1996) The posterolateral aspect of
the knee. Anatomy and surgical approach. Am J Sports Med
24(6):732–739
35. Vladimirov B (1968) Arterial sources of blood supply of
the knee-joint in man. Nauchni Tr Vissh Med Inst Sofi fiia
47(4):1–10
36. Scapinelli R (1968) Studies on the vasculature of the human
knee joint. Acta Anat (Basel) 70(3):305–331
37. Gollehon DL, Torzilli PA, Warren RF (1987) The role of the
posterolateral and cruciate ligaments in the stability of the
human knee. A biomechanical study. J Bone Joint Surg Am
69(2):233–242
38. Hoher J, et al. (1998) In situ forces in the posterolateral struc-
tures of the knee under posterior tibial loading in the intact
and posterior cruciate ligament-deficient
fi knee. J Orthop Res
16(6):675–681
39. Kaneda Y, et al. (1997) Experimental study on external tibial
rotation of the knee. Am J Sports Med 25(6):796–800
40. Markolf KL, Wascher DC, Finerman GA (1993) Direct in
vitro measurement of forces in the cruciate ligaments. Part II:
the eff
ffect of section of the posterolateral structures. J Bone
Joint Surg Am 75(3):387–394
41. Noyes FR, et al. (1993) Posterior subluxations of the medial
and lateral tibiofemoral compartments. An in vitro liga-
ment sectioning study in cadaveric knees. Am J Sports Med
21(3):407–414
42. Skyhar MJ, et al. (1993) The eff ffects of sectioning of the pos-
terior cruciate ligament and the posterolateral complex on
the articular contact pressures within the knee. J Bone Joint
Surg Am 75(5):694–699
43. Veltri DM, et al. (1995) The role of the cruciate and poste-
rolateral ligaments in stability of the knee. A biomechanical
study. Am J Sports Med 23(4):436–443
44. Veltri DM, et al. (1996) The role of the popliteofi fibular liga-
ment in stability of the human knee. A biomechanical study.
Am J Sports Med 24(1):19–27
45. Veltri DM, Warren RF (1994) Anatomy, biomechanics,
and physical findings in posterolateral knee instability. Clin
Sports Med 13(3):599–614
46. Nielsen S, et al. (1984) Rotatory instability of cadaver knees
after transection of collateral ligaments and capsule. Arch
Orthop Trauma Surg 103(3):165–169
47. Nielsen S, Helmig P (1986) Posterior instability of the knee
joint. An experimental study. Arch Orthop Trauma Surg
105(2):121–125
48. Nielsen S, Helmig P (1986) The static stabilizing function
of the popliteal tendon in the knee. An experimental study.
Arch Orthop Trauma Surg 104(6):357–362
49. Sapega AA, Covey DC (1994) The biomechanics of femoral
and tibial posterior cruciate ligament graft placement. Clin
Sports Med 13(3):553–559
340 The Traumatic Knee
50. Wroble RR, et al. (1993) The role of the lateral extraarticular
restraints in the anterior cruciate ligament-deficient
fi knee. Am
J Sports Med 21(2):257–262 (discussion 263)
51. LaPrade RF, et al. (1999) The eff ffects of grade III postero-
lateral knee complex injuries on anterior cruciate ligament
graft force. A biomechanical analysis. Am J Sports Med
27(4):469–475
52. DeLee JC, Riley MB, Rockwood CA Jr (1983) Acute poste-
rolateral rotatory instability of the knee. Am J Sports Med
11(4):199–207
53. Baker CL Jr, Norwood LA, Hughston JC (1983) Acute pos-
terolateral rotatory instability of the knee. J Bone Joint Surg
Am 65(5):614–618
54. Fleming RE Jr, Blatz DJ, McCarroll JR (1981) Posterior
problems in the knee. Posterior cruciate insuffi fficiency and
posterolateral rotatory insuffi fficiency. Am J Sports Med
9(2):107–113
55. LaPrade RF, Terry GC (1997) Injuries to the posterolateral
aspect of the knee. Association of anatomic injury patterns
with clinical instability. Am J Sports Med 25(4):433–438
56. Towne LC, et al. (1971) Lateral compartment syndrome of
the knee. Clin Orthop Relat Res 76:160–168
57. Wascher DC, et al. (1993) Direct in vitro measurement of
forces in the cruciate ligaments. Part I: the effect
ff of multiplane
loading in the intact knee. J Bone Joint Surg Am 75(3):377–
386
58. Grana WA, Janssen T (1987) Lateral ligament injury of the
knee. Orthopedics 10(7):1039–1044
59. Wright DG, et al. (1995) Open dislocation of the knee. J
Orthop Trauma 9(2):135–140
60. Hughston JC, et al. (1976) Classifi fication of knee ligament
instabilities. Part II. The lateral compartment. J Bone Joint
Surg Am 58(2):173–179
61. Jakob RP, Hassler H, Staeubli HU (1981) Observations on
rotatory instability of the lateral compartment of the knee.
Experimental studies on the functional anatomy and the path-
omechanism of the true and the reversed pivot shift sign. Acta
Orthop Scand Suppl 191:1–32
62. Twaddle BC, Bidwell TA, Chapman JR (2003) Knee dis-
locations: where are the lesions? A prospective evaluation of
surgical findings in 63 cases. J Orthop Trauma 17(3):198–
202
63. Krukhaug Y, et al. (1998) Lateral ligament injuries of the
knee. Knee Surg Sports Traumatol Arthrosc 6(1):21–25
64. Torg JS, Conrad W, Kalen V (1976) Clinical diagnosis of
anterior cruciate ligament instability in the athlete. Am J
Sports Med 4(2):84–93
65. Hughston JC, Norwood LA Jr (1980) The posterolateral
drawer test and external rotational recurvatum test for pos-
terolateral rotatory instability of the knee. Clin Orthop Relat
Res 147:82–87
66. Cooper JM, McAndrews PT, LaPrade RF (2006) Posterolat-
eral corner injuries of the knee: anatomy, diagnosis, and treat-
ment. Sports Med Arthrosc 14(4):213–220
67. Jacobson KE (1999) Technical pitfalls of collateral ligament
surgery. Clin Sports Med 18(4):847–882
68. Cooper DE (1991) Tests for posterolateral instability of the
knee in normal subjects. Results of examination under anes-
thesia. J Bone Joint Surg Am 73(1):30–36
69. Rosenberg TD, et al. (1988) The forty-fi five-degree posteroan-
terior flexion weight-bearing radiograph of the knee. J Bone
Joint Surg Am 70(10):1479–1483
70. Yu JS, et al. (1996) Posterolateral aspect of the knee:
improved MR imaging with a coronal oblique technique. Radi-
ology 198(1):199–204
71. Ross G, et al. (2004) Evaluation and treatment of acute pos-
terolateral corner/anterior cruciate ligament injuries of the
knee. J Bone Joint Surg Am 86-A(suppl. 2):2–7
72. Lee J, et al. (2003) Arcuate sign of posterolateral knee inju-
ries: anatomic, radiographic, and MR imaging data related to
patterns of injury. Skeletal Radiol 32(11):619–627
73. Juhng SK, et al. (2002) MR evaluation of the "arcuate" sign
of posterolateral knee instability. AJR Am J Roentgenol
178(3):583–588
74. Fanelli GC, Feldman DD (1999) Management of combined
ACL/PCL/posterolateral complex injuries of the knee. Opera-
tive Tech Sports Med 7:143–149
75. Kannus P (1989) Nonoperative treatment of grade II and III
sprains of the lateral ligament compartment of the knee. Am J
Sports Med 17(1):83–88
76. Hughston JC, Jacobson KE (1985) Chronic posterolat-
eral rotatory instability of the knee. J Bone Joint Surg Am
67(3):351–359
77. Noyes FR, Barber-Westin SD (1996) Treatment of complex
injuries involving the posterior cruciate and posterolateral
ligaments of the knee. Am J Knee Surg 9(4):200–214
78. Westrich GH, Hannafi fin JA, Potter HG (1995) Isolated
rupture and repair of the popliteus tendon. Arthroscopy
11(5):628–632
79. Swenson TM, Harner CD (1995) Knee ligament and menis-
cal injuries. Current concepts. Orthop Clin North Am
26(3):529–546
80. LaPrade RF (1997) Arthroscopic evaluation of the lateral
compartment of knees with grade 3 posterolateral knee com-
plex injuries. Am J Sports Med 25(5):596–602
81. Athanasian EA, Wickiewicz TL, Warren RF (1995) Osteone-
crosis of the femoral condyle after arthroscopic reconstruction
of a cruciate ligament. Report of two cases. J Bone Joint Surg
Am 77(9):1418–1422
82. Wentorf FA, et al. (2002) The infl fluence of the integrity of
posterolateral structures on tibiofemoral orientation when
an anterior cruciate ligament graft is tensioned. Am J Sports
Med 30(6):796–799
83. Jakob RP, Warner JP (1992) Lateral and posterolateral rota-
tory instability of the knee. In: Jakob RP, Stäubli HU, editors.
The knee and the cruciate ligaments: anatomy, biomechanics,
clinical aspects, reconstruction, complications, rehabilitation.
New York: Springer:463–494
84. Baker CL Jr, Norwood LA, Hughston JC (1984) Acute com-
bined posterior cruciate and posterolateral instability of the
knee. Am J Sports Med 12(3):204–208
85. Clancy WG Jr, Sutherland TB (1994) Combined posterior
cruciate ligament injuries. Clin Sports Med 13(3):629–647
86. Noyes FR, Barber-Westin SD (1996) Surgical restora-
tion to treat chronic defificiency of the posterolateral complex
and cruciate ligaments of the knee joint. Am J Sports Med
24(4):415–426
87. Albright JP, Brown AW (1998) Management of chronic pos-
terolateral rotatory instability of the knee: surgical technique
for the posterolateral corner sling procedure. Instr Course
Lect 47:369–378
88. Veltri DM, Warren RF (1994) Operative treatment of poste-
rolateral instability of the knee. Clin Sports Med 13(3):615–
627
89. Verma NN, et al. (2005) The docking technique for postero-
lateral corner reconstruction. Arthroscopy 21(2):238–242
90. Latimer HA, et al. (1998) Reconstruction of the lateral col-
lateral ligament of the knee with patellar tendon allograft.
Report of a new technique in combined ligament injuries. Am
J Sports Med 26(5):656–662
91. Santander JA, Iraporda HD (2002) Chronic posterolateral
instability of the knee: a new surgical approach. Arthroscopy
18(2):214–217
92. Arciero RA (2005) Anatomic posterolateral corner knee
reconstruction. Arthroscopy 21(9):1147
93. Hanypsiak BT, Parker RD (2007) Surgical treatment of pos-
terolateral corner injuries. In: ElAttrache NS, Harner CD,
Mirzayan R, Sekiya JK, editors. Surgical techniques in
sports medicine. Philadelphia: Lippincott Williams and
Wilkins:437–449
94. Yong CK (2006) Chronic posterolateral rotatory instability of
the knee. Med J Malaysia 61(suppl. B):27–31
 Combined injuries of the anterior cruciate ligament and posterolateral corner 341

95. Noyes FR, Barber SD, Simon R (1993) High tibial osteotomy ate ligament-deficient
fi knees. Knee Surg Sports Traumatol
and ligament reconstruction in varus angulated, anterior Arthrosc 4(1):32–38
cruciate ligament-deficient
fi knees. A two- to seven-year fol- 97. Noyes FR, Barber-Westin SD, Hewett TE (2000) High tibial
low-up study. Am J Sports Med 21(1):2–12 osteotomy and ligament reconstruction for varus angulated
96. Lattermann C, Jakob RP (1996) High tibial osteotomy alone anterior cruciate ligament-deficient
fi knees. Am J Sports Med
or combined with ligament reconstruction in anterior cruci- 28(3):282–296

N. Thomas, J. Carmichael Failure in ACL reconstruction:
etiology, treatment, and results
Introduction
R
econstruction of the anterior cruciate liga-
ment (ACL) is an increasingly common
surgical procedure. This trend is likely to
continue as the popularity of high-risk leisure
activities increases and the rising number of
female participants results in greater numbers
of ACL injuries. The high success rate of surgical
intervention (>90% in some studies (1,2)) com-
bined with a reluctance from the patient to mod-
ify or reduce activity even into middle age means
conservative treatment is often rejected. In the
USA there are >100,000 ACL reconstructions
performed each year (3). In the United Kingdom
the prevalence is estimated at 5000 per annum
(4). Currently between 3000 and 10,000 USA
residents and approximately 1000 UK patients
are estimated to be candidates for revision ACL
reconstruction annually (4).
It is a commonly held belief that the restoration of
functional stability will slow the onset of degener-
ative change within the knee. This theory is based
on studies demonstrating that delay in surgery
results in increased chondral and meniscal damage
seen at arthroscopy (5) and the protective nature
of the procedure is inferred from this.
The goal of ACL reconstruction is to restore func-
tional stability to the injured knee so as to allow
symptom-free pursuit of an active lifestyle. Pub-
lished success rates vary with some authors quoting
long-term functional stability of >90% (1,2) while
in other studies clinical failure rates of between 10
and 25% are described (4).
The indications for revision ACL reconstruction
are similar to the indications for the primary pro-
cedure. A patient who continues to have instability
or symptomatic laxity limiting activity following
ACL reconstruction is suitable for consideration
of revision surgery. These symptoms may follow
a period of stability and be a result of a further
injury, or occasionally, the primary surgery may
have failed to ever restore stability. The
Th defi
finition
of a clinical failure requiring intervention may also
include a stable but stiffff and painful knee with a
limited range of motion (6).
Chapter 27
Causes of failure of ACL reconstruction
ACL reconstruction can be considered to have failed
if the knee either experiences recurrent instability
or becomes stiff ff and painful with increased laxity
or proven ACL incompetence. Accurate assessment
of the cause and nature of failure is vital in plan-
ning treatment and also avoids the same pitfalls
experienced with the primary procedure. There Th are
four principal categories for causes of ACL recon-
struction failure:
1. technical errors:
– poor graft selection or harvest,
– improper tensioning or fi fixation,
– incorrect tunnel placement;
2. biological factors;
3. trauma;
4. unrecognized additional laxity.
The above-mentioned causes have been exten-
sively investigated and discussed in the literature
(1–3,7–64) with a significant
fi portion of the pub-
lished work focusing on the graft types and/or fi fixa-
tion techniques. It is an unfortunate truth that by
far the most common cause is technical error that
is attributed to 77–95% of all failures. Th The most
common technical error is tunnel malplacement
accounting for 70% of cases (6,30). If the femoral
tunnel is placed too anterior, then flexion
fl will cause
increased tension within the graft resulting in either
restricted flexion or graft failure. The optimum posi-
tion for the femoral tunnel is described as placing
the femoral tunnel at 10 o’clock in the right knee and
at 2 o’clock in the left (45,65) and as far posterior as
possible without compromising the posterior wall.
The tibial tunnel placement is also important – if
the tunnel is placed too far in front of the PCL, then
reduced extension will result due to impingement,
tension in flexion, and gradual graft attrition (36).
If the tunnel is too posterior, laxity in flexion may
result (66). If the femoral tunnel has been placed
using a trans-tibial technique, then malplacement
of the tibial tunnel will result in aberrant femoral
placement. It has been shown that if the tibial tun-
nel is placed too vertically in the coronal plane when
using this technique, a loss of flflexion and increased
anterior laxity may result (67).
344 The Traumatic Knee

The stiff
ff knee reduced range of motion (the captured knee) or
graft failure and recurrent instability. If the tun-
Restriction in knee motion following ACL recon- nels have been suffifficiently misplaced, then sta-
struction may involve a reduction in full extension bility may never have been achieved. An example
or flexion, or a painful reduction in both. In addi- of this is when the femoral tunnel is placed too
tion to the tunnel placement errors mentioned vertically, restoring AP stability but failing to
above, there are many other causes for loss of restore rotational control and thus not reducing
motion following ACL reconstruction. Stiffness ff symptomatic subluxation (Fig. 1).
can be due to impingement, scarring/capsuli- – Graft impingement: This can either be a result of
tis, refl
flex sympathetic dystrophy, or secondary tunnel malplacement or a consequence of a large
osteoarthritis. These conditions may cause restric- graft being placed in a small notch. The resulting
tion to extension, flexion, or a painful reduction in impingement can lead to formation of a cyclops
all movements. lesion as previously discussed or to gradual attri-
Loss of extension is most commonly due to abnor- tion of the graft and eventual failure (Fig. 2).
mal tissue within the intercondylar notch impinge- – Improper graft tensioning: The natural inclination
ment causing a mechanical block. Th This tissue can of the surgeon in reconstructing the ACL is to ten-
be scar tissue, a cyclops lesion or graft tissue due to
tunnel malplacement, failure of removal of the old
ACL, or an inadequate notch plasty. In these cases
flexion is usually normal but patients may com-
plain of morning stiff ffness that improves through
the day (6). When the situation fails to improve
with physiotherapy, surgical intervention may be
required in the form of arthroscopic debridement
and, where necessary, a revision notch plasty.
Stiff
ffness can be due to arthrofifibrosis or capsulitis
and resultant adhesion formation is characterized
by a painful restriction of motion, in both fl flexion
and extension. There may be associated alteration
in patello-femoral mechanics due to patella infera or
extensor mechanism weakness. In the early stages
of the condition treatment is aimed at reducing
the infl
flammation through the use of cold therapy,
anti-inflflammatories, gentle stretching, and night
splints. Manipulation under anesthetic should be
avoided initially as it may aggravate the inflamma-
fl
tory process. Once the acute infl flammatory stage Fig. 1 – Vertical tunnel placement.
is resolved there may be a role for arthroscopic
debridement and arthrolysis. If the condition pro-
gresses to the advanced stage of infrapatellar con-
tracture syndrome, then surgical debridement may
be the only option to improve knee motion but in
the established case some degree of permanent
restriction is usual.

The unstable knee

In order to adequately treat the unstable failed
ACL reconstruction the nature and cause of graft
failure must be understood. Occasionally, a his-
tory of clear trauma exists and the diagnosis and
reason for failure is clear. More commonly surgical
technique is at fault. The technical causes for graft
failure are:
– Tunnel malplacement: When tunnel placement is
such that abnormal graft tension exists, in either
flexion or extension, the result will be either a Fig. 2 – A cyclops lesion.

sion the graft in order to prevent stress relaxation
giving rise to recurrent laxity. It is important to
appreciate however that overzealous tensioning
is associated with graft failure through myxoid
degeneration and delayed vascularization (6).
– Graft selection: Numerous options exist, bone-
patella tendon-bone/hamstrings and autograft/
allograft/synthetic – each graft type has its advan-
tages and disadvantages and although the debate
continues, there is general agreement that syn-
thetic grafts and irradiated allografts have a higher
incidence of failure. The diff fferent graft types are
discussed in more detail later.
– Fixation technique: There is a range of fixation options
available and these will be discussed later (68).
Assessment
The assessment of the unstable knee following ACL
reconstruction is a complex and multi-factorial
process. It is vital to start with obtaining a thor-
ough detailed history including details of the origi-
nal injury, mode of failure (was there a re-injury),
experience of previous treatment, knowledge of the
problem, and expectations including occupational
and recreational aspirations. Even at this early stage,
the patient’s and surgeon’s expectations of outcome
must be matched. The patient must appreciate that
there has already been signifi ficant joint injury and
even a successful reconstruction resulting in a fully
stable knee will not return the knee to normal-
ity. The patient must also understand that there
remains the possibility for joint degeneration due
to chondral and meniscal damage already sustained.
Equally important is the explanation of alternative,
non-operative treatments available.
The most useful investigation to assess these
causes, the retained hardware, and any resulting
“cavitatory” defects is the standard series of four
plain radiographs. ThThis series should include:
1. AP standing.
2. Lateral in full hyperextension: This specifi fically
helps in the assessment of tunnel placement in
the sagittal plane. The use of maximal hyperex-
tension allows the tibial tunnel to be assessed
for placement anterior to Blumenstaat’s line and
subsequent anterior graft impingement.
3. Rosenberg: Provides additional information to
the standard AP regarding joint space narrowing
and notch morphology.
4. Skyline views: Complete the series for assess-
ment of degenerative change in the patello-fem-
oral joint.
It is also our practice to obtain an MRI scan preop-
eratively. While this only rarely changes the man-
agement plan, it does provide useful information
regarding degenerative change and exclusion of
Failure in ACL reconstruction: etiology, treatment, and results 345
additional ligamentous pathology such as occult PCL
disruption. The surgeon must be aware, however, of
the limitations of MRI in the diagnosis of chronic
PCL injuries and both clinical and surgical assess-
ments remain important (69). In addition, the MRI
firms the graft failure in a manner that patients
confi
are easily able to comprehend. When there is no
clear reason for primary graft failure, particular care
must be taken to detect a previously unrecognized
complex laxity, the commonest being postero-lateral
laxity that is best detected by the use of the dial test
at 20° with the patient in the prone position.
Treatment options
The patient with a failed ACL reconstruction pres-
ents a very different
ff clinical problem to the patient
presenting for the first time with a new injury.
Revision surgery is often considered a salvage pro-
cedure with limited goals and the literature fre-
quently quotes inferior results for revision when
compared to the primary procedure (70–73). Th The
inferior outcome may be due to limited graft choice,
diffi
fficulties in accurate tunnel placement, problem-
atic graft fixation,
fi or finally increased degenerative
change as a result of recurrent instability episodes
or abnormal joint constraint (5).
Before embarking on a definitive
fi treatment plan
we ask the following questions:
– Why did the primary graft fail?
– Have we obtained a full diagnosis?
– Have we fully counseled the patient?
– Does the patient understand and accept the pos-
sibility for changes in plan brought about by
unexpected examination under anesthesia (EUA)
or operative findings, which may increase reha-
bilitation time?
– Do the current bone tunnels allow the planned
surgery without compromising graft position
and for biological fixation?
fi
Unless the answer to all of these questions is firmly
positive, our default plan is a cautious two-stage
approach. When staged, there is the opportunity
to accurately assess the other ligamentous struc-
tures, EUA, and stress views under fluoroscopy,
for a complex laxity as well as inspection of the
chondral and meniscal surfaces to give the patient
a more realistic prognosis.
Management of hardware and tunnels
Diff
fferent graft fixation choices result in diff ffer-
ent problems when it comes to revision surgery.
Removal of fixation devices may cause bony
defects, stress risers, or, in the case of countersunk
346 The Traumatic Knee
transfi
fixion devices, morbidity distant to the knee
with large exposures required for removal. A good
general principle is that hardware should only be
removed when absolutely necessary (6).
Metallic implants can be ignored unless their reten-
tion will compromise tunnel placement or fixation.
fi
Bioabsorbable implants can be drilled through
avoiding the need for formal removal but a thor-
ough joint lavage needs to be performed following
this procedure to avoid chondral damage or inflam-
fl
matory response from particulate debris (Fig. 3).
When hardware removal is required, however, a full
set of revision instrumentation must be available
to avoid stripping screw heads and exacerbating
the bone loss. Where possible, previous operative
records should be scrutinized for implant identi-
fication to ensure the correct instrumentation is
available. When removing original hardware care
must be taken to ensure that the head of the screw
is fully visualized and the appropriate screwdriver
is fully seated in line with the shaft of the screw.
This can be aided by inserting a guide wire when
the screw is cannulated. In all cases where hardware
removal is planned the patient should be coun-
seled that a two-stage procedure may be required
to allow bone grafting of original tunnels.
For successful revision surgery the tunnel place-
ments cannot be compromised. Management
of previous tunnel malposition is technically
demanding and there are a variety of techniques
available depending on the position, orientation,
and size of the original tunnels and subsequent
defects. Existing reconstruction tunnels, including
bony defects resulting from hardware removal, can
be considered as belonging to one of the following
three groups:
1. Correct: This allows the original tunnels to be
reused.
Fig. 3 – Plain AP radiograph demonstrating extensive retained hardware.
2. Incompletely incorrect: In this instance the origi-
nal tunnels or the resultant bone defects overlap
the ideal tunnel placement. Unless addressed
this situation would compromise graft fixation.
fi
3. Completely incorrect: The original tunnels are
placed suffi
fficiently far from the ideal position
that they can be ignored altogether. It may occa-
sionally be necessary to alter the orientation of
revision tunnels to avoid converting completely
incorrect tunnels to more problematic incom-
pletely incorrect ones. Similarly, the use of dila-
tors rather than drills may prevent the breaching
of tunnel walls and the creation of large defects
(66). With both these options the most crucial
point is the maintenance of an ideal intra-artic-
ular footprint.
It is the management of the incompletely incor-
rect tunnel, including excessively widened tun-
nel, that creates the most difficulty. Options for
compensating for large cavities vary depending
on the size of the defect. When the tunnel is
only slightly larger than the graft (3–5 mm), the
use of stacked interference screws may be suf-
ficient (74,75). This technique should be used
with caution however as the resulting fixation
tends to be inferior and the rehabilitation may
be compromised.
The use of allograft material allows the use of
enlarged bone plugs to be shaped at the ends of
the graft to compensate for more signifi ficant bony
defects. The use of allograft in both primary and
revision ACL reconstruction has been debated for
a long time (76–78). There
Th is no donor site mor-
bidity when allografts are used and when com-
pared to two-staged procedures, the fi financial cost
can be justified.
fi There are risks however. Viral and
prion transmission is a concern (79) as is slower
incorporation and a reduction in the mechanical
properties due to sterilization techniques. As a
result of these concerns, combined with a lack of
availability, the United Kingdom has not seen the
widespread uptake of allograft techniques seen in
the USA.
Allograft bone dowel use is another alternative
that has been proposed to allow a single-stage
revision when extensive bone defects exist (80).
While the grafts allow sufficient
ffi structural support
for graft insertion, we have concerns regarding the
slower incorporation and subsequent implications
for rehabilitation procedures.
Our experience has been that after an adequate
debridement of pre-existing tunnels the resultant
defect is almost always larger than 10 mm. We
therefore favor staged reconstruction as a default
technique. ThThe first stage involves an EUA, assess-
ment of meniscal and chondral damage, removal
of old graft (including, where appropriate, met-
alwork) and tunnel preparation with curettage,

Fig. 4 – CT scan showing satisfactory graft incorporation.
drilling sclerotic tunnel walls, and bone grafting.
After an interval of usually 6 months a CT scan is
performed to confi firm graft incorporation. If this is
satisfactory, the revision ACL can be performed in
an optimal environment (Fig. 4).
Graft selection
The options available for ligament reconstruction
are:
– Autograft: Most commonly hamstrings, bone-
patellar tendon bone, or occasionally quadriceps
tendon. The debate as to which of these is the
most reliable has waged for many years and is
set to continue. Autograft remains the gold
standard graft and a discussion of which graft
is beyond the scope of this text though meta-
analysis studies have not shown any statistical
superiority.
– Allograft: The use of allograft in the revision set-
ting has many advantages (shorter surgical time,
no donor site morbidity, and a choice of sizes and
shapes, e.g.). The major concerns regarding their
use include graft incorporation, strength, costs,
and disease transmission. In a review Noyes et
al. concluded that allografts should only be used
in cases where a suitable autograft is not avail-
able (76).
– Synthetic: Used in the 1980s and abandoned due
to unacceptably high failure rates these are not
currently recommended practice (30,81). One
could theoretically make a case for their use as
extra-articular sites.
Graft fixation
The role of the graft fixation in ACL reconstruc-
tion is to maintain suffi
fficient graft stability in the
Failure in ACL reconstruction: etiology, treatment, and results 347
early stages of healing to allow incorporation. The Th
fixation must maintain stability without compro-
mising the biology of the healing graft. The Th aim
is to achieve a normal histological and, therefore,
functional transition between graft and host bone.
It is important to note, however, that in the early
postoperative period it is the graft fifixation that is
the weak link and no commonly used fixation
fi tech-
nique has the ultimate failure strength or stiff- ff
ness of the native graft (82) particularly when the
ffects of cyclical loading are taken into account.
eff
The techniques available for graft fixation in the
revision reconstruction are similar to those used
in the primary.
Fixation can be broadly classified
fi as either corti-
cal (suspensory) or apertural (intratunnel). Th The
theoretical advantages of apertural fi fixation are
restoration of a normal graft take-off ff point from
time of surgery, the lack of a bungee effect, ff the
compression of the graft to the host bone aiding
graft incorporation, and a shorter length between
fixation points giving a reduction in the eff ffect of
plastic graft deformation. Anchoring the graft dis-
tal to the joint as in suspensory fi
fixation also has its
advantages. The operation is technically easier, the
tunnels can be kept slightly smaller, there can be a
360° graft incorporation, and for tibial fixation
fi a
suspensory system does not risk pushing the graft
material toward the joint on insertion resulting in
a reduction of graft tension. Furthermore, the sus-
pensory system is useful in situations where the
posterior wall of the femoral tunnel has been com-
promised during preparation.
When maintaining stability for bone-to-bone
healing as in a patella tendon graft or allograft
construct, the interference screw is our fixation fi
of choice though a femoral system of Rigidfix fi
is sometimes used. This is not always suitable at
both the femoral and tibial attachment sites due
to graft tunnel mismatch. In such situations it
may be necessary to augment or replace the tibial
interference screw with a post-screw suspension
or staple system. For hamstring reconstructions
we use a sheathed interference screw (intrafix) fi for
tibial fixation
fi and a titanium transfi fix system for
the femoral.
Bone plug fixation
In considering the fixation
fi techniques available in
more detail it is important to separate both bone
plug-carrying grafts from soft tissue grafts and
the tibial from the femoral sites. With bone-car-
rying grafts the traditional form of fi
fixation is the
interference screw and this has in the past been
described as the fixation standard (2). It has the
combined advantages of being suffi fficiently strong
to meet the requirements of the activities of daily
living and rehabilitation in most cases combined
348 The Traumatic Knee
with the facility for augmentation when required
for the diffi
fficult case or non-compliant patient (82).
The concerns regarding interference screw fixation
Th
are the potential for graft damage during inser-
tion and the advancement of the tibial bone block
toward the joint during screw insertion resulting
in a loss of graft tension. In cases of graft tunnel
mismatch where the distal bone block does not
engage the tunnel interference screw fixation may
not be suitable and it may be necessary to fix fi the
bone block into a shallow groove on the front of
the tibia using staples.
Where the graft tunnel mismatch involves a rela-
tively short graft it may be difficultffi to obtain
adequate graft compression and fixation using an
interference screw. In this case it is possible to use
a post-screw suspending the graft with sutures
through the bone block. Some studies have, how-
ever, found this to be an inferior method of graft
fixation with reduced load to failure when com-
fi
pared to interference screw (49).
The standard femoral fixation is interference screw
usually placed intra-articularly. The
Th theoretical advan-
tages of interference screw fifixation are fixation of the
graft at its anatomical origin at the level of the joint.
This has been shown to improve the graft isometry
Th
(83). Although screw divergence is a common finding
if postoperative X-rays are carefully scrutinized (84),
it is not considered a clinical concern.
Alternatives include suspension using an endobut-
ton, screw post, or, in an attempt to reduce graft
slippage, rigid transfixion.
fi The suspensory fixa-
tion in bone-patellar tendon-bone grafts is usually
reserved for cases of posterior wall compromise
(85). Although this fi fixation involves suspension
from a length of suture material, the stability is
adequate and provides a good option in cases where
interference screw fixation is not appropriate. The
femoral cross-pins provide a fixation
fi that is similar
to the interference screws (86). If the bone plug is
smaller than 9 mm, however, the load to failure is
reduced due to block fracture.
Hamstring graft fixation
There are several methods available for fixation
of hamstrings grafts. As with bone block grafts, it
is the tibial side that is the most problematic as a
consequence of the reduced bone mineral density
(15) and tunnel orientation tending to be more
parallel with applied forces.
Tibial fixation of the hamstrings graft using inter-
ference screw is one commonly used technique that
has several advantages. Juxtaarticular fi fixation of
the hamstrings graft in the tibia has been shown to
improve knee stability when compared to fi fixation
further from the joint line. The
Th interference screw
also compresses the graft against the bone walls
reducing graft motion and aiding tendon-bone heal-
ing (68). The
Th principal weakness of interference
screw fixation for the soft tissue graft is that cycli-
cal loading of the knee can induce failure. This
Th raises
concerns for the use of interference fixation when
aggressive rehabilitation is planned (32). Many
studies identify a slight increase in laxity with the
use of hamstrings grafts when compared to BTB
(9,20,24,29). In a cadaveric study Rittmeister et al.
analyzed the source of this graft elongation with
hamstrings grafts fi fixed with bioabsorbable and
titanium interference screws (55). They found that
the majority (92%) of the elongation occurred as a
result of graft slippage with only 8% being attribut-
able to plastic deformation of the graft.
The use of a screw and pronged washer in fixation
of the graft on the tibial side is also common. Stiff-ff
ness and load to failure has been shown to be simi-
lar to interference screw fixation (87); however, the
graft fixation is distal to the joint that increases the
working length of the graft and does not prevent
the bungee and windscreen wiper effects.ff
Femoral fixation of the hamstrings graft is usu-
ally through one of the following three techniques:
interference screw, endobutton, or transfixion. fi
Interference screw is commonly used and has some
advantages in the femur compared to the tibia. The Th
femoral bone density is higher resulting in a more
secure fixation; second, the insertion of the femo-
ral interference screw is from inside to out that will
tend to increase graft tension. Finally the interfer-
ence screw will occlude the tunnel aperture and
secures the graft at the tunnel entrance reducing
the working length of the graft to the intra-artic-
ular portion.
Many surgeons prefer the use of the endobutton.
Concerns exist regarding sagittal and longitudinal
movement of the graft within the tunnel under
cyclical loading and this movement has been impli-
cated in tunnel widening (the bungee effect). ff In
2001, however, a study by Bartlett et al. showed
less widening in grafts fifixed with endobuttons than
those secured with interference screws (88). Tun-
nel widening can therefore not simply be attrib-
uted to fixation method but probably involves a
biological component as well.
Transfifixion pin is a form of suspensory fixation
where the graft is looped over a pin – either metal
or absorbable. The construct performs very well
under laboratory testing with published data quot-
ing ultimate load to failure of up to 1600 N – one of
the strongest fixation techniques available (89).
The two-stage revision ACL reconstruction
Stage 1
Stage 1 consists of an initial EUA and arthroscopy
with assessment and treatment of identified
fi chon-

dral and meniscal pathology. The failed graft mate-
rial is excised, the notch assessed, and where neces-
sary a notch plasty is performed. Where necessary
metalwork is removed and the tibial tunnel is bone
grafted using autologous graft from the iliac crest. A
high index of suspicion for infection should be main-
tained and synovial biopsies are taken for culture.
During the arthroscopy there is detailed assess-
ment and documentation of all chondral and
meniscal surfaces. The damage to the articular
surface is usually more severe than preoperative
radiological assessment suggests. Size location and
nature of all lesions are recorded; loose chondral
flaps are removed with shaver and instruments to
stable edges. Exposed subchondral bone is treated
with marrow stimulation through drilling or micro-
fracture. Where persistent pain exists following
micro-fracture, careful consideration must be given
to leg alignment and additional procedures such as
proximal tibial or distal femoral osteotomies with
or without chondrocyte implantation.
The intercondylar notch is addressed and the com-
bination of incompetent ACL graft and scar tissue
is carefully removed. Great care must be taken to
avoid iatrogenic posterior cruciate ligament injury.
The notch debridement is usually a straightforward
procedure. However, when synthetic ligament has
been used, the task can be signifi ficantly more time
consuming and difficult.
ffi Some carbon fiber grafts
may fail with the production of significant
fi debris
that may require the addition of a posterior portal
to allow adequate debridement.
The position and nature of retained hardware is
then confi firmed arthroscopically. If optimal tunnel
placement can be achieved without impinging on
the original hardware, then the metalwork can be
retained. Where this is not the case, the metalwork
must be removed as described earlier.
The tibial tunnel is also assessed for both posi-
tion and size. In cases where the tunnel interferes
with the ideal placement of the revision ligament,
bone grafting is performed. Following the initial
arthroscopy, the tibial tunnel is viewed with an
arthroscope in air. The Th sclerotic walls are thor-
oughly debrided with curette and rasp and a 2-mm
drill is used to perforate the tunnel walls in mul-
tiple locations. Bone graft dowels are harvested
from the iliac crest and if necessary supplemented
with a suitable bone graft expander or allograft.
The graft is impacted into the tibial tunnel taking
care not to introduce graft material into the joint.
In order to ensure the graft stays within the tun-
nel, the articular surface is viewed with the arthro-
scope during the impaction process.
It is not our practice to routinely graft the femoral
tunnel although this can be done when necessary.
The use of a suspensory fixation technique on the
femoral side ensures that adequate graft fixation
fi
Failure in ACL reconstruction: etiology, treatment, and results 349
can be achieved even when an element of tunnel
widening exists.
A CT scan is performed at approximately 6 months
to assess graft incorporation. Blurring of the tun-
nel margins, reactive sclerosis, and the presence of
bone within the tunnel are signs of sufficient
ffi heal-
ing to proceed to second stage. It is not necessary
to see complete tunnel obliteration; there is usu-
ally a funnel-like “open” appearance of the tunnel
at and just below the joint line – see Fig. 4.
Stage 2
The second stage is similar to a primary ACL recon-
struction. An initial EUA and arthroscopy with
appropriate meniscal and chondral intervention is
followed by the reconstruction. The scarring and
anatomical distortion caused by the primary proce-
dure may disguise the landmarks for tunnel place-
ment. The tibial tunnel is referenced from the PCL on
the medial side of the mid-intercondylar point. ThThe
femoral tunnel is referenced from the over-the-top
position. Accurate tunnel placement can be assisted
by the use of proprietary jigs. Occasionally imaging
may be required to accurately site the tunnels.
Ideally the femoral tunnel should be placed in vir-
gin bone. Frequently the primary tunnel has been
placed in a completely incorrect position and can
simply be ignored. If this is not the case, however,
then it may be possible to achieve virgin bone
placement by altering the drilling technique, i.e.,
if the femoral tunnel was placed using an inside-
out technique in the primary procedure, then an
outside-in technique may be used (and vice versa).
This alteration changes the tunnel angle suffi ffi-
ciently to allow virgin bone placement. Where
concern remains about tunnel placement and bone
integrity, it is important that suspensory fixation
fi
is used either in isolation or to augment any inter-
ference device used. Our normal practice is the use
of transfi
fixion pin femoral fixation and sheathed
interference screw for tibial fixation when using
hamstrings grafts or interference screw fi fixation at
both ends for bone-patellar tendon-bone grafts.
Graft selection is also varied according to the pri-
mary procedure. If hamstrings graft was used in
the primary, then our practice has been to use ipsi-
lateral bone-patellar tendon-bone graft for the revi-
sion. Similarly, when the primary procedure has
used patella tendon, we would use hamstrings for
the revision. When the primary procedure has uti-
lized a prosthetic ligament, we use the same graft
selection procedure as for a primary procedure.
Postoperative rehabilitation
Active knee flexion is started on the first postop-
erative day and resting with the heel supported is
350 The Traumatic Knee
encouraged to regain full hyperextension. Patients
are encouraged to perform static quadriceps con-
tractions to maintain function and ice therapy
is used regularly to control swelling. Patients are
mobilized on the first or second day after surgery
with elbow crutches; these are maintained until a
good gait pattern has been achieved.
The regimen remains largely unchanged for the
first 2 weeks at home with the emphasis being on
regaining full hyperextension, flexion
fl past 90°, a
reduction in swelling, rest, non-weight-bearing
exercises, and minimal walking. Outpatient reha-
bilitation is continued with a graduated series of
mobilizing, strengthening (isometric closed chain
initially followed by some open chain work), and
dynamic stability exercises. Running starts at 10
weeks or when the quiet (i.e., minimal pain and
swelling) knee has been achieved. Ongoing reha-
bilitation is tailored to the individual to include
sports-specifific training. Contact sports can be
resumed from 6 months.
We have not found it necessary to reduce the reha-
bilitation protocol in revision cases when using the
two-staged approach, as following the bone graft-
ing there is good-quality bone around the tunnels
and fixation is as secure as a primary procedure.
Using the same rehabilitation protocol for primary
and revision reconstruction in this manner has
not, in our experience, resulted in any difference
ff
in subjective and objective laxities at follow-up
between the groups.
Results
We have reviewed and published the results of
12-year experience in revision ACL surgery using
the two-stage technique (4). We have found that
technical errors in tunnel placement could be iden-
tifi
fied in 52 of 55 cases (28 femoral, 20 both, and
4 tibial). Tunnel enlargement was seen in all cases
with a mean diameter of 13.7 mm on the tibial AP
radiographs.
The results of our series compare very favorably
with the published literature with regard to laxity
measurements. More importantly, only 1 of the
49 cases with >3-year follow-up had experienced a
graft failure (2.04% at a mean follow-up of 6 years
(range 3–11)). We had one other patient with a
cruciometer reading of 5 mm suggesting recur-
rent laxity but this patient is coping well and does
not require intervention. If this second patient
is included, the total failure rate is 4.1% that still
compares very well with the published literature
and is despite an uncompromised rehabilitation
program. We attribute our better than average
success rate, at least in part, to the two-stage tech-
nique that allows uncompromised tunnel position-
ing in viable bone.
In spite of these excellent results, none of the stud-
ied patients returned to pre-injury levels of activity.
This can be explained by the presence of chondral
and meniscal injury but should form an important
part of the pre-surgery patient counseling.
Comparison of results for ACL revision surgery is
diffi
fficult and complicated. The defi finition for fail-
ure used varies as do the inclusion and exclusion
criteria. Comparison of studies looking at revision
surgery in isolated ACL laxity without the con-
founding variable of multi-ligament instability is
the most effffective way of judging the merits of sur-
gical technique.
In 2001, Noyes and Barber-Westin reported their
experience with revision ACL reconstruction using
BTB autografts (74). Although the group reported
was heterogeneous and included patients who
required multi-ligament reconstructions and high
tibial osteotomies, if the subgroup of patients who
did not have additional ligamentous or bony pro-
cedures is reviewed a failure rate of 16% (5/32) is
described. This represented a signifi ficant improve-
ment on earlier results published by the same
research group analyzing the use of BTB allografts
(76). In this study a failure rate of 33% was iden-
fied with the use of fresh-frozen, irradiated
tifi
allografts.
In 2004, Fox et al. reviewed their results with the
use of BTB fresh-frozen, unirradiated allografts
(90). Although they report failure in 28% their
criteria are very strict. If the criteria used are
adjusted to more in keeping with published lit-
erature (side-to-side difference
ff of <5 mm and/or a
pivot shift test of grade 2 or more), the failure rate
is only 6%.
More recently, in 2007, Battaglia et al. have pub-
lished a retrospective review of their experience
of revision ACL reconstruction by seven surgeons
over a 10-year period (91). The Th review includes
both autograft and allograft revisions and details a
rate of failure requiring further revision of 25% in
patients who received autograft and 30% in those
who had allograft surgery.
In 2008, Diamantopoulos et al. have published
a review of their experience with autograft revi-
sion using either BTB, hamstrings, or quadriceps
tendon grafts in 107 patients (22). All patients
who required such surgery were reviewed, includ-
ing those patients with additional laxity and both
one- and two-stage procedures. Th The authors quote
a 6.6% rate of KT1000 assessed side-to-side dif-
ference >5 mm. If the pivot shift test is used as
the marker for failure, then 10.3% of patients
demonstrated a grade C pivot clunk. As found in
our study, the authors comment that even with
excellent rates of stability restoration, only 36.4%
were able to return to the same or higher activity
level.

As in most aspects of orthopedic surgery, revi-
sion procedures for the ACL reconstruction are
both more challenging and more rewarding for
the surgeon. The combination of a complex surgi-
cal problem with frequently disheartened and very
well-educated patients requires great expertise
from the full range of the attending surgeon’s skills
from communication to operative planning and
execution. The treatment process benefi fits from a
well-organized, mature organizational setup, and a
well-motivated and experienced team.
References
1. Aglietti P, Buzzi R, Giron F, et al. (1997) Arthroscopic-as-
sisted anterior cruciate ligament reconstruction with the
central third patellar tendon. A 5–8-year follow-up. Knee
Surg Sports Traumatol Arthrosc 5(3):138–144
2. Steiner ME, Hecker AT, Brown CH Jr, Hayes WC (1994)
Anterior cruciate ligament graft fi fixation. Comparison of
hamstring and patellar tendon grafts. Am J Sports Med
22(2):240–246 (discussion 246–247)
3. Brown CH Jr, Carson EW (1999) Revision anterior cruci-
ate ligament surgery. Clin Sports Med 18(1):109–171
4. Thomas NP, Kankate R, Wandless F, Pandit H (2005) Revi-
sion anterior cruciate ligament reconstruction using a
2-stage technique with bone grafting of the tibial tunnel.
Am J Sports Med 33(11):1701–1709
5. Ohly NE, Murray IR, Keating JF (2007) Revision anterior
cruciate ligament reconstruction: timing of surgery and
the incidence of meniscal tears and degenerative change. J
Bone Joint Surg Br 89(8):1051–1054
6. Allen CR, Giffi
ffin JR, Harner CD (2003) Revision anterior
cruciate ligament reconstruction. Orthop Clin North Am
34(1):79–98
7. Aglietti P, Giron F, Buzzi R, et al. (2004) Anterior cruci-
ate ligament reconstruction: bone-patellar tendon-bone
compared with double semitendinosus and gracilis ten-
don grafts. A prospective, randomized clinical trial. J Bone
Joint Surg Am 86-A(10):2143–2155
8. Ahn JH, Lee YS, Ha HC (2008) Comparison of revision
surgery with primary anterior cruciate ligament recon-
struction and outcome of revision surgery between differ-ff
ent graft materials. Am J Sports Med: 36(10) 1189–95
9. Anderson AF, Snyder RB, Lipscomb AB Jr (2001) Anterior
cruciate ligament reconstruction. A prospective random-
ized study of three surgical methods. Am J Sports Med
29(3):272–279
10. Arnold MP, Kooloos J, van Kampen A (2001) Single-in-
cision technique misses the anatomical femoral anterior
cruciate ligament insertion: a cadaver study. Knee Surg
Sports Traumatol Arthrosc 9(4):194–199
11. Basso O, Johnson DP, Jewell F, Wakeley CJ (2001) TheTh out-
come of intra-articular debris, following anterior cruciate
ligament reconstruction. Knee 8(3):235–237
12. Bealle D, Johnson DL (1999). Technical pitfalls of anterior
cruciate ligament surgery. Clin Sports Med 18(4):831–
845, vi
13. Beynnon BD, Johnson RJ, Fleming BC, et al. (2002) Ante-
rior cruciate ligament replacement: comparison of bone-
patellar tendon-bone grafts with two-strand hamstring
grafts. A prospective, randomized study. J Bone Joint
Surg Am 84-A(9):1503–1513
14. Beynnon BD, Uh BS, Johnson RJ, et al. (2005) Rehabili-
tation after anterior cruciate ligament reconstruction: a
prospective, randomized, double-blind comparison of pro-
Failure in ACL reconstruction: etiology, treatment, and results 351
grams administered over 2 different
ff time intervals. Am J
Sports Med 33(3):347–359
15. Brand JC Jr, Pienkowski D, Steenlage E, et al. (2000)
Interference screw fixation strength of a quadrupled
hamstring tendon graft is directly related to bone min-
eral density and insertion torque. Am J Sports Med
28(5):705–710
16. Caborn DN, Coen M, Neef R, et al. (1998). Quadrupled
semitendinosus–gracilis autograft fixation
fi in the femoral
tunnel: a comparison between a metal and a bioabsorbable
interference screw. Arthroscopy 14(3):241–245
17. Carson EW, Anisko EM, Restrepo C, et al. (2004) Revision
anterior cruciate ligament reconstruction: etiology of fail-
ures and clinical results. J Knee Surg 17(3):127–132
18. Chen NC, Brand JC Jr, Brown CH Jr (2007) Biomechan-
ics of intratunnel anterior cruciate ligament graft fixation.
fi
Clin Sports Med 26(4):695–714
19. Clatworthy MG, Annear P, Bulow JU, Bartlett RJ (1999).
Tunnel widening in anterior cruciate ligament reconstruc-
tion: a prospective evaluation of hamstring and patella
tendon grafts. Knee Surg Sports Traumatol Arthrosc
7(3):138–145
20. Corry IS, Webb JM, Clingeleff ffer AJ, Pinczewski LA (1999)
Arthroscopic reconstruction of the anterior cruciate liga-
ment. A comparison of patellar tendon autograft and four-
strand hamstring tendon autograft. Am J Sports Med
27(4):444–454
21. Denti M, Lo Vetere D, Bait C, et al. (2008) Revision ante-
rior cruciate ligament reconstruction: causes of failure,
surgical technique, and clinical results. Am J Sports Med
36(10):1896–902
22. Diamantopoulos AP, Lorbach O, Paessler HH (2008) Ante-
rior cruciate ligament revision reconstruction: results in
107 patients. Am J Sports Med 36(5):851–860
23. Eriksson K, Anderberg P, Hamberg P, et al. (2001) A com-
parison of quadruple semitendinosus and patellar tendon
grafts in reconstruction of the anterior cruciate ligament.
J Bone Joint Surg Br 83(3):348–354
24. Feller JA, Webster KE (2003) A randomized comparison
of patellar tendon and hamstring tendon anterior cruciate
ligament reconstruction. Am J Sports Med 31(4):564–573
25.Forster MC, Forster IW (2005) Patellar tendon or four-strand
hamstring? A systematic review of autografts for anterior
cruciate ligament reconstruction. Knee 12(3):225–230
26. Fox AE, Johnson DS (2005) Anterior cruciate ligament
reconstruction: bone-patellar tendon-bone compared with
double semitendinosus and gracilis tendon grafts. J Bone
Joint Surg Am 87(8):1882–1883 (author reply 1883)
27. Giurea M, Zorilla P, Amis AA, Aichroth P (1999) Compara-
tive pull-out and cyclic-loading strength tests of anchorage
of hamstring tendon grafts in anterior cruciate ligament
reconstruction. Am J Sports Med 27(5):621–625
28. Glasgow SG, Gabriel JP, Sapega AA, et al. (1993). TheTh effffect
of early versus late return to vigorous activities on the out-
come of anterior cruciate ligament reconstruction. Am J
Sports Med 21(2):243–248
29. Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC
(2005) Reconstruction of the anterior cruciate ligament:
meta-analysis of patellar tendon versus hamstring tendon
autograft. Arthroscopy 21(7):791–803
30. Greis PE, Johnson DL, Fu FH (1993) Revision anterior
cruciate ligament surgery: causes of graft failure and tech-
nical considerations of revision surgery. Clin Sports Med
12(4):839–852
31. Harner CD, Irrgang JJ, Paul J, et al. (1992) Loss of motion
after anterior cruciate ligament reconstruction. Am J
Sports Med 20(5):499–506
32. Harvey AR, Thomas NP, Amis AA (2003) The eff ffect of
screw length and position on fi fixation of four-stranded
hamstring grafts for anterior cruciate ligament recon-
struction. Knee 10(1):97–102
352 The Traumatic Knee
33. Hoher J, Kanamori A, Zeminski J, et al. (2001) The posi-
tion of the tibia during graft fi
fixation aff
ffects knee kinemat-
ics and graft forces for anterior cruciate ligament recon-
struction. Am J Sports Med 29(6):771–776
34. Hoher J, Livesay GA, Ma CB, et al. (1999) Hamstring graft
motion in the femoral bone tunnel when using titanium
button/polyester tape fixation. Knee Surg Sports Trauma-
tol Arthrosc 7(4):215–219
35. Hoher J, Schefflffler SU, Withrow JD, et al. (2000) Mechani-
cal behavior of two hamstring graft constructs for recon-
struction of the anterior cruciate ligament. J Orthop Res
18(3):456–461
36. Howell SM, Taylor MA (1993) Failure of reconstruction
of the anterior cruciate ligament due to impingement by
the intercondylar roof. J Bone Joint Surg Am 75(7):1044–
1055
37. Johnson DL, Fu FH (1995) Anterior cruciate ligament
reconstruction: why do failures occur? Instr Course Lect
44:391–406
38. Johnson DL, Coen MJ (1995) Revision ACL surgery. Etiol-
ogy, indications, techniques, and results. Am J Knee Surg
8(4):155–167
39. Johnson RJ, Eriksson E, Haggmark T, Pope MH (1984)
Five- to ten-year follow-up evaluation after reconstruc-
tion of the anterior cruciate ligament. Clin Orthop Relat
Res (183):122–140
40. Karim A, Pandit H, Murray J, et al. (2006) Smoking and
reconstruction of the anterior cruciate ligament. J Bone
Joint Surg Br 88(8):1027–1031
41. Laxdal G, Sernert N, Ejerhed L, et al. (2007) A prospec-
tive comparison of bone-patellar tendon-bone and ham-
string tendon grafts for anterior cruciate ligament recon-
struction in male patients. Knee Surg Sports Traumatol
Arthrosc 15(2):115–125
42. Lemos MJ, Jackson DW, Lee TQ, Simon TM (1995) Assess-
ment of initial fixation of endoscopic interference femoral
screws with divergent and parallel placement. Arthros-
copy 11(1):37–41
43. Lephart SM, Kocher MS, Harner CD, Fu FH (1993) Quad-
riceps strength and functional capacity after anterior cru-
ciate ligament reconstruction. Patellar tendon autograft
versus allograft. Am J Sports Med 21(5):738–743
44. Liden M, Sernert N, Rostgard-Christensen L, et al. (2008)
Osteoarthritic changes after anterior cruciate ligament
reconstruction using bone-patellar tendon-bone or ham-
string tendon autografts: a retrospective, 7-year radiographic
and clinical follow-up study. Arthroscopy 24(8):899–908
45. Loh JC, Fukuda Y, Tsuda E, et al. (2003) Knee stability and
graft function following anterior cruciate ligament recon-
struction: comparison between 11 o'clock and 10 o'clock
femoral tunnel placement. 2002 Richard O'Connor Award
paper. Arthroscopy 19(3):297–304
46. Marder RA, Raskind JR, Carroll M (1991) Prospective
evaluation of arthroscopically assisted anterior cruci-
ate ligament reconstruction. Patellar tendon versus
semitendinosus and gracilis tendons. Am J Sports Med
19(5):478–484
47. Murty AN, el Zebdeh MY, Ireland J (2001) Tibial tunnel
enlargement following anterior cruciate reconstruction:
does post-operative immobilisation make a difference? ff
Knee 8(1):39–43
48. Musahl V, Plakseychuk A, VanScyoc A, et al. (2005) Vary-
ing femoral tunnels between the anatomical footprint and
isometric positions: eff ffect on kinematics of the anterior
cruciate ligament-reconstructed knee. Am J Sports Med
33(5):712–718
49. Paschal SO, Seemann MD, Ashman RB, et al. (1994) Inter-
ference fixation versus postfi fixation of bone-patellar ten-
don-bone grafts for anterior cruciate ligament reconstruc-
tion. A biomechanical comparative study in porcine knees.
Clin Orthop Relat Res (300):281–287
50. Pinczewski LA, Deehan DJ, Salmon LJ, et al. (2002) A five- fi
year comparison of patellar tendon versus four-strand
hamstring tendon autograft for arthroscopic reconstruc-
tion of the anterior cruciate ligament. Am J Sports Med
30(4):523–536
51. Pinczewski LA, Lyman J, Salmon LJ, et al. (2007) A 10-year
comparison of anterior cruciate ligament reconstructions
with hamstring tendon and patellar tendon autograft: a
controlled, prospective trial. Am J Sports Med 35(4):564–
574
52. Prodromos C, Joyce B, Shi K (2007) A meta-analysis of sta-
bility of autografts compared to allografts after anterior
cruciate ligament reconstruction. Knee Surg Sports Trau-
matol Arthrosc 15(7):851–856
53. Prodromos CC, Fu FH, Howell SM, et al. (2008) Controver-
sies in soft-tissue anterior cruciate ligament reconstruc-
tion: grafts, bundles, tunnels, fi
fixation, and harvest. J Am
Acad Orthop Surg 16(7):376–384
54. Prodromos CC, Joyce BT, Shi K, Keller BL (2005) A meta-
analysis of stability after anterior cruciate ligament recon-
struction as a function of hamstring versus patellar ten-
don graft and fixation type. Arthroscopy 21(10):1202
55. Rittmeister ME, Noble PC, Bocell JR Jr, et al. (2002) Com-
ponents of laxity in interference fifit fixation of quadrupled
hamstring grafts. Acta Orthop Scand 73(1):65–71
56. Roe J, Pinczewski LA, Russell VJ, et al. (2005) A 7-year
follow-up of patellar tendon and hamstring tendon
grafts for arthroscopic anterior cruciate ligament recon-
struction: diff
fferences and similarities. Am J Sports Med
33(9):1337–1345
57. Rupp S, Muller B, Seil R (2001) Knee laxity after ACL
reconstruction with a BPTB graft. Knee Surg Sports Trau-
matol Arthrosc 9(2):72–76
58. Scheffl
ffler SU, Schmidt T, Gangey I, et al. (2008) Fresh-
frozen free-tendon allografts versus autografts in anterior
cruciate ligament reconstruction: delayed remodeling and
inferior mechanical function during long-term healing in
sheep. Arthroscopy 24(4):448–458
59. Scheffl
ffler SU, Sudkamp NP, Gockenjan A, et al. (2002)
Biomechanical comparison of hamstring and patellar ten-
don graft anterior cruciate ligament reconstruction tech-
niques: the impact of fixation
fi level and fixation method
under cyclic loading. Arthroscopy 18(3):304–315
60. Spindler KP, Kuhn JE, Freedman KB, et al. (2004) Ante-
rior cruciate ligament reconstruction autograft choice:
bone-tendon-bone versus hamstring: does it really mat-
ter? A systematic review. Am J Sports Med 32(8):1986–
1995
61. Stringham DR, Pelmas CJ, Burks RT, et al. (1996) Com-
parison of anterior cruciate ligament reconstructions
using patellar tendon autograft or allograft. Arthroscopy
12(4):414–421
62. Tohyama H, Beynnon BD, Johnson RJ, et al. (1996) The
effect of anterior cruciate ligament graft elongation at
the time of implantation on the biomechanical behavior
of the graft and knee. Am J Sports Med 24(5):608–614
63. Wagner M, Kaab MJ, Schallock J, et al. (2005) Hamstring
tendon versus patellar tendon anterior cruciate ligament
reconstruction using biodegradable interference fit fi fixa-
tion: a prospective matched-group analysis. Am J Sports
Med 33(9):1327–1336
64. Webster KE, Feller JA, Hameister KA (2001) Bone tunnel
enlargement following anterior cruciate ligament recon-
struction: a randomised comparison of hamstring and
patellar tendon grafts with 2-year follow-up. Knee Surg
Sports Traumatol Arthrosc 9(2):86–91
65. Hefzy MS, Grood ES, Noyes FR (1989) Factors affect- ff
ing the region of most isometric femoral attachments.
Part II: the anterior cruciate ligament. Am J Sports Med
17(2):208–216

66. Getelman MH, Friedman MJ (1999) Revision anterior cru-
ciate ligament reconstruction surgery. J Am Acad Orthop
Surg 7(3):189–198
67. Howell SM, Gittins ME, Gottlieb JE, et al. (2001) The Th
relationship between the angle of the tibial tunnel in the
coronal plane and loss of flexion and anterior laxity after
anterior cruciate ligament reconstruction. Am J Sports
Med 29(5):567–574
68. Harvey A, Thomas NP, Amis AA (2005) Fixation of the
graft in reconstruction of the anterior cruciate ligament.
J Bone Joint Surg Br 87(5):593–603
69. Servant CT, Ramos JP, Thomas NP (2004) The accuracy of
magnetic resonance imaging in diagnosing chronic poste-
rior cruciate ligament injury. Knee 11(4):265–270
70. Harilainen A, Sandelin J (2001) Revision anterior cruciate
ligament surgery. A review of the literature and results of
our own revisions. Scand J Med Sci Sports 11(3):163–169
71. Johnson DL, Swenson TM, Irrgang JJ, et al. (1996) Revi-
sion anterior cruciate ligament surgery: experience from
Pittsburgh. Clin Orthop Relat Res (325):100–109
72. Noyes FR, Barber-Westin SD (1996) Revision anterior cru-
ciate ligament surgery: experience from Cincinnati. Clin
Orthop Relat Res (325):116–129
73. Uribe JW, Hechtman KS, Zvijac JE, Tjin-A-Tsoi ATEW
(1996) Revision anterior cruciate ligament surgery: expe-
rience from Miami. Clin Orthop Relat Res (325):91–99
74. Noyes FR, Barber-Westin SD (2001) Revision anterior cru-
ciate surgery with use of bone-patellar tendon-bone autog-
enous grafts. J Bone Joint Surg Am 83-A(8):1131–1143
75. Noyes FR, Barber-Westin SD (2001) Revision anterior cru-
ciate ligament reconstruction: report of 11-year experi-
ence and results in 114 consecutive patients. Instr Course
Lect 50:451–461
76. Noyes FR, Barber-Westin SD, Roberts CS (1994) Use of
allografts after failed treatment of rupture of the anterior
cruciate ligament. J Bone Joint Surg Am 76(7):1019–1031
(http://www.ejbjs.org/cgi/content/abstract/76/7/1019)
77. Pelker RR, Friedlaender GE, Markham TC, et al. (1984)
Eff
ffects of freezing and freeze-drying on the biomechanical
properties of rat bone. J Orthop Res 1(4):405–411
78. Stevenson S (1987) The immune response to osteochondral
allografts in dogs. J Bone Joint Surg Am 69(4):573–582
79. Asselmeier MA, Caspari RB, Bottenfi field S (1993) A review
of allograft processing and sterilization techniques and
Failure in ACL reconstruction: etiology, treatment, and results 353
their role in transmission of the human immunodefi ficiency
virus. Am J Sports Med 21(2):170–175
80. Battaglia TC, Miller MD (2005) Management of bony
defi
ficiency in revision anterior cruciate ligament recon-
struction using allograft bone dowels: surgical technique.
Arthroscopy 21(6):767
81. Greis PE, Steadman JR (1996) Revision of failed prosthetic
anterior cruciate ligament reconstruction. Clin Orthop
Relat Res (325):78–90
82. Brand J Jr, Weiler A, Caborn DN, et al. (2000) Graft fixa-fi
tion in cruciate ligament reconstruction. Am J Sports Med
28(5):761–774
83. Morgan CD, Kalmam VR, Grawl DM (1995) Isometry test-
ing for anterior cruciate ligament reconstruction revisited.
Arthroscopy 11(6):647–659
84. Lemos MJ, Albert J, Simon T, Jackson DW (1993) Radio-
graphic analysis of femoral interference screw placement
during ACL reconstruction: endoscopic versus open tech-
nique. Arthroscopy 9(2):154–158
85. Bush-Joseph CA, Bach BR Jr, Bryan J (1995) Posterior
cortical violation of the femoral tunnel during endoscopic
anterior cruciate ligament reconstruction. Am J Knee
Surg 8(4):130–133
86. Zantop T, Welbers B, Weimann A, et al. (2004) Biomechan-
ical evaluation of a new cross-pin technique for the fixa-fi
tion of difffferent sized bone-patellar tendon-bone grafts.
Knee Surg Sports Traumatol Arthrosc 12(6):520–527
87. Magen HE, Howell SM, Hull ML (1999) Structural proper-
ties of six tibial fixation methods for anterior cruciate liga-
ment soft tissue grafts. Am J Sports Med 27(1):35–43
88. Bartlett RJ, Clatworthy MG, Nguyen TN (2001) Graft
selection in reconstruction of the anterior cruciate liga-
ment. J Bone Joint Surg Br 83(5):625–634
89. Clark R, Olsen RE, Larson BJ, et al. (1998) Cross-pin
femoral fixation: a new technique for hamstring anterior
cruciate ligament reconstruction of the knee. Arthroscopy
14(3):258–267
90. Fox JA, Pierce M, Bojchuk J, et al. (2004) Revision ante-
rior cruciate ligament reconstruction with nonirradi-
ated fresh-frozen patellar tendon allograft. Arthroscopy
20(8):787–794
91. Battaglia MJ 2nd, Cordasco FA, Hannafin fi JA, et al. (2007)
Results of revision anterior cruciate ligament surgery. Am
J Sports Med 35(12):2057–2066
The PCL

J. Ménétrey Definition and diagnosis of posterior
cruciate ligament injury
and algorithm of treatment
Introduction
P
osterior cruciate ligament (PCL) injuries are
less frequent than anterior cruciate ligament
(ACL) injuries, but they are formidable when
complete. Still rarely diagnosed at the end of the
1970s, PCL injuries have gained attention in the
past 20 years and the science of PCL, although
less fertile than the one of ACL, has shown great
progress in the same time. PCL injuries represent
5–37% of all knee ligament injuries (1–7). Athletes
suff
ffer most of the time from isolated PCL lesions
that occur frequently in a hyperflexion
fl movement
(8, 9). However, in the trauma patients as many as
95% of patients with knee injuries have combined
ligamentous damage (4, 10).
The choice of appropriate treatment for isolated
PCL injury is still controversial (8, 9, 11–23).
However, there is an actual consensus that surgi-
cal treatment is indicated for PCL tears associated
with peripheral lesions or with multi-ligament
knee injuries (20, 24–27). ThTherefore, a crucial step
in the evaluation of PCL injury is to determine
the presence of associated lesions. Some authors
report acceptable results from conservative treat-
ment of a ruptured PCL with long-term follow-up
(22, 24, 28). However, other authors have sug-
gested that outcomes of conservative treatment
are fair to poor and characterized by residual lax-
ity and instability, limited functional capacity, and
late degenerative changes (12, 15–17, 24). On the
other hand, outcomes after surgical intervention
have also been disappointing with postoperative
residual grade I or II laxity (18, 20, 29–31).
Crucial to the outcome of any PCL injuries is deter-
mining the exact severity of the lesion and detect-
ing all associated lesions, especially the postero-lat-
eral corner (PLC). To do so, one needs to know the
mechanism of injury, perform a meticulous physical
examination when PCL injuries are suspected, and
eventually make complementary investigations
(MRI and stress radiographs) of precise anatomi-
cal lesions and their consequences on posterior and
rotational laxities. Anatomy, biology, and biome-
chanics of PCL are presented in other sections of
this book and will not be discussed in this chapter.
Chapter 28
Mechanism of injury
An acute injury to a static structure results from
elongation of that structure beyond its elastic lim-
its. This is most often the result of joint distraction
or dislocation in the direction resisted by the liga-
mentous structure itself and by other structures
(32). Certainly, the most common mechanism of
injury to the PCL is an anterior blow to the proxi-
mal tibia (the so-called “dashboard” injury) (32).
As mentioned, in sports-related injury, hyperflex- fl
ion is the most common mechanism of injury (8),
and has a tendency to result in a lesion on the tibial
side of the ligament. Other mechanism of injury
implies hyperextension with a loaded foot, and
extension injuries are commonly located on the
femoral side of the ligament (32). PCL and other
structures are also injured in different
ff knee disloca-
tion mechanisms: hyperextension, varus–internal
rotation, valgus–external rotation, postero-lateral,
and posterior.
Defifinition
Posterior instability is defined
fi as an abnormal
posterior laxity of the tibia that results, for the
patient, in an insecurity, sensation of uncontrolled
hyperextension, “feeling of weakness” in the knee,
and sometimes in anterior knee pain. This poste-
rior laxity depends on the degree of injury of the
PCL, the degree of injury of the postero-lateral
capsulo-ligamentous structures, and the degree of
injury of the postero-medial capsulo-ligamentous
structures.
Partial PCL rupture is defi fined as a continuity
of remaining ligament fi fibers or a retention of
fibers that are observed to resist tension while
complete PCL rupture is definedfi as none or a few
remaining intact fibers that are non-functional
to resist posterior load applied on the knee. Th The
PCL is the primary restraint to posterior drawer
in flexion (33); therefore, a PCL injury results in
a posterior drawer in flflexion. Thus, a PCL injury
is defi
fined as an abnormal posterior laxity at
358 The Traumatic Knee
80–90° of flexion. This posterior laxity should
be defined
fi in millimeters. The diff fferent ways to
measure this posterior laxity is discussed in the
section “Diagnostic.”
Lesion of the PLC implies injury of the lateral col-
lateral ligament, the popliteo-fibular ligament,
the popliteus tendon, the three popliteo-menis-
cal fascicles (ant-inf, post-inf, and post-sup), the
mid-third capsular ligament, the biceps femoris
(long/short head), or the ilio-tibial band. The
PLC is the primary restraint of varus–rotation–
adduction (LCL), external rotation (PFL), and
posterior drawer in extension (34–37). Thus, a
lesion of the PLC is defined as a posterior laxity
close to extension, an increased external rota-
tion, sometimes combined to varus laxity and
hyperextension.
Lesion of the postero-medial corner (PMC)
implies injury of the superficial
fi medial collat-
eral ligament (MCL), the deep MCL (ligament
menisco-femoral), the posterior oblique ligament
(POL), and the postero-medial capsule. Th The PMC
is the primary restraint of valgus–abduction–in-
ternal rotation of the tibia and posterior drawer
in extension (38, 39). Thus, a lesion of the PMC is
defi
fined as a posterior laxity close to extension, an
increased internal rotation, sometimes combined
with a valgus laxity.
Based on sectioning studies, posterior laxity in
intact knee is 3.0 (3.3) mm (33, 40–42). Pos-
terior laxity in case of partial PCL rupture is
5.6 (2.7) mm at 80° of flexion (41, 42). Poste-
rior laxity in case of complete rupture of PCL is
12 mm at 80° of flexion (33, 40, 41). Posterior
laxity in case of PLC section is 8 (5.7–10) mm
at 30° of flexion (41, 43), and 13 (1)° increase
in external rotation at 30° of flexion (43). The
combined sectioning of PCL and PLC results in
a posterior laxity superior to 12 mm at 80° of
flexion (33, 40, 41) and an increase in external
rotation superior of 20° at 30° of flexion (33,
40). The combined sectioning of PCL and PMC
results in a posterior laxity superior to 14 mm
at 80° of flexion (44).
Diagnostic
Clinical evaluation and physical examination
Patients suff
ffering from a PCL injury may be seen
in an emergency department with multiple trauma
or on a sport field after a seemingly benign injury,
or even limp to your offiffice several days to weeks
after the initial trauma. A PCL evaluation should
always start with the determination of the mecha-
nism of injury that can provide important infor-
mation as to the potential severity of the injury. A
patient suff ffering from a PCL injury shows a mod-
erate swelling, a slight limp, and a range of motion
that will lack 10–20° of flexion (26). The patient
will usually have discomfort with fl flexion and the
posterior drawer examination will be positive with
a posterior subluxation of the tibia of various
degrees (26). Often, in case of combined injury, the
soft tissues around the knee will be especially swol-
len and ecchymosis might be seen near the joint.
This appearance is very similar to a knee disloca-
tion and this diagnostic must always be ruled out.
The most accurate clinical test is the posterior
drawer test at 90° of flexion (12, 45). It is criti-
cal to develop a system to quantify the posterior
subluxation of the tibia and one way to do it is to
determine the “step-off.” ff The “step-off ff ” is deter-
mined as the distance of the medial tibial plateau
from the medial femoral condyle at 90° of flexion fl
(usually 10 mm). The physician’s index finger is
placed onto the anteromedial joint line with the
tip of the finger applied on the medial femoral con-
dyle (Fig. 1A and B). When a posterior load (poste-
rior drawer) is put on the tibia, the physician can
palpate the posterior sag of the tibia relative to
the medial femoral condyle (26, 46) (Fig. 1C and
D). According to Harner and Höher (26), a clini-
cal grade I injury has a palpable but diminished
“step-off ff ” (0–5 mm). A grade II injury has lost its
“step-off ff,” but the medial tibial plateau cannot be
pushed beyond the medial femoral condyle (pos-
terior laxity of 5–10 mm). A grade III injury has
also lost its “step-off ff,” but the tibia can be pushed
beyond the medial femoral condyle (corresponds
to a posterior laxity >10 mm). Another sign is the
posterior sag (Godfrey test) (47) observed at 90°
of flexion. A tangential view of the anterior tibial
tubercle allows the visualization of a posterior sag
of the involved side (Fig. 2).
A critical point from the initial examination is the
involvement of the PLC. In case of a posterior tib-
ial translation >10 mm (elimination of the “step-
ff ”), one must rule out an involvement of the
off
PLC (26). This may be diffi fficult to detect because
posterior tibial subluxation may diminish or even
negate PLC laxity (26, 43, 45, 48, 49). It is there-
fore important in this situation to reduce the tibia
to the “neutral position” and then test the PLC at
both 90° and 30° of flexion (Fig. 3) (26). The most
important tests for isolated and combined PCL
injuries are the posterior drawer tests at 90° of
flexion, dial tests and postero-lateral drawer tests
at 90° and 30° of flexion, the reverse pivot shift,
and the varus/valgus tests (Table 1). Description
of these tests is detailed in Chapters 4, 8, and 29.
 Definition and diagnosis of posterior cruciate ligament injury and algorithm of treatment 359

Fig. 1 – The knee placed at 90° of flexion, the “step-off ” is determined by the distance from the anteromedial margin of the tibia to the medial femoral
condyle: (A and B) on the normal knee (usually 10 mm); (C and D) on the injured knee. This test allocates a good evaluation of the posterior drawer starting
from the neutral point, drawer reduced, followed by the application of a posterior load causing the tibial subluxation beyond the femur. The diminution of
the “step-off ” under the finger allows for the clinical measurement of the posterior drawer (C and D).

Table I – Clinical evaluation for PCL injury – checklist.

Posterior tibial drawer test at 90° of flexion – step-off
Varus laxity in extension
Postero-lateral drawer test at 30° and 90° of flexion
(foot externally rotated 15°)
Dial test at 30° and 90° of flexion
External rotational recurvatum test
Reverse pivot shift test
Varus thrust (in chronic cases)
Postero-medial drawer test at 90° of flexion
(foot internally rotated 15°)

In case of combined ligament injuries, it is critical to

check the pulses in the feet (dorsalis pedis and tibi-
alis posterior) and to perform a meticulous neuro-
logical examination (especially sensory and motor
modalities in the peroneal nerve territory). If one
detects a diminished pulse by palpation, an arterio-
gram (angio-CT) should be obtained immediately.
Indeed, vascular lesion can be incomplete (intimal
tear) and in this situation, pulses will be present but
diminished. In one-third of the cases, the popliteal
Fig. 2 – Posterior sag (Godfrey test). A tangential view of the anterior tibial
tubercle allows for the visualization of a posterior sag of the involved side.
artery is completely disrupted and the absence of
pulses will require the completion of an arteriogram
in emergency. Once again, the fact that the knee is
reduced at the time of the examination does not
rule out that a dislocation and spontaneous reduc-
tion has not occurred (26, 50).
360 The Traumatic Knee

Fig. 3 – The postero-lateral drawer test is performed at 30° (A, B, and E) and at 90° (C, D, and F) of knee flexion. The examiner applies a posterior load and a load in
external rotation on the tibia (view from another angle: E and F). It is important to reduce the tibia to the “neutral position” before testing the postero-lateral corner.
 Definition and diagnosis of posterior cruciate ligament injury and algorithm of treatment 361

Imaging MRI is important to determine the location of

Once the physical examination is completed, radio-
graphs should be performed. Th The knee trauma
series (anterior–posterior (AP), lateral, and axial)
should always be obtained. In case of a suspected
fracture not well visualized on standard radio-
graphs, oblique views should be performed. Avul-
sion fracture of both small and large fragments
should be documented. Tibial plateau fracture,
even benign, associated to PCL injury is indicative
of combined ligament injury (26). Bony avulsion
of cruciate ligament insertions should be carefully
checked, as immediate repair of these injuries usu-
ally gives good results (Fig. 4C). Finally, one must
examine carefully the tibial tubercle and look at
avulsion fracture, and also look at fracture of the
fibular head as initial repair in this area usually
yields excellent results when compared to delayed
repairs or late reconstructions (26, 51).
MRI plays an important role in the evaluation of
PCL injuries. The accuracy of MRI for diagnosing
PCL tears ranges from 96 to 100% (26, 52–58).
the tear (femoral, mid-substance, and tibial) and,
therefore, to establish a therapeutic strategy in
the multiple-ligament injured knee and orient the
treatment in a less severe injury. In a T1-weighted
image, the PCL appears as a curvilinear homog-
enous black signal (Fig. 4A). This
Th represents the
larger anterolateral component, which is relatively
lax when the knee is in full extension (26). Mid-
substance tears are easily diagnosed (Fig. 4A).
Femoral insertion site “peel-off ff ” injuries can be
distinctly identifi
fied (Fig. 4B) as distal or tibial
insertion site injuries (Fig. 4C). Th This is valuable
information because these lesions can be surgically
repaired. MRI brings also valuable information in
multiple-ligament injured knee by helping in a bet-
ter defi
finition of all lesions, and, therefore, in the
strategy of treatment.
Despite the advances in diagnosis associated with
the latest development of MRI and its ability in
detecting the lesion of an anatomical structure
precisely, the extent of the lesion and its repercus-
sion on joint stability is diffi
fficult to establish (59,

Fig. 4 – (A) Mid-substance tear; (B) femoral avulsion of the PCL or “peel-off ” lesion;
(C) distal avulsion on the tibia. In case of suspicion on standard X-rays, do not hesitate
to perform CT scan or MRI.
362 The Traumatic Knee
Fig. 5 – Differential posterior tibial displacement (mm) as compared to
the intact knee, for each lesion and each stress radiographic technique.
The boxes represent the values between the 25th and 75th percentiles, the
central bar represents the mean value, the upper and lower lines represent
the extreme values, and the circles represent the outliers. (Reproduced with
courtesy of Ref. (41).)
Fig. 6 – Stress radiographs with the Telos 80° and 30° of flexion and 180-N posterior load, lateral view.
60). Instead, stress radiograph – already used in the
1970s and 1980s – has regained in interest since it
has been documented as being superior to both the
arthrometer and clinical examination. In fact stress
radiograph has proved to be more accurate than the
KT-1000 arthrometer and clinical posterior drawer
tests in determining the amount of posterior tibial
displacement (PTD) in knees with complete and
partial PCL ruptures (42). Several different
ff radio-
logical techniques have been described. However,
although their reliability in precisely measuring
posterior laxity is no longer questioned (10, 42,
61–63), there is still a lack of a recognized method
for discriminating between the various degrees of
laxity. Recently, we have conducted a study with
fresh-frozen knee cadaver specimens to determine
the correlation between established anatomical
lesions of the PCL and posterior structures and
the degree of posterior laxity as measured radio-
logically using four diff fferent stress radiographic
techniques (41). We have also compared the results
 Definition and diagnosis of posterior cruciate ligament injury and algorithm of treatment 363

obtained with the diff fferent techniques in order to This classifi

determine the most accurate method for defin- fi
ing the type of lesion. Results are summarized in
Fig. 5. In this study, we emphasize the importance
of stress radiographs in the evaluation of posterior
laxity. They should be used whenever a lesion of a
posterior structure is suspected. To achieve reliable
measurements, stress radiographs should always
be performed with a precise technique and by an
experienced X-ray technician. We found great vari-
ability between specifi fic stress radiographic tech-
niques and our results confirm fi previous reports
finding the Telos device the most reliable technique
(Fig. 6). We therefore recommend the use of the
Telos device, with radiographs taken at 30° or 80° of
flexion, when evaluating a knee for posterior laxity
fl
(41). Stress radiographic measurements allow for a
classifi
fication correlating the established anatomical
lesions to the radiologically measured PTD (41).
In case of chronic PCL injuries, for patients who
complained of pain and/or instability, a surgical
reconstruction can be proposed. In these cases, a
bone scan can be helpful in the evaluation (64).
An increased uptake in the medial and the patel-
lofemoral compartments may be the sign of early
articular cartilage damage, and therefore a surgical
reconstruction aiming at the restoration of a more
normal knee laxity may be indicated (26).
Classifification
fication is based on clinical examination
and its accuracy relies mainly on the examiner’s
experience. The classifification proposed by Cooper
(25) (Table 3) is more complex and again based
on clinical examination and therefore reserved to
experienced surgeons.
Table III – Classification of posterior injuries according to Coopera (25).
Grade I Isolated PCL injury
Grade II Two-ligament injury – stable to varus/valgus stress
at full extension
Grade III Three-ligament injury – unstable to varus/valgus
stress at full extension
Grade IV Dislocation
Based on our stress radiography findings (41), we
propose a classifi fication that we are currently test-
ing in a prospective clinical study, including all
patients with posterior knee instability (Table 4):
– A partial PCL injury (or grade I) results in a pos-
terior displacement of <3 mm at 30° and <6 mm
at 80° of flexion.
– A complete PCL injury (grade II) results in a pos-
terior displacement of 4–9 mm at 30° of flexion
fl
and 7–12 mm at 80° of flexion.
– The association of peripheral lesions (LCL, PLC,
MCL, and PMC) (grade III) results in posterior
displacement >9 mm at 30° and >12 mm at 80°
of flexion.
These “cut-offff values” have been recently confi
firmed
by another research team (67).

After the detection of a posterior pathology, a Table IVV – Geneva classification of posterior injuriesa (41).
mandatory step consists of the precise gradation At 30° At 80°
of the injury severity. As for many orthopedic and flexion flexion
traumatic injuries, a convenient and classical way (mm) (mm)
to characterize these posterior lesions is the use of Grade I Partial PCL injury <3 <6
a classifi
fication system. This is particularly impor- Grade II Isolated complete 4–9 7–12
tant in posterior lesions because isolated PCL and/ PCL injury
or low-grade posterior injuries have an extremely Grade III Complete PCL >9 >12
favorable prognosis when treated conservatively + LCL–PLC/
(8, 9, 65, 66). MCL–PMCb
Generally used is the classifi fication according to b
PCL: posterior cruciate ligament; LCL: lateral collateral ligament; PLC:
Harner and Höher (26) distinguishing between postero-lateral corner; MCL: medial collateral ligament; PMC: posterio-
isolated and combined injuries, with a further divi- medial corner.
sion of the isolated lesion in partial lesions (grade I a
Classification based on stress radiographs using Telos devices.
or II) and complete lesions (grade III) (Table 2).

Table II – Classification of posterior injuries according to Harner and

Höher (26). Algorithm of treatment
Grade I Palpable but diminished step-off 0–5 mm As already mentioned, to determine the good
Grade II Loss of step-off – tibia cannot be pushed 5–10 mm treatment option, it is crucial to know the precise
beyond femur extent of alll lesions. It is particularly important to
distinguish between isolated and combined PCL
Grade III Lost of step-off – tibia pushed beyond >10 mm injury. Indeed, most of the authors recommend
femur
conservative treatment for partial and isolated
364 The Traumatic Knee
complete PCL injury (8, 9, 26, 65, 66), while com-
bined injuries do better with a surgical treatment
within the first 2 weeks (26, 51, 68–71).
The general attitude to treatment of acute PCL inju-
ries is shown in Fig. 7. Th
The PCL suffffers partial injury
more commonly than the ACL. This is most probably
because of the more important anatomical and bio-
mechanical properties that the PCL possesses (72).
In young patients from different
ff athletic activities,
isolated partial and/or complete PCL injury (grade
I and II injuries) most often occurs in hyperflexion
fl
with impact at the anterior aspect of the proximal
tibia (8). The favorable course of these injuries is
most likely because of the integrity of the secondary
restraints (26) and the healing capacity of the PCL
from the remaining intact portion of the ligament
(73, 74). Conservative treatment consists of protec-
tion of the knee in extension 4–6 weeks according
to the severity of the lesion. Passive mobilization of
the knee in flexion begins in prone position during
the first week and is pursued with a progressive aug-
mentation of the range of motion (30-0-0 for 1 week,
60-0-0 for 1–2 weeks, and 90-0-0 for 2–3 weeks).
Quadriceps strengthening starts immediately. Mini-
squat exercises can be performed after 1 week.
Akisue et al. (75) followed 48 acute PCL-deficient fi
knees. Their results suggest that a high percentage
of acutely injured PCLs is likely to develop some-
what slack but continuous ligament-like tissue, and
this continuous PCL-like tissue might function as a
posterior restraint of the tibia to certain extent. The
Th
elongated but continuous PCL might partly explain
the relatively favorable prognosis of this injury (75).
Therefore, in general, isolated PCL injuries do not
Th
require surgery. However, PCL healing should be
closely followed and precisely evaluated at 1 year
using MRI and stress radiographs (73, 76). However,
not all of the isolated grade II PCL injuries evolve
well. Some patients may develop anterior and medial
compartment pain due to patellofemoral and medial
compartment chondrosis (12, 17, 22, 45), and thus
may finally require surgical treatment.
Proximal PCL avulsion or “peel-off ff ” injury should
be rapidly diagnosed and reinserted with tran-
sosseous sutures. Distal PCL avulsion is usually
characterized by the separation of the ligament
insertion with a piece of bone, and this bone plug
can be fixed back on the tibia with a screw and
washer through a posterior approach.
In combined PCL injuries, the PLC is the most often
involved (4, 48, 69). Laprade et al. (77) looked at 331
acute knee injuries of which 27 concerned the PCL.
Of these 27 PCL injuries, 16 (52%) had combined
ligament injuries. In this situation, conservative
treatment does not restore posterior and postero-
lateral stability (4, 26, 51, 69, 71), and knee kine-
matics (68, 70). In our experience, surgical treat-
ment performed within the fi first 2 weeks, when soft
tissues allow it, permits a better restoration of the
original anatomy, and thus to return to a more nor-
mal function of the knee. In this setting, all anatom-
ical lesions must be addressed and treated. In case
of a diffi
fficult multiple-ligament injured knee, only
the reconstruction of the ACL can be differed ff and
done in a second-stage operation.
In combined PCL and medial compartment inju-
ries, it is extremely important to make an early and
accurate diagnosis to afford
ff the patient the appro-
priate treatment. The combination of torn PCL,
MCL, POL, and PMC creates a “fl floating medial
condyle,” which leads, in our experience, to a severe
and complex laxity, a significant
fi decrease in knee
function, and serious limitations in sport activi-
ties. Therefore, this pathologic entity should be
rapidly recognized and a surgical treatment within
the first 2 weeks is recommended. By addressing
all lesions surgically, one gives the patient the best
chance for an acceptable clinical result.
In chronic combined injuries (Fig. 8), a precise
evaluation of all lesions should be realized and all
lesions addressed by either reconstructions (cruci-
ates + collaterals), reinsertions, or repairs (periph-
ery) if the available tissue is suffi fficient in quality
and volume. The objective is to reproduce the origi-
nal anatomy at the closest degree. Therefore,
Th the
surgeon must perfectly know the anatomy and bio-
mechanics of the ligamentous system he plans to
reconstruct. This type of surgery has to be meticu-
lously prepared, well planned, and performed by
an experienced team.
 Definition and diagnosis of posterior cruciate ligament injury and algorithm of treatment 365
Fig. 7 – Algorithm for acute PCL lesion.
Fig. 8 – Algorithm for chronic PCL lesion.
References
1. Bianchi M (1983) Acute tears of the posterior cruciate liga-
ment: clinical study and results of operative repair in 27
cases. Am J Sports Med 11:308–314
2. Clendenin MB, DeLee JC, Heckman JD (1980) Intersti-
tial tears of the posterior cruciate ligament of the knee.
Orthopedics 3:764–772
3. DeHaven KE (1980) Diagnosis of acute knee injuries with
hemarthrosis. Am J Sports Med 8:9–14
4. Fanelli GC (1995) Posterior cruciate ligament injuries in
trauma patients: part II. Arthroscopy 11:526–529
5. Lysholm J, Gillquist J (1981) Arthroscopic examination
of the posterior cruciate ligament. J Bone Joint Surg
63A:363–366
6. Miyasaka KC, Daniel DM (1991) Th The incidence of knee
ligament injuries in the general population. Am J Knee
Surg 4:3–8
7. Shelbourne KD, Rubinstein RA Jr (1994) Methodist Sports
Medicine Center’s experience with acute and chronic iso-
lated posterior cruciate ligament injuries. Clin Sports Med
13:541–543
8. Fowler PJ, Messieh SS (1987) Isolated posterior cruciate
ligament injuries in athletes. Am J Sports Med 15:553–
557
9. Parolie JM, Bergfeld JA (1986) Long-term results of non-
operative treatment of isolated posterior cruciate liga-
ment injuries in the athlete. Am J Sports Med 14:35–38
10. Janousek AT, Jones DG, Clatworthy M, et al. (1999) Pos-
terior cruciate ligament injuries of the knee joint. Sports
Med 28:429–441
11. Barrett GR, Savoie FH (1991) Operative management of
acute PCL injuries with associated pathology: long-term
results. Orthopedics 14:687–692
12. Clancy WG Jr, Shelbourne KD, Zoellner GB, et al. (1983)
Treatment of knee joint instability secondary to rupture
of the posterior cruciate ligament. Report of a new proce-
dure. J Bone Joint Surg 65A:310–322
13. Dandy DJ, Pusey RJ (1982) The long-term results of unre-
paired tears of the posterior cruciate ligament. J Bone
Joint Surg 64B:92–94
14. Fanelli GC, Giannotti BF, Edson CJ (1994) Th The posterior
cruciate ligament arthroscopic evaluation and treatment.
Arthroscopy 10:673–688
15. Hughston JC, Bowden JA, Andrews JR, et al. (1980) Acute
tears of the posterior cruciate ligament. Results of opera-
tive treatment. J Bone Joint Surg 62A:438–450
16. Jung YB, Jung HJ, Yang JJ, et al. (2008) Characteriza-
tion of spontaneous healing of chronic posterior cruciate
ligament injury: analysis of instability and magnetic reso-
nance imaging. J Magn Reson Imaging 27:1336–1340
17. Kaplan MJ, Clancy WG Jr (1994) Alabama Sports Medi-
cine experience with isolated and combined posterior cru-
ciate ligament. Clin Sports Med 13:545–552
18. Noyes FR, Barber-Westin SD (1994) Posterior cruciate
ligament allograft reconstruction with and without a liga-
ment augmentation device. Arthroscopy 10:371–382
19. Pournaras J, Symeonides PP (1991) Th The results of surgi-
cal repair of acute tears of the posterior cruciate ligament.
Clin Orthop 267:103–107
20. Schulte KR, Chu ET, Fu FH (1997) Arthroscopic poste-
rior cruciate ligament reconstruction. Clin Sports Med
16:145–156
366 The Traumatic Knee
21. St. Pierre P, Miller MD (1999) Posterior cruciate ligament
injuries. Clin Sports Med 18:199–221
22. Torg JS, Barton TM, Pavlov H, et al. (1989) Natural his-
tory of the posterior cruciate ligament-deficient
fi knee. Clin
Orthop 246:208–216
23. Whipple TL, Ellis FD (1991) Posterior cruciate ligament
injuries. Clin Sports Med 10:515–527
24. Boynton MD, Tietjens BR (1996) Long term follow-up of
the untreated isolated posterior cruciate ligament-defi- fi
cient knee. Am J Sports Med 24:306–310
25. Cooper DE (1999) Treatment of combined posterior cruci-
ate ligament and posterolateral injuries of the knee. Oper
Tech Sports Med 7:135–142
26. Harner CD, Höher J (1998) Evaluation and treatment of
posterior cruciate ligament injuries. Am J Sports Med
26(3):471–482
27. Veltri DM, Deng XH, Torzilli PA, et al. (1995) The Th role
of the cruciate and posterolateral ligaments in stability
of the knee. A biomechanical study. Am J Sports Med
23:436–443
28. Shino K, Horibe S, Nakata K, et al. (1995) Conservative
treatment of isolated injuries to the posterior cruciate
ligament in athletes. J Bone Joint Surg 77B:895–900
29. Chen CH, Chen Wj, Shih CH 2002 Arthroscopic recon-
struction of the posterior cruciate ligament.... Arthros-
copy 18:603–12
30. Fanelli GC, Edson CJ (2002) Arthroscopically assisted
combined anterior and posterior cruciate ligament recon-
struction in the multiple ligament injured knee:2- to
10-year follow-up. Arthroscopy 18:703–714
31. Deehan DJ, Salmon LJ, Russel VJ, Pinczewski LA (2003)
Endoscopic single-bundle posterior cruciate ligament
reconstruction: results at minimum 2-year follow-up.
Arthroscopy 19:955–962
32. Miller M, Bergfeld JA, Fowler PJ, et al. (1999) The poste-
rior cruciate ligament injured knee: principles of evalu-
ation and treatment. AAOS Instr Course Lect 48:199–207
33. Grood ES, Stowers SF, Noyes FR (1988) Limits of move-
ment in the human knee. Eff ffect of sectioning the pos-
terior cruciate ligament and posterolateral structures.
J Bone Joint Surg: 88–97
34. LaPrade RF, Terry GC (1997) Injuries to the posterolateral
aspect of the knee. Association of anatomic injury patterns
with clinical instability. Am J Sports Med 25:433–438
35. LaPrade RF, Wentorf FA, Crum JA (2004) Assessment of
healing of grade III posterolateral corner injuries: an in
vivo model. J Orthop Res 22:970–975
36. Laprade RF, Wentorf FA, Olson EJ, Carlson CS (2006) An
in vivo injury model of posterolateral knee instability. Am
J Sports Med 34:1313–1321
37. Maynard MJ, Deng X, Wickiewicz TL, Warren RF (1996)
The popliteofi fibular ligament. Rediscovery of a key ele-
ment in posterolateral stability. Am J Sports Med
24:311–316
38. Grood ES, Noyes FR, Butler DL, Suntay WJ (1981) Liga-
mentous and capsular restraints preventing straight
medial and lateral laxity in intact human cadaver knees. J
Bone Joint Surg 63A:1257–1269
39. Robinson JR, Bull AMJ, Thomas RdeW, Amis AA (2006)
The role of the medial collateral ligament and posterome-
dial capsule in controlling knee laxity. Am J Sports Med
34:1815-1823
40. Butler DL, Noyes FR, Grood ES (1980) Ligamentous
restraints to anterior–posterior drawer in the human knee:
a biomechanical study. J Bone Joint Surg 62A:259–270
41. Garavaglia G, Lubbeke A, Dubois-Ferrière V, et al. (2007)
Accuracy of stress radiography techniques in grading iso-
lated and combined posterior knee injuries: a cadaveric
study. Am J Sports Med 12:2051–2056
42. Hewett TE, Noyes FR, Lee MD (1997) Diagnosis of com-
plete and partial posterior cruciate ligament ruptures:
stress radiography compared with KT-1000 arthrometer
and posterior drawer testing. Am J Sports Med 25(5):648–
655
43. Noyes FR, Stowers SF, Grood ES, et al. (1993) Posterior
subluxations of the medial and lateral tibiofemoral com-
partments. An in vitro ligament sectioning study in cadav-
eric knees. Am J Sports Med 21:407–414
44. Ritchie JR, Bergfeld JA, Kambic H, Manning T (1998) Iso-
lated sectioning of the medial and posteromedial capsu-
lar ligaments in the posterior cruciate ligament-deficient
fi
knee. Am J Sports Med 26(3):389–394
45. Covey DC, Sapega AA (1993) Injuries to the posterior cru-
ciate ligament. J Bone Joint Surg 75A:1376–1386
46. Miller MD, Harner CD, Kashiwaguchi S (1994) Acute pos-
terior cruciate ligament injuries. In: Fu FH, Harner CD,
Vince KG, editors. Knee surgery, vol. 1. Baltimore: Wil-
liams & Wilkins: 749–768
47. Godfrey JD (1973) Ligamentous injuries of the knee. Curr
Pract Orthop Surg 5:56–92
48. Baker CL Jr, Norwood LA, Hughston JC (1984) Acute
combined posterior cruciate and posterolateral instability
of the knee. Am J Sports Med 12:204–208
49. Noyes FR, Barber-Westin SD (1996) Treatment of complex
injuries involving the posterior cruciate and posterolateral
ligaments of the knee. Am J Knee Surg 9:200–214
50. Washer DC, Dvirnak PC, DeCoster TA (1997) Knee dislo-
cation: initial assessment and implications for treatment.
J Orthop Trauma 11:525–529
51. Muller W (1983) The knee: form, function and ligament
reconstruction. Berlin: Springer-Verlag:246–248
52. Fisher SP, Fox JM, Del Pizzo W, et al. (1991) Accuracy of
diagnoses from magnetic resonance imaging of the knee.
A multi-center analysis of one thousand and fourteen
patients. J Bone and Joint Surg 73A:2–10
53. Grover JS, Basset LW, Gross ML, et al. (1990) Posterior
cruciate ligament: MR imaging. Radiology 174:527–530
54. Heron CW, Calvert PT (1992) Three-dimensional gradient-
echo MR imaging of the knee. Comparison with arthros-
copy in 100 patients. Radiology 183:839–844
55. Irizarry JM, Recht MP (1997) MR imaging of the knee
ligaments and the postoperative knee. Radiol Clin North
Am 35:45–76
56. Polly DW Jr, Callaghan JJ, Sikes RA, et al. (1988) The
Th accu-
racy of selective magnetic resonance imaging compared
with the findings of arthroscopy of the knee. J Bone Joint
Surg 70A:192–198
57. Roberts CC, Towers JD, Spangehl MJ, et al. (2007)
Advanced MR imaging of the cruciate ligaments. Radiol
Clin North Am 45:1003–1016
58. Turner DA, Prodromos CC, Petasnick JP, et al. (1985)
Acute injuries of the ligaments of the knee: magnetic reso-
nance evaluation. Radiology 154:717–722
59. Gross ML, Grover JS, Bassett LW, et al. (1992) Magnetic
resonance imaging of the posterior cruciate ligament.
Clinical use to improve diagnostic accuracy. Am J Sports
Med 20(6):732–737
60. Vaz CE, Camargo OP, Santana PJ, Valezi AC (2005) Accu-
racy of magnetic resonance in identifying traumatic
intraarticular knee lesions. Clinics 60(6):445–450
61. Margheritini
g F, Mancini L, Mauro CS, Mariani PP (2003)
Stress radiography for quantifying posterior cruciate liga-
ments defificiency. Arthroscopy 19(7):706–711
62. Schulz MS,, Russe K,, Lampakis
p G,, Strobel MJ (2005) Reli-
ability of stress radiography for evaluation of posterior
knee laxity. Am J Sports Med 33(4):502–506
63. Wirz P, von Stokar P, Jakob RP (2000) The ffect of knee
Th eff
position on the reproducibility of measurements taken
from stress films. A comparison of four measurement
methods. Knee Surg Sports Traumatol Arthrosc 8(3):143–
148
 Definition and diagnosis of posterior cruciate ligament injury and algorithm of treatment 367
64. Dye SG, Chew MH (1994) The use of scintigraphy to detect
increased osseous metabolic activity about the knee. Instr
Course Lect 43:453–469
65. Shelbourne KD, Davis TJ, Patel DV (1999) Th The natural
history of acute, isolated, nonoperatively treated poste-
rior cruciate ligament injuries. A prospective study. Am J
Sports Med 27:276–283
66. Shelbourne KD, Muthukaruppan Y (2005) Subjective
results of nonoperatively treated, acute, isolated posterior
cruciate ligament injuries. Arthroscopy 21:457–461
67. Sekiya JK, Whiddon DR, Zehms CT, Miller MD (2008) A
clinically relevant assessment of posterior cruciate liga-
ment and posterolateral corner injuries. Evaluation of
isolated and combined defi ficiency. J Bone Joint Surg Am
90:1621–1627
68. Apsingi S, Nguyen T, Bull AM, et al. (2008) The
Th role of PCL
reconstruction in knees with combined PCL and poste-
rolateral corner defificiency. Knee Surg Sports Traumatol
Arthrosc 16:104–111
69. Fanelli GC (1993) Posterior cruciate ligament injuries in
trauma patient. Arthroscopy 9:291–294
70. Markolf KL, Graves BR, Sigward SM, et al. (2007) Effects
ff
of posterolateral reconstructions on external tibial rota-
tion and forces in a posterior cruciate ligament graft. J
Bone Joint Surg Am 89:2351–2358
71. Staubli HU (1994) Posteromedial and posterolateral cap-
sular injuries associated with posterior cruciate ligament
insuffi
fficiency. Sports Med Arthrosc Rev 2:146–164
72. Harner CD, Xerogeanes JW, Livesay GA, et al. (1995) The Th
human posterior cruciate ligament complex: an interdis-
ciplinary study. Ligament morphology and biomechanical
evaluation. Am J Sports Med 23:736–745
73. Jungg TM,, Reinhardt C,, Scheffler
ffl SU,, Weiler A (2006) Stress
radiography to measure posterior cruciate ligament insuf-
ficiency: a comparison of five difffferent techniques. Knee
Surg Sports Traumatol Arthrosc 14(11):1116–1121
74. Shelbourne KD, Jennings RW, Vahey TN (1999) Magnetic
resonance imaging of posterior cruciate ligament injuries:
assessment of healing. Am J Knee Surg 12:209–213
75. Akisue T, Kurosaka M, Yoshiya S, et al. (2001) Evalua-
tion of healing of the injured posterior cruciate ligament:
analysis of instability and magnetic resonance imaging.
Arthroscopy 17:264–269
76. Mariani PP, Margheritini F, Christel P, Bellelli A (2005)
Evaluation of posterior cruciate ligament healing: a study
using magnetic resonance imaging and stress radiography.
Arthroscopy 21:1354–1361
77. LaPrade RF, Wentorf FA, Fritts H, et al. (2007) A prospec-
tive magnetic resonance imaging study of the incidence
of posterolateral and multiple ligament injuries in acute
knee injuries presenting with a hemarthrosis. Arthroscopy
23:1341–1347
78. Cooper DE (1991) Tests for posterolateral instability of
the knee in normal subjects. Results of examination under
anesthesia. J Bone Joint Surg Am 73:30–36
79. Keller PM, Shelbourne KD, McCarrol JR, et al. (1993)
Nonoperatively treated isolated posterior cruciate liga-
ment injuries. Am J Sports Med 21:132–136
80. Last RJ (1948) Some anatomical details of the knee joint.
J Bone Joint Surg Br 30B:683–688
81. Markolf KL, Mensch JS, Amstutz HC (1976) Stiffnessff and
laxity of the knee – the contributions of the supporting
structures. A quantitative in vitro study. J Bone Joint Surg
Am 58:583-594

S. Akhavan, R.D. Parker
Introduction
U
ntil 70 years ago, physicians considered the
cruciate ligaments, including the posterior
cruciate ligament (PCL), to be “vestigial and
relatively unimportant in knee instability” (1). Over
the last several years, however, the PCL has been
drawing increased interest in the orthopedic litera-
ture. While knowledge of these injuries has gener-
ally lagged behind that of anterior cruciate ligament
injuries (ACL), recent advances have increased our
knowledge of these injuries. Part of the diffi
fficulty in
the treatment of PCL injuries is due to their relative
rarity. As a result, few surgeons have ample experi-
ence with treatment of PCL ruptures.
While many advances have been made in the surgical
treatment of PCL tear, surgical indications still remain
somewhat controversial. In this chapter, we will dis-
cuss the natural history of PCL tears and explore the
current literature on surgical indications.
Epidemiology
The incidence of PCL injuries varies widely, depend-
ing on the population studied. In a general popula-
tion, the incidence has been quoted as low as 3%
(2). In a trauma population, however, the incidence
has been noted to be 38% in patients with a hemar-
throsis (3). Parolie and Bergfeld (4) found the inci-
A B
Fig. 1 – Isolated PCL injuries occur commonly in athletes by either (a) landing on knee with foot plantar flexed or (b) hyperflexion.
Chapter 29
Natural history of PCL ruptures
dence of PCL injuries to be 2% in asymptomatic
college football players at the National Football
League predraft examination. These wide ranges in
the literature are, in part, a reflection
fl of the dif-
ferent mechanism and level of energy imparted to
create a PCL tear in these diff
fferent patient popula-
tions.
In a trauma population, by far the most common
cause of PCL injuries is motor vehicle accidents
(3, 5). It is important to remember that these
injuries are different
ff than those suffffered by the
athlete. Typically, these injuries tend to be higher
energy and occur as the tibia is struck on the dash-
board during impact, driving it posteriorly (5).
The patient may have also suff ffered the injury after
being thrown from the vehicle. In the majority of
cases, there will be associated injuries including the
posterolateral corner (PLC), ACL (in hyperexten-
sion injuries), meniscus, medial collateral ligament
(MCL) injuries, chondral injuries, or some combi-
nation of the above as part of a more serious knee
dislocation (3, 5–7). In one series of 222 trauma
patients with a knee hemarthrosis, isolated PCL
injuries were found to occur only 3.5% of the time,
with the remainder being associated with some
other ligamentous injuries (3). It is important to
remember that many of these patients may have
other life- or limb-threatening injuries as well and
ligamentous knee injuries can easily be overlooked,
resulting in delayed diagnosis and treatment and
signifi
ficant morbidity (5). These findings stress the
370 The Traumatic Knee
importance of a thorough physical examination
when evaluating these patients with high-energy
knee injuries.
PCL injuries in athletes tend to be isolated with
lower velocity injury (Fig. 1a and b). These
Th inju-
ries tend to occur as the athlete falls onto his knee
with a plantar-flflexed foot or with hyperfl flexion.
One recent European series found sporting activi-
ties to account for about 40% of PCL injuries, with
soccer being the predominant sport (5). In these
patients, isolated PCL injuries occurred more com-
monly than those seen in a trauma population,
although almost half were still found to have a
combined injury (5). Interestingly, these patients
tend to present more acutely and tend to receive
treatment earlier than the trauma population.
Anatomy and biomechanics
Anatomy
The PCL acts as the primary restraint to posterior
displacement of the tibia. As a ligament, it is com-
posed primarily of type I collagen. Along with the
ACL, it receives its blood supply from the middle
geniculate artery, a branch of the popliteal artery.
Recent injection studies indicate that the artery
gives branches to the synovial tissue covering the
PCL, with the majority of blood vessels being located
in the proximal and distal third of the ligament. The
Th
central portion is relatively avascular, relying on dif-
fusion of nutrients from blood vessels in the more
vascular parts (8). Th
These findings may at least par-
tially account for the traditional poor results with
attempts at repair of midsubstance tears (9).
The nerve supply of the PCL is derived from the
Th
popliteal plexus and provides pressure, velocity,
A B
Fig. 2 – Left knee with (a) anterior portion of PCL is vertical as seen in this anatomical specimen and (b) the meniscofemoral ligaments of Humphrey and
Wrisberg are reflected exposing the PCL. Note how the fibers are coalesced though there are two regions of its origin.
and pain sensation (10). Various mechanorecep-
tors have been identified
fi in the PCL and electric
stimulation studies indicate that they may have
some control over all muscles acting on the knee
during the gait cycle (11). Disruption of the PCL
results in a loss of this control and may account
for some of the gait abnormalities seen in the PCL-
defi
ficient knee.
Anatomical studies have measured the PCL to be
between 32 and 38 mm in length from its ori-
gin to its insertion (12). Its cross-sectional area
is 31.2 mm at its midsubstance and is about 1.5
times larger than the ACL (7, 12). The PCL origi-
nates on the posterolateral aspect of the medial
femoral condyle and inserts in a depression 1 cm
below the tibial plateau.
The PCL is believed to be composed of two bundles.
The femoral attachment of the PCL is broad, mea-
suring close to 2 cm from anterior to posterior and
covering almost the entire aspect of the medial wall
of the intercondylar notch (13). ThThe two bundles
insert in separate regions on the femoral condyle
often as a coalesced structure, with the anterior
portion inserting more vertically than the poste-
rior portion, which inserts along the intercondylar
surface (Fig. 2a and b) (7). The
Th tibial attachment,
on the other hand, is relatively compact. The
Th ante-
rolateral (AL) bundle inserts along the posterior
aspect of the tibial plateau, from posterior edge of
the root of the medial meniscus to within 2 mm
of the posterior rim of the tibial plateau (13). It is
trapezoidal in shape and is wider posteriorly. Th The
posteromedial (PM) bundle inserts on the remain-
ing aspect of the posterior rim of the tibial plateau
and extends distally below the shelf of the tibial
plateau (13).
The meniscofemoral ligaments (MFL) of Hum-
phrey and Wrisberg play an important role in
determining the severity of PCL injuries. Th These
ligaments may often be confused with the PCL.

Th ligaments originate from the posterior horn of
The
the lateral meniscus and insert anterior and poste-
rior to the femoral attachment of the PCL, respec-
tively. At least one of these ligaments is present
in 93% of knees (13). Due to their attachment to
the relatively mobile meniscus, these ligaments
may sometimes be preserved following injury to
the PCL and may reduce the amount of apparent
posterior laxity (14). They may act as a splint, hold-
ing the ruptured PCL in position while it heals, and
therefore may play a significant
fi role in the non-
operative management of these injuries (13). The Th
posterior MFL, in particular, may be a relatively
large structure in some patients. While still con-
troversial, this may allow replacement of only the
AL bundle of the PCL if posterior MFL is substan-
tial and intact following PCL rupture (13).
Biomechanics
Th primary function of the PCL complex (the PCL
The
and the MFL) is to resist posterior translation of
the knee. This is most pronounced with the knee
held in neutral rotation at 90° of flexion where
sectioning may result in increased posterior trans-
lation to a maximum of 20 mm (15, 16). Internal
rotation decreases this amount of translation and
may be due to the contribution of other structures,
most notably the superfi ficial MCL (17). Other con-
tributors to posterior stability include the lateral
collateral ligament and the PLC. Th These structures
play a minimal role in patients with an intact PCL
but are crucial in maintaining stability in a patient
with a torn PCL (18). A secondary function of the
PCL is to assist the PLC in resisting external rota-
tion. With combined injuries to the PCL and PLC,
there is an increase in both posterior translation
and external rotation, greater than when either
structure is injured alone (16, 19).
As stated previously, the PCL is composed of an
AL and a PM bundle. While this distinction can be
created by dissecting each individual bundle, the
division is artifi
ficial and is not a natural phenom-
enon (13). The
Th main diff fference between these two
bundles is based on their unique tensioning dur-
ing knee motion. The Th AL bundle has been found
to be signifificantly stronger than the PM bundle
(20). This has been attributed to the larger cross-
sectional area of this bundle. Its course during
knee motion is crucial to its function (21). With
the knee extended, the fibers are curved in the sag-
ittal plane and therefore slack. As the knee fl flexes,
the AL bundle fibers become taught and more
vertically oriented, providing the main resistance
to posterior translation (as in a posterior drawer
test). The PM bundle, on the other hand, is loose
during knee flexion and tighter in knee extension.
Natural history of PCL ruptures 371
While this may provide some resistance to poste-
rior translation, the orientation of the fibers
fi in
full extension is almost entirely proximal-to-distal
and therefore not optimally oriented to withstand
posterior translation forces. It is therefore likely
that other structures (such as the PM and PLC)
also provide some degree of resistance as the knee
comes into extension
The individual contribution of the MFL to poste-
rior translation has also been extensively studied.
There have been many theories as to the function
of these ligaments in providing stability to the
knee joint, most notably by stabilizing the lateral
meniscus during knee motion (22). Biomechani-
cal studies of the strength of these ligaments have
revealed that the ultimate loads of these ligaments
may be similar to those of the PM bundle of the
PCL (23, 24). In the intact knee, the MF ligaments
contribute 28% of the total force resisting pos-
terior translation. In the PCL-defi ficient knee, the
MF ligaments have been shown to contribute 71%
(23). These
Th findings imply signifi
ficant contribution
of these ligaments to the management of the PCL-
defi
ficient knee.
Natural history of PCL injuries
History
The evaluation of patients with PCL injuries must
first focus on the mechanism of injury. As previ-
ously mentioned, the trauma patient with a PCL
injury has a high likelihood of having a combined
injury or for the injury to be missed all together.
As such, these patients are more likely to have co-
morbidity which may affect
ff the outcome of their
PCL injury, regardless of the treatment. TheTh ath-
lete, on the other hand, has a higher likelihood of
having an isolated injury although about half will
also have a combined injury (5). It is important to
remember that, unlike an ACL rupture, patients
with a PCL may not recall a pop or may only recall
a fairly innocuous injury.
The mechanism of injury should always be
assessed, if possible. Commonly, in motor vehicle
accidents, there will be a posteriorly directed force
to the proximal tibia as the knee impact on the
dashboard. In an athletic injury, the patient will
typically have fallen onto the knee with the foot
in plantar flexion. When examining these patients,
the knee and proximal tibia should therefore be
carefully assessed for any signs of abrasion or con-
tusion. In cases of low-energy and isolated injury,
patients may have only a mild to moderate effu- ff
372 The Traumatic Knee
sion, a slight limp, pain in the back in the knee, and
typically will lack about 10–20° of flexion.
fl
Classifification
PCL injuries can be classified fi based on the time
interval from injury (acute versus chronic) and
the presence of associated injuries (isolated versus
combined). The grading of PCL injuries is deter-
mined based on the position of the medial tibial
plateau in relation to medial femoral condyle. Nor-
mally, the tibial plateau lies about 1 cm anterior to
the medial femoral condyle with the knee fl flexed at
90°. A grade I injury results in posterior translation
from this position by 0–5 mm. In a grade II injury,
the tibial plateau will be flush with femoral condyles
or will posteriorly translate 5–10 mm. A grade III
injury results in posterior translation greater than
10 mm and will result in the tibial plateau trans-
lating posterior to the femoral condyles. Grade III
injuries typically refl
flect a combined injury, whereas
a grade I or II injury is typically isolated.
Biomechanics of the PCL-deficient
fi knee
It is not unusual for an isolated PCL tear to remain
asymptomatic, even when signs of posterior insta-
bility are seen on physical examination. In order to
understand the natural history of PCL injuries, it
is important to first understand the biomechanics
of the PCL-defi ficient knee. Over the last few years,
several studies have analyzed both biomechanical
and clinical findings in PCL-defi ficient knees.
As a primary restraint to posterior translation, the
PCL is crucial to the normal articular weight distri-
bution of the knee joint. In vitro studies have shown
that posterior translation of the tibia decreases the
load bearing of the meniscus while increasing that
of the articular cartilage (25). Sectioning studies of
the PCL have shown that there is an increase in the
contact pressures, most notably in the medial com-
partment (26). Clinical correlation of these findings
has been found during arthroscopy of symptomatic
PCL-defi ficient knees. In one study, arthroscopy at 5
years in patient with PCL-deficient
fi knees showed
degenerative changes of the medial femoral con-
dyle and patellofemoral joint in 77.8 and 46.7% of
patients, respectively. The incidence at 1 year was
signifi
ficantly greater when the PCL injury was com-
bined with injury to the PLC.
One recent study analyzed the kinematics of the
chronic PCL-defi ficient knee in six patients during
weight-bearing and non-weight-bearing activities
in various degrees of knee flexion (27). Patients
were found to have 10 mm of posterior sublux-
ation of the tibia with non-weight-bearing, of
which only 5 mm corrected with anterior drawer.
The tibia remained in this posteriorly subluxated
position during weight-bearing resulting in the
medial femoral condyle articulating anteriorly on
the medial tibial plateau. This change was not seen
in the lateral compartment. These
Th findings would
seem to support degenerative changes seen during
arthroscopy.
The subject of quadriceps strength in the PCL-de-
ficient knee has also been a point of debate. One
study of 25 athletes treated non-operatively with
a PCL-defificient knee found that 80% were satis-
fied with their knees at an average of 6.2 years fol-
low-up and that 84% had returned to their previous
activity (16% at a reduced level of performance).
The amount of laxity seen on physical exam with
a KT-1000 did not correlate with return of activ-
ity. Patients who had fully returned to sports
were found to have quadriceps strength that was
greater than 100% of the uninvolved extremity
and all patients who did not return had quadriceps
strength below 100% of the uninvolved extremity
(4). One recent kinematic study (28) of patients
with posterior instability during stair descent
found a higher satisfaction score in patients with
greater peak extensor torques. Another long-term
study, however, found no correlation between
isokinetic testing and subjective scores in patient
with PCL-defi ficient knee (29).
Natural history of the PCL-deficient
fi knee
There are few natural history studies in the litera-
ture for isolated PCL rupture. Most authors sepa-
rate PCL injuries into the following categories: iso-
lated versus combined and acute versus chronic.
Thus, treatment algorithms focus on these param-
eters (Figs. 3 and 4). It is generally agreed that the
prognosis of combined (particularly acute) injuries
involving the PLC is not as favorable as that of iso-
lated PCL ruptures as these patients will usually
have greater instability and will be more symptom-
atic (7). As a result, operative intervention is usu-
ally recommended for these patients.
Fowler and Messieh (30) reported on 13 patients
with a PCL rupture. All patients had a confirmed
fi
diagnosis by arthroscopy. Seven patients had a
complete rupture, five a partial rupture, and the
PCL was poorly visualized in one patient. With an
average follow-up of 2.6 years, all patients were able
to return to their pre-injury activities following a
course of physiotherapy. However, on objective test-
ing, only three were found to have no measurable
posterior excursion while all remaining patients had
5 mm or greater excursion. The authors concluded
that subjective good results do not necessarily cor-
relate with objective results of instability.

Fig. 3 – Algorithm for the treatment of acute PCL injuries.
Fig. 4 – Algorithm for the treatment of chronic PCL injuries.
Shelbourne et al. (31) prospectively evaluated
133 patients with an acute, isolated PCL tear for
an average of 5.4 years. Of this original series, 68
were available for objective follow-up with physi-
cal examination. The authors found that PCL laxity
did not increase with the time from injury. In addi-
tion, there was no correlation with the amount of
laxity and the objective and subjective knee scores,
and no correlation with the amount of joint space
narrowing. The authors were also not able to find
any predictive factors that predisposed patients to
deterioration of function. Regardless of the laxity
grade, 50% of patients were able to return to the
same level of activity as before the injury and 50%
were not. A follow-up study of subjective scores
Natural history of PCL ruptures 373
in the same patient population found no signifi- fi
cant deterioration of subjective knee scores with
time (32).
Several other studies, however, have demon-
strated deterioration of both subjective scores
and the radiographic appearance of the joint with
increasing time of injury. Boynton and Tietjens
(33) found signifi
ficant degeneration of the articu-
lar joint space with increasing time from injury. In
30 patients with normal menisci, they found that
81% complained of at least occasional pain and
that 56% had occasional swelling. In another series
(29), 40 patients treated non-operatively with a
PCL tear were reviewed for an average of 6 years
from the time of injury. Despite a mean isokinetic
374 The Traumatic Knee
score of 99% from the contralateral extremity, 68%
of patients had reduced their activity level from
before their injury and 90% complained of knee
pain with activity. The authors also found greater
degenerative changes on radiographs with increas-
ing time from injury.
Non-operative management and surgical indications
Prior to selecting a patient for non-operative man-
agement, it is extremely important to ensure that
the injury is indeed isolated. Th This will be deter-
mined as described above by a thorough physical
exam as well as advanced imaging. Our typical
approach in patients with a grade I or II injury
includes a 2-week period of immobilization with
crutches for weight-bearing, followed by a physical
therapy program emphasizing range of motion and
quadriceps strengthening to offset ff the posterior
subluxation of the tibia (7). The integrity of the
secondary restraints as well as evidence of conti-
nuity on MRI scan is a favorable prognostic factor
to non-operative treatment. In our experience, we
have seen healing of the PCL when there is imag-
ing evidence that it remains in continuity (Fig. 5).
Typically, the patient can be expected to return to
sports in 4–6 weeks. A special circumstance exists
with combined injuries involving the PCL, where
we will typically treat the MCL non-operatively
with functional bracing initially and then reassess
the patient for symptoms related to the PCL.
Treatment of grade III injuries remains somewhat
more controversial. In our experience, these patients
have usually sustained some degree of injury to the
PLC and, as such, will be treated operatively, espe-
cially in younger and active patients. If, however,
non-operative treatment is elected, we usually pro-
ceed with a course of immobilization in full exten-
sion with limited weight-bearing for 2–4 weeks.
Quadriceps-strengthening exercises are initiated
early while limiting the antagonist hamstring exer-
cises until later. In general, most patients will not be
able to return to sporting activities for a period of
3–4 months and may require functional bracing.
In patients with chronic PCL tears that are symp-
tomatic, we usually attempt a course of physical
therapy initially. ThThe patient will be fitted with a
knee brace that is limited in the terminal 15° of
extension until symptoms of posterior knee pain
have resolved.
In patients who do not improve, and who continue
to report pain and recurrent swelling, radiographs
will usually be negative. In this case, we prefer to
evaluate the patient with a bone scan and MRI.
If the findings of these evaluations are positive
in patients with a grade I or II tear that is unable
to modify their activity level, or in patients with a
grade III tear, we will typically recommend operative
intervention. If an operation is to be undertaken,
issue of alignment must be addressed at the same
time. Recent studies have found that increases in
the posterior tibial slope can result in a decrease in
the posterior tibial sag and shift the resting posi-
tion of the tibia anteriorly (34). However, further
long-term evaluation of this procedure is neces-
sary. Other operative indications for PCL ruptures
include combined ligamentous injuries involving
the PCL as well as bony avulsion injuries.
Conclusions
While most authors will agree that non-operative
management of isolated PCL injuries may result
in excellent function despite instability, the long-
term, natural history of this injury is still unknown.
It is important to remember that most patients
who suffffer PCL tears are fairly young and the long-
term eff
ffect of the abnormal kinematic and weight-
bearing of the PCL-defi ficient knee may eventually
lead to signifi
ficant degenerative changes in some
patient. Unfortunately, we are as of yet unable to
identify the patients who will develop degenera-
tive changes and those who will have no long-term
sequelae from a PCL tear. As operative techniques
continue to improve and the long-term effects ff of a
PCL-defificient knee become better defi fined, we may
find the operative indications for PCL ruptures to
expand signifificantly.
References
1. Herzmark MH (1938) The evolution of the knee joint. J
Bone Joint Surg 20(1):77–84
2. Miyasaka K, Daniel D (1991) The incidence of knee liga-
ment injuries in the general population. Am J Knee Surg
4:3–8
3. Fanelli GC, Edson CJ (1995) Posterior cruciate liga-
ment injuries in trauma patients: part II. Arthroscopy
11(5):526–529
4. Parolie JM, Bergfeld JA (1986) Long-term results of non-
operative treatment of isolated posterior cruciate ligament
injuries in the athlete. Am J Sports Med 14(1):35–38
5. Schulz MS, Russe K, Weiler A, et al. (2003) Epidemiol-
ogy of posterior cruciate ligament injuries. Arch Orthop
Trauma Surg 123(4):186–191
6. Sanders TG, Miller MD (2005) A systematic approach to
magnetic resonance imaging interpretation of sports med-
icine injuries of the knee. Am J Sports Med 33(1):131–
148
7. Wind WM Jr, Bergfeld JA, Parker RD (2004) Evaluation
and treatment of posterior cruciate ligament injuries:
revisited. Am J Sports Med 32(7):1765–1775
8. Petersen W, Tillmann B (1999) Blood and lymph supply
of the posterior cruciate ligament: a cadaver study. Knee
Surg Sports Traumatol Arthrosc 7(1):42–50

9. Pournaras J, Symeonides PP (1991) The results of surgi-
cal repair of acute tears of the posterior cruciate ligament.
Clin Orthop (267):103–107
10. Katonis PG, Assimakopoulos AP, Agapitos MV, Exarchou
EI (1991) Mechanoreceptors in the posterior cruciate
ligament. Histologic study on cadaver knees. Acta Orthop
Scand 62(3):276–278
11. Fischer-Rasmussen T, Krogsgaard MR, Jensen DB, Dyhre-
Poulsen P (2002) Muscle refl flexes during gait elicited by
electrical stimulation of the posterior cruciate ligament in
humans. J Orthop Res 20(3):433–438
12. Girgis F, Marshall J, Monajem A (1975) The cruciate liga-
ments of the knee joint: anatomical, functional and exper-
imental analysis. Clin Orthop 106:216–231
13. Amis AA, Gupte CM, Bull AM, Edwards A (2006) Anatomy
of the posterior cruciate ligament and the meniscofemo-
ral ligaments. Knee Surg Sports Traumatol Arthrosc
14(3):257–263
14. St Pierre P, Miller MD (1999) Posterior cruciate ligament
injuries. Clin Sports Med 18(1):199–221, vii
15. Bergfeld JA, McAllister DR, Parker RD, et al. (2001) The Th
eff
ffects of tibial rotation on posterior translation in knees
in which the posterior cruciate ligament has been cut.
83:1339–1343
16. Fu FH, Harner CD, Johnson DL, et al. (1994) Biomechan-
ics of knee ligaments: basic concepts and clinical applica-
tion. Instr Course Lect 43:137–148
17. Ritchie JR, Bergfeld JA, Kambic H, Manning T (1998) Iso-
lated sectioning of the medial and posteromedial capsu-
lar ligaments in the posterior cruciate ligament-deficient
fi
knee. Infl fluence on posterior tibial translation. Am J
Sports Med 26(3):389–394
18. Harner CD, Hoher J (1998) Evaluation and treatment of
posterior cruciate ligament injuries. Am J Sports Med
26(3):471–482
19. Harner CD, Xerogeanes JW, Livesay GA, et al. (1995) The Th
human posterior cruciate ligament complex: an interdis-
ciplinary study. Ligament morphology and biomechanical
evaluation. Am J Sports Med 23(6):736–745
20. Race A, Amis AA (1994) The mechanical properties of the
two bundles of the human posterior cruciate ligament. J
Biomech 27(1):13–24
21. Amis AA, Bull AM, Gupte CM, et al. (2003) Biomechanics
of the PCL and related structures: posterolateral, postero-
medial and meniscofemoral ligaments. Knee Surg Sports
Traumatol Arthrosc 11(5):271–281
Natural history of PCL ruptures 375
22. Moran CJ, Poynton AR, Moran R, Brien MO (2006) Anal-
ysis of meniscofemoral ligament tension during knee
motion. Arthroscopy 22(4):362–366
23. Gupte CM, Bull AM, Thomas RD, Amis AA (2003) The
meniscofemoral ligaments: secondary restraints to the
posterior drawer. Analysis of anteroposterior and rotary
laxity in the intact and posterior-cruciate-deficient
fi knee.
J Bone Joint Surg Br 85(5):765–773
24. Gupte CM, Bull AM, Thomas RD, Amis AA (2003) A review
of the function and biomechanics of the meniscofemoral
ligaments. Arthroscopy 19(2):161–171
25. Ahmed A, Burke D (1983) In-vitro measurements of static
pressure distribution in synovial joints, I: tibial surface of
the knee. J Biomech Eng 105:216–225
26. Skyhar MJ, Warren RF, Ortiz GJ, et al. (1993) The Th eff
ffects
of sectioning of the posterior cruciate ligament and the
posterolateral complex on the articular contact pressures
within the knee. 75:694–699
27. Logan M, Williams A, Lavelle J, et al. (2004) TheTh effffect of
posterior cruciate ligament defificiency on knee kinematics.
Am J Sports Med 32(8):1915–1922
28. Hooper D, Morrissey M, Crookenden R, et al. (2002)
Gait adaptations in patients with chronic posterior
instability of the knee. Clin Biomech (Bristol, Avon)
17:227–233
29. Keller PM, Shelbourne KD, McCarroll JR, Rettig AC (1993)
Nonoperatively treated isolated posterior cruciate liga-
ment injuries. Am J Sports Med 21(1):132–136
30. Fowler PJ, Messieh SS (1987) Isolated posterior cruciate
ligament injuries in athletes. Am J Sports Med 15(6):553–
557
31. Shelbourne KD, Davis TJ, Patel DV (1999) Th The natural
history of acute, isolated, nonoperatively treated poste-
rior cruciate ligament injuries. A prospective study. Am J
Sports Med 27(3):276–283
32. Shelbourne KD, Muthukaruppan Y (2005) Subjective
results of nonoperatively treated, acute, isolated poste-
rior cruciate ligament injuries. Arthroscopy 21(4):457–
461
33. Boynton MD, Tietjens BR (1996) Long-term followup of
the untreated isolated posterior cruciate ligament-defi- fi
cient knee. Am J Sports Med 24(3):306–310
34. Giffin JR, Stabile KJ, Zantop T, et al. (2007) Importance
of tibial slope for stability of the posterior cruciate
ligament deficient knee. Am J Sports Med 35(9):1443–
1449.

J. Höher, S. Shafizadeh
Introduction
T
he surgeon who is planning to perform poste-
rior cruciate ligament (PCL) reconstruction has
to consider several factors previous to surgery.
These elements of strategy include graft selection,
the use of one- or two-bundle technique, drilling of a
tibial tunnel or the use a tibial inlay technique, treat-
ment of concomitant ligament injuries, and in some
cases the requirement to address varus malalignment
with valgus high tibial osteotomy. If additional grafts
are needed for multiligament reconstruction (e.g.,
posterolateral reconstruction), autografts from the
contralateral side or allografts can be an alternative.
When choosing a graft for PCL reconstruction, one
should imagine the requirements for an ideal graft
as listed in Table 1.
Looking at the fifiber architecture of the PCL, with its
two functional bundles, it becomes obvious that no
existing graft can imitate the complex anatomical struc-
ture of the PCL. The insertion area of the anterolateral
(AL) and the posteromedial (PM) bundle of the PCL at
the tibia is located far back at the posterior aspect of
the tibia, approximately 10 mm below the joint sur-
face, and covers an area of 153 mm2 (±37 mm2). At
the femur the PCL insertion is relatively planar and
approximates a half-moon; it covers an area of 128
mm2 (±22 mm2). Relative to the insertion areas of the
PCL at tibia and femur, the ligament midsubstance is
found to be approximately three times smaller (1).
Regardless of the fact that the ideal PCL graft does
not exist, a variety of operation techniques have
been developed to reproduce the anatomy and to
restore biomechanics of the PCL as anatomical as
possible. Thus so far, no superior reconstruction
technique, including one- or two-bundle recon-
Table 1 – Characteristics for an ideal graft for PCL reconstruction.
• Structural properties identical to intact PCL
• Identical geometrical shape
• No harvest site morbidity
• Easy graft insertion (graft passage)
• Secure fixation in an anatomical position
• Fast graft incorporation
Chapter 30
The PCL: diff
fferent options in PCL
reconstruction: choice of the graft?
One or two bundles?
struction, graft choice, graft fixation, and onlay/
inlay technique, could be found to be the gold stan-
dard in PCL reconstruction.
Planning PCL reconstruction, the following general
considerations help to select the correct individual
graft. First, one should consider how many grafts
are needed (single/double-bundle (SB/DB) PCL
reconstruction, reconstruction of the posterolateral
corner, anterior cruciate ligament (ACL) reconstruc-
tion, etc.). Then one should check on the availability
of the possible grafts in the individual patient and
on the availability of allografts. It is important to be
aware of the specifi
fic design aspects of the graft and
ensure that they match requirements for the chosen
operative technique. Finally one has to be familiar
with various options of graft fi
fixation.
This chapter will focus on graft selection and SB
versus DB reconstruction and discuss the various
aspects of these issues.
Graft selection
Since graft selection is also infl
fluenced by other fac-
tors, such as surgeon’s experience and preference,
surgeons can practically choose between autograft,
Fig. 1 – Graft design of frequently used autograft tissues for PCL reconstruc-
tion. Bone-patellar tendon-bone graft (BPTB), quadruple hamstring graft,
and quadriceps tendon graft.
378 The Traumatic Knee

allograft, and synthetic graft materials. Further, Table 2 – Comparison of biomechanical and structural properties of the
with respect to the operative technique the surgeon intact PCL and common autografts and allografts (24–30).
can select a special graft design, as there are grafts Maximum Stiffness X-Area Length
with one bone block at one end, grafts with two bone strength (N/mm) (mm2) (mm)
blocks, one at each end of the graft, and soft tissue (N)
grafts without bone blocks (Fig. 1). In contrast to PCL AL bundle 1494 ± 390 306 ± 130 38–42
ACL reconstruction, where a minimum graft length
PCL PM bundle 242 ± 66 75 ± 31
is believed to be between 6.0 and 6.5 cm, in PCL
reconstruction a longer graft is needed. Depending 36.8 ± 52.2 ±
BPTB (10 mm) 2977 ± 516 455 ± 56
on the fixation technique, a minimum graft length 5.7 4.8
of 8 cm is necessary in PCL reconstruction. Fresh-frozen
2552 633
BPTB allograft
Radiated BPTB
Autografts 1990 531
allograft

Patellar tendon graft Quadriceps 325.6 ± 64.6 ± 86.4 ±

2352 ± 495
tendon 70 8.4 9.0
The patellar tendon graft (bone-patellar tendon-
bone (BPTB)) (Fig. 2) is harvested through a Quadruple
6–8-cm incision and consists of the central third of semitendinosus/ 4090 ± 295 776 ± 204 52 ± 5 100–120
the patellar tendon. The bone plugs have a length gracilis
of 20–25 mm at each end – proximally from the
patella and distally from the tibia. Variable diam-
Except for crosspin fixation techniques, all fixation
eters between 8 and 12 mm can be harvested. The Th
methods are possible using a BPTB transplant.
BPTB graft shows good biomechanical properties
Screw fixation techniques next to the bone plugs
concerning strength and stiff ffness (Table 2).
are preferred, since these fixation techniques allow
While generally the use of bone blocks has advan-
a stable and rapid bone to bone tunnel incorpora-
tages in terms of healing into bone, of filling of the
tion after 6–8 weeks leaving the ligament-to-bone
bone tunnels, and in terms of biomechanical aspects,
insertion intact (4).
such as stiff
ffness and strength, a specifi fic challenge
Complications such as anterior knee pain, pain
of PCL reconstruction is the passage of the graft
when kneeling, patellar fracture (5), patellofemoral
into the joint, making the turn at the proximal end
crepitation (6), numbness caused by damage of the
of the tibial tunnel. This turn has been referred to
infrapatellar branch of the saphenous nerve (7),
in the literature as the “killer turn” (2, 3). The
Th use of
possible loss of quadriceps strength with increased
a graft with a 20–30-mm bone block going around
rate of patellofemoral pain, and patellar tendinitis
that turn may be extremely difficultffi at the time
are associated with harvesting BPTB grafts.
of surgery and may make the procedure with this
Since PCL-deficient knees have higher rates of
type of graft critical. In order to make graft passage
femoropatellar and anterior knee pain, weaken-
more easy, resection of all PCL structures may be
ing of the most important PCL agonist causes
necessary. However, one should keep in mind that
higher femoropatellar pressure. Some authors
also at the entrance of the femoral tunnel the PCL
believe that therefore BPTB should be avoided
graft has to make a significant
fi turn.
in order to prevent further patellofemoral prob-
Besides the transtibial graft passage, the BPTB
lems (8–10).
graft can be fixed at the tibial side in a tibial inlay
technique to avoid the killer turn effect.
ff Quadriceps tendon graft
The quadriceps tendon graft consists of a 10–12 mm
strip with or without a bone block (20–25 mm)
from the proximal patella. It can usually be
retrieved with a free tendon end of approximately
8–10 cm length. The length of the incision may be
around 4–6 cm. Minimal-invasive techniques for
soft tissue quadriceps tendon harvesting (without
a bone block) exist (11).
Harvesting the quadriceps tendon can some-
times be more challenging than harvesting
other grafts. Opening of the suprapatellar reces-
sus should be avoided in order to prevent fluid
Fig. 2 – BPTB autograft. Note: A bone block is present on each end of the graft. drainage.
 The PCL: different options in PCL reconstruction: choice of the graft? One or two bundles? 379
Fig. 3 – Example of a quadriceps tendon
split autograft. Note: A bone block is used
for the tibial tunnel. The soft tissue end is
separated into strands being inserted into
two separate bone tunnels on the femoral
side for the anterolateral and posterome-
dial bundles of the PCL.
Th quadriceps tendon graft is 1.8 times thicker
The
than the BPTB graft, thus providing a larger
cross-sectional area than a BPTB graft of equal
width (12, 13). Compared with BPTB graft the
quadriceps tendon shows stronger biomechanical
properties.
However, the ultimate load values for tensile stress
of the quadriceps tendon are not increased with
the higher cross-sectional area (Table 2).
Because of the free tendon end for the femoral tun-
nel, transtibial graft passage is easier compared to
the graft passage of BPTB grafts. Using a quadri-
ceps tendon graft with a bone block allows either
a tibial fixation in the bony tunnel or a tibial inlay
fixation technique to avoid “killer turn”-associated
problems. Except for crosspin fixation techniques,
all fi
fixation types are possible at the femur.
In DB PCL reconstructions good results could be
achieved using a quadriceps graft with a femoral
tendon split (Fig. 3).
The harvest site morbidity of the quadriceps ten-
don includes all problems seen in BPTB harvest-
ing. The donor site morbidity of quadriceps ten-
don grafts is reported to be less, when compared
to BPTB grafts (14). Nevertheless, harvesting the
quadriceps tendon also weakens the quadriceps
muscle, the most important PCL agonist, with
increased postoperative rates of femoropatellar
and anterior knee pain (4).
Hamstring grafts
Hamstring tendon grafts are normally used as
multiple-stranded grafts to achieve a reasonable
graft length (Fig. 4). Th
The tendons can be harvested
over a 3–5 cm diagonal or vertical incision over the
pes anserinus.
In PCL reconstructions the grafts have to be longer
than in ACL reconstruction. Therefore, a double
semitendinosus and a double gracilis graft confi figu-
ration are mostly favored. The
Th tendons can be used
either as quadruple-stranded grafts in a single tun-
nel technique or as double-stranded grafts in a two
tunnel technique (15).
The ultimate failure load and stiff ffness measured
using a four-strand hamstring graft was the
highest among the three commonly used grafts
(Table 2). Also the biomechanical properties of
hamstring grafts off ffer good biomechanical prop-
erties concerning strength, stiffness,
ff and elastic
modulus.
Osseous integration requires tendon-to-bone
healing, which is infl fluenced by the fixation type.
A variety of fixation options exist using hamstring
tendons. To achieve ligament-to-bone contact
interference screw fixations are preferred at both
ends of the graft. If the tendon tissue is placed
in a bone tunnel, usually an indirect tendon-to-
bone interface with so-called Sharpey-like fi fibers
will develop (16). If a tight contact between ten-
don tissue and bone tunnel wall can be achieved
(e.g., with an interference screw), a new direct
ligament-to-bone insertion (with a calcified fi and
non-calcifified cartilage layer) may develop over
time (17, 18).
Tibial fixation remains an ongoing concern for
many surgeons due to issues of bone density and
prominence of subcutaneous hardware in the
proximal tibia.
General perception suggests that there is less
donor site morbidity associated with hamstring
autografts. It has to be stated that the hamstring
graft is not completely free of donor site morbid-
ity, and some investigators have actually found
no signifificant diff
fference in anterior knee pain
Fig. 4 – Example of hamstring autograft. Note: A four- to five-stranded
graft is necessary for sufficient
ffi graft diameter.
380 The Traumatic Knee
between hamstring and BPTB (6, 19–23). Never-
theless, harvesting hamstring autografts for PCL
reconstruction does not weaken the quadriceps
muscle directly, as BPTB and quadriceps tendon
grafts do.
A comparison of biomechanical and structural
properties between common autografts and
allografts is revealed in Table 2 (24–30).
It should be noted that the ultimate load in the
intact PCL was determined to be around 1800 N
for the entire ligament. However, these data have
been measured in old cadaveric knees. If the rela-
tionship between age and structural properties
follows the same pattern in the PCL as in the ACL
reconstruction, the ultimate load in a young human
may be as high as 3000–5000 N. In addition to the
structural properties of the graft material, which
primarily characterize the mechanical behavior of
the intraarticular graft portion, it is important to
note that the biomechanical function of the graft
in vivo largely depends on the mechanical charac-
teristics of the entire graft construct including its
fixation to bone (31). Issues of graft fixation, how-
fi
ever, will not be discussed in this chapter.
Allografts
The use of allografts in PCL reconstruction has
gained popularity in recent years for several rea-
sons (Table 3) (15, 32, 33).
Specifi
fically in technically demanding cases, such as
DB PCL reconstruction, combined PCL and postero-
lateral injuries, multiligamentous knee injuries, and
in revision cases, allografts can substantially reduce
harvest site morbidity and operating time (34, 35).
Therefore, the use of allografts in primary and revi-
sion knee ligament reconstruction has increased
by around 30% during recent years (36).
Depending on legal issues, prerequisites for the use
of allografts include information on the origin of
the tissues, donor age, tissue retrieval under ster-
ile conditions, fulfi
fillment of legal requirements for
storage (only deep-frozen or cryopreserved mate-
rials), and screening of the donors for possible dis-
ease transmission (15).
Table 3 – Advantages of allograft tissue for knee ligament reconstruction.
• Avoidance of graft harvest morbidity
• Reduction of operating time
• Improved cost effi
fficiency (depending on allograft costs)
• Larger and predictable graft sizes
• Unlimited availability even in revision cases and multiligamentous
knee reconstruction
• Improved cosmetic result
Today several tissue banks around the world pro-
vide a variety of allografts. In America the “Food
and Drug Administration” (FDA) and the “Ameri-
can Association of Tissue Banks” (AATB) control
around 150 tissue banks. The number of tissue
banks in Europe is also rising, while legal European
and National law issues are still limiting the num-
bers of tissue banks (37).
For PCL reconstruction, several allograft options
exist, providing strong and dense collagen tissue and
having suffi
fficient length for almost all PCL reconstruc-
tion techniques (15). Besides patellar tendons, quad-
riceps tendons, and hamstring tendons, as known
from autograft ligament reconstruction, additional
allograft tissues such as Achilles tendons (Fig. 5), tib-
ialis anterior tendons (Fig. 6), and tibialis posterior
tendons, are suitable for PCL reconstruction.
Several clinical studies comparing allografts and
autografts in knee ligament reconstruction exist.
Although these studies could not find signifi ficant
diff
fferences between the allograft and autograft
groups for knee laxity and outcome (38–41), some
recent clinical reports on increased long-term heal-
ing (41–43) and more frequent rerupture rates
(44) in ACL reconstruction and PCL reconstruc-
tion using allografts were published. Histological
studies on allograft ligament reconstruction in a
sheep model found delayed remodeling in the early
healing phase, which might have an influence fl on
mechanical strength and compromise long-term
stability (36).
Current screening, processing, and sterilization
techniques are able to reduce the risks of disease
transmission using allografts for knee ligament
reconstruction to a minimum; however, one should
be aware of the risks and the risks should not be
Fig. 5 – Example of an Achilles tendon allograft. Note: A bone block can be
created on one side of the graft. The soft tissue end reveals suffi
fficient length
for graft fixation.
Fig. 6 – Example of tibialis anterior allograft. Note: A twofolded graft is usually
suffi
fficient for an 8–9-mm bone tunnel.
 The PCL: different options in PCL reconstruction: choice of the graft? One or two bundles? 381

overlooked. Besides the risk of disease transmis-
sion, the potential of low-level immune response
has to be considered, with the use of allograft tis-
sues (32). Further specifi fic costs for allograft tis-
sues may be substantial and may limit their use in
the clinical setting (45).
Clinical and basic science literature could so far
not provide conclusive data on whether differences
ff
between allografts and autografts exist. Therefore,
Th
benefi
fits of using allografts in PCL reconstruction
have to be carefully balanced with the problems
and complications.
the tibial side the insertion site, however, is much
smaller, therefore making it technically more dif-
ficult and less necessary to use two bone tunnels
(Fig. 9).
Biomechanical studies
Several biomechanical, so-called controlled labora-
tory studies have focused on the effect
ff of DB PCL
reconstruction. In these studies human cadaveric
knees have been subjected to various external loads

Single-bundle versus double-bundle

reconstruction
When discussing SB versus DB reconstruction
for the PCL, one has to review the anatomy of
the normal knee and normal knee kinematics
with respect to the function of each bundle of
the PCL (Fig. 7).
As outlined earlier the PCL has two functional
bundles, the AL and the PM bundle. The Th AL bun-
dle represents the majority of the cross-sectional Fig. 8 – Posterior view of the tibial plateau of an anatomical specimen with
area while the PM bundle is the smaller bundle the insertion site areas of the PCL and its functional bundles (AL bundle:
(46). The
Th AL is more taut in flexion and loose in yellow; PM bundle: red).
extension while the PL is taut in extension and
deep flexion and relatively loose in mild flexion
(46). Due to these very distinct and different
ff func-
tions of the two bundles, it appears logical that
in order to restore normal knee kinematics one
has to reconstruct both bundles separately at the
time of surgery. Specifi
fically on the femoral side
the insertion site spans over an oval area of more
than 20 mm longitudinally making it easy to place
two bone tunnels within the footprint (Fig. 8). On

Fig. 9 – Schematic of double-bundle PCL reconstruction with two bone

Fig. 7 – Lateral view of the medial femoral condyle (lateral femoral condyle tunnels on the femoral side and one tunnel on the tibia side. Note: Various
removed) of an anatomical specimen with the insertion site areas of the PCL orientations of AL and PM bundles at full extension, 90° and 120° of knee
and its functional bundles (AL bundle: yellow; PM bundle: red). flexion.
382 The Traumatic Knee

such as posterior tibial loading, varus/valgus load-
ing, and/or external/internal rotational torque.
Under these conditions the kinematic changes of
tibia relatively to the femur can be measured in
response to external loads. Some approaches using
robotic technology further allow measuring the
in situ forces of the ligamentous structures. Usu-
ally the intact knee is used as the control; section-
ing the PCL and associated structures reveals the
pathologic conditions. After reconstructing these
structures of interest changes in identical load-
ing conditions can help to evaluate if normal knee
kinematics can be restored and if in situ forces are
similar to the intact structures. Table 4 gives an
overview on laboratory studies on DB PCL recon-
struction. In summary testing conditions in these
studies vary to a large extent and the results are
somewhat controversial. Overall there are some
studies demonstrating that DB PCL reconstruction
may lead to better restoration of normal knee kine-
matics than SB AL PCL reconstruction (28, 47).
Clinical studies
In the literature the concept of DB PCL reconstruc-
tions has been introduced by several authors since
the year 2002. The
Th techniques for DB PCL recon-
struction always include drilling of two bone tun-
nels on the femoral side; however, they vary on the

Table 4 – Overview of studies on double-bundle PCL reconstructions: biomechanical, cadaveric studies.

Conclusion
Reference Journal Year Study design Groups Endpoints Results in favor of
DB PCL
Biomechanical
Isometric versus DB-reconstruction
Race and Amis J Bone Joint testing: anterior
1998 SB versus DB PCL Knee kinematics better knee kinematics ++
(47) Surg Br or posterior
reconstruction than SB-reconstruction
loading
Robotic testing 5 DOF DB reconstruction
Am J Sports SB versus DB PCL
Harner et al. (28) 2000 posterior tibial kinematics, in better knee kinematics ++
Med reconstruction
loading situ forces than SB-reconstruction
Tibial inlay single
femur versus No difference in
Biomechanical
Bergfeld et al. Am J Sports double femur Posterior posterior laxity isolated
2005 testing: posterior −−
(48) Med tunnel, split translation injury model,
tibial loading
or straight Achilles no rotation
tendon
Single AL
reconstruction, good
Single AL restoration of normal
Biomechanical
J Bone Joint reconstruction Knee kinematics laxity
Markolf et al. (3) 2006 testing: posterior −+
Surg Am + additional PM 5DOF Additional PM
loading
reconstruction reconstruction, slight
reduction of laxity at
0/30°
Biomechanical
Am J Sports SB-AL + DB PCL Posterior DB lower posterior
Wiley et al. (49) 2006 testing: posterior +−
Med reconstruction translation laxity than SB
loading
No difference
Single AL in SB versus DB
Apsingi et al. Posterior loading, reconstruction reconstruction
KSSTA 2008 Posterior drawer −
(50) external rotation versus DB-PCL None restored external
reconstruction rotation when PCL
sectioned
No difference in forces
Robotic testing: PCL DB and PLC
5 DOF between AL and PM
Clin Orthop posterior tibial reconstruction
Mauro et al. (51) 2008 kinematics, Higher forces in PCL +(−)
Relat Res loading, external in PCL and PLC-
in situ forces with the PLC deficient
torque deficient knee
than reconstructed
 The PCL: different options in PCL reconstruction: choice of the graft? One or two bundles? 383

tibial side between one or two tunnels or the use of
the tibial inlay technique. The
Th operative techniques
for DB PCL reconstruction may use hamstring
grafts, split quadriceps grafts, as well as a combina-
tion of BPTB and hamstrings and may involve the
use of allograft tissue such as Achilles tendon or
tibialis anterior or posterior tendon. An overview
of operative techniques of DB PCL is presented in
Table 5.
While several operative techniques have been pub-
lished as a technical note without any information
on patient outcome, there have been much less
publications on the outcome of DB PCL recon-
struction. However, most papers are case series
studies (level 4 studies for scientific
fi evidence) that
have followed up patients either retrospectively or
prospectively. Few studies have compared DB PCL
reconstruction to SB PCL reconstruction and there
is not even a single randomized controlled study
representing a level 1 evidence-based study (62). In
Table 6 clinical outcome studies on DB PCL recon-
struction are listed revealing inconsistent results
with respect to the merit of the DB approach. Fur-
ther it is diffi
fficult to evaluate studies since patient

Table 5 – Surgical techniques (technical notes) for DB PCL reconstruction.

Femoral Tibial
Reference Journal Year Graft tissue
approach approach
Stähelin et al. (52) Arthroscopy 2001 Semitendinosus/gracilis autograft 2 bone tunnels 1 bone tunnel
Bordon et al.
Arthroscopy 2001 Tibialis anterior allograft 2 bone tunnels 1 bone tunnel
(53)
Chen et al. (54) Arthroscopy 2003 Quadriceps tendon + 2× semitendinosus 2 bone tunnels 1 bone tunnel
Richards and
Arthroscopy 2003 Quadriceps tendon split graft 2 bone tunnels 1 bone tunnel
Moorman (55)
Noyes (56) Arthroscopy 2003 Quadriceps tendon split graft 2 bone tunnels Tibial inlay
Kim et al. (57) Arthroscopy 2004 Tibialis posterior allograft threefold 2 bone tunnels 1 bone tunnel
Kim and Park (58) Arthroscopy 2005 Achilles tendon allograft 2 bone tunnels Tibial inlay
Makino et al. (59) Arthroscopy 2006 Tibialis anterior or posterior allograft 2 bone tunnels 2 tunnels
Jordan et al. (60) Sports Med Arthrosc 2007 BPTB allograft 2 bone tunnels Tibial inlay
Knee Surg Sports
Lee et al. (61) 2007 Tibialis anterior allograft threefold 2 bone tunnels 1 bone tunnel
Traumatol Arthrosc

Table 6 – Overview on clinical studies on double-bundle PCL-reconstruction.

Conclusion in
FU
Reference Journal Year N Design Graft Endpoint Major results favor of DB PCL
(years)
reconstruction
Lysholm Lysholm, laxity
Yoon Case series
Arthroscopy 2005 27 2.1 Split AT radiographic improved compared +−
et al. (63) Level IV
laxity to preoperative
Lysholm, Reduced laxity,
Garofalo BPTB +
Arthroscopy 2006 15 Case series 3.2 radiographic but 40% >5 mm, −
et al. (64) 2× ST
laxity improved lysholm
Knee Surg
IKDC normal/nearly
Nyland Sports
2002 19 Case series 2 Allograft IKDC score normal in 89% +
et al. (65) Traumatol
subjects
Arthrosc
Houe BPTB SB
Scand J Med No difference in SB
and Jorgensen 2004 16 Case series 2.9 versus Scores, laxity −
Sci Sports versus DB
(66) ST/Gr DB
Posterior No difference
Hatayama SB versus translation in translation
Am J Orthop 2006 20 Case series 2 −+
et al. (67) DB Second-look 30% rupture of PM
arthroscopy bundle
384 The Traumatic Knee
data are diffi
fficult to compare and concomitant knee
laxities such as posterolateral insuffi
fficiencies may
or may not be suffifficiently addressed at the time of
surgery.
In the literature there are no clinical reports on
complications of DB PCL reconstruction. Wiley et
al. found in a cadaver study that the risk of medial
condyle fracture may increase with two bone tun-
nels used as compared to only one (68).
As to date one has to conclude that although there
are few studies demonstrating benefits fi of DB PCL
reconstruction over SB AL PCL reconstruction in
the laboratory setting, clinically most studies fail to
demonstrate an advantage of DB PCL reconstruc-
tion. It should be kept in mind that DB reconstruc-
tion without doubt is more technically demanding
and more time-consuming that SB AL PCL recon-
struction. Therefore, in the clinical setting it may
be more important to address concomitant inju-
ries such as posterolateral and PM ligament insuf-
ficiency at the time of surgery than to focus on DB
reconstruction of the PCL (69).
Conclusion
Among others, important issues when planning PCL
reconstruction include the choice of the graft and the
issue of SB versus DB reconstruction of the PCL. The
surgeon can choose between several grafts varying
in terms of graft design, soft tissue graft, and grafts
including one or two bone blocks. Allograft tissues
are an attractive alternative to autograft tissues if
they are available. The surgeon performing PCL sur-
gery must be familiar with specific fi characteristics,
advantages, and disadvantages of the various grafts.
However, the surgeon must consider both the indi-
vidual situation of the patient and the level of expe-
rience he has with the use of the various grafts.
With respect to SB versus DB reconstruction there
seems to be insuffifficient support from the litera-
ture to recommend DB reconstruction of the PCL
at this point in time.
References
1. Harner CD, et al. (1999) Quantitative analysis of human
cruciate ligament insertions. Arthroscopy 15(7):741–749
2. Bergfeld JA, et al. (2001) A biomechanical comparison of
posterior cruciate ligament reconstruction techniques.
Am J Sports Med 29(2):129–136
3. Markolf KL, Zemanovic JR, McAllister DR (2002) Cyclic
loading of posterior cruciate ligament replacements fixed
fi
with tibial tunnel and tibial inlay methods. J Bone Joint
Surg Am 84-A(4):518–524
4. Strobel MJ, Weiler A (2008) Posterior cruciate ligament –
anatomy, diagnostic and operative technique. Tuttlingen:
Endo Press
5. Fu FH, et al. (2000) Current trends in anterior cruciate lig-
ament reconstruction. Part II. Operative procedures and
clinical correlations. Am J Sports Med 28(1):124–130
6. Anderson AF, Snyder RB, Lipscomb AB Jr (2001) Anterior
cruciate ligament reconstruction. A prospective random-
ized study of three surgical methods. Am J Sports Med
29(3):272–279
7. Jansson KA, et al. (2003) A prospective randomized study
of patellar versus hamstring tendon autografts for ante-
rior cruciate ligament reconstruction. Am J Sports Med
31(1):12–18
8. Freedman KB, et al. (2003) Arthroscopic anterior cruciate
ligament reconstruction: a metaanalysis comparing patel-
lar tendon and hamstring tendon autografts. Am J Sports
Med 31(1):2–11
9. Paulos LE, Wnorowski DC, Greenwald AE (1994) Infra-
patellar contracture syndrome. Diagnosis, treatment, and
long-term followup. Am J Sports Med 22(4):440–449
10. Rosenberg TD, et al. (1992) Extensor mechanism function
after patellar tendon graft harvest for anterior cruciate
ligament reconstruction. Am J Sports Med 20(5):519–525
(discussion 525–526)
11. Almazan Diaz A, et al. (2006) Minimally invasive quadri-
ceps tendon harvest. Arthroscopy 22(6):679.e1–679.e3
12. Harris NL, et al. (1997) Central quadriceps tendon for
anterior cruciate ligament reconstruction. Part I: morpho-
metric and biomechanical evaluation. Am J Sports Med
25(1):23–28
13. Staubli HU, et al. (1999) Mechanical tensile properties
of the quadriceps tendon and patellar ligament in young
adults. Am J Sports Med 27(1):27–34
14. Aglietti P, et al. (1993) Patellofemoral problems after
intraarticular anterior cruciate ligament reconstruction.
Clin Orthop Relat Res (288):195–204
15. Hoher J, Scheffl
ffler S, Weiler A (2003) Graft choice and graft
fixation in PCL reconstruction. Knee Surg Sports Trauma-
tol Arthrosc 11(5):297–306
16. Rodeo SA, et al. (1993) Tendon-healing in a bone tunnel.
A biomechanical and histological study in the dog. J Bone
Joint Surg Am 75(12):1795–1803
17. Weiler A, et al. (2000) Biodegradable implants in sports
medicine: the biological base. Arthroscopy 16(3):305–321
18. Weiler A, et al. (2001) The Th EndoPearl device increases
fixation strength and eliminates construct slippage of
hamstring tendon grafts with interference screw fi fixation.
Arthroscopy 17(4):353–359
19. Aune AK, et al. (2001) Four-strand hamstring tendon
autograft compared with patellar tendon-bone autograft
for anterior cruciate ligament reconstruction. A random-
ized study with two-year follow-up. Am J Sports Med
29(6):722–728
20. Beard DJ, et al. (2001) Hamstrings vs. patella tendon for
anterior cruciate ligament reconstruction: a randomised
controlled trial. Knee 8(1):45–50
21. Beynnon BD, et al. (2002) Anterior cruciate ligament
replacement: comparison of bone-patellar tendon-bone
grafts with two-strand hamstring grafts. A prospective,
randomized study. J Bone Joint Surg Am 84-A(9):1503–
1513
22. Ejerhed L, et al. (2003) Patellar tendon or semitendinosus
tendon autografts for anterior cruciate ligament recon-
struction? A prospective randomized study with a two-
year follow-up. Am J Sports Med 31(1):19–25
23. Eriksson K, et al. (2001) A comparison of quadruple semi-
tendinosus and patellar tendon grafts in reconstruction
of the anterior cruciate ligament. J Bone Joint Surg Br
83(3):348–354
24. Caborn DN, et al. (1998) Quadrupled semitendinosus–
gracilis autograft fixation
fi in the femoral tunnel: a com-
parison between a metal and a bioabsorbable interference
screw. Arthroscopy 14(3):241–245
 The PCL: different options in PCL reconstruction: choice of the graft? One or two bundles? 385
25. Fideler BM, et al. (1995) Gamma irradiation: effects
ff on
biomechanical properties of human bone-patellar tendon-
bone allografts. Am J Sports Med 23(5):643–646
26. Girgis FG, Marshall JL, Monajem A (1975) The Th cruciate
ligaments of the knee joint. Anatomical, functional and
experimental analysis. Clin Orthop Relat Res (106):216–
231
27. Hamner DL, et al. (1999) Hamstring tendon grafts for
reconstruction of the anterior cruciate ligament: biome-
chanical evaluation of the use of multiple strands and
tensioning techniques. J Bone Joint Surg Am 81(4):549–
557
28. Harner CD, et al. (2000) Biomechanical analysis of a dou-
ble-bundle posterior cruciate ligament reconstruction. Am
J Sports Med 28(2):144–151
29. Staubli HU, et al. (1996) Quadriceps tendon and patellar
ligament: cryosectional anatomy and structural proper-
ties in young adults. Knee Surg Sports Traumatol Arthrosc
4(2):100–110
30. Woo SL, et al. (1991) Tensile properties of the human
femur–anterior cruciate ligament–tibia complex. Th The
eff
ffects of specimen age and orientation. Am J Sports Med
19(3):217–225
31. Hoher J, et al. (2000) Mechanical behavior of two ham-
string graft constructs for reconstruction of the anterior
cruciate ligament. J Orthop Res 18(3):456–461
32. Baer GS, Harner CD (2007) Clinical outcomes of allograft
versus autograft in anterior cruciate ligament reconstruc-
tion. Clin Sports Med 26(4):661–681
33. Bartlett RJ, Clatworthy MG, Nguyen TN (2001) Graft
selection in reconstruction of the anterior cruciate liga-
ment. J Bone Joint Surg Br 83(5):625–634
34. Cole DW, et al. (2005) Cost comparison of anterior cru-
ciate ligament reconstruction: autograft versus allograft.
Arthroscopy 21(7):786–790
35. Harner CD, et al. (1995) The
Th human posterior cruciate liga-
ment complex: an interdisciplinary study. Ligament mor-
phology and biomechanical evaluation. Am J Sports Med
23(6):736–745
36. Scheffl
ffler SU, et al. (2008) Fresh-frozen free-tendon
allografts versus autografts in anterior cruciate ligament
reconstruction: delayed remodeling and inferior mechani-
cal function during long-term healing in sheep. Arthros-
copy 24(4):448–458
37. Buchmann S, et al. (2008) Allografts for cruciate ligament
reconstruction. Orthopade 37(8):772–778
38. Kleipool AE, Zijl JA, Willems WJ ((1998) Arthroscopic
anterior cruciate ligament reconstruction with bone-
patellar tendon-bone allograft or autograft. A prospec-
tive study with an average follow up of 4 years. Knee Surg
Sports Traumatol Arthrosc 6(4):224–230
39. Petersen W, et al. (2006) Importance of femoral tunnel
placement in double-bundle posterior cruciate ligament
reconstruction: biomechanical analysis using a robotic/
universal force-moment sensor testing system. Am J
Sports Med 34(3):456–463
40. Shelton WR, Papendick L, Dukes AD (1997) Autograft
versus allograft anterior cruciate ligament reconstruction.
Arthroscopy 13(4):446–449
41. Victor J, et al. (1997) Graft selection in anterior cruciate
ligament reconstruction – prospective analysis of patellar
tendon autografts compared with allografts. Int Orthop
21(2):93–97
42. Gorschewsky O, et al. (2002) Clinico-histologic compari-
son of allogenic and autologous bone–tendon–bone using
one-third of the patellar tendon in reconstruction of the
anterior cruciate ligament. Unfallchirurg 105(8):703–
714
43. Poehling GG, et al. (2005) Analysis of outcomes of anterior
cruciate ligament repair with 5-year follow-up: allograft
versus autograft. Arthroscopy 21(7):774–785
44. Siebold R, et al. (2003) Primary ACL reconstruction with
fresh-frozen patellar versus Achilles tendon allografts.
Arch Orthop Trauma Surg 123(4):180–185
45. Harner CD, et al. (1996) Allograft versus autograft ante-
rior cruciate ligament reconstruction:3- to 5-year out-
come. Clin Orthop Relat Res (324):134–144
46. Amis AA, et al. (2006) Anatomy of the posterior cruciate
ligament and the meniscofemoral ligaments. Knee Surg
Sports Traumatol Arthrosc 14(3):257–263
47. Race A, Amis AA (1998) PCL reconstruction. In vitro biome-
chanical comparison of "isometric" versus single and double-
bundled "anatomic" grafts. J Bone Joint Surg 80-B:173–179
48. Bergfeld JA, et al. (2005) A biomechanical comparison of
posterior cruciate ligament reconstructions using single-
and double-bundle tibial inlay techniques. Am J Sports
Med 33(7):976–981
49. Wiley WB, et al. (2006) Kinematics of the posterior cru-
ciate ligament/posterolateral corner-injured knee after
reconstruction by single- and double-bundle intra-articu-
lar grafts. Am J Sports Med 34(5):741–748
50. Apsingi S, et al. (2008) Control of laxity in knees with
combined posterior cruciate ligament and posterolateral
corner defi ficiency: comparison of single-bundle versus
double-bundle posterior cruciate ligament reconstruc-
tion combined with modifi fied Larson posterolateral corner
reconstruction. Am J Sports Med 36(3):487–494
51. Mauro CS, et al. (2008) Double-bundle PCL and poste-
rolateral corner reconstruction components are codomi-
nant. Clin Orthop Relat Res 466(9):2247–2254
52. Stähelin AC, Sudkamp NP, Weiler A (2001) Anatomic
double-bundle posterior cruciate ligament reconstruction
using hamstring tendons. Arthroscopy 17(1):88–97
53. Bordon PS, Nyland J, Caborn DN (2001) Posterior cruciate
ligament reconstruction (double bundle) using anterior
tibialis tendon allograft. Arthroscopy 17(4): E14
54. Chen CH, Chen WJ, Shih CH (2003) Double-bundle poste-
rior cruciate ligament reconstruction with quadriceps and
semitendinosus tendon grafts. Arthroscopy 19(9):1023–
1026
55. Richards RS 2nd, Moorman CT 3rd (2003) Use of
autograft quadriceps tendon for double-bundle pos-
terior cruciate ligament reconstruction. Arthroscopy
19(8):906–915
56. Noyes FR (2003) Anatomic reconstruction of the poste-
rior cruciate ligament after multiligament knee injuries.
A combination of the tibial-inlay and two-femoral-tunnel
techniques. Am J Sports Med 31(5):812–813 (author
reply 813–814)
57. Kim SJ, et al. (2004) Double-bundle technique: endoscopic
posterior cruciate ligament reconstruction using tibialis
posterior allograft. Arthroscopy 20(10):1090–1094
58. Kim SJ, Park IS (2005) Arthroscopic reconstruction of the
posterior cruciate ligament using tibial-inlay and double-
bundle technique. Arthroscopy 21(10):1271
59. Makino A, et al. (2006) Anatomic double-bundle poste-
rior cruciate ligament reconstruction using double-double
tunnel with tibial anterior and posterior fresh-frozen
allograft. Arthroscopy 22(6):684.e1–684.e5
60. Jordan SS, Campbell RB, Sekiya JK (2007) Posterior cru-
ciate ligament reconstruction using a new arthroscopic
tibial inlay double-bundle technique. Sports Med Arthrosc
15(4):176–183
61. Lee YS, et al. (2007) Transtibial double bundle posterior
cruciate ligament reconstruction using TransFix tibial
fixation. Knee Surg Sports Traumatol Arthrosc 15(8):973–
977
62. Eriksson E (2008) Double- or single-bundle PCL-reconstruc-
tion? Knee Surg Sports Traumatol Arthrosc 16(2):103
63. Yoon KH, et al. (2005) Arthroscopic double-bundle aug-
mentation of posterior cruciate ligament using split Achil-
les allograft. Arthroscopy 21(12):1436–1442
386 The Traumatic Knee
64. Garofalo R, et al. (2006) Double-bundle transtibial pos-
terior cruciate ligament reconstruction with a tendon-
patellar bone-semitendinosus tendon autograft: clinical
results with a minimum of 2 years’ follow-up. Arthroscopy
22(12):1331.e1–1338.e1
65. Nyland J, Hester P, Caborn DN (2002) Double-bundle
posterior cruciate ligament reconstruction with allograft
tissue:2-year postoperative outcomes. Knee Surg Sports
Traumatol Arthrosc 10(5):274–279
66. Houe T, Jorgensen U (2004) Arthroscopic posterior cru-
ciate ligament reconstruction: one- vs. two-tunnel tech-
nique. Scand J Med Sci Sports 14(2):107–111
67. Hatayama K, et al. (2006) A comparison of arthroscopic
single- and double-bundle posterior cruciate liga-
ment reconstruction: review of 20 cases. Am J Orthop
35(12):568–571
68. Wiley WB, et al. (2007) Medial femoral condyle strength
after tunnel placement for single- and double-bundle
posterior cruciate ligament reconstruction. J Knee Surg
20(3):223–227
69. Chhabra A, Kline AJ, Harner CD (2006) Single-bundle
versus double-bundle posterior cruciate ligament recon-
struction: scientifi
fic rationale and surgical technique. Instr
Course Lect 55:497–507

A.A.
C. Pelluchon
Amis, A. Edwards,
S. Apsingi
Graft tunnel positioning during PCL
reconstruction
Introduction
T
his chapter will review the scientific
fi and sur-
gical literature relating to PCL reconstruc-
tion, which is a subject that has received
relatively little attention and that remains a sub-
ject for debate. In order for a PCL reconstruction
to be classed as “successful” objectively, it has to
reduce the pathological posterior translation lax-
ity at least close to ‘normal’. Because of variabil-
ity between people, normal is usually defined fi as
being a match to the laxity measured on the con-
tralateral knee, with the proviso that the other
knee should itself not have a history of injury
that could have aff ffected its anterior-posterior
(AP) translation laxity (1). Methods for objective
measurement of tibial resting position and laxity
with respect to the femur are beyond the scope
of this chapter, but the reader should note the
probability that PCL damage will affectff the neu-
tral resting position of the tibia, which usually
drops posteriorly. Methods such as stress-view
radiography are available to document the exact
relationship between the bones, when the joint is
loaded in a device such as the Telos that imposes
a known anterior or posterior displacing force at
a fixed angle of knee flexion (2).
A principal ongoing area of debate in PCL recon-
struction is the question of whether it is better to
use a single-bundle or double-bundle reconstruc-
tion. The idea of using a double-bundle recon-
struction has arisen because of the observation
that the PCL fibers fan out in diff
fferent directions,
between the tibia and the femur. This implies that
they pull in difffferent directions, thus having dif-
fering functions in controlling tibiofemoral lax-
ity and kinematics. However, this entails a more
complex surgical procedure and superior clinical
performance should be expected in order to jus-
tify its use. The situation is complicated by the
presence of posterolateral corner injuries in many
cases of PCL injury (3).
This chapter will examine the behavior of the
natural PCL fibers as the knee moves in flex-
ion–extension. This motion causes patterns of
ligament fiber tightening and slackening, which
Chapitre 31
depend principally on their femoral attachments:
the attachments to the tibia are much less impor-
tant in infl
fluencing PCL fiber length change pat-
terns (4). Knowledge of the natural PCL fi fiber
behavior will guide PCL reconstruction. Th The title
of this chapter has deliberately avoided the use of
the word isometry because the PCL is not an iso-
metric structure. The word isometric means that
the fibers will have constant length when the
knee moves through an arc of flexion–extension;
fl
because the ligaments are elastic, this definition
fi
also depends on the measurement being taken
under carefully controlled and defined
fi joint load-
ing. The femoral isometric area on the medial
intercondylar area, where the PCL attaches, was
found to be at the proximal edge of the natural
PCL attachment; thus, an isometric graft tun-
nel will create a non-anatomical reconstruction
(5,6). There
Th is biomechanical evidence to show
that a PCL reconstruction that creates an isomet-
ric graft does not lead to physiological variation
of knee laxity when the knee flexes (7). In par-
ticular, the bulk of the PCL is known to slacken
when the knee is fully extended – this is seen
clearly in a sagittal plane MRI, where the PCL
fibers follow a slack, curved path – and (by defi fi-
nition) that behavior cannot occur in a constant-
length isometric graft. Similarly, the bulk of the
natural PCL is stretched when the knee is fl flexed
(8). This
Th behavior means that an isometric recon-
struction causes over-constraint when the knee
is extended, then allows excessive posterior
laxity when the knee flexes (7). Although there
was a time when isometric reconstructions were
believed to be essential for ACL reconstruction, it
is now accepted that a PCL reconstruction must
have greater respect for the anatomical fiber fi
architecture and attachments.
This chapter will give a brief summary of the func-
tional anatomy and biomechanics of the PCL,
which will act as a logical basis for recommenda-
tions about reconstruction methods; that will
include evidence relating to graft tunnel placement
for single- and double-bundle reconstructions. It
will also include a review of clinical reports about
PCL graft tunnel positioning.
388 The Traumatic Knee
Functional anatomy relating to PCL
reconstruction behavior
Th PCL has an extensive femoral attachment that
The
covers much of the surface of the medial wall of
the intercondylar notch. In anatomical terms, the
attachment is distal in the notch, adjacent to the
condylar articular cartilage (Fig. 1). When seen in
the flexed knee at surgery, this means that the PCL
attachment is shallow, and attaches around the
medial margin of the notch. It extends from the
highest (anterior) point in the notch, usually to
the lowest (posterior) extent, although the poste-
rior extent is variable (9). The
Th PCL attachment has
been reported to be 22+/-3 SD (range 13–27) mm
across (10). Because the PCL attachment borders
the articular cartilage, its distal (shallow) margin
is curved, while the proximal (deep) margin is
straight from anterior to posterior. This
Th results in
a shape that is close to a segment of a circle (11),
apart from the attachment of the anterior menis-
cofemoral ligament, that attaches between the PCL
and the articular cartilage, distally (12).
The tibial attachment is more compact and is
Th
located in the posterior intercondylar space, just
below the joint line. The
Th bulk of the PCL fibers
attach to the more anterior part of this attachment
area, that is on the “shelf” that is oriented supe-
riorly/posteriorly, between the posterior horns of
the menisci. This corresponds to the anterolateral
fiber bundle attachment, which has a mean size of
9 mm mediolaterally by 8 mm anteroposteriorly.
The more posterior fibers of the PCL attach further
Th
down the slope of the shelf and even pass “over the
back” to dissipate into the periosteum deep to the
origin of the popliteus muscle. The
Th posteromedial
bundle attachment is 10 mm mediolaterally by
6 mm superodistally (13).
As noted in the previous paragraph, the PCL has
often been split into two functional fiber
fi bundles.
Fig. 1 – The femoral attachment of the PCL extends by a mean of 22 mm
from anterior to posterior, and is adjacent to the condylar articular cartilage
distally, apart from the area of attachment of the anterior meniscofemoral
ligament, marked*.
While these are not separate anatomical entities,
this classifification does help to understand the dif-
fering behavior across the width of the PCL. Th The
PCL fiber bundles are defi fined with respect to their
femoral attachment, in contrast to the ACL bun-
dles. The bulk of the PCL consists of the antero-
lateral fiber bundle (ALB), the remainder being the
posteromedial bundle (PMB). Th These two bundles
are usually separated by probing the PCL during
repeated fl flexion–extension of the knee, when dif-
fering patterns of slackening/tightening become
apparent. Thus, the ALB attaches anteriorly, pri-
marily to the roof of the intercondylar notch,
while the PMB attaches posteriorly, to the medial
sidewall. ThThese locations lead to diffffering fiber ori-
entations in the notch: the ALB is close to the cen-
ter line from femur to tibia and hence oriented in
the sagittal plane, while the PMB slants across the
notch, from medial at the femur to slightly lateral
at the tibia. ThThe attachments of the fiber bundles
have been mapped in several studies (10,13,14).
The pattern of fiber tightening and slackening
when the knee flexes is best understood by refer-
ring the femoral fiber
fi attachments to the isomet-
ric area, which is approximately at the junction
between the roof and sidewall of the notch, at the
proximal edge of the PCL attachment (5). Fiber
attachments anterodistal to this zone move apart
when the knee flexes, which would tighten a graft
attached anterodistally (Fig. 2). Full knee extension
causes attachments anterior-distal to this zone
to approach the tibial attachment, so it slackens
the ALB. Conversely, the posterior-proximal PMB
attachment moves superiorly, rapidly tensing the
PMB in terminal extension. When the knee flexes,
the PMB slackens while the ALB tightens. At the
same time, the ALB takes a steeper orientation
with respect to the tibial plateau. In deep fl flexion,
the ALB eventually wraps around the roof of the
intercondylar notch and, as the femur rolls poste-
riorly off
ff of the edge of the plateau, the orientation
of the PCL reverses: it passes through the vertical
and then pulls posteriorly with respect to the tibia
(15). This may relate to PCL injury in hyperfl flexion,
although an alternative mechanism is the possibil-
ity of the PCL being nipped and sheared between
the posterior edges of the intercondylar notch
and tibial plateau. Because deep fl flexion causes
the femoral attachment orientation to rotate with
respect to the tibia, it also takes the attachment
of the PMB anteriorly and superiorly, so it is then
retightened and oriented effi fficiently to resist tibial
posterior translation (drawer). It follows from this
description that the ALB is the dominant structure
for resisting tibial posterior translation across the
mid arc of knee flexion, while the PMB comes into
prominence in deep flexion,
fl and these contribu-
tions have been quantifi fied (16). That work also

showed that, because the bulk of the PCL, the ALB,
is slack in knee extension, while the PMB is then
oriented in a proximal-distal direction (which is
not effi
fficient to resist tibial posterior translation),
the PCL is not the primary restraint to tibial poste-
rior translation in the extended knee, a role taken
by the posterolateral corner structures. It is this
evidence that supports the concept of a double-
bundle reconstruction from the mechanical view-
point. The ALB is the dominant structure in resist-
ing tibial posterior translation across much of the
arc of knee flexion, while the PMB acts to control
hyperextension and also posterior translation in
deep knee flexion.
fl
In addition to these fiber tension consider-
ations, the strength of the fiber bundles influ-
(a)
(b)
Fig. 2 – (a) Full knee extension slackens the ALB and tightens the PMB; (b)
when the knee flexes, the ALB tightens and the PMB slackens.
Graft tunnel positioning during PCL reconstruction 389
ences graft tunnel placement decisions. The ALB
is much stronger than the PMB: it has a much
larger cross-sectional area and tissue modulus,
so it is both stiffer and stronger than the PMB,
with a mean of 1.6 versus 0.3 kN in specimens
with a mean age of 75 years (17). Because of this,
the majority of surgeons who have published
descriptions of single-bundle PCL reconstruc-
tion chose to place their graft tunnels so as to
reproduce the ALB.
Because the PCL is close to the center of the knee,
it has a negligible role in limiting tibial internal–
external rotation. In summary, external rotation
is controlled primarily by the structures at the pos-
terolateral corner (18,29), and internal rotation
by the posteromedial capsular structures (20). It
is only after these primary rotational restraints
have been damaged that the PCL contributes sig-
nifi
ficantly to resisting tibial rotation, and that is
because the axis of tibial rotation moves away
from the normal central position. After damage
to the posterolateral corner, the axis of tibial rota-
tion moves medially (21), so that the PCL then
has a moment arm to resist tibial rotation. It has
been shown recently that an isolated PCL recon-
struction, whether single- or double-bundle, did
not have a significant
fi eff
ffect on the pathological
rotational laxities (both external and varus) of
knees with combined PCL plus posterolateral cor-
ner damage (22).
Single-bundle PCL reconstruction
A review of the literature on PCL reconstruction
(23) has found that most authors using a single-
bundle method placed their femoral graft tunnel
into the ALB attachment (Fig. 3). This
Th has followed
from the understanding that this is the site of the
bulk of the PCL strength, with a dominant role in
the control of tibial posterior laxity.
Fig. 3 – Mean location for ALB graft tunnel, from both anatomical studies
and clinical reports.
390 The Traumatic Knee
Edwards et al. (10) found that the ALB attachment
spread from the 9 to 12 o’clock positions around
the notch, when looking at the distal aspect of the
femur of a left knee flexed 90 degrees; the center
of the bundle attachment was sited 7+/-2 mm deep
to the edge of the articular cartilage in a proxi-
mal direction (that is, parallel to the shaft of the
femur, not perpendicular to the edge of the car-
tilage), at the 10:20 o’clock position. Mejia et al.
(14) found that, on average, the PCL attachment
extended beyond the highest point in the notch, to
12:40+/-15 min. Graft position is difficult
ffi to defi
fine
objectively because the distal aspect of the inter-
condylar notch, which is viewed by the surgeon, is
not circular. Therefore, it is a subjective judgment
when fitting an imaginary clock face, in order to
defi
fine tunnel positions; the roof of the notch is
closer to circular deeper into the knee.
A review of 50 articles on clinical PCL reconstruc-
tion (23) found that only 30 had definedfi their PCL
graft tunnel positions adequately to allow them to
be reproduced by the reader, and 15 of these had
used the combination of the clock face and depth
from the edge of the articular cartilage. (It is a gen-
eral principle that two measurements are required,
in order to defifine a position on a surface.) The
reported positions ranged from 10:00 to 11:00
o’clock, and from 2.5 to 13 mm deep, with a mean
of 10:48 o’clock and 7.0 mm deep. Th Thus, most had
been centred within the anatomical attachment of
the ALB. However, while there has been agreement
about placing the graft at 10:30 to 11:00 o’clock,
it is clear that there are diff
ffering opinions about
how deeply to center the tunnel (Aglietti (24) and
Nyland (25): 5 mm; Jung (26): 5-6 mm; Noyes (27):
6 mm; Cooper (28): 7 mm; Lill (29): 8 mm; Pinc-
zewski (30): 9 mm; Ahn (31): 10 mm), and it has
been noted above that that decision is important
for infl
fluencing the length change pattern as the
knee flexes-extends. Across the range reported, the
shallower reconstructions would tend to tighten
and slacken when the knee flexed-extended
fl more
than those placed deeply.
In an in vitro study, Race and Amis (7) exam-
ined a single-bundle reconstruction in which the
graft tunnel was centred higher in the notch than
the center of the ALB, between 11:30 and 12:00
o’clock. This gave good restoration of normal pos-
terior laxity from 0 to 60 degrees knee flexion,fl
but allowed excessive laxity in deeper fl flexion.
A graft placed so high in the notch eventually
passes through a vertical orientation as the knee
flexes (15), so it is not then able to withstand
fl
tibial posterior translation effi fficiently. Galloway
et al. (4) managed to extend the arc of efficientffi
restraint with a single-bundle reconstruction by
placing the graft tunnel as far distal as possible,
which is close to the articular cartilage margin
and near the 9 o’clock position. This tunnel posi-
tion causes graft tightening when the knee passes
through 90 degrees flexion,
fl and is a reproduction
of the attachment of the anterior meniscofemo-
ral ligament of Humphrey, which makes a signifi-fi
cant contribution to withstanding tibial posterior
translation in the flexed knee (32).
Double-bundle PCL reconstruction
The observations of the diff fferent orientations
and slackening-tensing patterns of the PCL fibers
fi
suggest that this complexity, and perhaps func-
tion, is not well reproduced by a single PCL graft
with approximately parallel fibers;
fi a double-
bundle graft structure appears to be a logical
progression. The objective evidence to support
double-bundle PCL reconstruction has derived
mainly from work in vitro. There
Th have been sev-
eral studies that found that double-bundle recon-
struction restored tibial posterior laxity closer to
normal than did a single-bundle reconstruction
(33,34,35,7). There
Th have been others where there
was not a clear advantage for the more complex
method (22,36,37). It is clear from a review of
these papers that the results depend very sensi-
tively on the femoral tunnel positions, with other
factors of graft choice and tensioning protocol
also being important.
The studies by Race and Amis (7) and by Mannor
et al. (35) both found that tibial posterior lax-
ity was excessive in the flexed knee when only a
single-bundle graft was used; their double-bundle
reconstructions controlled laxity signifi ficantly
better in the flexed
fl knee. The graft tunnels used
by Race and Amis (7) were both close to the artic-
ular cartilage margin, high and low in the notch,
approximately 11:30 to 12:00 and 07:00 o’clock
(Fig. 4). These positions spaced the grafts fur-
ther apart than the centers of the natural bundle
Fig. 4 – Double tunnels used by Race and Amis (1998), centred at 12:00 and
07:00 o’clock (Reproduced from Ref. 7 with permission.)

attachments. Mannor et al. (35) used a shallow
graft centred 5.2 mm from the cartilage at 11:00
o’clock and a deep graft centred 12.5 mm from
the cartilage at 09:00 o’clock (Fig. 5); these were
found to have reciprocal patterns of tension, in
line with the tightening–slackening observed.
Harner et al. (34) placed their grafts at the cen-
ters of the anatomical bundle attachments and
found signifi ficantly better control of posterior
drawer laxity across the whole range of knee flex-
fl
ion examined (Fig. 6). Again, the single-bundle
reconstruction allowed greater laxity in deeper
flexion: 3.5+/-2 mm at 120 degrees. Thus, all
fl
three of these studies found significant
fi defi
ficiency
in control of tibial posterior drawer in the flflexed
knee with a single-bundle PCL reconstruction;
the 11:00 o’clock graft tunnel positions used in
two of these studies (34,35) were the same as in
the most commonly described clinical technique.
In contrast, Bergfeld et al. (36) did not find any
signifi
ficant diff
fferences between their single-bundle
and double-bundle reconstructions. Their paper
did not specify the tunnel positions accurately, but
the illustration (Fig. 7) suggests that both tunnels
Fig. 5 – Typical graft tunnel entry points for double-bundle PCL reconstruc-
tion with tunnels placed at 9 and 11 o’clock, noting that this is based on a
subjective judgment of how best to fit the “clock face” into the intercondylar
notch.
Fig. 6 – Double tunnels used by
Harner et al. (2000), centred on
anatomical fiber bundle attach-
ments. (Reproduced from Ref. 34
with permission.)
Graft tunnel positioning during PCL reconstruction 391
were close together and may not have embraced
the whole extent of the PCL attachment, thus
limiting the scope to demonstrate different
ff and
complementary behavior. Similarly, while Markolf
et al. (37) showed that their reconstructions were
tested with their tunnels both close together and
widely spaced, it was not possible to discern the
tunnel positions in that study. They found that the
double-bundle reconstruction allowed signifi ficantly
less posterior drawer laxity than the single-bundle
reconstruction from 0 to 45 degrees knee fl flexion
and no diff fference in deeper knee flexion, in con-
trast to the other studies.
The center of the anatomical attachment of
the PMB was found by Edwards et al. (10) to be
10+/-3 mm deep from the edge of the articular car-
tilage, at 08:30 +/- 00:30 o’clock. There is a range
of opinion about PMB graft tunnel position in the
clinical literature, in relation to the depth from
the edge of the articular cartilage, but agreement
that the tunnel should be placed at 09:00 o’clock in
conjunction with the ALB tunnel at 11:00 o’clock
shown above (Fig. 8). Th The depth varied from 4 to
5 mm (38), via 8 mm (27) to 12 mm (25).
Fig. 7 – Double tunnels used by Bergfeld et al. (2005). (Reproduced from
Ref. 36 with permission.)
Fig. 8 – Typical double-bundle PCL reconstruction tunnels placed at centers
of anatomical fiber bundle attachments.
392 The Traumatic Knee
Conclusions
Th chapter has concentrated on describing the
This
tunnel locations used for both single- and double-
bundle PCL reconstructions. It has shown both the
results of anatomical measurements of the centers
of the functional fiber bundles and also the loca-
tions described in the clinical literature. Getting
the tunnels in the best places is only a part of the
job for the surgeon, but errors in tunnel placement
are the most common reason for failure of cruciate
ligament reconstructions. Tunnel malplacement
may lead to impingement onto the graft, exces-
sive tension and limitation of range of motion, or
excessive slackness and lack of control of laxity,
when the knee flexes-extends.
fl
It is clear (although not reviewed in this chapter)
that the development and use of double-bundle
reconstructions have not led to superior clini-
cal results; however, it does not mean that the
concept is not a logical progression, if seeking to
more closely reproduce the complex structure and
behavior of the natural PCL.
The more important points are as follows:
– The PCL is not an isometric structure; its fiber
bundles undergo large ranges of tightening and
slackening when the knee flexes-extends.
fl
– The tibial attachment is relatively compact and
graft location there has little effect
ff on PCL fiber
length-change behavior.
– On the femur, a shallow (distal) graft location
will tend to slacken when the knee extends and
to tighten in knee flexion. A posterior/deep graft
will have the opposite behavior.
– The most common femoral location for a single-
bundle PCL graft is centred 7+/-2 mm deep from
the edge of the articular cartilage, at the 10:30 to
11:00 o’clock position; that reproduces the ante-
rolateral fiber bundle of the PCL (Fig. 34.3).
– Judging the size and fit of the imaginary “clock
face” is a subjective process that may lead to dif-
fering opinions about correct graft placement.
– For a double-bundle reconstruction, the graft
that reproduces the posteromedial fiberfi bundle
of the PCL is usually placed at 09:00 o’clock, at 8
or 10+/-3 mm deep from the edge of the articular
cartilage, when measured in a direction parallel
to the axis of the femur, in addition to the ALB
tunnel at 11:00 o’clock (Fig. 34.8).
– The behavior of the reconstruction will also
depend on the tensioning protocol chosen.
Acknowledgements
During the course of their research work, Mr
Sunil Apsingi received support from Smith &
Nephew Endoscopy Co.; Mr Andrew Edwards
received support from the London Postgraduate
Deanery.
References
1. Rangger C, Daniel DM, Stone ML, et al. (1993). Diagnosis
of an ACL disruption with KT-1000 arthrometer measure-
ments. Knee Surg Sports Traumatol Arthrosc 1:60-66.
2. Garavaglia G, Lubbeke A, Dubois-Ferriere V, et al. (2007)
Accuracy of stress radiography techniques in grading iso-
lated and combined posterior knee injuries. Am J Sports
Med 35; 2051–2056.
3. Fanelli GC, Edson CJ (1995
( ) Posterior cruciate ligament
injuries in trauma patients: Part II. Arthroscopy 11:526–
529.
4. Galloway MT, Grood ES, Mehalik JN, et al. (1996) Poste-
rior cruciate ligament reconstruction. An in vitro study of
femoral and tibial graft placement. Am J Sports Med 24;
437–445.
5. Grood ES, Hefzy MS, Lindenfi field TN (1989) Factors aff
ffect-
ing the region of most isometric femoral attachments.
Part I: The posterior cruciate ligament. Am J Sports Med
17:197–207.
6. Sidles JA, Larson RV, Garbini JL, et al. (1988) Ligament
length relationships in the moving knee. J Orthop Res
6:593–610.
7. Race A, Amis AA (1998) PCL reconstruction – In vitro bio-
mechanical comparison of “isometric” versus single and
double bundled “anatomic” grafts. J Bone Joint Surg [Br]
80:173–179.
8. DeFrate LE, Gill TJ, Li G (2004) In vivo function of the
posterior cruciate ligament during weightbearing knee
flexion. Am J Sports Med 32:1923–1928.
9. Amis AA, Gupte C, Bull AMJ, et al. (2006) Anatomy of the
posterior cruciate ligament and the meniscofemoral liga-
ments. Knee Surg Sports Traumatol Arthrosc 14; 257–263.
10. Edwards A, Bull AMJ, Amis AA (2007) Th The attachments
of the fiber bundles of the posterior cruciate ligament: an
anatomic study. Arthroscopy 23:284–290.
11. Girgis FG, Marshall JL, Al Monajem ARS (1975) The Th
cruciate ligaments of the knee joint. Anatomical, func-
tional and experimental analysis. Clin Orthop Relat Res
106:216–231.
12. Gupte CM, Smith A, McDermott ID, et al. (2002). Menis-
cofemoral ligaments revisited; incidence, age correlation
and anatomical variations. J Bone Jt Surg [Br] 84:846–
851.
13. Harner CD, Baek GH, Vogrin TM, et al. (1999) Quanti-
tative analysis of human cruciate ligament insertions.
Arthroscopy 15:741–749.
14. Mejia
j EA,, Noyes
y FR,, Grood ES. (2002) Posterior cruciate
ligament femoral insertion site characteristics. Impor-
tance for reconstructive procedures. Am J Sports Med
30:643–651.
15. Komatsu T, Kadoya Y, Nakagawa S, et al. (2005) Move-
ment of the posterior cruciate ligament during knee fl flex-
ion--MRI analysis. J Orthop Res 23:334–339.
16. Race A, Amis AA (1996) Loading of the two bundles of the
posterior cruciate ligament: an analysis of bundle function
in A-P drawer. J Biomechanics 29:873–879.
17. Race A, Amis AA (1994) The mechanical properties of the
two bundles of the human posterior cruciate ligament.
J Biomechanics 27:13–24.
18. Gollehon DL, Torzilli PA, Warren RF (1987) The Th role of
the posterolateral and cruciate ligaments in the stability
of the human knee. A biomechanical study. J Bone Joint
Surg Am 69:233–242.

19. Grood ES, Stowers SF, Noyes FR (1988) Limits of move-
ment in the human knee: eff ffect of sectioning the posterior
cruciate ligament and posterolateral structures. J Bone
Joint Surg Am 70:88–97.
20. Robinson JR, Bull AMJ, Thomas R deW, et al. (2006) The Th
role of the medial collateral ligament and posterome-
dial capsule in controlling knee laxity. Am J Sports Med
34:1815–1823.
21. Amis AA (1999) The kinematics of knee stability. In: Jakob
RP, Fulford P, Horan F, editors. EFORT European Instruc-
tional Course Lectures, vol. 4. London: J Bone Jt Surg;
96–104.
22. Apsingi S, Nguyen T, Deehan D, et al. (2007) The Th role of
PCL reconstruction in knees with combined PCL and pos-
terolateral corner defi
ficiency. Knee Surg Sports Traumatol
Arthrosc (in press).
23. Apsingi S, Deehan D, Bull AMJ, et al. (2008) Femoral tun-
nel placement for PCL reconstructions – a comparison of
the tunnel positions reported in clinical studies with the
anatomical positions of the PCL fibre
fi bundles. Submitted
to Am J Sports Med Dec, 2007.
24. Aglietti P, Buzzi R, Lazzara D (2002) Posterior cruciate liga-
ment reconstruction with the quadriceps tendon in chronic
injuries. Knee Surg Sports Traumatol Arthrosc 10:266–273.
25. Nyland J, Hester P, Caborn DN (2002) Double-bundle
posterior cruciate ligament reconstruction with allograft
tissue:2-year postoperative outcomes. Knee Surg Sports
Traumatol Arthrosc 10:274–279.
26. Jung YB, Jung HJ, Tae SK, et al. (2005). Reconstruction of
the posterior cruciate ligament with a mid-third patellar
tendon graft with use of a modifi fied tibial inlay method. J
Bone Joint Surg Am 87 Suppl 1(Pt 2):247–263.
27. Noyes FR, Barber-Westin S (2005). Posterior cruciate liga-
ment replacement with a two-strand quadriceps tendon-
patellar bone autograft and a tibial inlay technique. J Bone
Joint Surg Am 87:1241–1252.
28. Cooper DE, Stewart D (2004) Posterior cruciate ligament
reconstruction using single-bundle patella tendon graft
with tibial inlay fixation: 2- to 10-year follow-up. Am J
Sports Med 32:346–360.
Graft tunnel positioning during PCL reconstruction 393
29. Lill H, Glasmacher S, Korner J, et al. (2001) Arthroscopic-
assisted simultaneous reconstruction of the posterior
cruciate ligament and the lateral collateral ligament using
hamstrings and absorbable screws. Arthroscopy 17:892–
897.
30. Pinczewski LA, Thuresson P, Otto D, et al. (1997)
Arthroscopic posterior cruciate ligament reconstruction
using four-strand hamstring tendon graft and interfer-
ence screws. Arthroscopy 13:661–665.
31. Ahn JH, Chung YS, Oh I (2003) Arthroscopic posterior
cruciate ligament reconstruction using the posterior
trans-septal portal. Arthroscopy 19:101–107.
32. Gupte CM, Bull AMJ, Th Thomas RD, et al. (2003). The
Th menis-
cofemoral ligaments: secondary restraints to the posterior
drawer. Analysis of anteroposterior and rotatory laxity in
the intact and posterior-cruciate-deficient
fi knee. J Bone Jt
Surg 85 B:765–773.
33. Amis AA (2004) Posterior cruciate ligament reconstruc-
tion: the double-bundle method is most effective ff for
restoring posterior tibiofemoral laxity. In: Williams RJ,
Johnson DP, editors. Controversies in knee surgery.
Oxford University Press: 375–383.
34. Harner CD, Janaushek MA, Kanamori A, et al. (2000) Bio-
mechanical analysis of a double-bundle posterior cruciate
ligament reconstruction. Am J Sports Med 28:144–151.
35. Mannor DA, Shearn JT, Grood ES, et al. (2000) Two-
bundle posterior cruciate ligament reconstruction. An in
vitro analysis of graft placement and tension. Am J Sports
Med 28:833–845.
36. Bergfeld
g JA, Graham SM, Parker RD, et al. (2005) Biome-
chanical comparison of posterior cruciate ligament recon-
structions using single- and double-bundle tibial inlay
techniques. Am J Sports Med 33:976–981.
37. Markolf KR, Feeley BT, Jackson SR, et al. (2006) Biome-
chanical studies of double-bundle posterior cruciate liga-
ment reconstructions. J Bone Jt Surg Am 88:1788–1794.
38. Kim SJ, Park IS, Cheon YM, et al. (2004) Double-bundle
technique: endoscopic posterior cruciate ligament recon-
struction using tibialis posterior allograft. Arthroscopy
20:1090–1094.

B.
C. Forsythe,
PelluchonR. Mascarenhas,
M.W. Pombo, C.D. Harner
Techniques in posterior cruciate
ligament reconstruction:
an arthroscopic approach
M
ost patients with isolated acute PCL inju-
ries do relatively well with conservative
treatment. As a result of excessive poste-
rior tibial translation, however, abnormal chon-
dral wear may occur. Pain rather than instability
becomes the major symptomatic issue. Conserva-
tive treatment of these injuries has been shown to
lead to a high incidence of acute and chronic chon-
dral injuries involving the medial femoral condyle
and patellofemoral joint (1–4). Patients are also
subject to acute and chronic meniscal tears (1,5,6).
Consequently, there is an emerging consensus that
isolated grade III PCL injuries are not as benign as
previously thought (7). Many surgeons have thus
elected to proceed with PCL reconstruction in
patients with isolated grade III injuries, especially
in the presence of instability and pain (8–17).
Several studies demonstrate that the vast majority
of patients continue to have residual posterior lax-
ity following surgery. Most patients improve only
one grade with respect to laxity following single-
bundle (SB) PCL reconstruction (14,17,18). Sev-
eral points have been investigated as contributing
factors, including graft fixation
fi and trans-tibial vs.
tibial inlay techniques. In trans-tibial reconstruc-
tions, the PCL graft makes an acute turn at the
posterior opening of the tibial tunnel. This “killer
turn” has been shown to lead to graft abrasion,
subsequent thinning of the graft, and eventual
laxity or rupture (19–21). To address this issue,
the tibial inlay technique was introduced by Jakob
and Ruegsegger (22) and by Berg (23). A potential
advantage lies in its direct fixation
fi at the tibial
attachment site (thus averting the “killer turn”).
The technique also enables graft tendon length
adjustment.
Biomechanical cadaveric studies have been per-
formed to test this hypothesis. Bergfeld et al. (24)
showed that the inlay technique results in less
posterior tibial translation and graft degrada-
tion. This result was corroborated by a cyclic load-
ing study by Markolf et al. (25). However, further
studies (26–29) failed to show differences
ff between
the tibial inlay and trans-tibial techniques with
respect to in-situ graft forces, laxity, and rupture.
Margheritini et al. (27) challenged the validity of
Chapitre 32
cyclic load testing in cadaveric studies since they
do not account for the biologic remodeling that
occurs in vivo. Retrospective studies comparing
trans-tibial vs. tibial inlay patients did not show
any signifi
ficant difffferences in subjective outcome
or knee laxity measurements (13,14). In summary,
the biomechanical advantages of the tibial inlay
technique have not translated into superior clini-
cal outcomes.
Double-bundle (DB) PCL reconstructions were
introduced to address the issues of residual laxity
and to improve clinical outcomes. Biomechani-
cal studies of DB reconstructions demonstrate a
degree of reciprocal tightening with knee range of
motion (30,31). The Th result is a reduction in both
posterior tibial translation and external rotation,
as well as more normal knee kinematics (31). Four
of five biomechanical studies performed demon-
strate superior performance of DB vs. SB recon-
structions (32–36). However, two clinical studies
found no significant
fi diff
fferences in Lysholm score,
activity level, or graft laxity between SB and DB
reconstructions (37,38).
DB anatomy can also be restored through augmen-
tation procedures when injury occurs to only one
of the two bundles. In our experience, this may be
the case in up to one-third of acute and chronic
posterior cruciate ligament (PCL) cases. Typically,
patients present with a torn anterolateral (AL)
bundle. Augmentation techniques have been per-
formed with good results, with preservation of the
posteromedial (PM) bundle and reconstruction of
the AL bundle (39–42). It is believed that healing
may occur between the native and graft ligaments,
resulting in the formation of a single ligament
(43). This phenomenon may diminish graft abra-
sion at the “killer turn” associated with trans-tibial
techniques.
Other potential sources of residual laxity include
graft type and subsequent fixation.
fi A recent sur-
vey of knee surgeons in the Herodicus Society
found the Achilles tendon allograft to be the most
popular graft choice in both acute and chronic PCL
reconstructions (44). The same survey found that
inference screw fixation was used by nearly 70% of
surgeons for femoral graft fi fixation. A more hetero-
396 The Traumatic Knee
geneous mixture of devices, including interference
screws, screws, and posts, and others were used for
tibial fixation (44).
With regard to the position of the knee at the time
of fixation, most surgeons have recommended
fixation at 90° of flexion with an applied anterior
drawer force (45–47). TheTh PCL has a dominant role
in knee stability at this angle. Furthermore, ten-
sioning in flexion avoids overconstraining the knee,
which may occur with single AL bundle reconstruc-
tions tensioned near full extension. A survey of the
Herodicus Society revealed that 55% of surgeons
tensioned their grafts near 90° of knee flexion (44).
While PCL injuries can occur in isolation, an
increasing number are being recognized as part
of a combined ligament injury pattern. Treatment
has typically been operative (48–51). A common
injury pattern involves damage to the PCL and
the structures of the posterolateral corner (PLC)
(49,52). Most patients with combined injuries will
benefifit from surgery (53–62). These patients are at
high risk for persistent and progressive functional
instability, and surgical treatment has given a more
predictable clinical outcome. Early and accurate
diagnosis of all concomitant ligamentous injuries
is essential.
In multiligamentous injury cases, reconstructions
are typically done using SB (anterolateral bundle)
reconstruction techniques. Isolated injuries con-
tinue to generate a fair amount of debate, but the
majority of surgeons treat isolated acute grade
I and II PCL injuries conservatively with limited
activities and/or rest for 4–6 weeks followed by
muscle strengthening focusing on the quadriceps.
We contend that acute isolated grade I and grade II
PCL injuries usually do not require surgical inter-
vention (4,62–66). The positive outcomes seen in
non-operative treatment of these injuries is most
likely related to the remaining integrity of the PCL
in partial injuries, other secondary restraints such
as the meniscofemoral ligaments, and the intrin-
sic healing capabilities of the PCL. Partial injuries
of the PCL are more likely to heal than those of
the ACL owing to its large size and superior blood
supply (46,66). Outcome studies in patients with
isolated grade II laxity demonstrate similar results
between patients treated operatively and conser-
vatively, with an average improvement of only one
laxity grade (67,68).
Due to the failure of non-operative treatment, we
are inclined to operate on young, athletic patients
with acute isolated grade III PCL injuries (1,4,63).
In addition, we recommend reconstruction in all
PCL-defi ficient patients who become symptomatic
in spite of maximized conservative treatment.
We believe this is especially important when the
articular compartments of the knee are still well
preserved. It is also essential to assess the entire
limb for asymmetric varus alignment and for
the presence of a dynamic varus thrust with gait
(54,69–72). Many believe that the most reliable
procedure for correcting varus malalignment is a
high tibial osteotomy (70,73,74). Corrections can
also be biplanar to manipulate and enhance the
native posterior slope in the PCL-deficient
fi knee
(75,76). On the other hand, patients with PCL
injuries and associated medial and patellofemoral
compartment arthrosis typically do not respond
well to isolated PCL reconstruction. We have uti-
lized a biplanar osteotomy in these patients to
reduce contact forces in the medial compartment
by decreasing varus and by increasing the poste-
rior slope of the tibia.
Technique
Our treatment algorithm begins with a careful his-
tory and physical examination. It entails careful
consideration of patient preferences, expectations,
and goals. Once the decision is made to pursue sur-
gery, a careful examination under anesthesia (EUA)
is performed. We use intra-operative fluoroscopy
to determine the amount of laxity in comparison
to the opposite knee. Note that because of the
proximity of the popliteal artery to the operative
site and tibial graft placement, a vascular surgeon
should be immediately available.
We prefer spinal anesthesia for isolated PCL recon-
struction. If the PLC or other structures require
reconstruction, general anesthesia may be used.
Range of motion is compared to the uninjured side
and losses are noted. A thorough EUA includes
anterior/posterior drawer, pivot shift, Lachman,
and varus/valgus stress tests. All tests should be
performed in 30° of flexion
fl as well as full exten-
sion. The PLC is examined with the dial and exter-
nal rotation tests. A pivot shift and reverse pivot
shift is also performed. Specifi fic injury patterns
should be readily recognized arthroscopically, such
as injury to either bundle vs. the entire PCL.
We occasionally use SB technique in performing
acute PCL reconstructions, especially in the set-
ting of combined injury patterns [196]. However,
because biomechanical data suggest that the addi-
tion of a second bundle signifi ficantly decreases
posterior tibial translation, the DB technique is
our preferred technique (33,36,77–79). Although
the tibial inlay procedure is favored by some sur-
geons, it is technically demanding. Th The patient is
also placed in a prone or lateral decubitus position,
adding operative time in the setting of combined
ligament injury repairs (23,70). It is suggested that
the theoretical benefifits may not outweigh the tech-
nical demands of this technique (23,26–29,80,81).
 Techniques in posterior cruciate ligament reconstruction: an arthroscopic approach 397
A variety of tissues and fifixation devices have been
used for reconstruction. We believe that proper
tunnel placement is more critical than graft type
or fixation technique. Autologous tissues typically
used today include hamstrings, bone-patellar ten-
don-bone, central quadriceps tendon, and iliotibial
band. Achilles tendon, bone-patellar tendon-bone,
and soft tissue grafts (tibialis anterior) are the
most commonly used allograft tissues.
We now favor tibialis anterior allograft tissue
because of its ease of passage and fixation,
fi lack of
donor site morbidity, and high tensile strength.
Additional benefi fits of this graft include its excep-
tional length and cross-sectional area, making it ver-
satile compared with other graft options. Multiple
methods of fixation exist, including the EndoBut-
ton (Smith & Nephew Endoscopy, Andover, Mass),
cortical screws and washers, and staples. No single
technique is universally accepted.
Presently, we employ three arthroscopic trans-tib-
ial techniques. They are all variations based on PCL
insertion site anatomy. Our indications for SB PCL
reconstruction include multiligamentous knee
injuries and acute PCL reconstructions. Our indi-
cations for augmentation are evolving, but include
mostly acute cases where there is preservation of
one of the remaining bundles of the PCL. Finally,
our indications for DB reconstructions are chronic
grade III PCL injury with either PLC or PM inju-
ries, revision cases, and severe acute isolated PCL
injuries in young patients. If there is significant
fi
malalignment, an opening wedge biplanar high
tibial osteotomy is performed initially. The
Th osteot-
omy must heal, and the patient must be rehabili-
tated before undergoing PCL reconstruction.
If the operation is performed in the acute setting,
the potential for fluid
fl extravasation should be
carefully considered. In this case, we recommend
using gravity flow rather than a fluid pump.
Calf pressure should be assessed frequently. If
increased calf pressure is noted during the case,
the arthroscopic procedure should be immediately
aborted. We have a low threshold for extending
lateral tibial incisions to complete fasciotomies of
compartments in the involved leg. Dorsalis pedis
and posterior tibial pulses are checked manually,
and a Doppler ultrasound device should be made
available throughout the procedure.
Once the EUA is completed, the portal sites and
skin incisions are carefully marked and injected
with 1% lidocaine with epinephrine. We do not use
a tourniquet as this allows for earlier identification
fi
of potential vascular injuries if they occur. The
Th knee
is prepped and draped in the usual sterile fashion. A
bump is placed underneath the ipsilateral buttock,
and also at the foot of the bed to allow position-
ing of the knee at 90°. A diagnostic arthroscopy is
initially performed to identify damaged structures
and cartilage lesions. The AL portal is the working
portal for the arthroscope, with the superolateral
portal used for outflflow and the anteromedial por-
tal used for instrumentation. First, the patellofem-
oral compartment is inspected, followed by the
cruciate ligaments within the femoral intercondy-
lar notch. The medial and lateral compartments are
then examined for meniscal and articular cartilage
lesions. Within the lateral compartment, the popli-
teus tendon is carefully examined. Upon confirma-
fi
tion of PCL rupture, we proceed with either SB or
DB PCL reconstruction.
In patients undergoing concomitant ACL recon-
struction, we perform SB PCL reconstruction. We
also perform SB PCL augmentation in patients
with partial PCL injuries as discussed previously.
Otherwise, DB PCL reconstruction is our preferred
procedure.
Once we have determined our procedure(s), the
remnants of the injured PCL are debrided with
a full-radius resector and a curette. The menis-
cofemoral ligaments of Humphrey and Wrisberg
are preserved if they remain intact. A 30° arthro-
scope is initially utilized to fully expose the PCL
side of the femoral notch. The femoral insertion of
the ligament is then identified,
fi and the footprint
is preserved to guide placement of the two femoral
tunnels in DB reconstructions (Fig. 1). The Th tibial
side of the ligament is then debrided. A 70° scope
is essential to accurately view the tibial insertion,
and care must be taken around the closely situated
neurovascular structures. A PM portal is estab-
lished under direct arthroscopic visualization to
protect the posterior neurovascular structures.
The tibial footprint is carefully dissected to allow
positioning of the PCL guide. With the PCL guide
set at 45°, the AL tibial tunnel is drilled through an
incision on the lateral tibia (Fig. 2). We dissect the
tibialis anterior in its fascial sheath from the tib-
ial crest to allow placement of the PCL guide. The Th
Fig. 1 – Right knee PCL femoral bundle insertions: the posteromedial
bundle has been resected. Note the residual anterolateral bundle remnant
(AL) and intact meniscofemoral ligament (MFL).
398 The Traumatic Knee
Fig. 2 – Anterolateral tibial tunnel placement with fluoroscopic guidance.
Fig. 4 – Lateral view of double-bundle PCL reconstruction: Placement of
tibial tunnel guidewires under fluoroscopic visualization.
Fig. 6 – Posteromedial tibial tunnel placement with fluoroscopic guidance.
guide tip is placed at the distal and lateral-most
aspects of the tibial footprint. The pin is advanced
under direct arthroscopic visualization with a 30°
arthroscope placed in the PM portal (Fig. 3), and
a lateral fluoroscopic x-ray is utilized to confi
firm
adequate positioning (Fig. 4). A PCL curette is
Fig. 3 – Right knee proximal tibial insertions: Anterolateral (AL) and pos-
teromedial (PM) guide pins as viewed through the posteromedial portal.
Fig. 5 – Protecting the neurovascular bundle with a PCL curette as the guide
pins are advanced under arthroscopic visualization through the posterome-
dial portal.
Fig. 7 – Advancing the posteromedial tunnel K-wire through the tibia with
fluoroscopic guidance.
used to protect the neurovascular bundle as guide
pins are advanced (Fig. 5). We advance the K-wire
with power initially, and we perforate the cortex
manually to avoid injury to posterior neurovascu-
lar structures. The PM tibial tunnel is established
in a similar manner through an anteromedial tibial
 Techniques in posterior cruciate ligament reconstruction: an arthroscopic approach 399
Fig. 8 – Double-bundle PCL reconstruction: fluoroscopic anteroposterior
view of tibial tunnel K-wires.
incision using a PCL drill guide (Figs. 7 and 8). Flu-
oroscopy in the anteroposterior and lateral planes
is used to confi
firm proper K-wire tunnel placement
prior to drilling (Figs. 4 and 8). Tunnels are then
drilled with a compaction drill bit, and initially
with power until the posterior tibial cortex is
encountered, which is perforated by hand reaming
to protect the neurovascular bundle (Fig. 9). Th The
tunnels are subsequently dilated to the appropri-
ate diameter.
The femoral tunnels are then addressed: the AL
bundle femoral origin is marked at the 1 o’clock
position, and the PM bundle femoral origin is
marked at the 4 o’clock position. Th
The femoral inser-
tion sites are then marked with an awl. If intact,
the meniscofemoral ligament of Wrisberg func-
tions as a landmark between the two bundle ori-
gins (Fig. 1). Th
The AL and PM femoral tunnels are
then drilled through the AL portal with the knee
in 130° and 110° of flexion, respectively. Drilling of
the AL tunnel is performed fi first. An acorn reamer
Fig. 9 – Completing the posteromedial tunnel through posterior tibial cor-
tex. The tunnel is completed manually with a cannulated drill; the K-wire is
protected from advancing with a PCL curette.
is inserted through the AL portal with the arthro-
scope in the anteromedial portal. An adequate
bone bridge is maintained between the two tun-
nels, and the PM femoral tunnel is then drilled in a
similar manner with an acorn reamer (Fig. 10). TheTh
tunnels are then dilated to the appropriate diam-
eter. Care should always be taken to protect the
undersurface of the patella and the lateral femoral
condyle from the reamers, as they can damage the
articular surfaces in cases of patella baja and incor-
rect portal placement.
As noted previously, we prefer using fresh-frozen
tibialis anterior tendon allograft tissue, sometimes
in combination with semitendinosus autograft. Th The
semitendinosus is harvested through a small incision
over the proximal medial tibia. The
Th free ends of the
allograft and/or autograft are whip-stitched with
number 2 silky Polydek and passed through 45-mm
Endoloops. The graft is then placed on a tensioning
board until the time for graft passage arises.
Next, the grafts are passed through the tibial tun-
nels and then through the femoral tunnels under
arthroscopic control. An 8 French pediatric feed-
ing tube is used to shuttle suture into the notch
and out the portals for subsequent graft pas-
sage. The AL graft is passed first, followed by the
PM component (Fig. 11). However, the latter is
passed underneath the meniscofemoral ligaments,
whereas the AL graft is passed above the menis-
cofemoral ligaments when present. An incision is
made on the distal medial femur along Langer’s
lines, and a plane beneath the vastus medialis is
developed by blunt dissection. Both grafts are tied
down over separate posts on the medial side of the
knee underneath the vastus medialis. We gener-
ally use AO 6.5 cancellous screws with washers to
capture the Endoloops at the end of each respec-
tive graft. The graft is then visualized arthroscopi-
cally, and the knee is cycled to confifirm good graft
position and to provide tensioning. This
Th completes
Fig. 10 – Drilling the posteromedial femoral tunnel through the anterolat-
eral portal under arthroscopic visualization.
400 The Traumatic Knee
Fig. 11 – Right knee: passing the posteromedial graft (PM graft) as viewed
arthroscopically within the notch.
Fig. 13 – Right knee: final arthroscopic view of the double-bundle PCL
reconstruction as viewed through the anterolateral parapatellar portal.
the graft passage and femoral fixation
fi of the PCL
reconstruction. Tension is applied to both grafts,
and the knee is cycled from fl flexion to extension
repeatedly. If reconstruction or repair of the PLC
is necessary, it should be addressed at this stage
before fixation of the grafts on the tibial side.
The tibial portion of the AL graft is secured over an
AO 4.5-mm bicortical screw post and washer with
the knee flexed at 90° and an anterior drawer force
applied. With the knee in 30° of flexion,
fl an ante-
rior drawer force is applied to the tibia, and the PM
graft is fixed over an AO 4.5-mm screw and washer
in a similar fashion (Fig. 12). The
Th knee is then taken
through a full range of motion, and the posterior
drawer and step-off ff are reexamined. Anteroposte-
rior and rotational stability are likewise assessed.
The graft is visualized arthroscopically at its femo-
ral and tibial insertions (Fig. 13). Th
The dorsalis pedis
pulse is palpated. Wounds are then irrigated and
closed with interrupted Vicryl sutures followed by
a running Caprosyn subcuticular stitch, with the
knee at 30° of flexion. The portals are closed with
interrupted nylon sutures. A sterile compressive
Fig. 12 – Lateral view of tibial posts: AO 4.5-mm cancellous screws with
washers. (Note placement of an interference screw through the fibular head
for concomitant posterolateral corner repair.)
dressing is applied followed by a Cryo/Cuff ff and a
knee brace with the knee in full extension. A bump
is placed behind the calf to prevent posterior tibial
sagging and subsequent stress on the PCL graft.
Distal pulses are checked again before transfer to
the post-anesthetic recovery room.
Complications
Intra-operative complications of PCL surgery entail
a spectrum of injuries, including compartment syn-
drome, neurovascular injuries, medial femoral con-
dyle osteonecrosis, and tourniquet complications.
Although compartment syndrome and tourniquet
problems do occur, they are considerably more com-
mon in multiligamentous knee injuries. Neurovascu-
lar injuries are relatively unique to PCL surgery due to
the proximity of the popliteal artery. Popliteal artery
and tibial nerve injuries, although uncommon, are
possible with both inlay and trans-tibial techniques.
With respect to trans-tibial techniques, neurovascu-
lar injuries have been reported to occur as either lac-
erations or thrombus formation (82,83). To reduce
risk to neurovascular structures, Fanelli has empha-
sized the importance of the PM incision as both a
working portal and a safety incision. It allows for
adequate visualization and protection of neurovas-
cular structures, and helps reduce the risk of com-
partment syndrome by acting as an outflow fl portal.
In addition to the popliteal artery and tibial nerve,
the peroneal nerve is also at risk in combined PLC/
PCL reconstructions. It should always be identified fi
and protected. Other potential intra-operative com-
plications include tibial fracture and medial femo-
ral condyle osteonecrosis. Osteonecrosis is likely
related to drilling femoral tunnels too close to the
articular surface, resulting in damage to the domi-
nant nutrient artery to the condyle (84,85).
 Techniques in posterior cruciate ligament reconstruction: an arthroscopic approach 401
Common postoperative complications include
anterior knee pain, residual laxity, and arthrofibro-
fi
sis. Motion loss for PCL reconstruction typically
occurs in flexion vs. extension. Potential causes
include multiple concurrent ligament procedures
(open medial-sided surgery in particular), the non-
isometric nature of PCL reconstructions, improper
tunnel placement, improper graft tensioning,
suprapatellar adhesions, and poor compliance
with physical therapy (86). Treatment includes
arthroscopic lysis of adhesions or manipulation.
Manipulation rates may be as high as 10–15% in
patients with multiligament injuries. Additionally,
10° of mean terminal flexion loss has been demon-
strated in several studies (87–89).
In many cases, PCL reconstructions gradually
loosen to grade I or II laxity. The
Th reasons for this
are multifactorial: malalignment, missed concomi-
tant injuries, and technical errors have all been
implicated. While most patients can tolerate some
residual laxity, reconstructed knees with grade
III instability are considered failures and need to
be revised. The
Th most common cause of failed PCL
surgery is failure to address concomitant PLC defi-fi
ciency (40%). Improper graft tunnel placement
(33%), associated varus malalignment (31%) and
primary suture repair (25%) have also been dem-
onstrated to be contributing factors (90). Patients
with residual laxity may present with anterior knee
pain as a result of increased patellofemoral forces
secondary to posterior sag. Symptomatic hardware
and postoperative synovitis may also contribute to
symptoms of knee pain.
Rehabilitation
A hinged knee brace is locked in extension for
the first postoperative week and is only unlocked
for range-of-motion exercises such as heel slides.
If the patient has a multiligamentous injury, the
brace is kept locked in full extension for 4 weeks
postoperatively, and crutches are utilized for
ambulation for 12 weeks as opposed to 8 weeks
for isolated PCL reconstruction. A physiothera-
pist should provide an anterior drawer force to the
proximal tibia to prevent posterior tibial sag while
the patient performs his or her range-of-motion
exercises. Quadriceps sets, straight leg raises, and
wall slides are the mainstays of treatment during
the first 2–3 months of therapy, and hamstring
exercises are avoided due to their tendency to
stress the reconstruction. Range of motion should
not exceed 90° of flexion during the first 2–3 post-
operative months.
Gait training begins at 4–6 weeks with the brace
unlocked and includes pool therapy. TheTh crutches
and brace are discontinued after 2–3 months if the
patient exhibits good quadriceps strength and con-
trol, full knee extension, knee flexion of 90–100°, and
a normal gait pattern. During this time period, wall
slides are progressed to mini-squats (0–45°), station-
ary cycling is added, and balance and proprioception
exercises such as single leg stances are introduced.
From 3–9 months, exercises are advanced to jogging
in the pool and walking on the treadmill. Closed-
chain kinetic exercises are also continued through-
out this period to improve functional strength and
proprioception. Quadriceps strength and hamstring
flexibility are maximized and maintained. Thera-
peutic exercises include cross-country ski machines,
slide board, running and cutting skills, and jump-
ing/plyometrics. Th The patient is expected to achieve
full pain-free range of motion, normal gait, and
good quadriceps strength and should have no patel-
lofemoral complaints by 9 months after surgery. The Th
ultimate goals include return to work and athletic
participation as well as the maintenance of strength
and endurance. This may involve sports-specifi fic
training or job restructuring as needed. Patient edu-
cation is essential to provide a clear understanding
of the possible limitations.
References
1. Boynton M, Tietjens B (1996) Long-term followup of the
untreated isolated posterior cruciate ligament deficient
fi
knee. Am J Sports Med 24:306–310
2. Clancy WG, Jr., et al. (1983) Treatment of knee joint insta-
bility secondary to rupture of the posterior cruciate liga-
ment. Report of a new procedure. J Bone Joint Surg Am
65(3):310–322
3. Dejour H, et al. (1988) The natural history of rupture of
the posterior cruciate ligament. Fr J Orthop Surg 2:112–
120
4. Keller PM, et al. (1993) Nonoperatively treated isolated
posterior cruciate ligament injuries. Am J Sports Med
21(1):132–136
5. Geissler W, Whipple T (1993) Intraarticular abnormalities
in association with posterior cruciate ligament injuries.
Am J Sports Med 21:846–849
6. Shino K, et al. (1995) Conservative treatment of isolated
injuries to the posterior cruciate ligament in athletes. J
Bone Joint Surg Br 77(6):895–900
7. Miller M, et al. (2005) Posterior cruciate ligament: current
concepts. Instr Course Lect Sports Med 297–302
8. Abbott L, et al. (1944) Injuries to the ligaments of the knee
joint. J Bone Joint Surg Am 26:503–521
9. Chan YS, et al. (2006) Arthroscopic reconstruction of the
posterior cruciate ligament with use of a quadruple ham-
string tendon graft with 3- to 5-year follow-up. Arthros-
copy 22(7):762–770
10. Chen CH, Chen WJ, Shih CH (2002) Arthroscopic recon-
struction of the posterior cruciate ligament: a comparison
of quadriceps tendon autograft and quadruple hamstring
tendon graft. Arthroscopy 18(6):603–612
11. Deehan DJ, et al. (2003) Endoscopic single-bundle poste-
rior cruciate ligament reconstruction: results at minimum
2-year follow-up. Arthroscopy 19(9):955–962
12. Jung YB, et al. (2004) Replacement of the torn posterior
cruciate ligament with a mid-third patellar tendon graft
402 The Traumatic Knee
with use of a modifi fied tibial inlay method. J Bone Joint
Surg Am 86-A(9):1878–1883
13. MacGillivray JD, et al. (2006) Comparison of tibial inlay
versus transtibial techniques for isolated posterior cruci-
ate ligament reconstruction: minimum 2-year follow-up.
Arthroscopy 22(3):320–328
14. Mariani PP, et al. (1997) Arthroscopic posterior cruciate
ligament reconstruction with bone-tendon-bone patellar
graft. Knee Surg Sports Traumatol Arthrosc 5(4):239–244
15. Sekiya JK, et al. (2005) Biomechanical analysis of a com-
bined double-bundle posterior cruciate ligament and
posterolateral corner reconstruction. Am J Sports Med
33(3):360–369
16. Seon JK, Song EK (2006) Reconstruction of isolated pos-
terior cruciate ligament injuries: a clinical comparison of
the transtibial and tibial inlay techniques. Arthroscopy
22(1):27–32
17. Wang CJ, Chen HS, Huang TW (2003) Outcome of
arthroscopic single bundle reconstruction for complete
posterior cruciate ligament tear. Injury 34(10):747–751
18. Sekiya JK, et al. (2005) Clinical outcomes after isolated
arthroscopic single-bundle posterior cruciate ligament
reconstruction. Arthroscopy 21(9):1042–1050
19. Cooper D (1999) Treatment of combined posterior cruci-
ate ligament and posterolateral injuries of the knee. Oper
Tech Sports Med 7:135–142
20. Fanelli GC, Giannotti BF, Edson CJ (1994) The posterior
cruciate ligament arthroscopic evaluation and treatment.
Arthroscopy 10(6):673–688
21. Miller M, Gordon W (1999) Posterior cruciate ligament
reconstruction: tibial inlay technique – principles and pro-
cedure. Oper Tech Sports Med 127–133
22. Jakob RP, Ruegsegger M (1993) [Th Therapy of posterior and
posterolateral knee instability]. Orthopade 22(6):405–
413
23. Berg EE (1995) Posterior cruciate ligament tibial inlay
reconstruction. Arthroscopy 11(1):69–76
24. Bergfeld JA, et al. (2001) A biomechanical comparison of
posterior cruciate ligament reconstruction techniques.
Am J Sports Med 29(2):129–136
25. Markolf KL, Zemanovic JR, McAllister DR (2002) Cyclic
loading of posterior cruciate ligament replacements fixedfi
with tibial tunnel and tibial inlay methods. J Bone Joint
Surg Am 84-A(4):518–524
26. Hiraga Y, et al. (2006) Biomechanical comparison of pos-
terior cruciate ligament reconstruction techniques using
cyclic loading tests. Knee Surg Sports Traumatol Arthrosc
14(1):13–19
27. Margheritini F, et al. (2004) Biomechanical comparison
of tibial inlay versus transtibial techniques for poste-
rior cruciate ligament reconstruction: analysis of knee
kinematics and graft in situ forces. Am J Sports Med
32(3):587–593
28. McAllister DR, et al. (2002) A biomechanical comparison
of tibial inlay and tibial tunnel posterior cruciate ligament
reconstruction techniques: graft pretension and knee lax-
ity. Am J Sports Med 30(3):312–317
29. Oakes DA, et al. (2002) Biomechanical comparison of tib-
ial inlay and tibial tunnel techniques for reconstruction of
the posterior cruciate ligament. Analysis of graft forces. J
Bone Joint Surg Am 84-A(6):938–944
30. Ahmad C, et al. (2003) Codominance of the individual
posterior cruciate ligament bundles. An analysis of bundle
lengths and orientation. Am J Sports Med 31:221–225
31. Fox RJ, et al. (1998) Determination of the in situ forces in
the human posterior cruciate ligament using robotic technol-
ogy. A cadaveric study. Am J Sports Med,. 26(3):395–401
32. Bergfeld JA, et al. (2005) A biomechanical comparison of
posterior cruciate ligament reconstructions using single-
and double-bundle tibial inlay techniques. Am J Sports
Med 33(7):976–981
33. Harner CD, et al. (2000) Biomechanical analysis of a dou-
ble-bundle posterior cruciate ligament reconstruction. Am
J Sports Med 28(2):144–151
34. Mannor DA, et al. (2000) Two-bundle posterior cruci-
ate ligament reconstruction. An in vitro analysis of graft
placement and tension. Am J Sports Med 28(6):833–845
35. Markolf KL, et al. (2006) Biomechanical studies of double-
bundle posterior cruciate ligament reconstructions. J
Bone Joint Surg Am 88(8):1788–1794
36. Race A, Amis AA (1998) PCL reconstruction: in vitro bio-
mechanical comparison of “isometric” versus single and
double-bundled “anatomic” grafts. J Bone joint Surg Br
80:173–179
37. Houe T, Jorgensen U (2004) Arthroscopic posterior cru-
ciate ligament reconstruction: one- vs. two-tunnel tech-
nique. Scand J Med Sci Sports 14(2):107–111
38. Wang CJ, et al. (2004) Arthroscopic single- versus double-
bundle posterior cruciate ligament reconstructions using
hamstring autograft. Injury 35(12):1293–1299
39. Ahn JH, et al. (2006) Arthroscopic femoral tension-
ing and posterior cruciate ligament reconstruction in
chronic posterior cruciate ligament injury. Arthroscopy
22(3):341e1–e4
40. Jung YB, et al. (2006) Tensioning of remnant posterior
cruciate ligament and reconstruction of anterolateral bun-
dle in chronic posterior cruciate ligament injury. Arthros-
copy 22(3):329–338
41. Wang CJ, Chan YS, Weng LH (2005) Posterior cruciate lig-
ament reconstruction using hamstring tendon graft with
remnant augmentation. Arthroscopy 21(11):1401
42. Yoon KH, et al. (2005) Arthroscopic double-bundle aug-
mentation of posterior cruciate ligament using split Achil-
les allograft. Arthroscopy 21(12):1436–1442
43. Ahn JH, et al. (2006) Arthroscopic transtibial posterior
cruciate ligament reconstruction with preservation of
posterior cruciate ligament fi
fibers: clinical results of mini-
mum 2-year follow-up. Am J Sports Med 34(2):194–204
44. Dennis MG, et al. (2004) Posterior cruciate ligament recon-
struction: current trends. J Knee Surg 17(3):133–139
45. Burns WC, 2nd, et al. (1995) TheTh eff
ffect of femoral tunnel
position and graft tensioning technique on posterior lax-
ity of the posterior cruciate ligament-reconstructed knee.
Am J Sports Med 23(4):424–430
46. Harner CD, Hoher J (1998) Evaluation and treatment of
posterior cruciate ligament injuries. Am J Sports Med
26(3):471–482
47. Harner CD, Janaushek MA, Kanamori A (1999) Effect ff of
knee flexion angle and tibial position during graft fixation
on the biomechanics of a PCL reconstructed knee. Trans
Orthop Res Soc 24:23
48. Clancy WG, Jr., Sutherland TB (1994) Combined posterior
cruciate ligament injuries. Clin Sports Med 13(3):629–
647
49. Cooper DE, Stewart D (2004) Posterior cruciate ligament
reconstruction using single-bundle patella tendon graft
with tibial inlay fixation:2- to 10-year follow-up. Am J
Sports Med 32(2):346–360
50. Fanelli GC, Edson CJ (2002) Arthroscopically assisted
combined anterior and posterior cruciate ligament recon-
struction in the multiple ligament injured knee: 2- to
10-year follow-up. Arthroscopy 18(7):703–714
51. Mariani PP, Margheritini F, Camillieri G (2001) One-stage
arthroscopically assisted anterior and posterior cruciate
ligament reconstruction. Arthroscopy 17(7):700–707
52. Mariani PP, et al. (2003) Surgical treatment of posterior
cruciate ligament and posterolateral corner injuries.
An anatomical, biomechanical and clinical review. Knee
10(4):311–324
53. Baker C, Norwood L, Hughston J (1983) Acute poste-
rolateral instability of the knee. J Bone Joint Surg Am
65:614–618
 Techniques in posterior cruciate ligament reconstruction: an arthroscopic approach 403
54. Cooper D, Warren R, Warner J (1991) The posterior cru-
ciate ligament and posterolateral structures of the knee:
anatomy, function and patterns of injury. Instr Course
Lect 40:249–270
55. DeLee JC, Riley MB, Rockwood CA, Jr., (1983) Acute pos-
terolateral rotatory instability of the knee. Am J Sports
Med 11(4):199–207
56. Fanelli GC (1993) Posterior cruciate ligament injuries in
trauma patients. Arthroscopy 9(3):291–294
57. Hughston JC, Degenhardt TC (1982) Reconstruction of
the posterior cruciate ligament. Clin Orthop Relat Res
164:59–77
58. Kim SJ, Kim HK, Kim HJ (1999) Arthroscopic posterior
cruciate ligament reconstruction using a one-incision
technique. Clin Orthop Relat Res 359:156–166
59. Satku K, Chew CN, Seow H (1984) Posterior cruciate liga-
ment injuries. Acta Orthop Scand 55(1):26-9
60. Schulte KR, Chu ET, Fu FH (1997) Arthroscopic poste-
rior cruciate ligament reconstruction. Clin Sports Med
16(1):145–156
61. Sisto DJ, Warren RF (1985) Complete knee dislocation. A
follow-up study of operative treatment. Clin Orthop Relat
Res 198:94–101
62. Torg JS, et al. (1989) Natural history of the posterior
cruciate ligament-deficient
fi knee. Clin Orthop Relat Res
246:208–216
63. Cross MJ, Powell JF (1984) Long-term followup of poste-
rior cruciate ligament rupture: a study of 116 cases. Am J
Sports Med 12(4):292–297
64. Dandy DJ, Pusey RJ (1982) The long-term results of unre-
paired tears of the posterior cruciate ligament. J Bone
Joint Surg Br 64(1):92–94
65. Fowler PJ, Messieh SS (1987) Isolated posterior cruciate
ligament injuries in athletes. Am J Sports Med 15(6):553–
557
66. Shelbourne K, Davis T, Patel D (1999) The natural history
of acute, isolated nonoperatively treated posterior cruci-
ate ligament injuries. Am J Sports Med 27:276–283
67. Shelbourne K, Muthukaruppan Y (2005) Subjective results
of nonoperatively treated, acute, isolated posterior cruci-
ate ligament injuries. Arthroscopy 21:457–461
68. Shelbourne K, Gray T (2002) Natural History of Acute Pos-
terior Cruciate Ligament Tears. J Knee Surg 15(2):103–
107
69. Dugdale TW, Noyes FR, Styer D (1992) Preoperative
planning for high tibial osteotomy. The Th eff
ffect of lateral
tibiofemoral separation and tibiofemoral length. Clin
Orthop Relat Res 274:248–264
70. Noyes FR, Barber-Westin SD (2006) Two-strand poste-
rior cruciate ligament reconstruction with a quadriceps
tendon-patellar bone autograft: technical considerations
and clinical results. Instr Course Lect 55:509–528
71. Noyes F, Barber-Westin S (1996) Treatment of complex
injuries involving the posterior cruciate and posterolateral
ligaments of the knee. Am J Knee Surg 9:200–214
72. Noyes FR, et al. (2006) Opening wedge high tibial osteot-
omy: an operative technique and rehabilitation program
to decrease complications and promote early union and
function. Am J Sports Med 34(8):1262–1273
73. Jackson D (1992) Posterior cruciate and associated ligament
instabilities. In AAOS Annual Meeting. Washington, DC
74. Noyes FR, et al. (1993) Posterior subluxations of the
medial and lateral tibiofemoral compartments. An in vitro
ligament sectioning study in cadaveric knees. Am J Sports
Med 21(3):407–414
75. Giffi
ffin JR, et al. (2004) Effffects of increasing tibial slope
on the biomechanics of the knee. Am J Sports Med
32(2):376–382
76. Rodner CM, et al. (2006) Medial opening wedge tibial
osteotomy and the sagittal plane: the eff ffect of increasing
tibial slope on tibiofemoral contact pressure. Am J Sports
Med 34(9):1431–1441
77. Chhabra A, Kline AJ, Harner CD (2006) Single-bundle
versus double-bundle posterior cruciate ligament recon-
struction: scientifi
fic rationale and surgical technique. Instr
Course Lect 55:497–507
78. Petrie RS, Harner C (1999) Double bundle posterior cru-
ciate ligament reconstruction technique: University of
Pittsburgh approach.Oper Tech Sports Med 7:118–126
79. Valdevit A, et al. (2002) Non-linear fitting of mechanical
data for effi
fficacy determination of single versus double
bundle Achilles tendon grafts for PCL reconstructions.
Biomed Mater Eng 12(3):309–317
80. Jakob RP, Edwards JC (1994) Posterior cruciate ligament
reconstruction: anterior-posterior two stage technique.
Sports Med Arthrosc Rev. 2:137–145
81. Miller MD, (1999) Posterior cruicate ligament reconstruc-
tion: tibial inlay technique. Sports Med Arthrosc Rev
7:225–234
82. Makino A, et al. (2005) Popliteal artery laceration during
arthroscopic posterior cruciate ligament reconstruction.
Arthroscopy 21(11):1396
83. Wu RW, Hsu CC, Wang CJ (2003) Acute popliteal artery
occlusion after arthroscopic posterior cruciate ligament
reconstruction. Arthroscopy 19(8):889–893
84. Athanasian EA, Wickiewicz TL, Warren RF (1995)
Osteonecrosis of the femoral condyle after arthroscopic
reconstruction of a cruciate ligament. Report of two cases.
J Bone Joint Surg Am 77(9):1418–1422
85. Reddy AS, Frederick RW (1998) Evaluation of the
intraosseous and extraosseous blood supply to the distal
femoral condyles. Am J Sports Med 26(3):415–419
86. Fanelli GC, Monahan T (2001) Complications in posterior
cruciate ligament and posterolateral corner surgery. Oper
Tech Sports Med 9(2):96–99
87. Fanelli GC, Giannotti BF, Edson CJ (1996) Arthroscopi-
cally assisted combined posterior cruciate ligament/
posterior lateral complex reconstruction. Arthroscopy
12(5):521–530
88. Harner CD, et al. (2004) Surgical management of knee dis-
locations. J Bone Joint Surg Am 86-A(2):262–273
89. Irrgang JJ, Harner CD (1995) Loss of motion following
knee ligament reconstruction. Sports Med 19(2):150–159
90. Noyes FR, Barber-Westin SD (2005) Posterior cruciate
ligament revision reconstruction, part 1: causes of surgi-
cal failure in 52 consecutive operations. Am J Sports Med
33(5):646–654
91. Klimkiewicz JJ, Harner CD, Fu FH (1999) Single bundle
posterior cruciate ligament reconstruction: University of
Pittsburgh approach. Oper Tech Sports Med 7:105–109
92. Noyes FR, Barber-Westin SD (1994) Posterior cruciate
ligament allograft reconstruction with and without a liga-
ment augmentation device. Arthroscopy 10(4):371–382
93. Noyes FR, Barber-Westin SD, Hewett TE (2000) High
tibial osteotomy and ligament reconstruction for varus
angulated anterior cruciate ligament-deficient
fi knees. Am
J Sports Med 28(3):282–296
94. Parolie JM, Bergfeld JA (1986) Long-term results of non-
operative treatment of isolated posterior cruciate ligament
injuries in the athlete. Am J Sports Med 14(1):35–38

S.-J. Kim
Defifinition
T
his technique is a combination of two dif-
ferent techniques without arthrotomy: an
arthroscopic double-bundle reconstruction
technique and an arthroscopic tibial-inlay tech-
nique.
History
Posterior cruciate ligament (PCL) reconstructions
using the traditional technique have shown incon-
sistent outcomes because the anatomy and bio-
mechanics of the PCL are complex. Biomechanical
studies revealed the tibial-inlay technique to have
a substantial advantage (1,2), and the double-bun-
dle reconstruction technique also showed a theo-
retical advantage (3–5). Recently, clinical trials
using arthroscopically assisted double-bundle and
tibial-inlay PCL reconstruction were performed
(6). However, they require a posterior surgical inci-
sion to approach tibial insertion of the PCL, and a
position change from supine to lateral.
Fig. 1 – Three portals are used: a parapatellar anteromedial portal, a low
anterolateral portal, and a high posteromedial portal.
Chapter 33
Arthroscopic reconstruction of the
posterior cruciate ligament using
double-bundle and tibial-inlay
technique
I have developed the arthroscopic procedure of
double-bundle, tibial-inlay technique to overcome
the complications of the arthrotomy and to per-
form the procedure more conveniently without
changing the position (3). To reproduce the ante-
rolateral and posteromedial bundles of the PCL at
the tibial site as the natural insertion of the PCL,
the Achilles tendon-bone allograft is used.
Contraindications
1. Narrow intercondylar notch
2. Abundant remnant
3. Poor bone quality of allograft
Surgical technique
Arthroscopic portals
Three special portals are used for a 1-incision tech-
nique of PCL reconstruction (Fig. 1) (7,8). First, a
parapatellar high anteromedial portal is made at
the highest position on the medial parapatellar
line, that is, just off
ff the medial edge of the patellar
tendon and the inferior border of the patella. This
Th
portal allows excellent viewing of the posterome-
dial compartments, and the tibial attachment site
of the PCL. Second, the low anterolateral portal is
located just above the lateral meniscus and 5 mm
anterior to lateral femoral condyle. This Th portal
allows preparation of the femoral tunnel without a
second incision of the skin over the medial femoral
condyle, with the knee flexed
fl 100–110°. Third, the
high posteromedial portal is placed 3 cm proximal
to the joint line and just posterior of the medial
femoral condyle. Th This portal provides better access
to the posterior tibial flat
fl surface of the PCL inser-
tion site, so that it facilitates debridement of the
PCL stump and elevation of the posterior capsule.
406 The Traumatic Knee
Fig. 2 – A 3-cm-long skin incision is made lateral to the proximal crest and
below to the tibial tuberosity. The tibialis anterior muscle is elevated later-
ally and the starting point of the tibial guide, 2 cm posterolateral to the
tibial tubercle below Gerdy’s tubercle, is exposed. The tip of the PCL tibial
drill guide system is inserted through the parapatellar anteromedial portal.
The drill guide angle to the long axis of the tibia is oriented 50°.
Fig. 4 – With the proximal tibia pushed backward to the femoral condyles
in 100° of flexion, the femoral tunnel is prepared with a cannulated headed
reamer.
Debridement of remnant
The remnant of ruptured PCL on the medial femo-
ral condyle is removed through the parapatellar
anteromedial portal. The remaining stump of the
PCL on the tibia is also removed through the high
posteromedial portal using a motorized shaver and
bipolar electrodes system, while viewing through
the parapatellar anteromedial portal. The posterior
knee joint capsule is elevated from its attachment
to the posterior flat spot on the tibia.
Preparation of the tibial and femoral tunnels
A 3-cm-long skin incision is made lateral to the
proximal crest and below to the tibial tuberosity.
The tibialis anterior muscle is elevated laterally
and the starting point of the tibial guide, 2 cm
posterolateral to the tibial tubercle below Gerdy’s
tubercle, is exposed. The tip of the PCL tibial drill
Fig. 3 – The desired femoral socket for the anterolateral bundle is believed
to be 2–3 mm posterior to the articular junction at the 1:00 o’clock point
on the right (11:00 o’clock on left), and that for the posteromedial bundle,
4–5 mm posterior to the articular junction at the 3:00 o’clock point on the
right (9:00 o’clock on left).
Fig. 5 – A specially designed guide pin with a slotted eye is used to pass the
flexible ruler and graft bundles.
guide system is inserted through the parapatellar
anteromedial portal and pushed back through the
intercondylar notch and positioned on the fossa for
PCL of the tibia 1.3 cm below the articular surface
and just lateral to midline. The drill guide angle to
the long axis of the tibia is oriented 50° (Fig. 2).
The guide pin is adjusted to the tibial tunnel length
to prevent overpenetration, and the protrusion of
the tip of the guide pin at the PCL insertion of tibia
during the drilling of the guide pin is confirmed
fi
through the posteromedial portal view. ThisTh tibial
tunnel is made with an 11-mm cannulated reamer.
The desired femoral socket for the anterolateral
bundle is believed to be 2–3 mm posterior to the
articular junction at the 1:00 o’clock point on
the right (11:00 o’clock on left), and that for the
posteromedial bundle, 4–5 mm posterior to the
articular junction at the 3:00 o’clock point on the

A B
Fig. 6 – The narrow flexible ruler is put into the tibial tunnel anteriorly and pulled by its tip through the notch and femoral tunnel. The scale at the edge of
the tibial tunnel is read through the high posteromedial portal (A) and that of the femoral tunnel is read through the low anterolateral portal (B).
right (9:00 o’clock on left) (Fig. 3). Th
The 9-mm diam-
eter headed reamer is introduced through the low
anterolateral portal toward the center of the ante-
rolateral bundle. With the proximal tibia pushed
backward to the femoral condyles in 100° of flex-fl
ion, the anterior femoral socket for the anterolat-
eral bundle is prepared with a cannulated headed
reamer (Fig. 4). The
Th direction of reamer is set coun-
terclockwise in order to allow for the tunnel to be
made in the intended location without wagging.
After removal of the headed reamer, the specially
designed guide pin with a slotted eye is advanced
proximally until the slotted eye is inside the ante-
rior femoral socket (Fig. 5). In a similar manner,
the posterior femoral tunnel for the posteromedial
bundle is prepared with a 7-mm diameter headed
reamer and a guide pin is also advanced into the
posterior femoral tunnel. The Th distance between
anterior femoral socket and posterior femoral tun-
nel is to be more than 4 mm to avoid tunnel bridge
collapse. The edges are chamfered to reduce stress
Fig. 7 – The bone plug for the tibial tunnel inlay is specially designed in a
cylindrical shape, 10 mm in diameter and 15 mm in height, including com-
pact bone with a cannulated coring reamer (Arthrex, GmbH, Germany), and
perpendicular to the fiber texture of the Achilles tendon.
Arthroscopic reconstruction of the posterior cruciate… 407
concentration on the graft. A longitudinal skin
incision about 3 cm long on the medial femoral
condyle is made along the guide pin for the pos-
teromedial bundle. The vastus medialis obliquus
muscle is undermined to expose the outer aperture
of the posterior femoral tunnel.
Intra-articular measuring of each bundle’s length
After the normal anterior tibial step off ff is main-
tained in neutral position by anterior translation
of the tibial condyle with the knee in 90° of fl
flexion,
the intra-articular length of each bundle of PCL is
measured with a narrow flexible ruler that is put
into the tibial tunnel anteriorly and pulled by its
tip through the notch and anterior femoral socket
and posterior femoral tunnel, respectively. Th The
scales at the edge are read through the high pos-
teromedial portal and the low anterolateral portal
sequentially (Fig. 6).
Preparation of the graft
Achilles tendon-bone allograft is used. Th The bone
plug for the tibial tunnel inlay is specially designed
in a cylindrical shape, 10 mm in diameter and
15  mm in height, including compact bone with a
cannulated coring reamer (Arthrex, GmbH, Ger-
many), and perpendicular to the fi fiber texture of
the Achilles tendon (Fig. 7). Six non-absorbable
Ethibond No. 2 sutures (Ethicon, Johnson &
Johnson, Somerville, NJ) are passed through the
center of the bone plug as grasp suture fashion
like the technique of bone plug fixation
fi for menis-
cal transplantation. The medial and lateral edges
of the Achilles tendon are able to be identifi fied by
inspecting the texture of tendon fibers,
fi because
408 The Traumatic Knee

A B
Fig. 8 – The proximal width of the tendon is divided two to three from medial to lateral (A) and split distally along the texture of fibers
fi into superficial and
deep layers manually (B).

Fig. 9 – The superficial layer bundle is fashioned to pass through a 7-mm

tunnel. The deep layer bundle, with 9-mm diameter Endopearl attached, is
fashioned to pass through a 9-mm tunnel.
Fig. 10 – The skin incision of the anteromedial portal is extended to 2.5 cm
for easy passage of the graft. Ethibond sutures that are anchored into the
bone plug are pulled out through the tibial tunnel to engage the bone plug
into the tibial tunnel.

B
Fig. 11 – The bone plug is completely engaged into the tibial tunnel (B) and double bundles into the
A femoral tuunnels (C).

the medial side of tendon fibers travel distally and tunnel and the deep layer bundle through a 9-mm
are rotated superfificially and lateral fibers travel tunnel. The length of the superfi
ficial layer bundle
deeply. The
Th proximal width of the tendon is divided is equal to the combined length of the measured
into two to three from medial to lateral and split intra-articular posteromedial bundle length and
distally along the texture of fibers
fi into superfi
ficial 50 mm, and that of the deep layer bundle, the
and deep layers manually (Fig. 8). Th The superfi
ficial length of measured intra-articular anterolateral
layer bundle is fashioned to pass through a 7-mm bundle and 25 mm. A 30-mm length of the super-

ficial layer bundle is sutured in a baseball stitch
fashion from the point of the measured postero-
medial bundle length toward the tip of the tendon
and attached to the leading sutures using a modi-
fied Bunnel stitch, and a 25-mm length of the deep
layer bundle is sutured in the same manner from
the point of the measured anterolateral bundle to
the tip of the tendon, and a 9-mm diameter Endo-
pearl (Linvatec, Largo, FL) is attached (Fig. 9).
Graft placement and fixation
fi
The skin incision of the anteromedial portal is
extended to 2.5 cm for easy passage of the graft
(Fig. 10). A tendon leader is passed through the tib-
ial tunnel and pulled out with the grasper through
the intercondylar notch and the parapatellar
anteromedial portal. The proximal tip of the ten-
don leader is connected to three pairs of Ethibond
No. 2 sutures that are anchored into the bone plug,
and the distal tip of the tendon leader is pulled out
through the tibial tunnel. Babcock tissue forceps
(Philling Weck, City, State) is used to pass through
the intercondylar notch and to place the bone plug
into the tibial tunnel. ThenTh the sutures on the
bone plug are pulled distally to engage it into the
tibial tunnel (Fig. 11). The tip of the guide pin with
the slotted eye is withdrawn into the joint from
the anterior femoral socket. The leading suture
of Endopearl attached to the deep layer bundle is
hooked into the eye of the guide pin and the guide
pin is pulled out of the medial femoral condyle,
bringing the leading suture. The deep layer bundle
is guided into the anterior femoral socket for the
anterolateral bundle. In the same manner, the
superfificial layer graft is guided into the posterior
femoral tunnel. After complete seating of the bone
plug into the tibial tunnel is confi firmed, a guide-
wire for the interference screw is inserted into the
tibial tunnel until the tip of the guidewire appears
on the posterior aperture of the tunnel. By pull-
ing the sutures on the bone plug tightly, the bone
plug of the graft is fixed
fi into the tibial tunnel with
an absorbable interference screw until the tip of
the screw appears on the posterior tibial aperture.
In addition, sutures on the bone plug are tied to
the anterior aperture of the tibial tunnel using a
suture washer (Smith & Nephew, Andover, MA) for
additional fixation. Tension is applied on the deep
layer bundle in the anterior femoral socket while
moving the knee 20 times through a full range of
motion. Femoral fixation of the deep layer bundle
is obtained with the absorbable interference screw
through the low anterolateral portal with the
knee in 90° of flexion while applying an anteriorly
directed force to maintain the normal anterior tib-
ial step offff. Once more, tension is applied on the
Arthroscopic reconstruction of the posterior cruciate… 409
Fig. 12 – Femoral fixation of the superficial layer bundle is obtained with
the absorbable interference screw from the outside in a near extension
position.
superfi ficial layer bundle in the posterior femoral
socket while moving the knee 20 times through a
full range of motion. Femoral fifixation of the super-
ficial layer bundle is obtained with the absorbable
interference screw from the outside in nearly an
extension position, and its free end is addition-
ally fi
fixed with a staple on the cortex of the medial
femoral condyle (Fig. 12).
Pearls and pitfalls
The tibial tunnel through the anterolateral tibial
cortex can be made easily and precisely because
the tibial tunnel from the anterolateral cortex has
a shorter tunnel length than that from the antero-
medial cortex, and the cortex of the upper antero-
lateral metaphysis of tibia is thinner than that of
the lower anteromedial one. In addition, the tibial
tunnel from anterolateral cortex can avoid damage
to the pes anserinus, and the whole tibial tunnel is
observed through the posteromedial portal during
the tunneling and aperture chamfering. Femoral
sockets are prepared from inside-out through a low
anterolateral portal to minimize damaging the vas-
tus medialis obliquus (7,8). The femoral tunneling
through the low and far anterolateral portal with
the knee pushed backward in 100° of fl flexion can
make the angle between the femoral tunnels and
the graft as much as that of the outside-in tech-
nique.
Postoperative care
A long leg cylinder splint is used to immobilize the
knee in full extension for 2 weeks. Partial weight
bearing is permitted immediately with the appli-
cation of crutches. Straight leg raising exercise
is initiated as soon as postoperative pain is sub-
sided. The PCL brace is applied after 2 weeks with
410 The Traumatic Knee
initiation of range of motion up to 90°. The brace is
unlocked at the end of 6 weeks. The PCL brace was
applied totally for 6–8 weeks. A low-impact sports
program is initiated after 6 months. Return to
contact sports and heavy labor is permitted after
9 months.
Outcomes
I evaluated the clinical results of four diff
fferent PCL
reconstruction techniques in 39 patients. Achilles
tendon-bone allografts were used in all patients.
General inclusion criteria were as follows: (a) iso-
lated posterior instability greater than grade II
without contralateral knee injury, (b) no previ-
ous surgery on the aff ffected knee, and (c) absence
of fracture around the knee. Exclusion criteria
included patients who received revision operation,
patients with generalized joint laxity, and patients
who had combined ligaments injuries.
Eighteen patients had PCL operation using tran-
stibial technique: 8 patients (Group T1) using sin-
gle-bundle technique and 10 patients (Group T2)
using double-bundle technique.
Twenty-one patients received PCL operation using
arthroscopic tibial-inlay technique: 11 patients
(Group I1) using single-bundle technique and 10
patients (Group I2) using double-bundle technique.
The average period of follow-up was 42.5 months
in Group T1, 40.7 months in Group T2, 34.1
months in Group I1, and 26.6 months in Group I2.
The ratio of male to female was as follows: 5 to 3 in
Group T1, 8 to 2 in Group T2, 8 to 3 in Group I1,
and 7 to 3 in Group I2. The average age was 32.4
years in Group T1, 35.3 years in Group T2, 31.9
years in Group I1, and 33.6 years in Group I2.
The postoperative mean side-to-side diff fferences
of posterior tibial translation at 90° by the Telos
stress radiography were 5.17 ± 2.48 mm in Group
T1, 5.42 ± 1.90 mm in Group T2, 4.55 ± 1.86 mm
in Group I1, and 3.73 ± 1.75 mm in Group I2.
A statistically significant
fi diff
fference was found
between groups T1 and I2 (p = 0.036) and T2 and
I2 (p
( = 0.007). Final examination with a goniom-
eter showed mean side-to-side difference
ff of flexion
losses was 2.68 ± 0.59° in Group T1, 3.42 ± 0.98°
in Group T2, 4.20 ± 1.74° in Group I1, and 3.74 ±
0.73° in Group I2 (p
( = 0.345). Mean preoperative
Lysholm scores were 88.6 ± 7.10 in Group T1, 88.4
± 6.44 in Group T2, 79.12 ± 19.43 in Group I1, and
84.70 ± 11.51 in Group I2 (p
( = 0.495).
Conclusion drawn from this investigation was that
arthroscopic double-bundle, tibia-inlay technique
could be one of the alternative techniques in PCL
reconstruction.
Complications
There were two cases of intraoperative complica-
tion. One case was a break in the cylinder bone
plug during graft placement on the tibial tunnel.
The remnant bone plug was stabilized by fixation
with extra interference screws. Th
The other case
involved a rupture of the Ethibond suture of the
bone plug during the tensioning procedure. Addi-
tional immobilization was applied postoperatively
during 4 weeks.
References
1. Berg EE (1995) Posterior cruciate ligament tibial inlay
reconstruction. Arthroscopy 11(1):69–76
2. Bergfeld JA, McAllister DR, Parker RD, et al. (2001) A biome-
chanical comparison of posterior cruciate ligament recon-
struction techniques. Am J Sports Med 29(2):129–136
3. Kim SJ, Park IS (2005) Arthroscopic reconstruction of the
posterior cruciate ligament using tibial-inlay and double-
bundle technique. Arthroscopy 21(10):1271
4. Stahelin AC, Sudkamp NP, Weiler A (2001) Anatomic
double-bundle posterior cruciate ligament reconstruction
using hamstring tendons. Arthroscopy 17(1):88–97
5. Stannard JP, Riley RS, Sheils TM, et al. (2003) Anatomic
reconstruction of the posterior cruciate ligament after
multiligament knee injuries. A combination of the tibial-
inlay and two-femoral-tunnel techniques. Am J Sports
Med 31(2):196–202
6. Noyes FR, Medvecky MJ, Bhargava M (2003) Arthroscopi-
cally assisted quadriceps double-bundle tibial inlay pos-
terior cruciate ligament reconstruction: An analysis of
techniques and a safe operative approach to the popliteal
fossa. Arthroscopy 19(8):894–905
7. Kim SJ, Kim HK, Kim HJ (1998) A modifi fied endoscopic
technique for posterior cruciate ligament reconstruction
using allograft. Arthroscopy 14(6):643–648
8. Kim SJ, Min BH (1994) Arthroscopic intraarticular inter-
ference screw technique of posterior cruciate ligament
reconstruction: one-incision technique. Arthroscopy
10(3):319–323

R. Badet, P. Verdonk,
S. Rocha Piedade
Technique in PCL reconstruction:
mini posterior approach
Defifinition
T
his technique of minimal invasive surgical
(MIS) approach was developed in an anatomic
study performed in 20 cadaveric knees. Th This
MIS approach eliminates section or dissection of
any posterior anatomical structures in the popliteal
region including the medial gastrocnemius muscle
(MGM) and popliteus muscle. Since 2002, the
authors have been used this surgical approach that
allows a limited soft tissue dissection and adequate
visualization of the posterior area of the knee.
History
The posterior cruciate ligament (PCL) is an intra-
articular and extra-synovial ligament. Its orienta-
tion is from anterior, in the lateral side of femoral
condyle, to posterior, at the tibial attachment 1 cm
below the tibial plateau on the posterior surface of
proximal tibia. This
Th orientation fits the ligament as
the major stabilizer against posterior tibial drawer
with the knee flexed
fl 80–90°. It is estimated that a
PCL injury makes up as many as 20% of ligament
injuries. In the orthopedic literature, recommen-
dations for treating PCL injuries vary greatly. How-
ever, it is a consensus that a PCL avulsion fracture,
which usually occurs at the tibial insertion, should
be submitted to early surgical treatment (1).
Several authors have been reported satisfactory
results with open reduction and internal fi fixation
in the early acute phase of this injury (2–5). Wener
Muller (6) emphasized that PCL avulsion fracture
presents the most favorable outcomes in PCL inju-
ries. Diff
fferent technical options and diff
fferent sur-
gical approaches can be used to gain access to the
posterior area of the knee.
In this chapter, we present a new surgical approach
performed by mini-invasive means to access the
PCL tibial attachment and the posterior area of the
tibia. This technique was described for PCL tibial
avulsion fracture and PCL reconstruction by Inlay
Chapitre 34
technique. However, this surgical approach is also
useful for remotion of popliteo cystis (Baker cyst)
and pigmented villonodular synovitis localized in
the posterior aspect of the knee joint. The Th tech-
nique was based on the results of an anatomical
dissection study performed on 20 cadaver knees.
Several techniques were described in the literature on
concerning the surgical approach to the posterior area
of the knee joint. Th
The classic posterior approach to the
knee was introduced by Trickey (7), Fig. 1A. This
Th tech-
nique involves a large curvilinear incision centered
in the posterior fl
flexion crease of the knee. However,
sometimes the dissection or section of both the medial
head of the gastrocnemius muscle and the popliteus
muscle could be followed by important secondary
restraints for posterior and posterolateral laxity.
This technique was modifi fied by Burks and Berg
(8), Fig. 1B. Comparing to Trickey’s approach, the
authors described a less traumatic technique with
smaller skin incision. With an inverted L-shaped
skin incision centered in a posterior fl flexion crease
of the knee, they reached the posterior area of tibia
between the medial and lateral heads of the gastroc-
nemius. In this surgical approach, the medial head
of gastrocnemius is dissected along their medial bor-
der, and after the muscle belly and the neurovascular
bundle are retracted laterally. A longitudinal capsu-
lotomy y allows exposing the posterior fragment and
the PCL mid-substance can be access adequately.
Considering PCL fracture avulsion and PCL recon-
struction (Inlay technique), in 2002, we developed
MIS approach to the posterior area of the knee (9)
(Fig. 1C). Th
This technique is reproducible and allows a
safe and adequate surgical exposure. Particularly, this
surgical approach avoids the section or dissection of
any posterior anatomical structures in the popliteo
region including the MGM and popliteus muscle.
Indications, brief description
– PCL fracture avulsion at the tibial attachments
– PCL reconstruction (inlay technique)
412 The Traumatic Knee

Fig. 1 – Skin incision in three

different techniques of surgical
approaches to the posterior aspect
of knee joint: Trickey (A), Burks et
al. (B), and Badet et al. (C).

Fig. 2 – (A) Level of fibular head

(yellow dotted line) projected to
the tibia as an anatomical refer-
ence for PCL tibial insertion in
the radiographic lateral view; (B)
anatomical PCL tibial insertion;
and (C) anatomical landmarks:
semimenbranosus tendon (SMT),
flexion crease (FC), and PCL tibial
insertion (*).

Fig. 3 – Avulsion of the tibial

insertion of the PCL (A) and liga-
ment tear (B).

Fig. 4 – During the procedure the knee can be mobilized.

Fig. 5 – Location of the joint line.


– Popliteus cyst (Baker)
– Pigmented villonodular synovitis (posterior area
of the knee)
Relative contraindications
Revision cases are relative contra-indications. The
surgical approach is diffi
fficult and can be dangerous
due to adhesions.
Preoperative physical findings
fi
Plain radiographs include anteroposterior and late-
ral views. As presented in Fig. 2A, and 2B, the level
of the fibular head is an anatomical reference to
native PCL tibial insertion.
Imaging and other diagnostic studies
magnetic resonance imaging (MRI) are also useful
in confi
firming bone avulsion fracture and associ-
ated ligament injury and cystic lesions (Fig. 3B ).
Surgical technique
This MIS procedure necessitates the following
requirements:
– Correct positioning of the patient
– Correct location of the skin incision
– Perfect knowledge on the difffferent surgical steps
and their correct sequence
Positioning of the patient
Th patient is in a decubitus ventralis position with
The
the feet in neutral rotation. The knee should be draped
in such a manner that the surgeon is able to freely fl
flex
and extend it during the procedure (Fig. 4).
Approach and skin incision
In this surgical approach, three anatomical land-
marks must be considered to identify the PCL
native tibial insertion (Fig. 1A–C).
1. The flexion crease
This can be visualized easily by introducing a demo-
graphic pencil in the fl
flexion crease with the knee
in flexion. Retracting the pencil will now leave a
mark on the exact position of the fl flexion crease
(Fig. 5A).
Technique in PCL reconstruction: mini posterior approach 413
2. The level of the fibular head
This level should be checked prior to the surgery
on a conventional profi file x-ray of the knee joint.
Usually, it could be used as bone reference to the
level of the native PCL tibial attachments on the
posterior surface of the tibia (Fig. 2A–C).
3. The location of the insertion of the PCL
The projection of this point on the skin is situated
halfway in the mediolateral direction on the calf at
the level of the fibular head (Fig. 5B).
4. The course of the semimembranous and semitendinous
muscles from proximal to distal and from lateral to medial
An inverted L-shaped skin incision is made. Th The
horizontal arm of the incision is 3 cm in length, is
positioned in the flexion crease, and starts laterally
from the intersection with the hamstrings. It ends
approximately 1 cm from the skin projection of the
insertion point of the PCL.
The vertical arm of the incision is 3–4 cm in length
and is positioned approximately 1 cm medially to
the skin projection of the insertion point of the
PCL (Fig. 5B).
Step-by-step description of the technique
Pearls and pitfalls
During this approach, it is essential to keep the
knee in a slightly flexed
fl position to facilitate the
exposure and to keep the vascular pedicle at a safe
distance from the incision (Fig. 4). In the intra-
muscular approach, the pedicle is protected by the
lateral part of the MGM. The correct position of
the three retractors should be checked regularly.
An approach performed laterally to the MGM is
not recommended since it is in permanent con-
tact with the popliteal vessels. Moreover, a vas-
cular bundle from the central popliteal vessels to
the MGM is located approximately 4 cm distal to
the medial femoral condyle. This
Th branch limits this
MIS approach (Fig. 10).
In the case of technical diffi
fficulties, the extension
of the presented exposure is limited distally by
these perforating horizontal vascular branches.
Nonetheless, by flexing the knee, the approach can
be extended distally.
Alternative technique I (if necessary)
The skin incision can be extended distal and lateral
to the MGM by careful dissection of the popliteal
vessels, and medially by converting the MIS skin
incision to a classic reversed Trickey incision.
414 The Traumatic Knee

Fig. 6 – L-shaped skin incision (A), vertical incision of the subcutaneous fascia (B), Identification of the semi-membranosus and semitendinosus tendons (C)
and distal and lateral dissection from these tendons. The head of the MGM is exposed (D).

Fig. 7 – The medial border of the MGM is dissected proximally toward its insertion on the medial femoral condyle (A and B). The authors advise to expose
the posterior knee joint capsule through the superior part, proximal insertion of the MGM.
Therefore, the MGM fascia is cleaved at the medial one-third part in the direction of its fibers starting proximal at the femoral condyle origin and ending
approximately 4 cm distal to it. This avoids problems with the deep vascular bundle. The MGM is cleaved using the MAYO dissection scissors, and the muscle
is retracted by a medial, lateral, and inferior retractor (C).

Fig. 8 – A good visualization of the posterior knee capsule is then obtained (A). Subsequently, the medial joint capsule is opened obliquely with a scalpel
from proximal to distal and from medial to lateral (8B). This exposes the lateral aspect of the medial femoral condyle. It also visualizes the posterior area of
the tibia enabling fixation of the PCL graft (8C).

Fig. 9 – Fixation of the intercondylar eminence fracture (9A) and Baker’s cyst
excision (9B).

References
1. Morgan EA, Wroble RR (1997) Diagnosing posterior cruci-
ate ligament injuries. Phys Sportsmed. 1997 25(11):29-3
2. Torisu T (1979) Avulsion fracture of the tibial attachment
of the posterior cruciate ligament. Indications and results
of delayed repair. Clin Orthop Relat Res 143:107–114
3. Torisu T (1977) Isolated avulsion fractures to the tibial
attachment of the posterior cruciate ligament. J Bone
Joint Surg Am 59:68–72
4. Lee HG (1937) Avulsion fracture of the tibial attachments
of the cruciate ligaments: treatment by operative reduc-
tion. J Bone Joint Surg 19:460–468
5. Brenan JJ (1960) Avulsion injuries of the posterior cruci-
ate ligament. Clin Orthop Relat Res 18:153–163
Technique in PCL reconstruction: mini posterior approach 415
Fig. 10 – A vascular bundle from
the central popliteal vessels to
the MGM is located approximately
4 cm distal to the medial femoral
condyle. Th is branch limits this MIS
approach.
6. Muller W (1983) The knee: form, function and ligament
reconstruction. Berlin Heidelberg: Springer: 210–211
7. Trickey EL (1980) Injuries to the posterior cruciate liga-
ment. Diagnosis and treatment of early injuries and
reconstruction of late instability. Clin Orthop Relat Res
147:76–81
8. Burks RT, Schaff
ffer JJ (1990) A simplifi
fied approach to the
tibial attachment of the posterior cruciate ligament. Clin
Orthop Relat Res 254:216–219
9. Badet R, Lootens T, Neyret Ph (2002) Le Ligament Croisé
Postérieur: Abord de la surface rétrospinale, 10èmes
Journées Lyonnaises de Chirurgie du Genou, Lyon, 10-12
octobre. In: Chambat P, Neyret Ph, Deschamps G, editors.
Le Genou du sportif. Montpellier, France: Ed. Sauramps:
347–357
 Chapter 35

F. Margheritini,
M. Aboelnour, P.P. Mariani
Results of PCL reconstruction

Introduction diffi
fficulties in recruiting homogenous study group.
Then difffferent surgical techniques, using diff fferent

P
osterior cruciate ligament (PCL) reconstruc- type of grafts with different
ff rehabilitation protocol
tion has gained a great interest in the scien- make the comparison more diffi fficult (Fig. 1).
tifi
fic community over the last decades. Despite
this increasing interest, the management of PCL
injuries remains a matter of debate, largely due to
the lack of prospective studies delineating the true Isolated PCL reconstruction
natural history of the injury and the absence of
randomized trials comparing the outcomes of cur- The results of PCL reconstructions in so-called iso-
rent modes of treatment. Furthermore, from the lated injury were initially described by Clancy et
clinical viewpoint, PCL injuries are associated with al. (1) who reported the results of 23 patients who
a great variety of peripheral lesions, justifying the underwent single-bundle autologous bone-patellar

Fig. 1 – Charts showing differences in surgical techniques, grafts, and scoring systems used among the studies published in the last 3 years (2 years mini-
mum follow-up).
418 The Traumatic Knee
tendon-bone (BPTB) autograft replacement with a
transtibial tunnel technique. Ten patients who had
reconstruction after acute PCL injury had static
and functional results that were graded as good or
excellent. Eleven out of 13 patients, for whom sur-
gery was done in the setting of chronic PCL insta-
bility, were graded as good or excellent concerning
static and functional results.
Mariani et al. (2) retrospectively reviewed
24 patients after arthroscopic single-bundle PCL
reconstruction with a BPTB autograft for chronic
PCL insuffifficiency. At a minimum follow-up of
2 years, they found that 25% of patients were nor-
mal and 21% of patients were abnormal or severely
abnormal by IKDC criteria. Chen et al. (3) retro-
spectively reviewed the outcomes of quadriceps
tendon-patellar bone graft for PCL reconstruction
at a minimum follow-up of 3 years. Twenty-nine
patients with grade III PCL injury and marked
instability underwent arthroscopic reconstruction.
Twenty-four (83%) patients achieved good or excel-
lent Lysholm knee scores and 25 (86%) patients had
ligament laxity of less than 5 mm. TheTh authors con-
cluded that the quadriceps tendon autograft was an
acceptable graft choice for PCL reconstruction.
Sekiya et al. (4) reported on the retrospective
outcomes of 21 patients who had undergone
arthroscopic single-bundle PCL reconstruction
using an Achilles tendon allograft for isolated grade
III injuries. In this study, only 57% of patients had
normal or near-normal knee function by IKDC
assessment standards at an average follow-up of 5.9
years. In addition, instrumented laxity examination
revealed that only 62% of patients had less than 3
mm side-to-side diff fference in corrected posterior
displacement. Kim et al. (5) presented 37 patients
with posterior cruciate ligament injuries at a mini-
mum of 2-year follow-up following arthroscopic
PCL reconstruction using miscellaneous patellar
tendon auto/allograft, and they reported an aver-
age side-to-side difference
ff in posterior translation,
measured by KT-2000 arthrometer, of 6.08 mm
preoperatively and 2.2 mm postoperatively.
Garofalo et al. (6) in 2006, presenting their results
of double-bundle reconstruction in isolated
patients, found an excellent/good score according
to the Lysholm scale for all patients but one, with a
stress x-rays value of 5.9 mm (side to side) at 2 years
minimum follow-up. Chan et al. (7) reached almost
the same results of the previous authors in 20
patients treated with a single-bundle technique for
an isolated PCL lesion at an average follow-up of 40
months. In final IKDC ratings, 85% of patients were
assessed as normal or near normal (grade A or B).
Wu et al. (8) presented the 5-year follow-up of
22 patients treated for an isolated PCL lesion with
an arthroscopic single-bundle reconstruction with
a quadriceps tendon. The Th data showed that 18 of
the patients (82%) revealed less than 5 mm liga-
ment laxity when measured by KT-1000 with the
86% of patients showing excellent or good results
when using Lysholm knee score to evaluate their
subjective symptoms.
Combined PCL reconstruction
The results of treatment for PCL injuries com-
bined with PLC injuries in the literature are varied.
In 1984, Baker et al. (9) reported 90% subjectively
good and 73% objectively good results in 11 patients
undergoing open repair for acute combined PCL and
arcuate complex tear. In 1996, Noyes and Barber-
Westin (10) reported 64% fully functional, 27% par-
tially functional, and 9% failure in 23 knees under-
going combined PCL reconstruction and proximal
advancement of the lateral collateral ligament and
the PLC, with a follow-up of 23–90 months. In 2002,
in Wang’s (11) series of 25 patients, all had transtib-
ial single-bundle PCL reconstruction and PLC recon-
struction using Larson’s technique plus some addi-
tional lateral collateral ligament (LCL) advancement,
with an overall satisfactory result in 68% of patients
and restoration of ligament stability in 44%. In 2002,
Freeman et al. (12) suggested that there was a sig-
nifi
ficant improvement in functional outcome in the
group (5 cases) that underwent a transtibial single-
bundle PCL reconstruction and PLC reconstruction
using Larson’s technique, compared with the group
(13 cases) only receiving a PCL reconstruction.
In 2003, in Kim’s (13) series of 25 patients with
posterolateral rotatory instability (PLRI) combined
with PCL injuries, all had transtibial single-bundle
PCL reconstruction and PLC reconstruction using
biceps tenodesis, with satisfactory results by IKDC
scores in 76% and restoration of external rota-
tional stability in 64%, with no differences
ff com-
pared with isolated PLRI group.
In 2004, Fanelli’s (14) series of 41 patients all had
transtibial single-bundle PCL reconstruction using
Achilles allograft, biceps tenodesis, and posterolateral
capsular shift, with satisfactory posterior stability in
70% and restoration of external rotational stability in
98%. In our series of 39 patients, all had tensioning
and augmentation for PCL reconstruction and PLC
reconstruction using a tibial tunnel or fibular
fi tunnel
technique with overall satisfactory results in 82% and
restoration of external rotational stability in 74%.
Single bundle vs. double bundle
Houe and Jorgensen (15) evaluated 16 patients at a
mean follow-up of 35 months and found no signifi-
fi

cant diff
fferences in Lysholm score, activity level, or
graft laxity, with reconstruction using a BPTB graft
in one femoral tunnel was compared with semi-
tendinosus/gracilis grafts in two femoral tunnels
(level II). Similarly, Wang et al. (11) prospectively
followed 35 patients for a minimum of 2 years to
compare single-bundle and double-bundle PCL
reconstruction with a hamstring autograft (level
II). They found no signifi
ficant diff
fference in ligament
laxity, functional score, or radiographic changes
between the two groups. Same results were found
by Hatayama et al. in 2006 (16) in a group of 20
patients treated for isolated/combined PCL inju-
ries with a single- or double-bundle procedure with
hamstrings graft. Further studies evaluating the
long-term outcomes in larger cohorts of patients
more carefully selected are needed to accurately
compare the relative benefi fits of single-bundle and
double-bundle techniques.
Tibial tunnel vs. inlay
MacGillivray et al. (17) compared single-bundle
endoscopic transtibial reconstructions with a tib-
ial-inlay technique and found that there were no
signifi
ficant diff
fferences in posterior drawer testing,
KT-1000, functional testing, or Lysholm, Tegner, and
American Academy of Orthopedic Surgeons (AAOS)
knee scores at a minimum 2-year follow-up (level
III). Seon and Song (18) compared transtibial tun-
nel fixation using quadrupled semitendinous graft
with a tibial-inlay technique using BPTB autograft
at a minimum 2-year follow-up (level III). This study
included 43 patients, all are chronic isolated PCL
Fig. 2 – Diagram showing the average preoperative and postoperative side-to-side differences according to stress x-rays. Note that those listed are the only
studies using stress x-rays for assessing the clinical results.
Results of PCL reconstruction 419
injury. Mean Lysholm scores for transtibial and
tibial-inlay groups were 91.5 and 93.5, respectively;
however, this diff
fference was not signifi
ficant.
Discussion
Results of PCL reconstructions are still controver-
sial. The reasons have to be found in the diffi
fficulties
in recruiting homogenous study population. It is at
least interesting to note that the majority of the
study published deal with isolated PCL lesion that
have been frequently referred as “rare entity.” TheTh
diffi
fficulties in diagnosis and grading the injury could
be the reason why final
fi statement can be diffifficultly
achieved. Furthermore, one more point is often
underestimated when discussing the results and
this is the post-operative physiotherapy regime,
which often changes quite widely among authors.
Most of the published studies used more than one
scoring system, and after analyses of the results,
we found that the use of IKDC score leads to lower
percentage of excellent/good results when com-
pared with the use of HSS’s results. The Th reason
could be found in the more recent development
of the IKDC, which incorporates a more accurate
evaluation test and includes the use of arthromet-
ric evaluation. Even so, we know that the arthro-
metric evaluation is not reliable in quantifying the
amount of posterior subluxation, which could be
only assessed using stress x-rays. Different
ff authors
underlined the importance of stress x-rays in
assessing the degree of posterior subluxation, but
only few out of hundreds of clinical studies have
used this method (Fig. 2).
420 The Traumatic Knee
Recently, a review paper published in the Cochrane
Library (19) ended with a fi final statement where
the lack of randomized control trials (RCTs) for the
treatment of PCL injuries was the main reason in
justifying the lack of guidelines in PCL treatment.
Even with all these limitations, we can achieve
some final conclusions:
– The operative management does not eliminate
abnormal PCL laxity.
– The correction achieved is generally around 1+
laxity.
– There are no clinical, statistically signiofi ficative,
diff
fference at the moment among the results
obtained with diff fferent surgical techniques.
– The treatment should address associated instabil-
ities or PCL laxity will increase postoperatively.
– The time of the surgery can infl fluence the results,
the earlier is the treatment the better is the result.
– The graft should be protected for a longer time
than the ACL, for preventing graft stretching and
knee laxity.
References
1. Clancy WG, Jr., Shelbourne KD, Zoellner GB, et al. (1983)
Treatment of knee joint instability secondary to rupture
of the posterior cruciate ligament. Report of a new proce-
dure. J Bone Joint Surg 65A:310–322
2. Mariani PP, Adriani E, Santori N, Maresca G (1997)
Arthroscopic posterior cruciate ligament reconstruction
with bone- tendon-bone patellar graft. Knee Surg Sports
Traumatol Arthrosc 5:239–244
3. Chen CH, Chen WJ, Shih CH (2002) Arthroscopic recon-
struction of the posterior cruciate ligament: a comparison
of quadriceps tendon autograft and quadruple hamstring
tendon graft. Arthroscopy 18:603–612
4. Sekiya K, West RV, Ong BC (2005) Clinical outcomes after
isolated arthroscopic single-bundle posterior cruciate liga-
ment reconstruction. J Arthrosc Relat Surg 21:1042–1050
5. Kim SJ, Shin SJ, Kim HK, et al. (2000) Comparison of
1- and 2-incision posterior cruciate ligament reconstruc-
tions. Arthroscopy 16:268–278
6. Garofalo R, Jolles BM, Moretti B, Siegrist O (2006) Dou-
ble-bundle transtibial posterior cruciate ligament recon-
struction with a tendon-patellar bone-semitendinosus
tendon autograft: clinical results with a minimum of 2
years’ follow-up. Arthroscopy 22(12):1331–1338
7. Chan YS, Yang SC, Chang CH, et al. (2006) Arthroscopic
reconstruction of the posterior cruciate ligament with use
of a quadruple hamstring tendon graft with 3- to 5-year
follow-up. Arthroscopy 22(7):762–770
8. Wu CH, Chen AC, Yuan LJ, et al. (2007) Arthroscopic
reconstruction of the posterior cruciate ligament by
using a quadriceps tendon autograft: a minimum 5-year
follow-up. Arthroscopy 23(4):420–427
9. Baker CL, Jr., Norwood LA, Hughston JC (1984) Acute
combined posterior cruciate and posterolateral instability
of the knee. Am J Sports Med 1984;12:204–208
10. Noyes FR, Barber-Westin S (2005) Posterior cruciate liga-
ment replacement with a two-strand quadriceps tendon-
patellar bone autograft and a tibial inlay technique. J Bone
Joint Surg Am 87(6):1241–1252
11. Wang CJ, Chen HS, Huang TW, Yuan LJ (2002) Outcome
of surgical reconstruction for posterior cruciate and pos-
terolateral instabilities of the knee. Injury 33(9):815–821
12. Freeman RT, Duri ZA, Dowd GS (2002) Combined chronic
posterior cruciate and posterolateral corner ligamentous
injuries: a comparison of posterior cruciate ligament
reconstruction with and without reconstruction of the
posterolateral corner. Knee 9(4):309–312
13. Kim SJ, Shin SJ, Jeong JH (2003) Posterolateral rotatory
instability treated by a modifi fied biceps rerouting tech-
nique: technical considerations and results in cases with
and without posterior cruciate ligament insuffi fficiency.
Arthroscopy 19(5):493–499
14. Fanelli GC, Edson CJ (2004) Combined posterior cruciate
ligament-posterolateral reconstructions with Achilles ten-
don allograft and biceps femoris tendon tenodesis: 2- to
10-year follow-up. Arthroscopy 20(4):339–345
15. Houe T, Jørgensen U (2004) Arthroscopic posterior cru-
ciate ligament reconstruction: one- vs. two-tunnel tech-
nique. Scand J Med Sci Sports 14(2):107–111
16. Wang CJ, Weng LH, Hsu CC, Chan YS (2004) Arthroscopic
single- versus double-bundle posterior cruciate liga-
ment reconstructions using hamstring autograft. Injury
35(12):1293–1299
17. Hatayama K, Higuchi H, Kimura M, et al. (2006) A com-
parison of arthroscopic single- and double-bundle poste-
rior cruciate ligament reconstruction: review of 20 cases.
Am J Orthop 35(12):568–571
18. MacGillivrayy JD, Stein BE, Park M, et al. (2006) Compari-
son of tibial inlay versus transtibial techniques for isolated
posterior cruciate ligament reconstruction: minimum
2-year follow-up. Arthroscopy 22(3):320–328
19. Seon JK, Song EK (2006) Reconstruction of isolated pos-
terior cruciate ligament injuries: a clinical comparison of
the transtibial and tibial inlay techniques. Arthroscopy
22(1):27–32
20. Peccin MS, Almeida GJ, Amaro J, et al. (2005) Interven-
tions for treating posterior cruciate ligament injuries
of the knee in adults. Cochrane Database Syst Rev 2:
CD002939
21. Noyes FR (1996) PCL & posterolateral complex injuries.
Overview. Am J Knee Surg 9(4):171
 Chapter 36

B. Forsythe,
R. Mascarenhas,
Combined injuries to the posterior
M.W. Pombo, C.D. Harner
cruciate ligament and medial
collateral ligament of the knee

Introduction PCL reconstruction. Grade I and II injuries are

defi
fined as less than 5 mm of opening with valgus

P
osterior cruciate ligament (PCL) tears with stress and between 5 and 10 mm of opening with
concomitant medial collateral ligament valgus stress with a firm endpoint, respectively (5).
(MCL) or posteromedial injuries are a rare However, if the patient demonstrates complete val-
but recognized injury pattern. Unlike the poste- gus opening of the knee in full extension with no
rolateral corner (PLC), the medial side generally endpoint, suggesting grade III injury to the MCL,
has a higher potential to heal conservatively. Nev- reconstruction of the PCL with repair of the MCL
ertheless, we have a low threshold to surgically within 3 weeks of injury is preferred.
address the medial side if significantfi instabil- Our operative technique entails initial reconstruc-
ity exists in a PCL defi ficient knee. Bergfeld et al. tion of the PCL. This often results in signifi ficant
showed that complete injuries to the superficial fi reduction of the valgus instability. If a signifi- fi
MCL in combination with the PCL led to increased cant degree of valgus opening persists after PCL
laxity in internal tibial rotation and significant
fi reconstruction, then medial-sided procedures are
increases in posterior tibial translation (1). They performed. A side-to-side difference
ff of 5–8 mm is
recommended restoration of the MCL in com- associated with signifi ficant structural damage to
bined PCL-MCL injuries to restore normal knee the MCL (6). Avulsions or intra-substance tears of
biomechanics. the MCL may be directly repaired and are best per-
The MCL and medial capsuloligamentous complex formed acutely when the quality of tissue is robust
are the major static stabilizers of the medial side of (3,7–10). Usually, grade III MCL injuries localize
the knee. Dynamic stabilizers include the sartorius, to the femoral side which is confi firmed by mag-
gracilis, semimembranosus, and the medial head
of the gastrocnemius (2). Th The posterior oblique
ligament (POL), a thickening of the deep posterior
capsule in layer two, lies posterior and deep to the
MCL (Fig. 1). As a large fan-shaped structure, the
MCL has fibers under tension at all degrees of knee
flexion. In flexion, the anterior fibers tighten as
the posterior fi
fibers relax.
With the knee in extension, the POL prevents
medial opening with valgus loading. Together, the
MCL and POL resist abnormal external tibial rota-
tion (1,3). The capsule, ACL, POL, medial menis-
cus, and semimembranosus all contribute to valgus
restraint in full extension. Increased medial open-
ing to valgus force in full extension indicates com-
bined MCL and POL damage, and potential injury
to the ACL and PCL. Treatment of residual medial
laxity in combined ligamentous injuries typically
entails advancement of the POL or reattachment
of the avulsed MCL ligament.
Groff
ff and Harner proposed an algorithm for the
treatment of both isolated and combined injuries
to the MCL (4): For grade I and II MCL injuries Fig. 1 – Advancement of the POL is based on the location of the MCL injury
combined with grade III ruptures of the PCL, the and the degree of residual medial laxity present: (A) proximal, (B) mid-
patient completes 4 weeks of rehabilitation before substance, or (C) distal.
422 The Traumatic Knee
Fig. 2 – Coronal T2-weighted magnetic resonance imaging of a patient
with an acute ACL injury shows a grade II proximal MCL tear with associated
mid-substance MCL injury and medial capsular injury with meniscocapsular
junction edema. This injury was subsequently treated with a proximal and
mid-substance posterior oblique ligament advancement.
netic resonance imaging (Fig. 2). They are treated
with POL advancement or graft reconstruction
(3,9,11–14). Furthermore, distal avulsions may
be whip stitched and subsequently reattached (see
Fig. 3 for example of a distal avulsion of the MCL).
Concomitant injuries such as peripheral meniscal
tears, capsular avulsions, and osteochondral inju-
ries are all repaired primarily. We advocate for early
range of motion exercises in patients with com-
bined repairs secondary to the increased risk for
postoperative stiffness.
ff This combined treatment
algorithm subjects the patient to fewer operations,
decreases the concern for late instability, and lim-
its the possibility of postoperative stiffness.
ff
A complete examination of a patient with suspected
PCL/MCL defi ficiency includes a specifi
fic evaluation
for valgus alignment. In chronically PCL-deficient
fi
knees with signifi ficant valgus deformity, bony
realignment via varus high tibial osteotomy should
be performed before any soft tissue procedures.
Soft tissue reconstruction/repair should then be
pursued at least 6 months after the initial osteot-
omy procedure. In the acute setting, osteotomy
may be performed at the same time as soft tissue
procedures or staged to follow the soft tissue pro-
cedure at a later date.
Technique
The patient is brought to the operating room and
is placed supine on the operating table. We prefer
spinal anesthesia but may elect for general endo-
tracheal anesthesia for concomitant ACL or PLC
reconstructions. Following administration of anes-
thesia, a complete physical examination is per-
formed on the injured limb. Th The posterior drawer
and reverse pivot shift tests assess the integrity of
the PCL. Posterolateral stability of the injured knee
should be examined in both 30° and 90° of fl flexion
via the dial and external rotation tests. ACL injury
should be ruled out with the Lachman, anterior
drawer, and pivot shift maneuvers. Th The collateral
ligaments must be assessed with varus and valgus
stress tests in both full extension and 30° of fl flex-
ion. Intraoperative fluoroscopy is utilized to obtain
anteroposterior and lateral images as a reference
point for subsequent tunnel placement. A Foley
catheter is placed. The dorsalis pedis and posterior
tibial pulses are palpated and marked. The patient
is carefully padded and then prepped and draped in
the usual sterile fashion with alcohol and Betadine
solution.
Diagnostic arthroscopy is then initiated with a 30°
arthroscope and followed with a 70° arthroscope.
The ACL is examined to ensure that it is compe-
tent. The medial and lateral compartments as well
as the patellofemoral joint and trochlea are then
examined to evaluate the status of the menisci and
articular cartilage. A full radius resector is then
introduced. Posteromedial corner scar tissue is
meticulously debrided from the posterior aspect of
the knee near the insertion of the PCL. This allows
for assessment of the integrity of the two bundles
that comprise the PCL, and rupture patterns are
identifi
fied. The capsular-tibial junction should be
clearly visualized. A curette is used to bluntly dis-
sect any capsule that may be adhered to the PCL
insertion. We then turn our attention to the tibial
tunnels.
Both 30° and 70° arthroscopes are used through the
anterolateral and accessory posteromedial portals
to triangulate on the tibial insertion site. We pre-
fer double-bundle PCL reconstructions; however, a
single-bundle PCL reconstruction is performed in
the setting of concomitant ACL reconstructions or
PCL augmentation procedures (where only one of
the two PCL bundles is injured). A small incision
is made on the proximal anterolateral tibia. A 30°
arthroscope is placed in the posteromedial portal
to visualize the PCL guide and drill. Th
The tibial foot-
print is carefully dissected to allow positioning of
the PCL guide. With the PCL guide set at 45°, the
anterolateral tibial tunnel is drilled through an
incision on the lateral tibia. We dissect the tibialis
anterior in its fascial sheath from the tibial crest to
allow placement of the PCL guide. The guide tip is
placed at the distal and lateral most aspects of the
tibial footprint. The pin is advanced under direct
arthroscopic visualization (30° scope), and lateral
fluoroscopic x-ray is utilized to confifirm adequate
 Combined injuries to the posterior cruciate ligament and medial collateral ligament of the knee 423
positioning. We advance the K-wire with power
initially and perforate the cortex manually to avoid
injury to posterior neurovascular structures. Th The
posteromedial tibial tunnel is established in a sim-
ilar manner through an anteromedial tibial inci-
sion with the use of a PCL drill guide. Lateral and
anteroposterior fluoroscopy is utilized to confi firm
good positioning. TheTh tunnel is then drilled with
a compaction drill bit. It is initially drilled with
power until the posterior tibial cortex is encoun-
tered, which is perforated by hand. Next, the tun-
nels are dilated to the appropriate diameter.
The femoral tunnels are then prepared. The ante-
Th
rolateral bundle femoral origin is marked at the
1 o'clock position and the posteromedial bundle
femoral position at the 4 o'clock position, both
with an awl. The anterolateral tunnel is located just
off
ff of the articular surface and the meniscofemo-
ral ligament of Wrisberg, if still intact, serves as a
valuable landmark between the two bundle origins.
The anterolateral and posteromedial femoral tun-
Th
nels are then both drilled through the anterolat-
eral portal with the knee flexed
fl to 130° and 110°,
respectively. Drilling of the anterolateral tunnel
is performed first.
fi An acorn reamer is inserted
through the anterolateral portal with the arthro-
scope in the anteromedial portal. It is important
to maintain an adequate bone bridge maintained
between the two tunnels, and the posteromedial
femoral tunnel is then drilled in a similar manner.
The tunnels are then dilated to the appropriate
Th
diameter.
Tibialis anterior allografts are prepared at the
beginning of the case and kept under constant
tension after the free ends are whipstitched with
no. 2 silky Polydek and passed through 45 mm
Endoloops. Under arthroscopic control, the grafts
are passed through the tibial tunnels and then
through the femoral tunnels. Th The anterolateral
component is passed first, followed by the postero-
medial component. An 8-French pediatric feeding
tube is used as a suture shuttle for graft passage.
An incision is made on the distal medial femur, and
a plane beneath the vastus medialis is developed
through blunt dissection. Separate posts are used
to fixate each graft on the medial side of the knee
underneath the vastus medialis. We prefer to use
AO 6.5 cancellous screws with washers to capture
the Endoloops at the end of each respective graft.
The graft is then visualized arthroscopically to con-
Th
firm good graft position and the knee is flexed and
extended to provide tensioning.
After fixation of the femoral components of the
PCL reconstruction, attention is paid to recon-
struction and/or repair of the MCL. Before the
case begins, MRI findings are reviewed in detail
to assess the anatomic location of the MCL injury:
proximal, mid-substance, or distal avulsion (Figs. 2
Fig. 3 – Coronal T2-weighted magnetic resonance imaging of a patient
with an acute ACL rupture shows avulsion of the medial collateral ligament
from its tibial attachment site. Medial capsular injury is also seen along
with likely underlying meniscal capsular injury with extrusion of the medial
meniscus.
and 3). The vast majority of MCL sprains and tears
occur proximally and do well with conservative
management. In the event that residual laxity per-
sists, two options are available for reconstruction:
POL advancement with imbrication of the proxi-
mal MCL or reattachment of the proximal MCL by
whip-stitching the ligament and anchoring it with
either a staple or an AO 6.5 cancellous screw and
soft tissue (spiked) washer.
The POL advancement begins with an 8 cm inci-
sion beginning at the medial epicondyle, and
extending inferiorly and perpendicular to the joint
line with the knee flexed
fl to 90°. The infrapatellar
branch of the saphenous nerve is identified fi and
tagged, and the MCL is then exposed through this
incision. Layer I is initially exposed. It is longitudi-
nally incised at the posterior border of the super-
ficial MCL, which is identifi fied by palpation of the
medial epidcondyle and the posterior aspect of the
proximal medial tibia. The POL is thus exposed as
it lies in continuity with the posterior border of the
superfi ficial MCL, representing a thickening of the
posteromedial capsule of the knee joint. A dissec-
tion is carried forth between the POL and the pos-
terior border of the superficial
fi MCL with Metzen-
baum scissors. The MCL rupture pattern and the
aff
ffected fibers are then identifi fied and correlated
with the MRI findings.
Following debridement of scar tissue, the deep
layer of the MCL is inspected. In the setting of an
avulsion, it can be reattached with Mitek suture
anchors just above or below the joint line. A ron-
geur is used to establish a bleeding, bony surface.
Intraoperative fluoroscopy is used to confi firm extra-
424 The Traumatic Knee
Fig. 4 – Left knee distal MCL avulsion: The MCL is whip-stitched distally
and advanced.
Fig. 6 – Left knee proximal MCL rupture: Horizontal mattress sutures are
placed through the posterior oblique ligament and superficial MCL, begin-
ning at the medial epicondyle.
Fig. 8 – Right knee mid-substance MCL rupture: Sutures are passed posteri-
orly for reattachment of the meniscus to the deep MCL and capsule.
articular placement of anchors. Advancement or
imbrication of the deep MCL is also possible if lax-
ity persists. This can be accomplished with no. 2
silky Polydek utilized in a figure of eight fashion
with the knee flexed
fl to 30°.
Following inspection or repair of the deep MCL, the
proximal origin and distal insertion of the MCL are
evaluated. Distally, avulsions are repaired by whip-
Fig. 5 – Left knee distal MCL avulsion: Fixation is achieved with an AO can-
cellous screw and spiked soft tissue washer.
Fig. 7 – Left knee proximal MCL rupture: Sutures are tied with the knee in
15° of flexion.
Fig. 9 – Right knee mid-substance MCL rupture: Anteriorly, sutures are
passed in a horizontal mattress fashion for subsequent advancement of the
posterior oblique ligament.
stitching the ligament and anchoring with a screw
and soft tissue (spiked) washer. Proximally, fifixa-
tion can be achieved with Mitek suture anchors or
by whip-stitching and anchoring with a screw and
soft tissue (spiked) washer. Proximal laxity within
the ligament may also be treated by POL advance-
ment, as described below (Figs. 6 and 7). In both
instances, fluoroscopy is used to guide placement
 Combined injuries to the posterior cruciate ligament and medial collateral ligament of the knee 425
Fig. 10 – Right knee: Completion of posterior oblique ligament advance-
ment for mid-substance MCL laxity. Note that sutures are placed posteri-
orly for reattachment of the meniscus to the deep MCL. Also note that the
sutures are tied with a bump beneath the thigh with the knee in 15° of
flexion.
of screws and anchors. Th The knee is held at 15° of
flexion with an applied varus force during fixation
of the ligament origin or insertion.
In the setting of a superficial
fi MCL mid-substance
tear, residual laxity is addressed by imbrication of
the MCL and advancement of the POL. It is impor-
tant to remember that recession of the MCL may
partially withdraw a normal meniscus from the
medial compartment, and this must be addressed.
After the interval between the POL and the poste-
rior border of the superfificial MCL is developed, the
meniscus is detached from the deep MCL and cap-
sule. It is subsequently repaired to the capsule and
deep MCL once the extent of the POL advancement
is determined (Fig. 8). Th The POL is then advanced
onto the posterior border of the superficial fi MCL
with no. 2 Tycron sutures in a horizontal mat-
tress fashion (Figs. 9 and 10). The
Th medial meniscus
should be carefully examined and any tearing at its
attachment to the POL should also be repaired. The Th
knee is then extended and flexed from 0° to 100°
to ensure that there is stability of the MCL at its
repair site without a residual fl flexion contracture
(Fig. 11).
The tibial portion of the anterolateral graft is then
Th
secured over an AO 4.5 mm bicortical screw and
washer with the knee flexed at 90°, with an ante-
rior drawer force applied. The knee is then brought
to 30° of flexion and the posteromedial component
is tensioned over a separate AO 4.5 mm bicortical
screw and washer, as an anterior drawer force is
again applied to the tibia. The grafts are visualized
arthroscopically and knee range of motion and
stability are reexamined. Th The dorsalis pedis pulse
is palpated. With the knee at 30° of flexion
fl and
an anterior drawer force applied, the wounds are
thoroughly irrigated with antibiotic solution and
closed with Vicryl followed by a running subcu-
ticular stitch. Portals are closed with interrupted
Fig. 11 – Right knee: Full extension achieved following advancement of
the posterior oblique ligament for a mid-substance MCL rupture.
nylon stitches. A Hemovac drain is placed with an
exit point superior to the medial incision. A stan-
dard sterile surgical dressing is applied along with
a brace locked with the knee in full extension. A
soft bolus is placed behind the calf. Distal pulses
are checked, and the patient is transferred to the
postanesthetic recovery room.
Complications
Intraoperative complications of PCL surgery entail
a unique spectrum of injuries, the most serious
of which include compartment syndrome and
neurovascular injuries. Neurovascular injuries,
fically popliteal artery injuries, are relatively
specifi
unique to PCL surgery due to the proximity of the
popliteal artery. The
Th posteromedial portal is thus
crucial to safe arthroscopic reconstruction of the
PCL. It allows for adequate visualization and pro-
tection of neurovascular structures, and it helps to
reduce the risk of compartment syndrome by act-
ing as an outflflow portal.
Symptomatic hardware and postoperative syno-
vitis may contribute to symptoms of knee pain.
Other potential intraoperative complications
include medial femoral condyle osteonecrosis
and tibial fracture. Motion loss for PCL recon-
struction typically occurs in flexion
fl versus exten-
sion. Suprapatellar adhesions are one of the main
causes and treatment may include manipulation or
arthroscopic lysis of adhesions.
Patients with residual laxity may present with ante-
rior knee pain as a result of increased patellofemo-
ral forces secondary to posterior sag. Furthermore,
it is not uncommon for PCL reconstructions to
gradually loosen to grade I or II laxity. Th
The reasons
for this are multifactorial: malalignment, missed
concomitant injuries, and technical errors have all
been implicated. While most patients can endure
some degree of residual laxity, PCL-reconstructed
426 The Traumatic Knee
knees with grade III instability are considered fail-
ures and need to be revised.
Rehabilitation
Patients with grade I and II MCL tears, in conjunc-
tion with PCL tears, are treated initially with tem-
porary immobilization and protected weight bear-
ing with crutches. Weight bearing with the knee
locked in extension is encouraged as pain subsides.
Isokinetic, isotonic, and isometric strengthening
regimens are subsequently implemented. Crutches
are continued until the patient walks without a
limp. Grade I MCL injuries typically heal within
2 weeks, while grade II MCL injuries take slightly
more time, at 3–4 weeks. Following resolution
of the MCL injury, defi finitive management of the
residual PCL injury is then addressed.
Patients with grade III PCL injuries and residual
MCL laxity are usually treated operatively. A hinged
brace is locked in full extension for 4 weeks postop-
eratively and crutches are utilized for ambulation
for 12 weeks (as opposed to 8 weeks for isolated
PCL reconstruction.). The brace is only unlocked
for range of motion exercises such as heel slides. A
physiotherapist should provide an anterior drawer
force to the proximal tibia to prevent posterior tibial
sag while the patient performs their exercises. Fur-
thermore, valgus loads are avoided to protect the
MCL reconstruction. Quadriceps sets, straight leg
raises, and wall slides are the core exercises during
the first 2–3 months of therapy. Hamstring exer-
cises are generally avoided as they risk stressing
the PCL reconstruction. Range of motion is limited
to 90° of flexion during the first 2–3 postoperative
months. Gait training begins at 4–6 weeks with the
brace unlocked. Pool therapy is a useful adjunct.
The crutches and brace are discontinued when the
patient exhibits good quadriceps strength and con-
trol, full knee extension, knee flexion of 90–100°,
and a normal gait pattern. This typically occurs
between 2 and 3 months postoperatively. Dur-
ing this time period, wall slides are progressed to
minisquats (0–45°), stationary cycling is added,
and balance and proprioception exercises such as
single leg stances are introduced. Jogging in the
pool and walking on the treadmill are begun from
3 to 9 months postoperatively. Functional strength
and proprioception are improved throughout this
period through the continuation of closed-chain
kinetic exercises. Quadriceps strength and ham-
string flexibility are maximized and maintained
and running, cutting, jumping, and plyomet-
ric exercises are gradually initiated. The
Th patient
should achieve full pain-free range of motion, nor-
mal gait, and good quadriceps strength and should
have no patellofemoral complaints by 12 months
after surgery. The ultimate goals include athletic
participation and/or return to work, and this may
involve sports-specifi
fic training or job restructur-
ing as needed.
References
1. Ritchie JR, Bergfeld JA, Kambic H, et al. (1998) Isolated
sectioning of the medial and posteromedial capsular liga-
ments in the posterior cruciate ligament-deficient
fi knee.
Infl
fluence on posterior tibial translation. Am J Sports Med
26(3):389–394
2. Warren LA, Marshall JL, Girgis F (1974) The Th prime static
stabilizer of the medical side of the knee. J Bone Joint
Surg Am 56(4):665–674
3. Jacobson KE, Chi FS (2006) Evaluation and treatment of
medial collateral ligament and medial-sided injuries of the
knee. Sports Med Arthrosc 14(2):58–66
4. Groffff YJ, Harner CD (2003) Medial collateral ligament
reconstruction. In: Jackson DW, editor. Reconstructive
knee surgery. 2nd ed. Philadelphia, PA: Lippincott Wil-
liams & Wilkins.
5. Grood ES, Noyes FR, Butler DL, et al. (1981) Ligamentous
and capsular restraints preventing straight medial and
lateral laxity in intact human cadaver knees. J Bone Joint
Surg Am 63(8):1257–1269
6. Hillard-Sembell D, Daniel DM, Stone ML, et al. (1996)
Combined injuries of the anterior cruciate and medial
collateral ligaments of the knee. Effect
ff of treatment on
stability and function of the joint. J Bone Joint Surg Am
78(2):169–176
7. Indelicato PA (1995) Isolated medial collateral ligament
injuries in the knee. J Am Acad Orthop Surg 3(1):9–14
8. Indelicato PA (1995) The importance of the posterior
oblique ligament in repairs of acute tears of the medial lig-
aments in knees with and without an associated rupture
of the anterior cruciate ligament. Results of long-term
follow-up. J Bone Joint Surg Am 77(6):969
9. Sims WF, Jacobson KE (2004) The posteromedial corner
of the knee: medial-sided injury patterns revisited. Am J
Sports Med 32(2):337–345.
10. Woo SL, Vogrin TM, Abramowitch SD (2002) Healing and
repair of ligament injuries in the knee. J Am Acad Orthop
Surg 8(6):364–372
11. Hughston JC (1994) Th The importance of the posterior
oblique ligament in repairs of acute tears of the medial lig-
aments in knees with and without an associated rupture
of the anterior cruciate ligament. Results of long-term
follow-up. J Bone Joint Surg Am 76(9):1328–1344.
12. Hughston JC, Barrett GR (1983) Acute anteromedial rota-
tory instability. Long-term results of surgical repair. J
Bone Joint Surg Am 65(2):145–153
13. Hughston JC, Eilers AF (1973) The Th role of the posterior
oblique ligament in repairs of acute medial (collateral) lig-
ament tears of the knee. J Bone Joint Surg Am 55(5):923–
940
14. Hughston JC, et al. (1976) Classifi fication of knee ligament
instabilities. Part I. The medial compartment and cruciate
ligaments. J Bone Joint Surg Am 58(2):159–172.

K. Corten, J. Bellemans PCL injury associated with
a posterolateral tear
General considerations
Natural history
F
ifty percent to 90% of posterior cruciate liga-
ment (PCL) injuries are combined with inju-
ries to other structures in the knee (1,2). In
vitro studies have shown that the posterolateral
corner structures (PLSs) and the cruciate liga-
ments have a very close load-sharing relationship
which contributes to the intriguing biomechanical
behavior of the knee joint (1,3,4). Concomitant
injuries of both structures are therefore not infre-
quent with 60% of patients with a PCL injury being
reported to have a PLS lesion (1).
There is little information on the long-term natu-
Th
ral history of non-operatively treated PLS injuries.
Isolated PLS lesions are rare with only account-
ing for 1.6–8% of acute ligamentous knee injuries
(5,6). Misdiagnosing this injury can have far-reach-
ing consequences for the integrity and functional-
ity of the knee joint. Untreated grade III PLS tears
do not heal (7) and early (<2–3 weeks) treatment
has a trend toward better outcome than late recon-
structions (8–10). It has also been shown that the
incidence of cruciate ligament injury increases in
the presence of a residual posterolateral rotatory
instability (PLRI) (3,6). High PCL graft forces have
been detected in PLS defificient knees (1,4,8,11–14),
and consequently a high number of patients have
a history of repeated cruciate ligament surgery for
failure of the graft (15,16). In addition, it has been
documented that PLS reconstructions restore PCL
graft force levels to normal (13,17).
Depending on the severity of the PLS lesion, the
biomechanical integrity of the knee becomes more
or less distorted. This might lead to an overload of
the cartilage and subsequent accelerated cartilage
degeneration (7,18). Kannus et al. demonstrated
that 6 out of 12 patients with a non-operated grade
III PLS injury developed secondary osteoarthritis
at an average interval of 8 years (19). Combined
PCL and PLS injuries are particularly debilitating,
since the restraints to both posterior tibial transla-
tion and external tibial rotation are compromised
Chapter 37
(1). In the PCL-defi ficient knee, the rotational axis
shifts toward the posteromedial compartment in
90° of flexion. In combined lesions, this shift is
more pronounced, even in lower degrees of knee
flexion. Subsequently, higher loads are acting on
the medial cartilage (20). Th These experimental data
were confi firmed by arthroscopic findings identify-
ing a signifificantly higher amount of medial femo-
ral cartilage degeneration in combined PCL- and
PLS-defificient knees (60.6%) than in those with
an isolated injury (36.6%). Th The patellofemoral
compartment was the second most common com-
partment involved in cartilage degeneration (18).
This was consistent with Skyhar’s experimental
findings of increased patellofemoral contact pres-
sures in combined PCL- and PLS-deficient fi knees
(20). Cartilage degeneration in combined injuries
is more progressive than in isolated PCL injuries
(18,21). Varus alignment can develop over time,
and the posterolateral restraints become more lax
leading to a so-called double varus deformity. As
this malalignment becomes even more chronic,
excessive lateral stress may lead to a hyperexten-
sion-recurvatum deformity, which is frequently
referred to as “triple varus” deformity (22).
Biomechanics and etiology
It is well established that the PCL and the PLS work
synergistically to limit both posterior tibial trans-
lation and external tibial rotation. Combined sec-
tioning of both structures results in signifificantly
increased laxity compared with sectioning of either
structure alone (14). Hughston described the term
PLRI to describe the posterior subluxation of the
lateral tibial plateau that can occur with an exter-
nal tibial rotation torque in knees with pathologic
posterolateral laxity (22).
Several anatomical studies have meticulously
described the complex anatomy of the PLS. Based
on the currently available biomechanical data,
the PLS can be divided into three main stabiliz-
ing parts: the lateral collateral ligament (LCL), the
popliteus muscle-tendon unit (PMTU), and the
posterolateral capsule. The two most important
428 The Traumatic Knee
stabilizing structures of the PMTU are the popli-
teus tendon (PT) and the popliteofi fibular ligament
(PFL) (1,3,14,23). The
Th LCL and PMTU function as a
unit to resist lateral joint opening and external tib-
ial rotation with a reciprocal interaction depending
on the degree of knee flexion (3,24).
Road traffiffic accidents (pedestrians) (73%), falls
from height (2%), work-related (4%) accidents,
and contact-sports injuries (21%) are the most
common causes of PLS injuries (16,25). Varus, val-
gus, hyperextension, and external rotation forces,
as well as the position of the knee during trauma,
determine the extent and type of damage. Th The most
typical injury mechanism is a direct varus force to
the anteromedial aspect of the hyper-extended
knee (25,26). This is typically seen in contact sports
like rugby, American football and soccer. A tackle
can cause a direct blow to the inner aspect of the
thigh with the tibia in external rotation, or it can
cause a sudden hyperextension of the knee with
the fixed tibia internally rotated, thereby injur-
ing the anterior cruciate ligament (ACL) (27,28).
PLS injuries can also be the result of an external
rotation torque and varus moment with the knee
in variable amounts of flexion, like in skiing when
the ski bindings fail to release (24,27,28). A clear
pattern of injury was demonstrated in a cadaveric
study simulating an external rotational injury in
30° flexion. All specimens sustained a combined
ACL and LCL injury and none sustained a PCL
disruption. In four specimens, the PT was injured
or the fibular head was fractured, rendering the
PMTU incompetent (29).
Clinical findings
Obtaining a clear insight in the exact trauma
mechanism will help to gain a high level of suspi-
cion for PLS injury. Patients with an acute isolated
PLS injury usually have pain in the posterolateral
aspect of the knee. Sportsmen may not remember
the mechanism, or even a specific fi incident, and
may have been able to continue playing, albeit with
an odd sensation of hyperextension when stand-
ing. Neurological symptoms indicating a common
peroneal nerve injury can be found in as high as
13–16% of cases (9).
Patients with chronic PLRI may present with
medial and (postero-)lateral joint-line tenderness
(15). Patients can have functional instability with
the knee giving way into hyperextension during
activities such as ascending and descending stairs.
Instability during twisting, pivoting, or cutting
manoeuvres may be present as well (15). A high
index of suspicion for PLRI should be present in
cases of failed cruciate ligament reconstructions
(3,16).
In the acutely injured knee, the posterolateral
aspect should be examined for edema, ecchymosis,
and induration. These patients can have diff ffuse
posterolateral tenderness with point tenderness
localized over the fibular head (arcuate fracture) or
at the lateral joint line (Segond fracture). Abrasion,
laceration, or ecchymosis in the region of the tibial
tubercle should raise the suspicion of concurrent
injury of the PCL. Th The same findings at the medial
side of the leg may be indicative of a significant
fi
varus moment on the knee joint. Absence of an
eff
ffusion should alert the clinician to the possibility
of rupture of the capsule.
Patients with a suspected PLRI should be care-
fully observed for limb alignment. An abnormal
gait pattern characterized by a (hyperextension)
varus thrust or increased knee flexion during the
stance phase may be present. Some patients with
a marked PLS lesion may present with a voluntary
posterolateral drawer sign (15).
We find the dial test, the external rotation recurva-
tum test, and the varus stress test to be the most
reproducible tests in patients with PLRI. Other
tests are the posterolateral and posterior drawer
test and the reverse pivot shift test. As for other
authors, we find
fi the dial test to be the most useful
test. We conduct this test in the prone position in
order to prevent the tibia from posterior sagging.
The test can be falsely negative, even in combined
injuries (30). We therefore agree with Noyes (31)
that not only the increased external rotation but
also the final position of the posteriorly sublux-
ated lateral tibial plateau should be part of the
diagnostic criteria in evaluating PLRI. The
Th dial test
can be falsely positive in grade 3 medial collateral
ligament injuries, since this can cause excessive
external rotation due to anterior translation of the
medial tibial plateau (32). Therefore,
Th it is recom-
mended to conduct a valgus stress test at 0° and
30° of knee flexion following a positive dial test.
Technical investigations
Acute PLS injuries are often accompanied by
osseous injuries, which might be appreciable on
standard AP and lateral radiographs of the knee.
In chronic cases, a standing full leg radiograph is
obligatory in order to evaluate the alignment.
The arcuate sign is an avulsion fracture of the prox-
imal fibula at the attachment site of the PLS. It is
believed to be pathognomonic of PLS injury and is
highly suggestive for a concomitant PCL rupture
(28). The features of the arcuate sign can diff ffer
with regard to the specifific site of injury (28,33). It
can also be visible as fibular head edema on mag-
netic resonance imaging (MRI) (28). Th The presence
of a Segond fracture is indicative of an ACL rupture

Fig. 1 – MRI demonstrating intact iliotibial tract (left),
t intact LCL (middle), and torn popliteus muscle-tendon unit (PMTU).
but can also occur in association with PLS injuries
(34). The iliotibial band (ITB) can avulse from its
tibial insertion. Distinguishing this injury from the
Segond fracture may be difficult
ffi on XR, but MRI
helps to depict the origin of these avulsive injuries
(35). An anterior rim tibial plateau fracture can
also be an indicator of PLS injury (35).
MRI scan is very helpful in most cases (Fig. 1). It
is extremely important to inspect the PLS when-
ever a PCL rupture is detected on MRI. Most of the
structures of the posterolateral corner are shown
well on standard MRI planes, except for the PFL
which is best seen on coronal oblique imaging (34).
Several studies have indicated very high accuracy
rates (up to 100%) for MRI in the diagnosis of LCL
and biceps femoris tendon tears (28,36). MRI may
demonstrate an abnormal signal about the per-
oneal nerve as well, indicating nerve damage (6).
Arthroscopic findings
Capsular ruptures may cause extravasation of
fluid into the fascial compartments of the leg, and
therefore arthroscopy should be delayed for at
least 2 weeks following the acute injury.
Several arthroscopic signs are indicative for a PLS
lesion. An increased amount of lateral joint laxity
can be appreciated arthroscopically as the so-called
drive-through sign (10,37). Direct visualization of
the injury of the PT is sometimes possible, but
more often, reduced tightness of the tendon in the
lateral gutter can been seen (38) (Fig. 2). Th
The popli-
teomeniscal fascicles and the coronary ligament to
the posterior aspect of the lateral meniscus may be
damaged. Other lesions include the meniscofemo-
Fig. 2 – Arthroscopic view of a torn popliteus tendon in a right knee.
PCL injury associated with a posterolateral tear 429
ral and meniscotibial portions of the mid-third lat-
eral capsular ligament (9). Th
The PFL can sometimes
be identifi
fied as vertically oriented fibres descend-
ing from the inferior surface of the PT underneath
the lateral meniscus (39).
Surgical approach to the posterolateral corner
In combined PCL-PLS injuries, we always start with
the PCL reconstruction, followed by repair or recon-
struction of the PLS. A skin bridge of 7 cm between
both incisions should always be preserved (40).
We refer the reader to the previous chapters for the
technical description of PCL reconstruction.
In order to address the PLS, the patient is placed in the
supine position with a tourniquet on the thigh and
a small bump under the ipsilateral buttock. The Th PLS
is best exposed with the knee flexed to 90°, allowing
for relaxation and protection of the peroneal nerve.
The lateral epicondyle is palpated and marked along
with the fibular head and Gerdy’s tubercle.
A curvilinear incision is made approximately 5 cm
proximal and just posterior to the lateral femoral
epicondyle and extending just distal to the point
between the fibular head and Gerdy’s tubercle.
Anterior and posterior skin flaps are raised to
expose the iliotibial tract (ITB), the posterior aspect
of biceps femoris muscle, and the fi fibular head.
Before dissecting the deep portions of the PLS, one
should always first
fi isolate the peroneal nerve. The
nerve is most easily visualized proximally, just pos-
terior to the muscle belly of the biceps femoris (41).
The nerve is overlapped by the medial margin of the
biceps femoris tendon, and ends superfi ficially at the
fibular head (42). Once the nerve is identifi fied and
liberated, it should be protected with a vessel loop
or a Penrose drain during the whole procedure.
Option 1: The two-step deep dissection
First, the interval between the biceps femoris and
the posterior aspect of the ITB can be bluntly devel-
oped. Subsequently, the plane between the lateral
head of the gastrocnemius and the popliteus mus-
cle and the posterior capsule is dissected. Start this
430 The Traumatic Knee
dissection distally. A meniscus repair retractor can
be placed anterior to the gastrocnemius tendon in
order to provide a clear view of the posterolateral
tibial plateau and the musculotendinous junction
of the popliteus, approximately 10 mm distal to
the margin of the articular cartilage (8).
Next, a 4–5 cm incision is made along the midpor-
tion of the ITB over the lateral femoral epicondyle
down to the popliteus sulcus. This
Th allows for visu-
alization of the remnants of the LCL and PT, which
will allow for proper identification
fi of the femoral
isometric point (FIP).
In case a fibular tunnel needs to be created, the
anterior and posterior borders of the fibular
fi head
can be exposed sub-periosteally using a combina-
tion of electrocautery and a periosteal elevator.
We find this two-step dissection of the deep PLS to
be suffi
fficient and easy to conduct when the poste-
rolateral sling procedure is conducted.
Option 2: The three-step deep dissection
As a first step, the musculotendinous junction of
the popliteus muscle and the PFL attachment site
on the posteromedial downslope of the fibular sty-
loid is identifi
fied.
Through the interval between the peroneal nerve
and the long head of the biceps, the interval ante-
rior to the lateral gastrocnemius and posterior to the
popliteus muscle is created by blunt dissection. This
Th
allows access to the posteromedial aspect of the fi
fibu-
lar styloid and the posterolateral aspect of the tibia.
As the second step, the attachment site of the LCL
on the fibular head is identifified.
A 2-cm horizontal incision through the anterior
arm of the long head of the biceps femoris is made
1 cm proximal to the lateral aspect of the fi fibular
head. This opens the bursa between the LCL and
the biceps tendon. TheTh attachment site of the LCL
on the anterolateral aspect of the fifibular head can
be identifi
fied through this bursa.
As the third step, the femoral attachment sites of
the LCL and PT are identifi fied.
Therefore, an incision, approximately 10-cm long,
is made horizontally through the ITB. This
Th incision
originates distally from just proximal to Gerdy’s
tubercle and extends proximally to the distal termi-
nation of the lateral intermuscular septum. Anterior
and posterior retraction of the ITB allows for identi-
fication of the LCL and PT femoral attachments.
fi
In order to expose the femoral attachment site of the
PT, a vertical arthrotomy approximately 1 cm anterior
to the normal course of the LCL needs to be made.
Option 3: Osteotomy of Gerdy’s tubercle
An osteotomy of Gerdy’s tubercle has been
described (43). The rationale of this exposure is
that the deep PLS can be clearly addressed by
retracting the ITB together with its tubercle of
insertion upward to its attachment on the femoral
condyle. This approach might be helpful in revision
cases in order to obtain a good view of the severely
distorted posterolateral anatomy.
Acute PCL + posterolateral corner injury
If possible, surgical repair within 3 weeks of injury
has been reported to obtain the best chance of a
good outcome (10,15,34). Identification
fi of the
individual structures becomes more difficult
ffi after
3 weeks due to the development of scar tissue and
tissue retraction. Once the patient has presented at
the clinic, we aim for reestablishing 0–90° of knee
motion and early isometric muscle function, while
observing the swelling and skin condition, and
preferably aim to conduct the procedure within the
first 3 weeks after the injury.
The LCL is one of the commonest structures of the
PLS to be injured (25,34,44). Proximal LCL injuries
are commonly associated with PT avulsions. Distal
LCL injuries are usually (71% of cases) combined
with distal biceps tendon avulsions and menisco-
capsular avulsions from the tibia. ThThe LCL is most
frequently injured at its distal insertion (25).
In the acute phase, we plan to perform a single stage
combined open PCL reconstruction as well as imme-
diate posterolateral corner repair or reconstruction.
The debate remains whether repair is better than
reconstruction or vice versa and this decision is
not always easy to make. Acute disruptions of the
PLS are often extensive and therefore not always
amendable for suture repairs only. Stannard
reported high failure rates (34%) in patients who
had an acute primary repair (45). We agree with
Noyes (44) that very often at least 1 component
of the PLS needs to be considered for graft recon-
struction or augmentation.
The LCL is most frequently disrupted to an extent
that primary suture repair would be expected to
have a high failure rate. Mid-substance tears can
sometimes be treated by suturing and augmenta-
tion of the LCL with a strip from the biceps tendon
or the ITB (25,46). In case the LCL is not repair-
able, we use the anterior part of the biceps tendon
for reconstruction.
In case the PMTU appears to be torn as well, we
conduct a Larson type reconstruction.
The posterolateral corner sling procedure (47) is
used in cases of acute mid-substance tears of the
PMTU which are not repairable.
The capsular shift as described by Hughston (2) is
our preferred capsular tightening procedure in the
rare case, where the PLS is only stretched and not
completely torn.
 PCL injury associated with a posterolateral tear 431

Large avulsion fractures of the fibular

fi head can
be fixed using a long 3.5 mm cortical screw with a
washer. The screw can be fixed longitudinally into
the fibular shaft. In smaller bony avulsions, we pre-
fer reattachment with suture anchors or soft tissue
screws with washers (40).
Acutely injured and dislocated knees have an
increased risk for complications, especially reduced
range of motion, arthrofibrosis,
fi and heterotopic
bone formation (44,48,49).
The same rehabilitation protocol is used as in the
Th
chronic reconstructed cases.
Chronic PCL + posterolateral rotatory instability
In chronic lesions, several options are available as
augmentation or formal reconstruction.
One of the more popular augmentation tech-
niques is Clancy’s biceps tenodesis procedure
(50). The goal of this procedure is to augment the
PLS by transferring the biceps tendon to the ante-
rior aspect of the lateral epicondyle with its distal
attachment to the fibula left intact. The tendon is
fixed to the femur with a screw and washer. Clancy
reported good results in 77% of 39 patients,
with 54% returning to their previous sporting
levels (51). We do not use this technique. First,
the dynamic stabilizing effect
ff of the biceps ten-
don is sacrifi
ficed. Furthermore, this technique is
very difficult
ffi to duplicate because of the extreme
length of the biceps tendon required to displace
the intact biceps over the femoral screw. Overcon-
straining the lateral aspect of the knee has been
documented in up to 71% of cases (52). This
Th over-
correction is not always without consequences
since loss of terminal flexion and biceps tendon
ruptures have been documented. In Kim’s series
in total 8 of 52 knees (17%) had a correction loss
of more than 5° at an average follow-up of 1 year
(42). Also, the biceps tendon complex should be
intact which is often not the case in patients with
PLRI.

injury

LCL PMTU

Midsubstance tear Direct repair Stretch injury: Complete injury

if possible Hughston shift

Stretch-partial injury: Isolated injury:

Biceps split augmentation Posterolateral sling

Complete tear If + LCL tear:

Larson reconstruction

Isolated: + PMTU tear:

Anatomic Reconstruction Larson reconstruction

Fibular avulsion
+ biceps avulsion?

Small bony fragment:

anchor or screw + washer

Large bony fragment:

Long 3.5 mm cortical screw

Femoral avulsion
+ PT avulsion?

Direct repair:
anchor or screw
432 The Traumatic Knee
For these reasons, formal reconstruction of the
posterolateral complex is therefore today more
commonly advocated than augmentation.
At present, there is no clear and evidence-based
consensus about which reconstructive procedure
is the best to conduct. Few scientifi
fic data currently
exist to provide definitive
fi and clear-cut recom-
mendations. In this section, we describe the recon-
structive options currently used by the authors.
Our current routine is to start the procedure with
an arthroscopically assisted double-bundle PCL
reconstruction with subsequent reconstruction of
the posterolateral corner.
In the rare case where the PMTU is left intact and
only the LCL needs reconstruction, we use the
anterior part of the biceps tendon.
Larson technique
In case the PMTU is damaged and demonstrates
moderate laxity, the technique described by Lar-
son is used (40). This technique attempts to recon-
struct the LCL (the anterior limb of the reconstruc-
tion) and also the PFL (the posterior limb of the
reconstruction) (40). TheTh authors find this tech-
nique reliable and relatively easy to conduct. We
prefer using this technique in cases of doubt about
the integrity of the PMTU in combination with an
LCL tear. The technique is based on the relative
isometry of the ligaments on the lateral side of the
knee. The anterior aspect of the fibular head has
an isometric relationship with the posterior aspect
of the lateral femoral epicondyle. The
Th same is true
for the posterior aspect of the fibular
fi head and the
anterior aspect of the epicondyle (53).
In this technique, the FIP is identifified equidistant
between the femoral insertion of the LCL and PT. A
tunnel is drilled at this point as well as through the
Chronic PCL + posterolateral rotatory
instability
LCL
Isolated injury:
Split biceps tendon
Increased PMTU laxity:
Larson reconstruction
fibular head. A tendon allograft is pulled through
the fibular tunnel. The anterior limb of the recon-
struction is then passed underneath the ITB and
is attached in the anterior aspect of the femoral
tunnel. The second limb of the reconstruction runs
from the posterior aspect of the fibular
fi head to the
anterior aspect of the femoral tunnel. The poste-
rior limb is passed underneath the biceps femoris,
the ITB and the anterior limb. Both limbs are fixed
fi
with an interference screw in a figure-of-eight
fashion, leaving the posterior limb longer.
Posterolateral sling technique (Fig. 3)
Albright reported on the posterolateral corner
sling procedure (47). ThThis procedure involves the
creation of an extra-articular sling that extends
from the posterolateral tibia to the FIP. We have
used this procedure with good success for 12 years
now and have found this technique to be reproduc-
ible and reliable.
A tibial tunnel is created just distal and medial to
Gerdy’s tubercle. The guide pin should exit where
the PT traverses the back of the tibia approximately
10 mm distal to the joint line and 2 cm medial to
the lateral tibial condyle. This
Th can be accomplished
by a free-hand technique or using an ACL guide. A
femoral guide wire is then placed at a point midway
between the femoral attachment of the LCL and
the PT. The isometry is tested using a pliable wire
which is pulled trough the tibial tunnel and fi fixed
to the femoral guide wire. The femoral guide wire is
replaced until there is minimal change of length of
the pliable wire during a full range of motion, indi-
cating isometry. The allograft is pulled trough the
tibial tunnel from posterior to anterior. Next, the
allograft is fi
fixed with an interference screw in the
femoral tunnel. The graft should be passed deep
PMTU
LCL intact:
Posterolateral sling
LCL torn:
Split biceps tendon +
Posterolateral sling

to the LCL, the ITB, and the anterior arm of the
long head of the biceps femoris. The graft is fixed
on the tibia with an interference screw and a staple
with the knee held in 90° of flexion, slight valgus,
and 10° of internal rotation. Finally, the graft is
sutured over the remnants of the PFL and the pos-
terolateral knee capsule.
Unanswered issues
Two-tailed versus single-tailed PMTU reconstructions?
The 3D in vitro kinematic evaluations conducted
by Nau clearly identifiedfi that two-tailed recon-
struction techniques aiming to reconstruct both
the PT and PFL were associated with significant fi
internal rotation of the tibia during the entire path
of motion. This was not seen in single-tailed PFL or
PT reconstruction techniques (54,55).
Theoretically, if the axis of rotation of the tibia rel-
ative to the femur is considered to be near the PCL
tibial attachment site, the graft attached to the
posterior fibular head has a biomechanical advan-
tages compared with when the graft is attached
to the posterolateral tibia, since the lever arm of
the former is approximately 50% greater than that
of the latter (56). Hence, a PFL graft should be
more effffective in controlling varus rotation than
a posterolateral sling graft. This
Th was, however, not
observed in Markolf’s study in which equivalent
PCL graft forces and varus rotations were noted
for both reconstructions (13).
Laprade evaluated a combined LCL and PMTU
anatomic sited reconstruction technique. With the
applied varus moment, he observed some commi-
nution of the fibular styloid which caused loosen-
ing of the fixation of the LCL graft (8). In another
study, combined LCL and PMTU reconstructions
pulled the tibia into a signifi ficant valgus align-
ment and the tibia internally rotated when a varus
moment was applied. ThisTh was, however, not seen
in isolated LCL reconstructions (13).
Isometry
The authors believe that identifi
fication of true isom-
etry on the lateral side of the knee is not possible
(57). Therefore, one should aim for identifi fication
of the most isometric point. We always start at the
midpoint between the LCL and PT insertion site.
A pliable wire running through the tibial tunnel is
bend around a guide wire which is inserted at the
suspected FIP. If the wire length increases more than
2 mm during knee flexion, the guide wire should be
PCL injury associated with a posterolateral tear 433
corrected to a more posterior position. If it shortens
more than 2 mm, the guide wire should be corrected
to a more anterior position. Others have found the
FIP to be situated at the intersection of Blumen-
saat’s line and the extension of the posterior femo-
ral cortex on a lateral XR (58). Identification
fi of the
FIP should be performed with the same tibial rota-
tion as during tensioning and fixating of the graft.
Rehabilitation
The estimated peak external rotation moment for
the PMTU (105 N) and the LCL (168 N) during gait
is lower than the failure strength of most recon-
struction grafts (24,59). Furthermore, dynamic
rehabilitation can be protective, since muscle loads
of the hamstrings and quadriceps provide dynamic
stability and reduce loads in the PCL graft (60,61).
Some authors allow for early limited motion, along
with adequate protection against varus and hyper-
extension (25). Passive range of motion should be
performed in the prone position in order to pre-
vent posterior sagging of the tibia (16,25).
Isometric quadriceps exercises should be started
immediately (56). Hamstring exercises are initially
not allowed in order to prevent early overloading
of the reconstruction (16,25).
Some authors allow immediate full weight bearing
with a locked knee brace (27). Others wait several
weeks before full weight bearing is initiated, usu-
ally in the third postoperative month (10,16,25).
In our protocol, only partial weight bearing using
two crutches is allowed during the first
fi 4 weeks.
Isometric quadriceps strengthening exercises
are initiated at the second postoperative day. A
hinged brace is fixed
fi in 15° of flexion for 4 weeks.
The brace is loosened for flexion from week 5, and
weight bearing is gradually increased to full weight
bearing at week 8. Th The brace remains locked at
−15° of extension until 8 weeks postoperatively.
Closed-chain kinetic exercises are initiated once
full weight bearing is allowed.
Walking and swimming is permitted after 3 months.
Non-contact sports are allowed after 6 months and
contact sports after 9 months at the earliest. Con-
tact sports are allowed once the side-to-side differ-
ff
ence in isometric strength of the quadriceps and
hamstrings is less than 15% with Cybex testing.
Published results
Albright et al. published their results on the poste-
rolateral corner sling procedure, which eliminated
in 87% of patients the reverse pivot-shift, hyperex-
434 The Traumatic Knee

Fig. 3 – Posterolateral sling procedure (right knee). (A–E) Creation of the

tibial tunnel (see text paragraph 3). (F–H) Creation of the femoral tunnel
just anterior to the lateral epicondyle. (I, J) Isometry testing using a metal
wire. (K, L) Introduction of the graft through the tibial tunnel, underneath
the ITB, and into the femoral tunnel. (M–O) Fixation on the femoral side
using an interference screw, on the tibial side with a staple, while the knee
is held in flexion and the tibia in endorotation.
PCL injury associated with a posterolateral tear 435
436 The Traumatic Knee
tension, and varus laxity (47). In our own depart-
ment, 27 patients were evaluated 39 months fol-
lowing the posterolateral corner sling procedure
in combination with one or both cruciate recon-
structions. Our initial results are comparable
with those of Albright at short-term follow-up
(62). We were, however, able to reevaluate 21 of
27 patients 48 months later. At that time, 66% of
patients demonstrated a significantfi deterioration
in their functional score as compared with 4 years
earlier. All of these patients had cartilage damage
at the time of defi finitive surgery. Those patients
without chondrosis preserved their functionality
level. There are two potential explanations for this
finding. First, the posterolateral corner sling pro-
cedure may not be adequate enough to restore the
normal kinematics of the knee. Second, patients
with cartilage damage at the time of surgery might
represent a diff fferent group of pathologies from
those without chondrosis, and this might be an
indication that we need to approach both groups
diff
fferently (62). Further research is therefore war-
ranted. Yoon retrospectively compared the poster-
olateral sling procedure (25 patients at 39 months)
with an anatomical two-tailed reconstruction of
the PMTU and LCL (21 patients at 22 months).
Signifificantly more patients in the sling group had
residual increased tibial external rotation (12%
vs. 5% of patients) and varus rotation (28% vs.
14% of patients). Twenty-four percent of the sling
patients needed additional LCL advancement (10).
The question remains whether this advancement
was sufficient.
ffi
Khanduja presented the results of 19 patients
with a Larson-type procedure in combination
with a single-bundle PCL reconstruction (mean
66.8 months). Ninety-five fi percent of patients
regained normal to nearly normal posterolateral
stability. All patients were satisfiedfi with the out-
come and 68% were able to return to their pre-
injury activity level. However, 32% of patients
continued to experience minimal instability (27).
Strobel evaluated 17 patients with chronic cruciate
reconstructions in combination with an isomet-
ric LCL and PFL reconstruction. The symptoms of
instability were signifificantly improved. Posterolat-
eral laxity was corrected to the normal or nearly
normal level in 88.2% of cases (16).
Several papers have documented the downsides
and potential complications associated with recon-
structive procedures for combined PCL and poste-
rolateral corner injury.
Twenty-three percent of patients in Stannard’s
series required an arthroscopic adhesiolysis. Multi-
ligament reconstructed knees were more prone to
this complication than isolated PLS reconstructed
knees (58). In our own series, 2 of 27 patients
(7.4%) required a mobilization under general
anaesthesia for prolonged stiffness.
ff Their range
of motion returned to normal compared with the
contralateral knee (62).
Published failure rates vary from 37% after primary
repair (45) and 24% after biceps tendon rerouting
(42) to 9–10% after allograft LCL augmentation
or replacement procedures (44,45). Noyes evalu-
ated 57 failed posterolateral procedures in 30 con-
secutive knees. The most common causes of failure
were non-anatomical graft reconstruction (77%),
untreated varus malalignment (37%), and failure
to successfully reconstruct all ruptured knee liga-
ments, including the cruciates (93%) (44).
The place of the high tibial osteotomy
in the posterolateral corner injured knee
It is important to distinguish osseous from liga-
mentous deformity before planning soft tissue
reconstructions of the PLS. Limb alignment is a
strong determinant of the knee adduction moment
and the corresponding lateral compartment tensile
loads. Correcting the mechanical axis into neutral
or slight valgus alignment reduces the tensile loads
in the PLS reconstruction graft. Therefore,
Th failure
to correct varus alignment will often result in
failure of the PLS reconstruction (1,5,63). Thirty-
seven percent of 30 knees with a failed PLS recon-
struction had an untreated varus alignment in the
series evaluated by Noyes (44). The
Th so-called triple
varus knee they described represents three patho-
logic entities: (a) a tibiofemoral osseous malalign-
ment, (b) an increased lateral tibiofemoral com-
partment separation, and (c) a varus recurvatum
due to the abnormal increased external tibial rota-
tion and knee hyperextension in knees with PLS
defi
ficiency (64).
Indications
In patients with chronic ligamentous injuries, we
obtain long leg standing radiographs on which the
mechanical axis is always assessed prior to any
ligamentous reconstructive procedure.
Varus deformity should in our opinion be corrected
by open wedge osteotomy. The need for adjusting
the sagittal plane by altering the tibial slope should
be considered at the same time. In cases of ACL
defi
ficiency, an anterior closing wedge technique
could be considered, since this technique is usually
associated with an almost automatic decrease in
tibial slope, whereas an opening wedge technique
frequently leads to an increase in tibial slope, due
to a tendency to position the wedge anteriorly
(65). In PCL-defificient knees, the increased poste-

rior translation of the tibia can therefore be coun-
teracted or stabilized by increasing the tibial slope
by an anteromedial positioned wedge (66).
Strategy
We recommend a staged approach, accomplishing
the HTO first, followed by the ligamentous recon-
structions 4–6 months later if further knee insta-
bility with functional impairment persists (5,67).
We try to correct the varus alignment such that
the corrected mechanical axis passes through the
downslope of the lateral tibial spine (resulting in
approximately 2–3° of mechanical valgus). ThisTh is
diff
fferent to the setting of medial compartment
arthrosis, where the mechanical axis should be cor-
rected into the lateral compartment, usually aim-
ing for a mechanical axis of 3–5° valgus (67).
We prefer a medial opening wedge osteotomy
since it has the theoretical advantage of a tight-
ening eff
ffect on the capsule, and since it is asso-
ciated with a tendency to increase slightly the
posterior slope (68). It has been demonstrated
in a cadaveric biomechanical study that an open
wedge osteotomy increases both varus and exter-
nal rotation stability (7). We fi
find it easier to cor-
rect the sagittal plane deformity with a medial
opening wedge than with a lateral closing wedge.
Another advantage of working at the medial side
is the avoidance of the proximal tibiofifibular joint
and the peroneal nerve.
Fig. 4 – Double bundle reconstructed
PCL before (left)t and after (right)t open
wedge high tibial osteotomy in order
to correct underlying varus deformity.
PCL injury associated with a posterolateral tear 437
Postoperatively, a hinge brace is worn for 8 weeks
and patients are restricted from full weight bear-
ing during this period. Crutches are used until
suffi
fficient bone healing is present on radiographic
examination. The use of a stationary bicycle and
swimming is started at 8 weeks postoperatively.
Closed chain and proprioceptive exercises are
initiated once suffi
fficient bone healing is present.
Patients are allowed to jog from 6 months postop-
eratively.
Results
Several authors have demonstrated that isolated
HTO can be suffifficient in treating these patients
(5,66,69). Thirty-eight percent of 21 patients
treated with HTO reported satisfactory results at
37 months follow-up in the study by Laprade et
al. However, 72% of his patients required a sec-
ond-stage ligament reconstruction at an average
of 13.8 months following the initial procedure.
Patients with multiple-ligament knee injuries, a
history of high-energy injury pattern, and a lower
preoperative functional level were found to be
more likely to require a second-stage ligamentous
reconstruction (5). Naudie demonstrated that
HTO improved the subjective feeling of instability
in 16 of 17 patients with a posterolateral thrust at
a minimum follow-up of 2 years (66).
These results indicate that there is a place for HTO
in the treatment of combined PCL and posterolat-
eral corner injury, despite the fact that corrective
osteotomies have run out of favor for the treat-
ment of unicompartmental osteoarthritis.
References
1. Harner CD, Vogrin TM, Höher J, et al. (2000) Biomechani-
cal analysis of a posterior cruciate ligament reconstruc-
tion: defi
ficiency of the posterolateral structures as a cause
of graft failure. Am J Sports Med 28:32–39
2. Hughston JC, Jacobson KE (1985) Chronic posterolateral
rotatory instability of the knee. J Bone Joint Surg Am
67:351–359
3. Pasque C, Noyes FR, Gibbons M, et al. (2003) The Th role of
the popliteofifibular ligament and the tendon of the popli-
teus in providing stability in the human knee. J Bone
Joint Surg Br 85:292–298
4. Vogrin TM, Hoher J, Aroen A, et al. (2000) Effects
ff of sec-
tioning the posterolateral structures on knee kinematics
and in situ forces in the posterior cruciate ligament. Knee
Surg Sports Traumatol Arthrosc 8:93–98
5. Arthur A, LaPrade RF, Agel J (2007) Proximal tibial open-
ing wedge osteotomy as the initial treatment for chronic
posterolateral corner defi ficiency in the varus knee. Am J
Sports Med 35:1844–1850
6. Larsen MW, Toth A (2005) Examination of posterolateral
corner injuries. J Knee Surg 18:146–150
7. LaPrade RF, Wentorf FA, Olson EJ, et al. (2006) An in
vivo injury model of posterolateral knee instability. Am J
Sports Med 34:1313–1321
438 The Traumatic Knee
8. LaPrade RF, Johansen S, Wentorf FA, et al. (2004) An
analysis of an anatomical posterolateral knee reconstruc-
tion: an in vitro biomechanical study and development of
a surgical technique. Am J Sports Med 32:1405–1414
9. Malone AA, Dowd GSE, Saifuddin A (2006) Injuries of the
posterior cruciate ligament and posterolateral corner of
the knee. Injury 37:485–501
10. Yoon KH, Bae DK, Ha JH (2006) Anatomic reconstructive
surgery for posterolateral instability of the knee. Arthros-
copy 22:159–165
11. Krudwig WK, Witzel U, Ullrich K (2002) Posterolateral
aspect and stability of the knee joint. II. Posterolateral
instability and effect
ff of isolated and combined postero-
lateral reconstruction on knee stability: a biomechanical
study. Knee Surg Sports Traumatol Arthrosc 10:91–95
12. LaPrade RF, Muench C, Wentorf F, et al. (2002) The Th effffect
of injury to the posterolateral structures of the knee on
force in a posterior cruciate ligament graft. Am J Sports
Med 30:233–238
13. Markolf KL, Graves BR, Sigward SM, et al. (2007) Popli-
teus bypass and popliteofi fibular ligament reconstructions
reduce posterior tibial translations and forces in a poste-
rior cruciate ligament graft. Arthroscopy 23:482–487
14. Sekiya JK, Haemmerle MJ, Stabile KJ (2005) Biomechani-
cal analysis of a combined double-bundle posterior cruci-
ate ligament and posterolateral corner reconstruction. Am
J Sports Med 33:360–369
15. Covey DC (2001) Injuries of the posterolateral corner of
the knee. J Bone Joint Surg Am 83-A(1):106–118
16. Strobel MJ, Schulz MS, Petersen WJ (2006) Combined ante-
rior cruciate ligament, posterior cruciate ligament, and pos-
terolateral corner reconstruction with autogenous hamstring
grafts in chronic instabilities. Arthroscopy 22:182–192
17. Markolf KL, Graves BR, Sigward SM (2007) How well do
anatomical reconstructions of the posterolateral corner
restore varus stability to the posterior cruciate ligament
reconstructed knee? Am J Sports Med 35:1117–1123
18. Strobel MJ, Weiler A, Schulz MS, et al. (2003) Arthroscopic
evaluation of articular cartilage lesions in posterior cruci-
ate ligament-defi ficient knees. Arthroscopy 19:262–268
19. Kannus P (1989) Nonoperative treatment of grade II and
III sprains of the lateral ligament compartment of the
knee. Am J Sports Med 17:83–88
20. Skyhar MJ, Warren RF, Ortiz GJ, et al. (1993) The Th effffects
of sectioning of the posterior cruciate ligament and the
posterolateral complex on the articular contact pressures
within the knee. J Bone Joint Surg Am 75:694–699
21. Mavrodontidis AN, Papadonikolakis A, Moebius UG, et al.
(2003) Posterior tibial subluxation and short-term arthri-
tis resulting from failed posterior cruciate ligament recon-
struction. Arthroscopy 19:1–5
22. Amendola A (2003) The role of osteotomy in the multiple
ligament injured knee. Arthroscopy 19(suppl 1):11–13
23. Laprade RF, Ly VT, Wentorf F, et al. (2003) The posterolat-
eral attachments of the knee: a qualitative and quantita-
tive morphologic analysis of the fibular collateral ligament,
popliteus tendon, popliteofi fibular ligament, and lateral
gastrocnemius tendon. Am J Sports Med 31:854–860
24. LaPrade RF, Tso A, Wentorf FA (2004) Force Measure-
ments on the fibular collateral ligament, popliteofi fibular
ligament, and popliteus tendon to applied loads. Am J
Sports Med 32:1695–1701
25. Tzurbakis M, Diamantopoulos A, Xenakis T (2006) Sur-
gical treatment of multiple knee ligament injuries in 44
patients:2–8 years follow-up results. Knee Surg Sports
Traumatol Arthrosc 14:739–749
26. Fanelli GC, Edson CJ (1995) Posterior cruciate liga-
ment injuries in trauma patients: Part II. Arthroscopy
11(5):526–529
27. Khanduja V, Somayaji HS, Harnett P (2006) Combined
reconstruction of chronic posterior cruciate ligament and
posterolateral corner defi ficiency. J Bone Joint Surg Br
88:1169–1172
28. Lee J, Papakonstantinou O, Brookenthal KR, et al. (2003)
Arcuate sign of posterolateral knee injuries: anatomic,
radiographic, and MR imaging data related to patterns of
injury. Skeletal Radiol 32:619–627
29. Csintalan RP, Ehsan A, McGarry MH (2006) Biomechani-
cal and anatomical eff ffects of an external rotational torque
applied to the knee. Am J Sports Med 34:1623–1629
30. Wiley WB, Askew MJ, Melby A, et al. (2006) Kinemat-
ics of the posterior cruciate ligament/posterolateral
corner–injured knee after reconstruction by single- and
double-bundle intra-articular grafts. Am J Sports Med
34:741–749
31. Noyes FR, Barber-Westin SD, Grood ES (2001) Newer con-
cepts in the treatment of posterior cruciate ligament rup-
tures. In: Insall JN, Scott WN, editors. Surgery of the Knee.
3rd ed. New York, NY: Churchill Livingstone: 841–878
32. Pritsch T, Blumberg N, Haim A (2006) The Th importance of
the valgus stress test in the diagnosis of posterolateral
instability of the knee. Injury 37:1011–1014
33. Pacholke DA, Helms CA (2007) MRI of the posterolateral
corner injury: a concise review. J Magn Reson Imaging
26:250–255
34. Harish S, O’Donnell P, Connell D, et al. (2006) Imaging of
the posterolateral corner of the knee. Clinical Radiology
61:457–466
35. Bennett DL, George MJ, El-Khoury GY, et al. (2003) Ante-
rior rim tibial plateau fractures and posterolateral corner
knee injury. Emerg Radiol 10:76–83
36. Bolog N, Hodler J (2007) MR imaging of the posterolat-
eral corner of the knee. Skeletal Radiol 36:715–728
37. LaPrade RF (1997) Arthroscopic evaluation of the lateral
compartment of knees with grade 3 posterolateral knee
complex injuries. Am J Sports Med 25:596–602
38. Ferrari DA (2005) Arthroscopic evaluation of the popliteus:
clues to posterolateral laxity. Arthroscopy 21(6):721–726
39. Aronowitz ER, Parker RD, Gatt CJ (2001) Arthroscopic
identifi
fication of the popliteofi fibular ligament. Arthros-
copy 17:932–939
40. Larsen MW, Moinfar AR, Moorman CT (2005) Postero-
lateral corner reconstruction: fibular-based technique. J
Knee Surg 18:163–166
41. Verma NN, Mithöfer K, Battaglia M, et al. (2005) The Th
docking technique for posterolateral corner reconstruc-
tion. Arthroscopy 21:238–242
42. Kim S-J, Shin S-J, Jeong J-H (2003) Posterolateral rota-
tory instability treated by a modifi fied biceps rerouting
technique: technical considerations and results in cases
with and without posterior cruciate ligament insuffi- ffi
ciency. Arthroscopy 19:493–499
43. Garofalo R, Wettstein M, Fanelli G, et al. (2007) Gerdy
tubercle osteotomy in surgical approach of posterolateral
corner of the knee. Knee Surg Sports Traumatol Arthrosc
15:31–35
44. Noyes FR, Barber-Westin SD, Albright JC (2006) An
Analysis of the causes of failure in 57 consecutive pos-
terolateral operative procedures. Am J Sports Med
34:1419–1430
45. Stannard JP, Brown SL, Farris RC, et al. (2005) Posterolat-
eral corner of the knee: repair versus reconstruction. Am J
Sports Med 33:881–888
46. Veltri DM, Warren RF (1994) Operative treatment of pos-
terolateral tenodesis for posterolateral instability of the
knee. Am J Sports Med 13:615–627
47. Albright JP, Brown AW (1998) Management of chronic
posterolateral rotatory instability of the knee: surgical
technique for the posterolateral corner sling procedure.
Instr Course Lect 47:369–378
48. Jung YB, Lee YS, Jung HJ (2007) Heterotopic bone for-
mation after posterior cruciate ligament reconstruction

using inlay method and posterolateral corner sling with
tibia tunnel: report of one case. Knee Surg Sports Trauma-
tol Arthrosc 15:729–732
49. Stannard JP, Wilson TC, Sheils TM, et al. (2002) Het-
erotopic ossification
fi associated with knee dislocation.
Arthroscopy 18:835–839
50. Clancy WG (1988) Repair and reconstruction of the poste-
rior cruciate ligament. In: Chapman M, editor. Operative
orthopaedics. Philadelphia, PA: JB Lippincott 1651–1655
51. Clancy Jr WG, Sutherland TB (1994) Combined posterior
cruciate ligament injuries. Clin Sports Med 13(3):629–647
52. Fanelli GC, Giannotti BF, Edson CJ (1996) Arthroscopically
assisted combined posterior cruciate ligament/posterior
lateral complex reconstruction. Arthroscopy 12:521–530
53. Larson RV, Tingstad E (2003) Lateral and posterolat-
eral instability of the knee in adults. In: Delee JC, Drez
D, Miller M, editors. Orthopaedic sports medicine: prin-
ciples and practice. 2nd ed. Philadelphia, PA: WB Saunders
Co:1968–1994
54. Nau T, Chevalier Y, Hagemeister N, et al. (2005) Compari-
son of 2 surgical techniques of posterolateral corner recon-
struction of the knee. Am J Sports Med 33:1838–1845
55. Nau T, Chevalier Y, Hagemeister N, et al. (2005) 3D kine-
matic in-vitro comparison of posterolateral corner recon-
struction techniques in a combined injury model. Knee
Surg Sports Traumatol Arthrosc 13:572–580
56. Lee MC, Park YK, Lee SH (2003) Posterolateral recon-
struction using split Achilles tendon allograft. Arthros-
copy 19:1043–1049
57. Sidles JA, Larson RV, Garbini JL, et al. (1988) Ligament
length relationships in the moving knee. Orthop Res
6:593–610
58. Stannard JP, Brown SL, Robinson JT, et al. (2005) Recon-
struction of the posterolateral corner of the knee. Arthros-
copy 21:1051–1059
59. LaPrade RF, Bollom TS, Wentorf FA, et al. (2005) Mechani-
cal properties of the posterolateral structures of the knee.
Am J Sports Med 33:1386–1391
60. Gill TJ, DeFrate LE, Wang C, et al. (2003) The
Th biomechani-
cal eff
ffect of posterior cruciate ligament reconstruction
on knee joint function: kinematic response to simulated
muscle loads. Am J Sports Med 31:530–536
61. Hoher J, Vogrin TM, Woo SL-Y, et al. (1999) In situ forces
in the posterior cruciate ligament in response to muscle
loads: a cadaveric study. J Orthop Res 17:763–768
62. Corten K, Bellemans J (2008) Cartilage damage deter-
mines intermediate outcome in the late multiple ligament
and posterolateral corner reconstructed knee. A 5- to
10-year follow-up study. Am J Sports Med 36:267–275
63. Goradia VK, Van Allen J (2002) Chronic lateral knee insta-
bility treated with a high tibial osteotomy. Arthroscopy
18:807–811
64. Noyes FR, Barber-Westin SD, Roberts CS (2003) High tib-
ial osteotomy in knees with associated chronic ligament
defi
ficiencies. In: Jackson RW, editor. Master techniques in
orthopaedic surgery, reconstructive knee surgery. 2nd ed.
Philadelphia, PA: Lippincott Williams & Wilkins:229–260
65. Brown G, Amendola A (2000) Radiographic evaluation
and preoperative planning for high tibial osteotomies.
Oper Tech Sports Med 8:2–14
PCL injury associated with a posterolateral tear 439
66. Naudie D, Amendola A, Fowler P (2001) Opening wedge
high tibial osteotomy for chronic posterior instability. In:
Proceedings of AOSSM meeting, Keystone, CO, July 2001
67. Noyes FR, Barber-Westin SD, Hewett TE (2000) High
tibial osteotomy and ligament reconstruction for varus
angulated anterior cruciate ligament deficient
fi knees. Am
J Sports Med 28:282–296
68. LaPrade RF, Morgan PM, Wentorf FA, et al. (2007) The Th
anatomy of the posterior aspect of the knee: an anatomic
study. J Bone Joint Surg Am 89:758–764
69. Badhe NP, Forster IW (2000) High tibial osteotomy in knee
instability: the rationale of treatment and early results.
Knee Surg Sports Traumatol Arthrosc 10:38–43
70. Bottomley N, Williams A, Birch R, et al. (2005) Dis-
placement of the common peroneal nerve in posterolat-
eral corner injuries of the knee. J Bone Joint Surg [Br]
87-B:1225–1226
71. Coobs BR, LaPrade RF, Griffi ffith CJ, et al. (2007) Biome-
chanical analysis of an isolated fibular (lateral) collateral
ligament reconstruction using an autogenous semitendi-
nosus graft. Am J Sports Med 35:1521–1527
72. Dowd GS (2004) Reconstruction of the posterior cruciate
ligament: indications and results. J Bone Joint Surg [Br]
86-B:480–491
73. Kanamori A, Lee JM, Haemmerle MJ, et al. (2003) A bio-
mechanical analysis of two reconstructive approaches to
the posterolateral corner of the knee. Knee Surg Sports
Traumatol Arthrosc 11:312–317
74. Keene JS, Davis RA (2005) Technique to facilitate graft
passage in posterolateral reconstructions of the knee.
Arthroscopy 21:637.e1–637.e4
75. LaPrade RF, Wentorf FA, Engebretsen L, et al. The eff ffect
of a proximal tibial medial opening wedge osteotomy on
posterolateral knee instability: a biomechanical study. Am
J Sports Med. In press
76. McGuire DA (2003) Should allografts be used for routine
anterior cruciate ligament reconstructions? Yes, allografts
should be used in routine ACL reconstruction. Arthros-
copy 19:421–424
77. Montgomery AS, Birch R, Malone A (2005) Entrapment
of a displaced common peroneal nerve following knee lig-
ament reconstruction. J Bone Joint Surg [Br] 87-B:861–
862
78. Noyes FR, Barber-Westin SD (1996) Surgical restoration
to treat chronic defificiency of the posterolateral complex
and cruciate ligaments of the knee joint. Am J Sports Med
24:415–426
79. Pavlovich RI, Nafarrate EB (2002) Trivalent reconstruction
for posterolateral and lateral knee instability. Arthroscopy
18: E1 1–3
80. Shuler MS, Jasper LE, Rauh PB, et al. (2006) Tunnel con-
vergence in combined anterior cruciate ligament and pos-
terolateral corner reconstruction. Arthroscopy 22:193–
198
81. Terry GC, LaPrade RF (1996) The Th posterolateral aspect
of the knee: anatomy and surgical approach. Am J Sports
Med 24:732–739
82. Hughston JC, Andrews JR, Cross MJ, et al. (1976) Clas-
sifi
fication of knee ligament instabilities. Part II. The lateral
compartment. J Bone Joint Surg Am 58A:173–179
Bicruciate injuries
and dislocations

G.C. Fanelli, C.J. Edson The multiple-ligament injured knee
Abstract
T
he multiple-ligament injured knee is a com-
plex problem in orthopedic surgery. Most
dislocated knees involve tears of the anterior
cruciate ligament (ACL), posterior cruciate liga-
ment (PCL), and at least one collateral ligament
complex. Careful assessment of the extremity
vascular status is essential because of the possibil-
ity of arterial and/or venous compromise. Th These
complex injuries require a systematic approach to
evaluation and treatment. Physical examination
and imaging studies enable the surgeon to make
a correct diagnosis and to formulate a treatment
plan. Arthroscopically assisted combined ACL/PCL
reconstruction is a reproducible procedure. Knee
stability is improved postoperatively when evalu-
ated using knee ligament rating scales, arthrome-
ter testing, and stress radiographic analysis. Acute
medial collateral ligament (MCL) tears when com-
bined with ACL/PCL tears may, in certain cases, be
treated with bracing. Posterolateral corner injuries
combined with ACL/PCL tears are best treated
with primary repair as indicated combined with
reconstruction using a post of strong autograft
(split biceps tendon, biceps tendon, semitendino-
sus) or allograft (Achilles tendon, bone-patellar
tendon-bone) tissue. Surgical timing depends
upon the ligaments injured, the vascular status of
the extremity, reduction stability, and the overall
health of the patient. We prefer the use of allograft
tissue for reconstruction in these cases because of
the strength of these large grafts, and the absence
of donor site morbidity.
Introduction
The dislocated knee is a severe injury resulting from
violent trauma. It results in disruption of at least
three of the four major ligaments of the knee and
leads to signifi
ficant functional instability. Vascular
and nerve damage, as well as associated fractures,
may contribute to the challenge of caring for this
injury. Historical treatment was primarily limited
Chapitre 38
to immobilization. However, with the advent of
better surgical instrumentation and technique, the
management of combined anterior and posterior
cruciate ligament (ACL/PCL) tears associated with
medial or lateral collateral ligament (MCL/LCL)
disruption has become primarily surgical.
This article presents the basic knee anatomy,
mechanisms and classififications of injury, evalua-
tion, treatment, postoperative rehabilitation, and
our experience with treating the dislocated knee.
Anatomy
Stability of the knee is due to several anatomic
structures. The articulation of the femorotibial
joint is maintained, in part, by the bony anatomy
of the femoral condyles and the tibial plateau. TheTh
menisci serve to increase the contact area between
femur and tibia and thus increase stability of the
joint. The four major ligaments (ACL, PCL, MCL,
and LCL) and the posterior medial and posterior
lateral corners are the most signifi ficant ligamen-
tous stabilizers of the knee. In addition to these
static anatomic structures, dynamic anatomic
structures, such as the musculature that crosses
the knee joint, also play a role in stabilization. In
any knee injury, examination must include evalua-
tion of all these anatomic structures.
When evaluating a dislocated knee, it is imperative
to evaluate the structural integrity of any remain-
ing ligamentous structure; consequently, the func-
tions of these structures must be well understood.
The ACL primarily prevents anterior translation
of the tibia relative to the femur, and accounts for
about 86% of the total resistance to anterior tibial
translation (1). It is also involved in limiting inter-
nal and external rotation of the tibia relative to the
femur when the knee is in extension (2). The Th ACL
will also limit varus and valgus stress in the face of
either an LCL or MCL injury.
The PCL may be considered the primary static sta-
bilizer of the knee given its location near the cen-
ter of rotation of the knee and its relative strength
(3). The PCL has been shown to provide 95% of
444 The Traumatic Knee
the total restraint to posterior tibial displacement
forces acting on the tibia (1). The
Th PCL works in con-
cert with structures of the posterior lateral corner,
and injury to both structures is required to signifi-fi
cantly increase posterior translation (4).
The MCL and LCL act alone to resist valgus and
varus stresses, respectively, at 30° of knee flexion.
fl
Together, they act in a secondary fashion to limit
anterior and posterior translation, and rotation of
the tibia on the femur. The anatomy of the poste-
rior lateral corner of the knee is complex; its major
structures consist of (a) the LCL, (b) the arcuate
complex, (c) the popliteal tendon, and (d) the
popliteal-fi
fibular ligament (5). The posterolateral
corner primarily resists posterior lateral rotation
of the tibia relative to the femur but also contrib-
utes to resisting posterior tibial translation. Th The
posteromedial corner of the knee consists primar-
ily of the posterior oblique portion of the MCL and
associated joint capsule. These
Th structures provide
resistance to valgus stress and posterior medial
tibial translation. Evaluation of traumatic knee
dislocation must include these anatomical struc-
tures; typically, three areas or more are injured in
knee dislocation. Failure to recognize and treat
capsular and ligamentous injury, besides the obvi-
ous ACL/PCL injury, will result in less than optimal
results (6–8).
Neurovascular structures are also at risk of injury.
The popliteal fossa is defi
fined by the tendons of the
pes anserinus and semimembranosus medially and
the biceps tendon laterally. The
Th space is closed dis-
tally by the medial and lateral heads of the gastroc-
nemius and proximally by the hamstrings. Within
this space, the popliteal artery and vein and the
tibial and peroneal branches of the sciatic nerve
are located. The popliteal artery may be most at
risk to injury in knee dislocations. Th The popliteal
artery is tethered proximally at the adductor hia-
tus as it exits from Hunter’s canal, and distally as it
passes under the soleus arch, making it vulnerable
to injury in these areas. This artery is considered to
be an “end artery” of the lower limb; if it is injured,
the surrounding geniculate arteries are not suffi- ffi
cient to maintain collateral blood flow
fl to the lower
extremity. The popliteal vein is in close association
with the artery but seems to be less at risk during
injury than the popliteal artery. From a surgical
standpoint, the popliteal vessels are located directly
posterior to the posterior horns of the medial and
lateral meniscus, and dissection in this area may
put these structures at risk if not adequately pro-
tected. The sciatic nerve divides into its peroneal
and tibial divisions within the popliteal space.
These nerves are less likely to be injured with knee
dislocation, probably because they are not tethered
as the popliteal artery is. The
Th peroneal nerve is at
higher risk, as its course around the fi fibular head
functionally decreases its potential excursion, and
violent varus injuries may result in traction and/
or avulsion injuries to this nerve. Its location must
be identifi
fied during dissections to reconstruct the
posterolateral corner.
Classifification
Classifi
fication of knee dislocation is primarily
based on the direction the tibia dislocates relative
to the femur (9,10). ThisTh results in five diff
fferent
categories: anterior, posterior, lateral, medial, or
rotatory. The anterior-medial and lateral, poste-
rior-medial and lateral dislocations are classifi fied
as “rotatory” dislocation. Other factors to be con-
sidered include whether (a) the injury is open or
closed, (b) the injury is due to “high-energy” or
“low-energy” trauma, (c) the knee is completely
dislocated or subluxed, and (d) there is neurovas-
cular involvement. Furthermore, one should be
acutely conscious of the fact that a complete dislo-
cation may spontaneously reduce, and any triple-
ligament knee injury constitutes a frank disloca-
tion (7,11,12).
Reports vary, but anterior and/or posterior dislo-
cation appears to be the most common direction
of dislocation. Frassica and coworkers (13) found
a 70% incidence of posterior, 25% anterior, and
5% rotatory dislocations in their series. Green (14)
reported a 31% anterior, 25% posterior, and 3%
rotatory dislocation in his series. Rotatory disloca-
tions occur less frequently; however, the postero-
lateral dislocation seems to be the most common
combination. This particular pattern may be irre-
ducible secondary to the medial femoral condyle
becoming “button-holed” through the anterome-
dial joint capsule. In addition, the MCL invagi-
nates into the joint space, blocking reduction. This
Th
“button-holing” results in a “skin furrow” along
the medial joint line, as the subcutaneous tissue
attachments to the joint capsule drag the skin into
the joint (15). Attempts at reduction in this sce-
nario make the skin furrow more pronounced.
The actual incidence of difffferent directional dislo-
cation is not as important as correctly diagnosing
the direction of injury, and how it relates to poten-
tial neurovascular injury. Hyperextension injuries
(or posterior dislocations), because of the tethered
popliteal artery and vein, may have the highest
incidence of associated vascular injury; however,
any dislocation, if initial displacement is severe
enough, will result in injury to the popliteal artery.
The common peroneal nerve is less at risk because
it has a greater excursion than the popliteal ves-
sels, but it is still susceptible when a varus force
is applied to the knee. Posterolateral dislocation

is associated with a high incidence of injury to the
common peroneal nerve (16,17).
Open knee dislocations are not uncommon.
Reported incidence is between 19% and 35% of
all dislocations (17,18). An open knee dislocation,
in general, caries a worse prognosis secondary to
severe injury to the soft tissue envelop. Further-
more, an open injury may require an open liga-
ment reconstruction, or staged reconstruction, as
arthroscopically assisted techniques cannot be
performed in the acute setting with these open
injuries.
Distinguishing between low- and high-energy
injuries is important. Low-energy or low-velocity
injuries, usually associated with sports injuries,
have a decreased incidence of associated vascular
injury. High energy or velocity injuries, second-
ary to motor vehicle accidents or falls from height,
tend to have an increased incidence of vascular
compromise. With decreased pulses in an injured
limb and the history of a high-energy injury, one
should obtain vascular studies urgently.
Mechanism of injury
Th mechanism of injury for the two most common
The
knee dislocation patterns, anterior and posterior,
are reasonably well described. Kennedy (16) was
able to reproduce anterior dislocation by a hyperex-
tension force acting on the knee. At 30° of hyperex-
tension, Kennedy found that the posterior capsule
failed. When extended further, to about 50°, the
ACL, PCL, and popliteal artery fail. There
Th is some
question whether the ACL or the PCL fails first
fi with
hyperextension (16,19); however, in our (7) clinical
experience, both the ACL and PCL fail with disloca-
tion. Others (13,20,21) series demonstrated both
ACL and PCL tears with complete knee dislocation.
A posterior directed force applied to the proximal
tibia when the knee is flexed to 90° is thought to
produce a posterior dislocation, the so-called dash-
board injury (20). Medial and lateral dislocations
result from varus/valgus stresses applied to the
knee. A combination of varus/valgus stress with
hyperextension/blow to proximal tibia will likely
produce one of the rotatory dislocations.
Associated injuries
Several anatomic structures are at risk in the dis-
located knee. The four major ligaments of the knee
as well as the posterior medial and lateral corners
can be compromised. Vascular and nerve injuries
are common. There may also be associated bony
The multiple-ligament injured knee 445
lesions, avulsion fractures of the ACL or PCL, frank
tibial plateau or distal femur condylar fractures, or
ipsilateral tibial or femoral shaft fractures.
There is evidence in the literature that a frank dislo-
cation may not result in complete rupture of three
of the four major ligaments (16,17,22); however,
this seems to be the exception rather than the rule.
Several authors in their series have found that a
frank dislocation of the knee invariably results in
rupture of at least three of the four major liga-
ments. Sisto and Warren (21) found that all knees
in their series had three or more ligaments compro-
mised. In Frassica et al. (13) series, all 13 patients
treated operatively were found to have ACL, PCL,
and MCL disruptions. In Fanelli et al. (7) series, 19
of 20 were found to have a third component (poste-
rior lateral corner or MCL) in addition to complete
ACL and PCL disruption. With a frank dislocation
of the knee, careful ligament examination is neces-
sary to fully diagnose the extent of the injury.
The incidence of vascular compromise in knee dis-
locations has been estimated to be about 32% (14).
When limited to anterior or posterior dislocation, the
incidence may be as high as 50% (23). Recent stud-
ies confi
firm the signifi
ficant incidence of arterial injury
(13,21,24,25), reaffi
ffirming the need for careful vascu-
lar evaluation. The popliteal artery is an “end-artery”
to the leg, with minimal collateral circulation through
the genicular arteries. Furthermore, the popliteal
vein is responsible to the majority of venous outflow fl
from the knee. If either structure is compromised
to the point of prolonged obstruction, ischemia and
eventual amputation is often the result (26,27).
Two mechanisms have been described for injury to
the popliteal artery: one is a “stretching” mechanism,
seen with hyperextension, until the vessel ruptures.
This may occur secondary to the “tethered” nature
of the artery at the adductor hiatus and the entrance
through the gastrocnemius-soleus complex. This type
of injury should be suspected with an anterior dislo-
cation. Posterior dislocations may cause direct contu-
sion of the vessel by the posterior plateau, resulting
in intimal damage. Under no circumstance should
compromised vascular status be attributed to arte-
rial spasm; in this circumstance, there is often intimal
damage and impending thrombosis formation. Cone
(28) points out that initial examination may be nor-
mal; however, thrombus formation can occur hours
to days later (28–31), and recent series have dem-
onstrated delayed thrombus formation (13,21). Fur-
thermore, bicruciate ligament ruptures presenting as
a “reduced” dislocated knee may have as high an inci-
dence of arterial injury as a frank dislocation (12).
Popliteal vein injury occurs much less frequently, or
at least, historically, had not been reported. Despite
this, venous occlusion must also be recognized and
appropriately treated. Historically, whether to repair
venous injury seemed controversial. Ligating the
446 The Traumatic Knee
popliteal vein, a common practice during the Vietnam
conflflict, led to severe edema, phlebitis, and chronic
venous stasis changes. Venous repair was thought to
lead to thrombophlebitis and pulmonary embolism.
Currently, if obstruction to outfl
flow is recognized, sur-
gical repair of the popliteal vein is warranted (32).
Injury to either the peroneal nerve or the tibial
nerve has been documented (16,17,21–25,33) with
an incidence of about 20–30%. Th The nervous struc-
tures about the knee are not as tightly anchored as
the popliteal vessels; this probably accounts for the
lower incidence of injury compared to neighboring
vascular structures. The mechanism of injury is usu-
ally one of stretch. The
Th peroneal nerve seems to be
more frequently involved than the tibial nerve, prob-
ably due to its anatomical location. With any varus
loading of the knee, the peroneal nerve is placed
under tension. In Shields’ (17) series, posterior dis-
location caused the majority of the nerve injuries.
Given the fact that knee dislocation is usually sec-
ondary to violent trauma, associated fractures are
common; the incidence may be as high as 60% (22).
Tibial plateau fractures and ligament avulsion frac-
tures from the proximal tibia or distal femur are com-
mon (13,18,21–33,34). Recognition of these injuries
is also important, as additional bony involvement
has implications on definitive
fi treatment. Associ-
ated distal femur fractures and proximal tibial frac-
tures treated with intramedullary nailing make bone
tunnel placement for ACL and PCL reconstruction
diffi
fficult. With violent trauma, any fracture or avul-
sion conceivable may occur with a dislocated knee;
however, there is suggestion that medial and lateral
dislocations are associated with some increased fre-
quency of minor bony lesions (35).
Fracture dislocations represent a separate entity
in the spectrum of pure knee dislocation to tibial
plateau fractures. Pure knee dislocation requires
only soft tissue reconstruction to gain stability;
tibial plateau fractures require purely bony stabi-
lization. Fracture dislocations of the knee often
involve both bony and ligamentous repair or
reconstruction, adding an element of complexity
to their treatment (10,36). Long-term outcome
of fracture-dislocation injuries to the knee joint
falls somewhere between tibial plateau fractures
and pure dislocations, with tibial plateau fractures
doing the best and dislocations the worst (36).
Initial evaluation and management
General considerations
Obvious deformity may be present on initial exam-
ination. However, in a polytrauma patient who is
intubated and sedated, the injury may escape ini-
tial evaluation. Abrasions or contusions about the
knee, gross crepitus, or laxity may allude to injury
in an otherwise normal appearing knee. This
Th impor-
tance of immediate recognition of knee dislocation
or fracture dislocation lay not with the treatment
of instability but with the recognition of potential
vascular injury and possible vascular compromise
(12). Neurovascular status must be assessed on
both lower extremities. Neurologic exam may be
diffi
fficult in the polytrauma patient, and is not as
important initially as is serial neurologic examina-
tion. Vascular exam is more pressing as ischemia
greater than 8 h usually results in amputation (14).
In the reduced knee, a white, cool limb that is obvi-
ous on physical exam and denotes arterial dam-
age requires immediate arteriogram. However,
normal pulses, Doppler signals, and capillary refill
fi
do not rule out an arterial injury (28). Th
Thrombosis
may occur hours to days later, necessitating serial
examination. If there is any question of perfusion
of the limb, arteriogram is warranted.
Imaging studies
Prior to any manipulation, AP and lateral radio-
graphs of the affffected extremity are completed.
This is important to confifirm the direction of dis-
location and any associated fractures and aids in
planning the reduction maneuver. In the pres-
ence of cyanosis, pallor, weak capillary refill,
fi and
decreased peripheral temperature following reduc-
tion, arteriography must be considered. Venogra-
phy may be required if the clinical picture indicates
adequate limb perfusion but obstruction of out-
flow.
After the acute management of the dislocated
knee, an MRI may be obtained subacutely to con-
firm, and aid in planning reconstruction of, com-
promised ligamentous structures.
Reduction
An unreduced dislocated knee constitutes an
orthopedic emergency, and reduction should be
undertaken as soon as possible, preferably in the
emergency department. Prior to manipulation,
adequate AP and lateral x-ray evaluation are per-
formed. This allows for determination of the direc-
tion of the dislocation, any associated fractures,
and assists in planning the reduction maneuver.
In the isolated knee dislocation, intravenous mor-
phine or conscious sedation is usually required.
Slow, gradual longitudinal traction is applied to
the leg from the ankle, and the proximal tibia is

manipulated in the appropriate direction to effect
ff
a reduction. Once reduced, x-ray evaluation to
firm tibiofemoral congruency is performed as
confi
well as repeated neurovascular exam. The Th limb is
than placed in either a long leg splint or extension
knee immobilizer. It is imperative to perform x-ray
evaluation after placement in the splint or brace,
as posterior subluxation of the tibia on femur is
common. A “bump” consisting of a towel or pad
behind the gastrocnemius-soleus complex may aid
in maintaining reduction.
The “dimple sign” indicates a posterolateral dislo-
cation, and closed reduction may not be successful.
The medial femoral condyle penetrates the medial
joint capsule, causing interposition of soft tissue
in the joint, warranting open reduction (10,15).
Physical examination
Physical examination features of the ACL/PCL/
PLC injured knee include abnormal anterior and
posterior translation at both 25° and 90° of knee
flexion which is usually greater than 15 mm. At 90°
fl
of knee flexion, the tibial step off
ff is absent, and the
posterior drawer test is 2+ or greater indicating
greater that 10 mm of pathologic posterior tibial
displacement. The Lachman test and pivot shift
phenomenon are positive indicating ACL disrup-
tion, and there may be hyperextension of the knee.
We have identifi fied and described three types of
posterolateral instability (PLI): A, B, and C.
PLI in the multiple-ligament injured knee
includes at least 10° of increased tibial external
rotation compared with the normal knee at 30°
and 90° of knee flexion (positive dial test and
external rotation thigh-foot angle test), and vari-
able degrees of varus instability depending upon
the injured anatomic structures. PLI type A has
increased external rotation only, correspond-
ing to injury to the popliteofi fibular ligament,
and popliteus tendon only. PLI type B presents
with increased external rotation, and mild varus
of approximately 5 mm increased lateral joint
line opening to varus stress at 30° knee fl flexion.
This occurs with damage to the popliteofi fibular
ligament, popliteus tendon, and attenuation of
the fibular collateral ligament. PLI type C pres-
ents with increased tibial external rotation, and
varus instability of 10 mm greater than the nor-
mal knee tested at 30° of knee flexion with varus
stress. This occurs with injury to the popliteofi fib-
ular ligament, popliteus tendon, fi fibular collateral
ligament, and lateral capsular avulsion in addi-
tion to cruciate ligament disruption.
The medial collateral ligament is tested with val-
gus stress at 0° and 30° of knee fl flexion to assess
The multiple-ligament injured knee 447
the superfi
ficial medial collateral ligament, the pos-
terior oblique ligament, and the posterior medial
capsule. Extensor mechanism stability is assessed
by medial and lateral patellar glide to assess the
integrity of the lateral and medial patellar reti-
naculum.
Vascular injuries
A full spectrum of vascular injuries may be encoun-
tered. The overall clinical picture may vary from an
uncomplicated, bicruciate ligament injury with
possible intimal damage with a normal physical
exam to a polytrauma patient, with a closed head
injury, intra-abdominal bleeding, and dislocated
knee with vascular compromise. Life-threatening
injuries are addressed fi
first. The orthopedic surgeon
needs to be aware of the total limb ischemia time.
If there is any suspicion of arterial damage, a vas-
cular consult is obtained immediately. Reduction is
performed to see if this restores blood flowfl to the
limb. When the total ischemia time approaches 6
h (14), there is an urgency to restore flowfl to the
lower extremity. An intraoperative angiogram
during vascular exploration and shunting may be
required at the expense of high-quality preopera-
tive angiogram (10). Mechanism of injury should
also be noted. A high-energy injury (motor vehicle
accident, fall from height) may be more suspicious
for vascular injury, and one may elect to obtain
arteriograms despite normal vascular exam (12).
When an isolated dislocated knee with suspected
arterial injury occurs (asymmetric pulses, Dop-
pler, or ankle-brachial index), arteriography is per-
formed as the simple presence of pulses does not
rule out vascular damage (28). Any suspicion war-
rants a vascular surgery consult. When the limb is
well perfused, and all indices are normal, one may
elect to forego a formal arteriogram, if there are
frequent neurovascular checks to the lower extrem-
ity. Despite the historical preference to obtain an
arteriogram in the presence of a knee dislocation
as a screening tool, it has been demonstrated that
arteriography following significant
fi blunt trauma
to the lower extremity with normal vascular exam
has a low yield rate for detecting surgical vascular
lesions (12,38–40).
Popliteal vein injury is also possible. When the clini-
cal picture warrants, a venogram may be useful.
Absolute surgical indications
A state of irreducibility and vascular injury war-
rants immediate surgical intervention. Four com-
448 The Traumatic Knee
partment fasciotomy of the limb is considered
when ischemia time is greater than 2.5 h. Inability
to maintain reduction also mandates external skel-
etal fixation or early ligamentous reconstruction
to stabilize the knee to avoid potential recurrent
vascular compromise. Open dislocations and open
fracture dislocations requires immediate surgi-
cal debridement to decontaminate the wound. An
external fixator may be a reasonable option in the
case of an open dislocation with a large soft tis-
sue defect, or an open fracture dislocation. In this
circumstance, access to soft tissue would be main-
tained for surgical debridement.
Defifinitive surgical management
Historical management
Knee dislocations were initially managed conser-
vatively with a cylinder cast for several months
(41,42). Early reports by Kennedy (16) and Meyers
et al. (18) reported reasonable outcomes for non-
operatively treated knee dislocations. However,
there was suggestion that surgically stabilized dis-
located knee would fare better in the long term.
A Recent report by Almekinders and Logan (24)
compared surgically stabilized knees with conser-
vative treatment and concluded that conservative
treatment was comparable with surgical treat-
ment. Despite similar outcomes, the conservatively
treated knees were grossly unstable compared with
surgically stabilized knees. Their study was retro-
spective from 1963 to 1988 and the typical surgi-
cal treatment during this period was in most cases
open direct repair of the ligaments. Sisto and War-
ren (21) found similar results comparing 4 conser-
vatively treated knees with 16 direct suture repair
of torn ligaments. Frassica et al. (13) also evaluated
early (within 5 days of injury) direct repair (with or
without augmentation) of torn ligamentous struc-
tures in 13 of 17 patients. They concluded that
better results were obtained with early versus later
direct repair of torn ligaments. This study supports
surgical management of the dislocated knee and
introduces the concept of benefi fit from a ligamen-
tously stable knee.
Within the last decade, the technique of arthroscop-
ic-assisted ACL/PCL reconstruction has become
popular. Several advancements have made these
techniques possible: (a) better procurement, steril-
ization, and storage of allograft tissue, (b) improved
arthroscopic surgical instrumentation, (c) bet-
ter graft fixation methods, (d) improved surgical
technique, and (e) improved understanding of the
ligamentous anatomy and biomechanics of the
knee. Few reports of combined ACL/PCL recon-
struction are available in the literature, but surgical
reconstruction appears to aff fford at least the same
results, if not better, that direct repair of the liga-
ments. Shapiro and Freedman (25) reconstructed 7
ACL/PCL injuries with primarily allograft Achilles
tendon or bone-patellar tendon-bone. They found
that three patients had excellent results, three good
results, and one had fair results. Furthermore, aver-
age KT-1000 was +3.3 mm side-to-side difference,
ff
with very little varus/valgus instability or signifi- fi
cant posterior drawer. All seven of their patients
were able to return to school or the workplace.
Fanelli et al. (6) reported on 20 ACL/PCL
arthroscopic-assisted ligament reconstructions.
In their study group, there was 1 ACL/PCL tear,
10 ACL/PCL/posterior lateral corner tears, 7 ACL/
PCL/MCL tears, and 2 ACL/PCL/MCL/posterior
lateral corner tears. Achilles tendon allografts
and bone-patellar tendon-bone autografts were
used in PCL reconstructions, auto- and allograft
bone-patellar tendon-bone was used in ACL recon-
struction. An additional component, not previ-
ously mentioned with any consistency in the lit-
erature, was the addressing of the associated MCL
or posterior lateral corner injury. It is imperative
to address these injuries as well, or the results of
ACL/PCL reconstruction alone will be less than
optimal.
Postoperatively, significant
fi improvement was found
utilizing the Lysholm, Tegner, and Hospital for Spe-
cial Surgery knee ligament rating scales, and the
KT-1000 arthrometer. Overall postoperatively, 75%
of patients had a normal Lachman test, 85% no lon-
ger displayed a pivot shift, 45% restored a normal
posterior drawer test, and 55% displayed grade I
posterior laxity. All 20 knees were deemed function-
ally stable and all patients returned to desired levels
of activity. These authors concluded that results of
reconstruction are reproducible and that appropri-
ate reconstruction will produce a stable knee.
Noyes and Barber-Westin (43) evaluated surgically
reconstructed ACL/PCL tears (all had additional
MCL or LCL/PCL reconstruction) at an average of
4.8 years. Seven of these knees were acute knee dis-
locations and four were chronically unstable knees
secondarily to knee dislocations. At follow-up, five
fi
of the seven acute knee injures had returned pre-
injury level of activity. Three
Th of the four chronic
knee injuries were asymptomatic with activities
of daily living. Arthrometric measurements at 20°
showed less than 3 mm of side-to-side differenceff
with anterior-posterior translation in 10 of the 11
knees; at 70°, there were 9 knees that had less than
3 mm side-to-side diff fference in anterior-posterior
translation. These authors concluded that simulta-
neous bicruciate ligament reconstruction is war-
ranted to restore function to the knee.

Fanelli sports injury clinic experience
Our practice is located in a tertiary care regional
trauma center. There is a 38% incidence of PCL tears
in acute knee injuries, with 45% of these PCL injured
knees being combined ACL/PCL tears (44,45). Care-
ful assessment, evaluation, and treatment of vas-
cular injuries are essential in these acute multiple-
ligament injured knees. There
Th is an 11% incidence of
vascular injury associated with these acute multiple-
ligament injured knees at our center (39).
Our preferred approach to combined ACL/PCL
injuries is an arthroscopic ACL/PCL reconstruction
using the transtibial technique, with collateral/cap-
sular ligament surgery as indicated. Not all cases are
amenable to the arthroscopic approach and the oper-
ating surgeon must assess each case individually.
Surgical timing
Surgical timing is dependent upon vascular sta-
tus, reduction stability, skin condition, systemic
injuries, open versus closed knee injury, menis-
cus and articular surface injuries, other orthope-
dic injuries, and the collateral/capsular ligaments
involved. Certain ACL/PCL/MCL injuries can be
treated with brace treatment of the medial collat-
eral ligament followed by arthroscopic combined
ACL/PCL reconstruction in 4–6 weeks after heal-
ing of the MCL. Other cases may require repair or
reconstruction of the medial structures and must
be assessed on an individual basis.
Combined ACL/PCL/posterolateral injuries are
addressed as early as safely possible. ACL/PCL/
posterolateral repair-reconstruction performed
between 2 and 3 weeks postinjury allows seal-
ing of capsular tissues to permit an arthroscopic
approach, and still permits primary repair of
injured posterolateral structures.
Open multiple-ligament knee injuries/dislocations
may require staged procedures. The
Th collateral/cap-
sular structures are repaired after through irriga-
tion and debridement, and the combined ACL/PCL
reconstruction is performed at a later date after
wound healing has occurred. Care must be taken in
all cases of delayed reconstruction to confirm
fi that
the tibiofemoral joint is reduced by serial anterior-
posterior and lateral radiographs.
The surgical timing guidelines outlined above
should be considered in the context of the individ-
ual patient. Many patients with multiple ligament
injuries of the knee are severely injured multiple-
trauma patients with multisystem injuries. Modi-
fiers to the ideal timing protocols outlined above
include the vascular status of the involved extrem-
ity, reduction stability, skin condition, open or
closed injury, and other orthopedic and systemic
The multiple-ligament injured knee 449
injuries. These additional considerations may cause
the knee ligament surgery to be performed earlier
or later than desired. We have previously reported
excellent results with delayed reconstruction in
the multiple-ligament injured knee (6,7).
Graft selection
The ideal graft material is strong, provides secure
fixation, is easy to pass, readily available, and has
low donor sit morbidity. The
Th available options in the
United States are autograft and allograft sources.
Our preferred graft for the PCL is the Achilles ten-
don allograft because of its large cross-sectional
and strength, absence of donor site morbidity, and
easy passage with secure fixation.
fi We prefer Achil-
les tendon allograft or bone-patellar tendon-bone
allograft for the ACL reconstruction. The
Th preferred
graft material for the posterolateral corner is a split
biceps tendon transfer, or free autograft (semiten-
dinosus) or allograft tissue when the biceps tendon
is not available (46). Cases requiring medial collat-
eral ligament and posteromedial corner surgery
may have primary repair, reconstruction, or a com-
bination of both. Our preferred method for MCL
and posteromedial reconstructions is a postero-
medial capsular shift with autograft or allograft
supplementation as needed.
Surgical approach
Our surgical approach is a single-stage arthroscopic
combined ACL/PCL reconstruction using the tran-
stibial technique with collateral/capsular ligament
surgery as indicated. ThThe posterolateral corner is
repaired, and than augmented with a split biceps
tendon transfer, biceps tendon transfer, semiten-
dinosus free graft, or allograft tissue. Acute medial
injuries not amenable to brace treatment undergo
primary repair, and posteromedial capsular shift,
and/or allograft reconstruction as indicated. TheTh
operating surgeon must be prepared to convert to
a dry arthroscopic procedure, or open procedure if
fluid extravasation becomes a problem.
Surgical technique
The principles of reconstruction in the multiple-
ligament injured knee are to identify and treat all
pathology, accurately place tunnels, create ana-
tomic graft insertion sites, utilize strong graft mate-
rial, provide secure graft fixation,
fi and provide the
appropriate postoperative rehabilitation program.
The patient is positioned supine on the operating
room table. The surgical leg hangs over the side of
450 The Traumatic Knee
the operating table, and the well leg is supported by
the fully extended operating table. A lateral post is
used for control of the surgical leg. A leg holder is
not used. The surgery is done under tourniquet con-
trol unless prior arterial or venous repair contrain-
dicates the use of a tourniquet. Fluid infl flow is by
gravity. We do not use an arthroscopic fl fluid pump.
Allograft tissue is prepared prior to bringing the
patient into the operating room. Arthroscopic
instruments are placed with the infl flow in the supe-
rior lateral portal, arthroscope in the inferior lat-
eral patellar portal, and instruments in the inferior
medial patellar portal. An accessory extracapsular
extra-articular posteromedial safety incision is
used to protect the neurovascular structures, and
to confi
firm the accuracy of tibial tunnel placement.
The notchplasty is performed first and consists of
Th
ACL and PCL stump debridement, bone removal,
and contouring of the medial wall of the lateral
femoral condyle and the intercondylar roof. Th This
allows visualization of the over-the-top position
and prevents ACL graft impingement through-
out the full range of motion. Specially curved PCL
instruments are used to elevate the capsule from
the posterior aspect of the tibia.
The PCL tibial and femoral tunnels are created with
Th
the help of the PCL/ACL drill guide. TheTh transtibial
PCL tunnel courses from the anteromedial aspect
of the proximal tibial 1 cm below the tibial tubercle
to exit in the inferior lateral aspect of the PCL ana-
tomic insertion site. The PCL femoral tunnel origi-
nates externally between the medial femoral epi-
condyle and the medial femoral condylar articular
surface to emerge through the center of the stump
of the anterolateral bundle of the PCL. The Th PCL
graft is positioned and anchored on the femoral or
tibial side, and left free on the opposite side.
The ACL tunnels are created using the single-inci-
sion technique. The tibial tunnel begins externally
at a point 1 cm proximal to the tibial tubercle on
the anteromedial surface of the proximal tibia to
emerge through the center of the stump of the
ACL tibial footprint. The femoral tunnel is posi-
tioned next to the over-the-top position on the
medial wall of the lateral femoral condyle near the
ACL anatomic insertion site. The tunnel is created
to leave a 1–2 mm posterior cortical wall so that
interference fixation can be used. The ACL graft is
positioned and anchored on the femoral side, with
the tibial side left free. Attention is then turned to
the posterior lateral corner.
Posterolateral reconstruction with the free graft
figure of eight technique utilizes semitendinosus
autograft or allograft, Achilles tendon allograft, or
other soft tissue allograft material. A curvilinear
incision is made in the lateral aspect of the knee
extending from the lateral femoral epicondyle to
the interval between Gerdy’s tubercle and the fi fibu-
lar head. The fibular head is exposed and a tunnel is
created in an anterior to posterior direction at the
area of maximal fibular diameter. The tunnel is cre-
ated by passing a guide pin followed by a cannulated
drill usually 7 mm in diameter. TheTh peroneal nerve
is protected during tunnel creation, and through-
out the procedure. The free tendon graft is then
passed through the fibular
fi head drill hole. An inci-
sion is then made in the iliotibial band in line with
the fibers directly overlying the lateral femoral epi-
condyle. The graft material is passed medial to the
iliotibial band, and the limbs of the graft are crossed
to form a figure of eight. A drill hole is made 1 cm
anterior to the fibular collateral ligament femoral
insertion. A longitudinal incision is made in the lat-
eral capsule just posterior to the fi fibular collateral
ligament. The graft material is passed medial to the
iliotibial band, and secured to the lateral femoral
epicondylar region with a screw and spiked liga-
ment washer at the above-mentioned point. The Th
posterolateral capsule that had been previously
incised is then shifted and sewn into the strut of
figure of eight graft tissue material to eliminate
posterolateral capsular redundancy. Th The anterior
and posterior limbs of the figure of eight graft mate-
rial are sewn to each other to reinforce and tighten
the construct. The iliotibial band incision is closed.
The procedures described are intended to eliminate
posterolateral and varus rotational instability.
Posteromedial and medial reconstructions are per-
formed through a medial hockey stick incision. Care
is taken to maintain adequate skin bridges between
incisions. The superfificial medial collateral ligament
is exposed, and a longitudinal incision is made just
posterior to the posterior border of the MCL. Care
is taken not to damage the medial meniscus during
the capsular incision. The interval between the pos-
teromedial capsule and medial meniscus is devel-
oped. The posteromedial capsule is shifted antero-
superiorly. The
Th medial meniscus is repaired to the
new capsular position, and the shifted capsule is
sewn into the medial collateral ligament. When
superfificial MCL reconstruction is indicated, this
is performed by allograft tissue, or semitendino-
sus autograft. This graft material is attached at the
anatomic insertion sites of the superficialfi medial
collateral ligament on the femur and tibia. The Th pos-
teromedial capsular advancement is performed and
sewn into the newly reconstructed MCL.
Graft tensioning and fifixation
The PCL is reconstructed first followed by the ACL
and by the posterolateral complex, and medial liga-
ment complex. Tension is placed on the PCL graft
distally using the Arthrotek knee ligament tension-

ing device, and the tension is set for 20 pounds.
This restores the anatomic tibial step off ff. The knee
is cycled through a full range of motion to allow
pretensioning and settling of the graft. The Th knee
is placed in 70° of fl
flexion, and fixation is achieved
on the tibial side of the PCL graft with a screw and
spiked ligament washer and bioabsorbable interfer-
ence screw. The Arthrotek knee ligament tension-
ing device is applied to the ACL graft, and set to 20
pounds. The knee is placed in 70° of flexion, and
final fixation is achieved of the ACL graft with a
bioabsorbable interference screw, and spiked liga-
ment washer back-up fixation. Tensioning the ACL
graft at 70° of knee flflexion enabled us to maintain
the neutral position of the knee by monitoring the
tibial step off
ff at the time of final graft fixation. The
knee is then placed in 30° of fl
flexion, the tibial inter-
nally rotated, slight valgus force applied to the knee,
and final tensioning and fixation of the posterolat-
eral corner is achieved. The MCL reconstruction is
tensioned with the knee in 30° of flexion with the
leg in a figure four position. Full range of motion is
confi
firmed on the operating table to assure the knee
is not “captured” by the reconstruction.
Technical hints
The posteromedial safety incision protects the neu-
rovascular structures, confirms fi accurate tibial tun-
nel placement, and allows more expeditious com-
pletion of the surgical procedure. The single incision
ACL reconstruction technique prevents lateral
cortex crowding, and eliminates multiple through
and through drill holes in the distal femur reduc-
ing stress riser eff
ffect. It is important to be aware of
the two tibial tunnel directions, and to have a 1-cm
bone bridge between the PCL and ACL tibial tun-
nels. This will reduce the possibility of fracture. We
have found it useful to use primary and back-up fix- fi
ation. Primary fixation is with resorbable interfer-
ence screws, and back-up fixation is performed with
a screw and spiked ligament washer. Secure fixation
fi
is critical to the success of this surgical procedure.
The order of tensioning is the PCL first, the ACL
second, the posterolateral third, and the MCL last.
Restoration of the normal tibial step-off ff at 70° of
flexion has provided the most reproducible method
of establishing the neutral point of the tibia-femo-
ral relationship in our experience.
Postoperative rehabilitation
The knee is maintained in full extension for 3
weeks non-weight bearing. Progressive range of
The multiple-ligament injured knee 451
motion occurs during weeks 4 through 6. Progres-
sive weight bearing occurs at the end of 6 weeks.
Progressive closed kinetic chain strength training
and continued motion exercises are performed. ThThe
brace is discontinued after the 10th week. Return
to sports and heavy labor occurs after the ninth
postoperative month when suffifficient strength and
range of motion has returned.
Complications
Potential complications in treatment of the multi-
ple-ligament injured knee include failure to recog-
nize and treat vascular injuries (both arterial and
venous), iatrogenic neurovascular injury at the
time of reconstruction, iatrogenic tibial plateau
fractures at the time of reconstruction, failure to
recognize and treat all components of the instabil-
ity, postoperative medial femoral subchondral col-
lapse, knee motion loss, and postoperative ante-
rior knee pain.
Results
Recent published results in the treatment of the
multiple-injured knee provide insight into this
complex problem. Wang et al. (48) reviewed the
results of 25 combined arthroscopic single-bundle
PCL and posterolateral complex reconstructions.
The average time from injury to surgery was 10
months with an average follow-up of 40 months.
Restoration of ligamentous stability was obtained
in only 44%, with 20% having 5–10 mm of residual
laxity. Forty-four percent of the knees had degen-
erative changes at the time of surgery. Their study
recommended early surgical repair of the multiple-
injured knee.
Ohkoshi et al. (49) studied a two-stage recon-
struction technique with autograft tissue for knee
dislocations. Their study group consisted of nine
knees undergoing a two-stage reconstruction with
autograft tissue. Stage 1 consisted of PCL recon-
struction using semitendinosus and gracilis ham-
string autografts from the contralateral knee at 2
weeks postinjury. Stage 2 consisted of ACL recon-
struction plus/minus MCL and/or posterolateral
reconstruction at 3 months postinjury. The Th ACL
reconstruction was performed with ipsilateral
hamstring or bone-patellar tendon-bone autograft
reinforced by an artifificial ligament. MCL recon-
struction was performed with autogenous semi-
tendinosus plus artifi
ficial ligament reinforcement.
Posterolateral reconstruction was performed with
biceps tendon transfer. All knees in their study
452 The Traumatic Knee
demonstrated negative Lachman’s test, 66% nega-
tive posterior drawer test, and 44% grade 1 pos-
terior drawer. All knees were stable to varus and
valgus stress. KT-1000 arthrometer side-to-side
diff
fference values were reported to be 2.3 mm ±
1.9 mm, and passive range of motion of the surgi-
cal knee being 0–139°.
Mariani et al. (50) have recently reported their
results of one-stage arthroscopically assisted ACL
and PCL reconstruction. Their study group con-
sisted of 15 knees. The ACL reconstructions were
performed using hamstring autografts, and the
PCL reconstruction using bone-patellar tendon-
bone autografts. KT-2000 arthrometer reported
side-to-side diff fference measurements were 5.8 mm
± 1.1 mm. Hospital for Special Surgery knee liga-
ment rating scale preoperative and postopera-
tive scores were 32 and 89 points, respectively.
Lysholm knee ligament rating scale preoperative
and postoperative scores were 65 and 95 points,
respectively.
Richter et al. (51) compared surgical and non-sur-
gical treatment in patients with traumatic knee
dislocations. Their study group consisted of 89
patients. Sixty-three underwent surgical repair
and/or reconstruction within 2 weeks of injury,
and 26 patients had non-surgical treatment. The Th
average follow-up was 8.2 years. Lysholm knee lig-
ament rating scale scores were 78.3 for the surgical
group and 64.8 for the non-surgical group, a statis-
tically significant
fi diff
fference. Tegner knee ligament
rating scale scores were 4.0 for the surgical group
and 2.7 for the non-surgical group, a statistically
signifi
ficant diff
fference. These authors recommended
early surgical treatment of traumatic knee disloca-
tions.
Harner et al. (52) have demonstrated excellent
objective and functional results after surgical
reconstruction of the multiple-ligament injured
knee. Nearly all of their patients were able to
return to normal activities of daily living; how-
ever, the ability of their patients to return to high
demand sports and strenuous manual labor was
less predictable.
Fanelli sports injury clinic experience
Results without the Arthrotek graft tensioning boot
We have previously published the results of our
arthroscopically assisted combined ACL/PCL and
PCL/posterolateral complex reconstructions using
the reconstructive technique described in this
chapter (6,7,53–55). Our most recently published
2–10 years results of combined ACL-PCL recon-
structions without the Arthrotek graft tensioning
boot are presented here (54).
This study presented the 2–10 years (24–120
months) results of 35 arthroscopically assisted
combined ACL/PCL reconstructions evaluated pre-
and postoperatively using Lysholm, Tegner, and
Hospital for Special Surgery knee ligament rating
scales, KT-1000 arthrometer testing, stress radiog-
raphy, and physical examination.
This study population included 26 males, 9 females,
19 acute, and 16 chronic knee injuries. Ligament
injuries included 19 ACL/PCL/posterolateral insta-
bilities, 9 ACL/PCL/MCL instabilities, 6 ACL/PCL/
posterolateral/MCL instabilities, and 1 ACL/PCL
instability. All knees had grade III preoperative
ACL/PCL laxity and were assessed pre- and post-
operatively with arthrometer testing, three differ-
ff
ent knee ligament rating scales, stress radiogra-
phy, and physical examination. Arthroscopically
assisted combined ACL/PCL reconstructions were
performed using the single-incision endoscopic
ACL technique, and the single-femoral tunnel-
single bundle transtibial tunnel PCL technique.
PCLs were reconstructed with allograft Achilles
tendon (26 knees), autograft BTB (7 knees), and
autograft semitendinosus/gracilis (2 knees). ACLs
were reconstructed with autograft BTB (16 knees),
allograft BTB (12 knees), Achilles tendon allograft
(6 knees), and autograft semitendinosus/gracilis
(1 knee). MCL injuries were treated with bracing or
open reconstruction. PLI was treated with biceps
femoris tendon transfer, with or without primary
repair, and posterolateral capsular shift procedures
as indicated. No Arthrotek graft tensioning boot
was used in this series of patients.
Postoperative physical examination results
revealed normal posterior drawer/tibial step offff in
16/35 (46%) of knees. Normal Lackman and pivot
shift tests in 33/35 (94%) of knees. Posterolateral
stability was restored to normal in 6/25 (24%) of
knees, and tighter than the normal knee in 19/25
(76%) of knees evaluated with the external rota-
tion thigh-foot angle test. Thirty degrees varus
stress testing was normal in 22/25 (88%) of knees,
and grade 1 laxity in 3/25 (12%) of knees. Thirty
degrees valgus stress testing was normal in 7/7
(100%) of surgically treated MCL tears, and nor-
mal in 7/8 (87.5%) of brace-treated knees. Postop-
erative KT-1000 arthrometer testing mean side-to-
side difffference measurements were 2.7 mm (PCL
screen), 2.6 mm (corrected posterior), and 1.0 mm
(corrected anterior) measurements, a statistically
significant
fi improvement from preoperative sta-
tus (p
( = 0.001). Postoperative stress radiographic
side-to-side difffference measurements measured
at 90° of knee flexion, and 32 pounds of posteri-
orly directed proximal force were 0–3 mm in 11/21
(52.3%), 4–5 mm in 5/21 (23.8%), and 6–10 mm

in 4/21 (19%) of knees. Postoperative Lysholm,
Tegner, and HSS knee ligament rating scale mean
values were 91.2, 5.3, and 86.8, respectively, dem-
onstrating a statistically significant
fi improvement
from preoperative status (p( = 0.001). No Arthrotek
graft tensioning boot was used in this series of
patients.
The conclusions drawn from the study were that
combined ACL/PCL instabilities could be success-
fully treated with arthroscopic reconstruction and
the appropriate collateral ligament surgery. Sta-
tistically significant
fi improvement was noted from
the preoperative condition at 2–10 years follow-up,
using objective parameters of knee ligament rating
scales, arthrometer testing, stress radiography,
and physical examination. Postoperatively, these
knees are not normal, but they are functionally
stable. Continuing technical improvements will
most likely improve future results.
Results with the Arthrotek graft tensioning
boot
Two-year follow-up results of 15 arthroscopic-as-
sisted ACL PCL reconstructions using the Arthrotek
graft tensioning boot are described below (56).
This study group consists of 11 chronic and 4 acute
Th
injuries. These injury patterns included six ACL
PCL PLC injuries, four ACL PCL MCL injuries, and
five ACL PCL PLC MCL injuries. The Arthrotek
graft tensioning boot was used during the proce-
dures as in the surgical technique described above.
All knees had grade III preoperative ACL/PCL laxity
and were assessed pre- and postoperatively using
Lysholm, Tegner, and Hospital for Special Surgery
knee ligament rating scales, KT-1000 arthrometer
testing, stress radiography, and physical examina-
tion.
Arthroscopically assisted combined ACL/PCL
reconstructions were performed using the sin-
gle-incision endoscopic ACL technique, and the
single-femoral tunnel-single-bundle transtibial
tunnel PCL technique. PCLs were reconstructed
with allograft Achilles tendon in all 15 knees. ACLs
were reconstructed with Achilles tendon allograft
in all 15 knees. MCL injuries were treated surgi-
cally using primary repair, posteromedial capsular
shift, and allograft augmentation as indicated. PLI
was treated with allograft semitendinosus free
graft, with or without primary repair, and postero-
lateral capsular shift procedures as indicated. The
Th
Arthrotek graft tensioning boot was used in this
series of patients.
Postreconstruction physical examination results
revealed normal posterior drawer/tibial step off ff in
13/15 (86.6%) of knees. Normal Lackman test in
The multiple-ligament injured knee 453
13/15 (86.6%) knees, and normal pivot shift tests
in 14/15 (93.3%) knees. Posterolateral stability was
restored to normal in all knees with PLI when eval-
uated with the external rotation thigh-foot angle
test (nine knees equal to the normal knee and two
knees tighter than the normal knee). Thirty degree
varus stress testing was restored to normal in all 11
knees with posterolateral lateral instability. Thirty
and zero degree valgus stress testing was restored
to normal in all nine knees with medial side laxity.
Postoperative KT-1000 arthrometer testing mean
side-to-side diff
fference measurements were 1.6 mm
(range −3 to 7 mm) for the PCL screen, 1.6 mm
(range −4.5 to 9 mm) for the corrected posterior,
and 0.5 mm (range −2.5 to 6 mm) for the corrected
anterior measurements, a significant
fi improvement
from preoperative status. Postoperative stress
radiographic side-to-side difference
ff measurements
measured at 90° of knee flexion and 32 pounds of
posteriorly directed proximal force using the Telos
stress radiography device were 0–3 mm in 10/15
knees (66.7%), 4 mm in 4/15 knees (26.7%), and
7 mm in 1/15 knees (6.67%). Postoperative Lysh-
olm, Tegner, and HSS knee ligament rating scale
mean values were 86.7 (range 69–95), 4.5 (range
2–7), and 85.3 (range 65–93), respectively, demon-
strating a significant
fi improvement from preopera-
tive status.
The study group demonstrates the effifficacy and suc-
cess of using a mechanical graft tensioning device
(Arthrotek graft tensioning boot) in single-bundle,
single-femoral tunnel arthroscopic PCL recon-
struction.
Conclusions/Summary
Multiple-ligament injuries of the knee are com-
plex injuries requiring a systematic approach to
evaluation and treatment. Gentle reduction and
documentation and treatment of vascular inju-
ries are primary concerns in the acute dislocated/
multiple-ligament injured knee. Arthroscopically
assisted combined ACL/PCL reconstruction with
appropriate collateral ligament surgery is a repro-
ducible procedure. Knee stability is improved
postoperatively when evaluated with knee liga-
ment rating scales, arthrometer testing, and stress
radiographic analysis. Acute MCL tears when com-
bined with ACL/PCL tears may in certain cases be
treated with bracing. Posterolateral corner injuries
combined with ACL/PCL tears are best treated
with primary repair as indicated, combined with
reconstruction using a post of strong autograft
(split biceps tendon, biceps tendon, semitendino-
sus), or allograft tissue. Surgical timing depends
upon the ligaments injured, the vascular status of
454 The Traumatic Knee
the extremity, reduction stability, and the overall
health of the patient. We prefer the use of allograft
tissue for reconstruction in these cases because of
the strength of these large grafts and the absence
of donor site morbidity.
Future directions
We have now converted to performing the double-
bundle, double-femoral tunnel PCL reconstruction
surgical technique. Th This double-bundle, double-
femoral tunnel technique more closely approxi-
mates the anatomic insertion site of the native PCL
and should theoretically provide improved results.
Our early clinical results are encouraging; however,
there are no long-term clinical results available as
of this writing.
Another area of interest is the incorporation of
autologous platlette rich fibrin
fi matrix into the
grafts used in the cruciate and collateral ligament
reconstructive procedures. There
Th are several stud-
ies indicating favorable eff ffects on the ligament
graft tissue and the clinical results (57–59). We
have demonstrated favorable 1–2 years clinical
results with respect to graft incorporation, wound
healing, and early stability.
References
1. Butler DL, Noyes FR, Grood ES (1980) Ligamentous
restraints to anterior-posterior drawer in the human knee.
A biomechanical study. JBJS 62A:259–270
2. Wilson SA, Vigorita VJ, Scott WN (1994) Anatomy.
In: Scott WN, editor. The knee. St. Louis, MO: Mosby
books
3. Van Dommelen BA, Fowler PJ (1989) Anatomy of the pos-
terior cruciate ligament. A review. AJSM 17:24–29
4. Gollehon DL, Torzilli PA, Warren RF (1987) The Th role of
the posterior lateral corner and cruciate ligaments in the
stability of the human knee. A biomechanical study. JBJS
69A:233–242
5. Seebacher JR, Inglis AE, Marshall JL, et al. (1982) The Th
structure of the posterolateral aspect of the knee. JBJS
64A:536–541
6. Fanelli GC, Gianotti BF, Edson CJ (1996) Arthroscopically
assisted combined anterior and posterior cruciate liga-
ment reconstruction. Arthroscopy 12(1):5–14
7. Fanelli GC, Gianotti BF, Edson CJ (1996) Arthroscopically
assisted combined posterior cruciate ligament/posterior
lateral complex reconstruction. Arthroscopy 12(5):521–
530
8. Fanelli GC, Gianotti BF, Edson CJ (1994) The posterior
cruciate ligament arthroscopic evaluation and treatment.
Arthroscopy 10(6):673–688
9. Ghalambor N, Vangsness CT (1995) Traumatic dislocation
of the knee: a review of the literature. Bull Hosp Joint Dis
54(1):19–24
10. Good L, Johnson RJ (1995) The Th dislocated knee. JAAOS
3(5):284–292
11. Shelbourne KD, Porter DA, Clingman JA, et al. (1991)
Low-velocity knee dislocation. Orthop Rev 20:995–1004
12. Wascher DC, Dvirnak PC, Decoster TA (1997) Knee dislo-
cation: initial assessment and implications for treatment.
J Orthop Trauma 11(7):525–529
13. Frassica FJ, Sim FH, Staeheli JW, et al. (1991) Dislocation
of the knee. CORR 263:200–205
14. Green A, Allen BL (1977) Vascular injuries associated with
dislocation of the knee. JBJS 59A:236–239
15. Wand JS (1989) A physical sign denoting irreducibility of
a dislocated knee. JBJS 71B:862
16. Kennedy JC (1963) Complete dislocation of the knee joint.
JBJS 45A:889–904
17. Shields L, Mital M, Cave EF (1969) Complete dislocation
of the knee: experience at the Massachusetts General Hos-
pital. J Trauma 9:192–215
18. Meyers MH, Harvey JP, Jr. (1971) Traumatic disloca-
tion of the knee joint: a study of eighteen cases. JBJS
53A:16–29
19. Girgis FG, Marshall JL, Monajem A (1975) The Th cruciate
ligaments of the knee joint. CORR 106:216–231
20. Roman PD, Hopson CN, Zenni EJ, Jr. (1987) Traumatic
dislocation of the knee: a report of 30 cases and literature
review. Orthop Rev 16:917–924
21. Sisto DJ, Warren RF (1985) Complete knee dislocation:
a follow-up study of operative treatment. CORR 198:94–
101
22. Meyers MH, Moore TM, Harvey JP, Jr. (1975) Traumatic
dislocation of the knee joint. JBJS 57A:430–433
23. Welling RE, Kakkasseril J, Cranley JJ (1981) Complete
dislocations of the knee with popliteal vascular injury. J
Trauma 21:450–453
24. Almekinders LC, Logan TC (1991) Results following treat-
ment of traumatic dislocation of the knee joint. CORR
284:203–207
25. Shapiro MS, Freedman EL (1995) Allograft reconstruction
of the anterior and posterior cruciate ligaments after trau-
matic knee dislocation. AJSM 23(5):580–587
26. Ashworth EM, Dalsing MC, Glover JL, et al. (1988) Lower
extremity vascular trauma: a comprehensive, aggressive
approach. J Trauma 28:329
27. Rich NM, Hobson RW, Wright CB (1974) Repair of lower
extremity venous trauma: a more aggressive approach
required. J Trauma 14:639
28. Cone JC (1989) Vascular injury associated with fracture-
dislocations of the lower extremity. CORR 243:30–35
29. Grimley RP, Ashton F, Slaney G, et al. (1981) Popliteal arterial
injuries associated with civil knee trauma. Injury 13:1–6
30. O’Donnell TF Jr, Brewster DC, Darling RC, et al. (1977)
Arterial injuries associated with fractures and/or disloca-
tions of the knee. J Trauma 17:775–784
31. Savage R (1980) Popliteal artery injury associated with knee
dislocation: improved outlook? Am Surg 46:627–632
32. Rich NM, Hobson RW, Collins GJ, et al. (1976) The Th eff ffect
of acute popliteal venous interruption. Ann Surg 183:365–
368
33. Wright DG, Covey DC, Born CT, et al. (1995) Open disloca-
tion of the knee. J Orthop Trauma 9(2):135–140
34. Malizos KN, Xenakis T, Mavrodontidis AN, et al. (1997)
Knee dislocations and their management. Acta Orthop
Scand (Suppl 275) 68:80–83
35. McCoy GF, Hannon DG, Barr RJ, et al. (1987) Vascular
injury associated with low-velocity dislocations of the
knee. JBJS 69B:285–287
36. Moore TM (1981) Fracture-dislocation of the knee. CORR
156:450–453
37. Hill JA, Rana NA: Complications of posterolateral disloca-
tion of the knee: case report and literature review. CORR
154:212–215.
38. Applebaum R, Yellin AE, Weaver FA, et al. (1990) Role of
routine arteriography in blunt lower-extremity trauma.
Am J of Surg 160:221–225

39. Fanelli GC (1999) American Academy of Orthopaedic
Surgeons 66th Annual Meeting. February 4–9, 1999. Ana-
heim, CA.
40. Trieman GS, Yellin AE, Weaver FA, et al. (1992) Evaluation
of the patient with a knee dislocation: the case for selec-
tive arteriography. Arch Surg 127(9):1056–1063
41. Myles JW (1967) Seven cases of traumatic dislocation of
the knee. Proc R Soc Med 60:279
42. Taylor AR, Arden GP, Rainey MA (1972) Traumatic dislo-
cations of the knee: a report of forty three cases with spe-
cial reference to conservative treatment. JBJS 54B:94
43. Noyes FR, Barber-Westin SD (1997) Reconstruction of the
anterior and posterior cruciate ligaments after knee dislo-
cation. AJSM 25(6):769
44. Fanelli GC. PCL injuries in trauma patients. Arthroscopy
9:291–294
45. Fanelli GC, Edson CJ (1995) PCL injuries in trauma
patients, part II. Arthroscopy 11:526–529
46. Fanelli GC, Feldmann DD (1998) The use of allograft tissue
in knee ligament reconstruction. In: Parisien JS, editor. Cur-
rent techniques in arthroscopy, 3rd ed. New York: Thieme
Th
47. Fanelli GC (1999) American Academy of Orthopaedic
Surgeons 66th Annual Meeting. February 4–9, 1999. Ana-
heim, CA
48. Wang CJ, Chen HS, Huang TW, Yuan LJ (2002) Outcome
of surgical reconstruction for PCL and PLC instabilities of
the Knee. Injury 33(9):815–821
49. Ohkoshi Y, Nagasaki S, Shibat N, et al. (2002) Two-stage
reconstruction with autografts for knee dislocations.
CORR 398:169–175
50. Mariani PP, Margheritini F, Camillieri G (2001) One-stage
arthroscopically assisted anterior and posterior cruciate
ligament reconstruction. Arthroscopy 17(7):700–707
51. Richter M, Bosch U, Wipperman B, et al. (2002) Compari-
son of surgical repair or reconstruction of the cruciate
ligaments versus nonsurgical treatment in patients with
traumatic knee dislocations. Am J Sports Med 30(5):718–
727
The multiple-ligament injured knee 455
52. Harner C, Waltrip R, Bennett C, et al. (2004) Surgi-
cal management of knee dislocations. JBJS (AM) 86
(2):262–273
53. Fanelli GC, Edson CJ (2002) Arthroscopically assisted
combined ACL/PCL reconstruction. 2-10 year follow-up.
Arthroscopy18(7):703–714
54. Fanelli GC, Edson CJ (2004) Combined posterior cruciate
ligament–posterolateral reconstruction with Achilles ten-
don allograft and biceps femoris tendon tenodesis:2-10
year follow-up. Arthroscopy 20(4):339–345
55. Fanelli GC, Orcutt DR, Edson CJ (2005) Current concepts.
The multiple ligament injured knee: evaluation, treatment,
and results. Arthroscopy 21(4):471–486
56. Fanelli GC, Edson CJ, Orcutt DR, et al. (2005) Treatment
of combined anterior posterior cruciate ligament medial
lateral side knee injuries. J Knee Surg 18(3):240–248
57. Sanchez M, Azofra J, Aizpurua B, et al. (2003) Application
of growth factor rich autologous plasma in arthroscopic
surgery. Cuadernos de Arthroscopia 10:12–19
58. Weiler A, Forster C, Hunt P, et al. (2004) The
Th infl
fluence of
locally applied platelet derived growth factor BB on free
tendon graft remodeling after anterior cruciate ligament
reconstruction. Am J Sports Med 4:881–891
59. Yasuda K, Tomita F, Yamazaki S, et al. (2004) The
Th effffect of
growth factors on biomechanical properties of the bone
patellar tendon bone graft after anterior cruciate ligament
reconstruction. Am J Sports Med 4:870–880
Recommended readings
1. Fanelli GC, editor (2001) Posterior cruciate ligament inju-
ries: a practical guide to management. New York: Springer-Ver-
lag
2. Fanelli GC, editor (2004) The multiple ligament injured
knee: a practical guide to management. New York: Springer-
Verlag
 Chapter 39

F.U. Veith, J. Ménétrey Surgical treatment of cartilage tear:

principles and results

Introduction proteoglycans. This layer contributes to resist com-

Basic science: properties
and healing potential after injury
Composition of hyaline articular cartilage
pressive loads. The deep layer, with collagen fibers
and chondrocytes oriented perpendicular fashion to
the articular surface, also contributes to resistance
to compressive stress. Furthermore, the negative
charge of the carboxyl and sulfate groups situated
on the glycosaminoglycans creates an affi ffinity for
water which contributes to resistance against load.

T
he articular cartilage extracellular matrix con-
sists of water and a macromolecular frame-
work. Water and electrolytes offer
ff viscoelastic
properties and provide nutrition of chondrocytes
through diff ffusion and discharge of metabolites.
The macromolecular framework comprises type II
collagen with minute amounts of types V, VI, IX, X,
XI, XII, and XIV as well as large aggregating sulfated
proteoglycans along with other glycoproteins.
Chondrocytes, which are interspersed in the
matrix, which they synthesize, originate from mes-
enchymal stem cell origin. Th There is evidence that
some growth factors such as transforming growth
factor- (TGF-), bone morphogenic proteins
(BMPs), insulin-like growth factor (IGF), fibroblast
fi
growth factor (FGF), and platelet-derived growth
factor (PDGF) infl fluence migration and mitosis of
chondrocytes as well as matrix production. Such
eff
ffect has been demonstrated in vivo and has
opened a pathway for potential treatment of car-
tilage defect. However, further study will be neces-
sary to characterize the healing process and estab-
lish standardized treatment protocol (1).
Human articular cartilage also ensures a func-
tion of volume expansion. The negative charge
mentioned above also results in repelling forces
between aggrecans which contributes to volume
expansion. Another function of articular cartilage
is joint lubrifi
fication, which is obtained by the inter-
action between water and the matrix generates
piezoelectric charges which stimulate water flow, fl
contribute to creating viscosity in the knee joint.
Cartilage also provides adhesion of cartilage to bone:
under the deep layer of the cartilage, a thin zone
of calcifi
fied cartilage provides adhesive properties.
Recently, some evidence has suggested the role of
cartilage in the upregulation of growth factors. Aaron
(2) has suggested that electric and electromagnetic
fields in cartilage can produce such an eff
ffect.
Healing potential after injury
Despite its capacity to withstand intensive and
repetitive physical stress, cartilage does not respond
well to injuries once they have occurred. Hunter, as

Functions of articular cartilage

Human articular cartilage offers ff resistance to
mechanical stress. The cartilage is organized in dif-
ferent layers which can withstand combined and
different
ff types of mechanical stress (Fig. 1). The
superfi
ficial layer of articular cartilage, which pro-
tects the deeper layers, consists of a tightly packed
type II and IX collagen fibers
fi parallel to the articu-
lar surface and a cellular layer of fl
flattened chondro-
cytes. Collagen IX is thought to provide resistance
to shear. This layer off
ffers resistance to shear. The Fig. 1 – Articular cartilage layers. Collagen fibers are tangentially oriented
transitional layer of articular cartilage is composed in the superficial layer (resistance to shear) while they gradually get verti-
of collagen fibers which are oriented obliquely to cally oriented as they reach the deeper layers (resistance to compression).
the articular surface, spherical chondrocytes, and The calcified layers provide adhesion of the cartilage to bone .
458 The Traumatic Knee
early as 1743, stated that “once destroyed, is not
repaired” (3). The response of cartilage to injury
diff
ffers from that of other tissues because of its
intrinsic complexity, its avascularity, the lack of
chondrocytes migration, and the limited ability of
mature chondrocytes to replicate and adapt their
synthetic patterns. Disruption of normal cartilage
tissue results in further degeneration.
Partial-thickness cartilage lesions
Following a partial-thickness chondral injury,
necrosis develops at the periphery of the lesion.
After a limited and clinically insignificant
fi phase
of division, chondrocytes around the site of injury
cease to multiply or synthesize matrix and tend to
form clusters (4).
That clustering phenomenon is so typical of injury
and osteoarthritis that it is often used as one on
the criteria when judging cartilage repair or trans-
plants on a microscopic level.
Hence, after a low-energy trauma, partial-thick-
ness articular cartilage defects do not signifificantly
heal. The natural history of commonly found
asymptomatic lesions is unclear, but many authors
believe that small lesions are only rarely associated
with signifificant clinical symptoms in the short
term (5–8) Whether or not asymptomatic inju-
ries will eventually lead to pain and dysfunctions
varies with characteristics linked to the initial
lesion (location, pattern, and depth) coupled with
factors related to the patient (sex, age, weight,
physical activities, comorbidities, and associated
abnormalities aff ffecting the lower limb such as liga-
mentous instability, menisci disruption, malalign-
ment) (6,9). However, a vicious circle might result
in further degeneration (see Fig. 1). Th This pattern
suggests that options for conservative treatment
are limited in the long term, even for small lesions
which might not initially present with symptoms.
Consensus is that once symptomatic, pain related
to cartilage lesion is likely to persist or worsen
without treatment (10–12). Therefore, early diag-
nosis is critical in off
ffering the patient a successful
treatment.
The avascular nature of articular cartilage entails
that if pure cartilage injuries occur, the inflamma-
fl
tory cascade is not triggered. It has even been sug-
gested that articular cartilage matrix may contain
inhibitors of vascular and macrophage invasion,
and consequently, clot formation (6). Hemorrhage
only occurs if the subchondral bone is exposed.
That is why, paradoxically, a full-thickness tear
present with a higher healing potential than a low
energy partial-thickness lesion.
Full-thickness cartilage lesions
On a macroscopic level, the architectural complex-
ity of articular cartilage makes it difficult
ffi to repro-
duce after injury. On a microscopic level, the defect
created by cartilage lesion is fifilled with a fibrin clot,
trapping cells from blood and marrow. Th The infl flam-
matory phases then produce a maturing, cellular
mass before the reparative tissue in the cartilage
defect undergoes a metaplasia to a hyaline-like
chondroid tissue. The deeper portions form bone,
reconstituting the subchondral plate. Even though
infl
flammatory response induces primitive mesen-
chymal cells to produce fibrocartilage, the latter
is composed of type I collagen, unlike hyaline car-
tilage which is mainly composed of collagen type
II. Consequently, proteoglycan content decreases
and the tangential collagen layers of the superfi- fi
cial zone do not appear (13). Overall, the repair
cartilage which replaces the bruised cartilage has
inferior biomechanical and biochemical features
compared with hyaline cartilage (6,14,15).
Because full-thickness disruptions are fi filled with
fibrocartilage with diminished biomechanical
functions, it is likely that the age, weight, level and
nature of physical activity of the patient, associ-
ated meniscal and ligamentous lesions, size of
the lesion (16), as well as its location in relation
to the weight bearing surface of the joint, along
with a variety of other mechanical and biochemical
factors which are diffi fficult to quantify determine
whether the lesions are symptomatic or not (6,16)
(Fig. 2).
Some factors might positively influence fl the out-
come of cartilage lesions. For instance, it has been
suggested that continuous passive motion can
favorably inflfluence reparation (17–20). Experi-
mental animal studies also showed evidence that
young age might contribute to reparation (21).
Overall, it is noteworthy that what was once
thought to be a perennial belief that articular car-
tilage was incapable of healing has been severely
shaken by recent studies. Frisbie (22), in an animal
model using horses, showed that repair tissue con-
tained about 70% type II collagen at 1 year, sug-
gesting a possible regeneration of healthy cartilage.
Steadman (23) believes that repair tissue remodels
in the long run to become stable after observing
a high success rate of microfracture surgery after
chondral injury in a series of patients.
There are controversies concerning the self-lim-
ited nature of most of the cartilage lesions. Data
which could help identify the injuries which will
stabilize and those which will not are not avail-
able today. Conservative treatments chiefl fly rely on
rest, avoidance of activities which put stress on the
knee joint, physiotherapy aimed to stabilize the
knee by balanced muscular contractions and pro-
prioceptive exercise, and analgesics such as anti-
infl
flammatory drugs. Other therapeutic options,
such as bracing or intra-articular injections, have
also been proposed.
 Surgical treatment of cartilage tear: principles and results 459

Probably
asymptomatic
Probably symptomatic replacement if small lesion

Exposure of
subchondral bone
Full thickness
cartilage defect

No primary
Partial thickness
cartilage defect response

Decreases resistance
to compression, tear Chondrocyte
and shear damage

Altered matrix
architecture

Fig. 2 – Schematic representation of the potential evolution of a cartilage injury leading to a symptomatic or an asymptomatic lesion.

Surgical treatments have been developed to address
failure of conservative treatments. For focal grade
III and IV lesions according to the International
Cartilage Repair Society (ICRS) classification,
fi
operative techniques offffer a wide array of treat-
ment options, ranging from palliative procedures
to restorative techniques.
Physiopathology and nature of cartilage lesions
types of chondral and osteochondral lesions
In decreasing order of prevalence, chondral and
osteochondral diseases of the knee can be classi-
fied as follows:
– Focal chondral lesions (the main focus of this
chapter)
– Chondromalacia patellae
– Osteochondrosis dissecans
– Osteoarthritis
– Others
Mechanism of injury
It is interesting to analyze the nature and quan-
tity of energy which are necessary to disrupt a
normal articular surface. Chondral surfaces of the
knee joint are extremely resistant. However, joint
cartilage incurs injury when exposed to excessive
compression, tear and shear forces. Repo (24),
after submitting human cartilage to blunt trauma,
showed that it could withstand impact loads of as
much as 25 N/mm2 (25 MPa) without noticeable
damage (chondrocyte death or cartilage fi fissures).
There are still controversies today as to weather
the increase in impact loading will first damage the
patellofemoral articular cartilage or cause a femo-
ral fracture (25). Zimmerman (26) infl flicted repeti-
tive cycles of 1000 psi compression load on carti-
lage plugs in vitro and showed disruption in tissue.
Increasing loads or cycles induced the propagation
of vertical fissures from the joint surface to calci-
fied cartilage and the extension of oblique fissures
into areas of intact cartilage, extending the damage
and creating cartilage flaps and free fragments.
The fact that higher loads can cause similar changes
with fewer cycles suggests that injury can follow
an acute impact loading of the articular surface
or twisting movements of the joint. It may also
result from overuse. The circumstances leading
to constraints on cartilage may have traumatic or
degenerative origins (27) or both combined in a
causal cascade. Traumatic chondral lesions gener-
ally occur as a result of compression and rotational
shearing forces (28). It is reasonable to assume
that the size of the ensuing lesion will correspond
to the contact area of the cartilage with the oppos-
ing chondral surface.
When load shifts, torsion or impact occurs rapidly.
There is not enough time for the water to move
460 The Traumatic Knee
within the matrix in order to ensure adaptational
deformation of cartilage. Proteoglycan molecules
are consequently damaged, whereas their new syn-
thesis by traumatized and apoptotic chondrocytes
is impaired. The loss of proteoglycan has been asso-
ciated with stiff
ffness and loss of impermeability of
articular cartilage. Furthermore, in rapid move-
ments, muscles cannot contract in order to absorb
excessive energy (29–31).
Pathological patellar tracking (30,31), unphysi-
ological load transmission (34), and alteration of
center of motion (35) have been implicated in the
genesis of chondral defect in the human knee.
It has been suggested that lesions moderate in
surface (mean area of 2.1 cm2 according to Hjelle,
with 88% of the lesions measuring less than 4 cm2)
follow a traumatic event, whereas larger defects
result from repeated micro traumas or degenera-
tive changes (36).
Focal chondral lesions have been associated to
trauma. In an arthroscopic study, Hjelle at al. (36)
reviewed patient suffffering from chondral or osteo-
chondral lesions of the knee. Of these patients,
38% remembered having sustained an acute
trauma that they could correlate with their com-
plaints. When narrowing down the patients to the
ones who presented focal lesions, that percentage
increased to 61%.
Associated knee lesions
Although isolated chondral lesions can occur,
with a reported prevalence of approximately 4%,
chondral injuries are generally associated with
other intra-articular abnormalities, such as liga-
mentous and meniscal injuries, synovitis, and less
commonly pathology of synovial plica and corpus
liberum (36). Questions remain as to the causal
relationship between cartilage injuries of the knee
and associated lesions.
Menisci lesions
When arthroscopically reviewing focal chondral or
osteochondral lesions of the knee, Hjelle et al. (36)
found concomitant menisci lesions in 42%. In the
Curl study (37), medial meniscus injury was the
most common associated lesion after 30 years of
age. Medial meniscus injuries were more common
in male than in female patients. Lateral meniscal
injuries were more frequent in younger males than
females, with an inversion of this tendency after
woman reached the age of 50 years.
Casscells (38), after he conducted a retrospective
study on 350 knees after arthrotomy and menis-
cectomies were performed, as well as a cadav-
eric and arthroscopic study (39) states that torn
menisci and cartilage defects are concomitant but
unrelated findings. Other authors like Noble (40)
corroborate this opinion.
However, there has been evidence of a positive
correlation between the delay of meniscal surgery
after injury and the severity of cartilage disease in
the knee (41).
Anterior cruciate ligament tears
Anterior cruciate ligament (ACL) lesions were
concomitant to focal chondral or osteochondral
defects in 26% of the knees reviewed by Hjelle
et al. (36). In the Curl study (37), ACL tear is
the most frequently associated injury for young
patients. In the Curl series, roughly 40% of the
patients younger than 30 years who sufferff from
chondral injuries have associated ACL tears.
The prevalence decreases with age (some 30%
in the third decade, approximately 10% in the
fifth decade). Casscells (38) has also reported
on the strong prevalence of chondral lesions in
knees suff
ffering from ACL tears. Hjelle et al. (36)
reports both menisci and ACL tear association
to chondral focal lesions in 12% of the cases. In
the Hjelle series, focal chondral or osteochon-
dral defects were found in 19% of the patients.
In these patients, 61% related their current knee
problem to a previous trauma, and a concomitant
meniscal or ACL injury was found in 42% and
26%, respectively.
Morphology of chondral lesion
Situation
In a study encompassing a 1000 knee arthrosco-
pies, Hjelle et al. (36) showed that the preferential
site for focal chondral lesions was the medial femo-
ral condyle (58%). The remaining lesions were situ-
ated on the patella (11%), the lateral tibia (11%),
the lateral femoral condyle (9%), the trochlea (6%),
and the medial tibia (5%). Those
Th findings are con-
sistent with the observations made by Curl et al.
(37) who showed that the most common locations
for grade III lesions were the patella and the medial
femoral condyle. Grade IV lesions were predomi-
nantly located on the medial femoral condyle.
Size
In the Hjelle series (36), the mean chondral or
osteochondral defect area was 2.1 cm2 (range,
0.5–12; SD, 1.5). Eighty-eight percent of the chon-
dral or osteochondral defects were less than 4 cm2
(19% of the defects were less than 1 cm2; 26%
ranged from 1 to 2 cm2; 42% ranged from 2 to 4
cm2; and 12% were more than 4 cm2).
Number of lesions
Curl et al. (37) found an average of 2.7 lesions per
knee. According to Hjelle (36), when narrowing
down those lesions to focal chondral lesions only (as
opposed to osteoarthritis, chondromalacia patella

osteochondritis dissecans) 80% of the injuries were
unique, 12% were double, and 8% were triple.
Arthroscopic aspect of lesions
Curl and coworkers (37) qualified
fi the arthroscopic
aspect of chondral lesions, using the modified
fi Out-
erbridge classifi
fication (see below). Grade III lesions
of the patella were the most common (41.0%), fol-
lowed by grade II lesions (28.1%), grade IV (19.2%),
and grade I lesions (9.7%). In the Hjelle series (36),
using the ICRS classifi fication (see below), 14%
of the main focal defects were grade I, 26% were
grade II, 55% were grade III, and 5% (n = 10) were
grade IV.
Epidemiology
Prevalence
It is diffi
fficult, if not impossible, to establish who,
in the general population, suffers ff from chon-
dral lesion of the knee. An unknown number
of people who sustain articular surface injuries
will never develop symptoms or seek medical
treatment. Consequently, epidemiologic studies
of cartilage defects are conducted for patients
with symptomatic knees requiring arthroscopy,
which entails a considerable bias. In a study of
200 arthroscopies performed on symptomatic
patients, Zamber et al. (42) found that 62% of
them presented with at least one cartilage lesion.
The retrospective study by Curl and coworkers
(37) reviewed 31,516 knee arthroscopies. Chon-
dral lesions were found in 63% arthroscopies.
The prospective study of 1000 arthroscopies of
the knee conducted by Hjelle et al. (36) has also
considerably contributed to mapping the chon-
dral pathology of the knee.
In the collective of 1000 patients requiring knee
arthroscopy for various reasons, 61% of them
revealed chondral or osteochondral lesions, of
which 44% were osteoarthritis, 28% focal chondral
lesions, 23% chondromalacia patella, 2% osteo-
chondritis dissecans, and 3% others. Focal chon-
dral or osteochondral were found in 19% of the
arthroscopies.
Levy et al. (43) have described an increasing fre-
quency of chondral injuries in collegiate and pro-
fessional players, suggesting that athletes prac-
ticing activities involving repetitive joint impact,
pivoting movements, and rapid deceleration
motions were a target population for surgical pro-
cedure (44,45).
Age
In Zamber et al. study (42), 76% of patients suf-
fering from chondral lesions were older than 30
Surgical treatment of cartilage tear: principles and results 461
years. According to Curl et al. (37), the average
age of the patients with lesions was 43 years, pre-
dominantly in male patients (61.6% vs. 38.4% for
female patients). Overall, the majority (72%) of
grade IV lesions were found in patients older than
40 years. Patients younger than 40 years with
grade IV lesions accounted for 5% of all arthros-
copies.
Morphology of chondral lesion
Chondral or osteochondral injuries are difficult
ffi to
diagnose because there is no consistent or linear
correlation between clinical presentations on one
hand and the local gross and microscopic aspect of
the lesion on the other (42). Consequently, when
ffering from chondral injuries
treating a patient suff
of the knee, a global and personalized evaluation,
as well as thorough investigations, is necessary
before deciding on a treatment.
Patient evaluation and diagnosis
Patient evaluation
Symptoms
Chondral injuries of the knee are not associated
with any specifi
fic symptoms. Patients present with
disabling symptoms including pain in the knee,
low-grade effusion,
ff retropatellar crepitus, and
symptoms evocative of meniscal tears such as lat-
eral and medial tenderness associated to locking.
Personal history
Patient evaluation should take into account:
– Mechanism of injury: single or repetitive
trauma.
– Symptoms: onset, character, evolution, timing,
alleviating/aggravating factors, associated symp-
toms.
– Weight profifile: Felson (46) showed that elevated
BMI, in combination with lower limb malalign-
ment, increases the risk of knee osteoarthritis
progression. Furthermore, obesity might be
linked to an inability to comply with rehabilita-
tion protocols.
– Nature and intensity of physical activities.
– Prior treatments: conservative and surgical treat-
ments, response to treatment.
– Functional expectations.
Physical examination and investigations
Again, because the manifestations of cartilage
injury of the knee are often non-specifi
fic, physical
examination and investigations are mainly aimed
to identify concomitant pathologies of the lower
limbs and knee, such as instability of the joint,
malalignment of the lower extremity, patellofem-
462 The Traumatic Knee
oral mal-tracking, and incompetent or injured
menisci.
Diagnosis
Radiographic evaluation
Radiographic evaluation should include weight
bearing AP, AP at 45° of flexion (schuss), lateral,
and axial or skyline (Merchant) views. Th The follow-
ing elements should be documented by specific fi
radiographic imaging:
– Osteoarthritis and osteochondrosis dissecans:
standing AP, lateral, and patellar skyline (Mer-
chant).
– Lower limb malalignment: full-length alignment
views.
– Femoropatellar disease: patellar skyline (Mer-
chant), full-length alignment views.
– Articular cartilage damage to the posterior femo-
ral condyle: weight bearing AP at 45° of flexion
fl
(schuss) view (this view allows examination of
the posterior femoral condyle by placing it into a
tangential position relative to the tibial plateau).
Magnetic resonance imaging
Magnetic resonance imaging (MRI) offers ff a non-
invasive method for the assessment of articular
cartilage abnormalities. MRI of joints following an
acute impact or torsional load can reveal changes in
subchondral bone even when the articular surface
is intact (47,48). Rapid technical progress in MRI
imaging has made it possible to provide crucial
preoperative information. The determination of
chondral lesions are based on the signal-to-noise
ratio of the image, and the spatial resolution of the
imaging technique.
Specialized proton-density weighted, high-resolu-
tion, fast-spin-echo sequence (with or without fat
suppression) is recommended for assessment of
articular cartilage in the knee in order to decrease
prolonging the total imaging time (49). Based on a
comparison with arthroscopy, Potter (49) has dem-
Fig. 3 – MRI image of a grade IV osteochondral lesion of the patella (see
arrow) (fat saturated intermediate weighed steady state gradient echo
image). Courtesy of Dr. Frank Kolo, Department of Radiology, University
Hospital of Geneva, Geneva, Switzerland.
onstrated that this specialized sequence can deter-
mine location, size, and depth of cartilage lesions
thus providing an accurate yet uninvasive assess-
ment of lesions of the articular cartilage of the
knee (Figs. 3 and 4). Fat-saturation protocols com-
bined with ionic gadolinium diethylenetriamine
penta-acetic acid (Gd-DTPA) contrast (50,51) can
describe biomechanical and biochemical changes
associated with matrix degeneration. Advantages
include multiplanar vision with three dimensional
reconstructions. Disadvantages include prolonged
acquisition time, need for additional sequences,
as the fat-suppressed gradient-echo sequence is
not optimum for the assessment of ligaments,
menisci, or subchondral bone. Some authors have
called into question the quality of the reconstruc-
tions derived from the initial sagittal volumetric
sequence.
Today there is still a need for a recognized MRI
classifi
fication of chondral lesion.
Many MRI classifi fications try and mirror the
Outerbridge classification.
fi However, correlation
between Outerbridge arthroscopic grades and
classifi
fications based on MRI has not been estab-
lished with certainty, correlation rates varying
from poor to excellent according to different
ff stud-
ies (49,52–54). Authors like Kawahara et al. (53),
Gagliari et al. (55), or Disler et al. (56) have shown
that Outerbridge grade-1 lesions (softening) are
not reliably detected with MRI.
Future developments include standardized pro-
tocols as well as new techniques which might for
instance allow the evaluation of the quality of
repair tissue postoperatively. MRI can help evalu-
ate the degree of defect filling, the success of inte-
gration, the possible presence of proud subchon-
dral bone formation, the graft’s quality (substance
and surface), and the appearance of the underlying
bone. Recent techniques, including delayed gado-
linium-enhanced MR imaging and mapping of T1p
(for glycosaminoglycan content) and T2 values (for
Fig. 4 – MRI image of a grade IV osteochondral lesion of the patella (see
arrow) (axial RHO fat saturated image). Courtesy of Dr. Frank Kolo, Depart-
ment of Radiology, University Hospital of Geneva, Geneva, Switzerland.

collagen content), may correlate with histologic
and biochemical characteristics of repair tissue in
the matrix.
Arthroscopy
Arthroscopic evaluation of chondral defect allows
precise localization, and qualification
fi of the defect
Arthroscopy is also key in the assessment of asso-
ciated pathologies that might aff ffect the opposing
articular surface, ligament, and menisci. Conse-
quently, arthroscopic grading of articular cartilage
lesions is key to the patients’treatment. However,
one has to be aware of its inter-observer and intra-
observer variability. Grading of articular cartilage
lesions depends on direct assessment. Different ff
grading systems are presented below. Th The lesions
were initially classifi fied according to the visual
evaluation of the surface of the injury. The Th Bauer
and Jackson classifi fication (57) and the Insall clas-
sifi
fication (58) need to be mentioned for historical
purposes. The more recent classifi fications focus on
arthroscopic appearance because the correlation
between the aspect of the surface of the lesion and
its clinical manifestation has not been proven.
Outerbridge classification
fi : Outerbridge, in an effort
ff
to classify difffferent grades of chondromalacia
patellae, described four types of lesions (59):
International Cartilage Repair Society classification
fi : ation of surgical treatment. Some surgical proce-
In recent years, planning cartilage repair proce-
dures has required the evaluation of the location,
depth, and area of the lesions as well as the status
of the surrounding cartilage. Th Thus, newer classifi fi-
cation systems that focus on objectively measur-
able parameters regarding the extent of the lesion
have replaced the ones which mainly focus on the
surface appearance of the lesions. The system rec-
ommended by the ICRS, which was first fi published
in 1998 and recently revised, is now considered as
the international standard classifi fication (5).
Brittberg and Winalski (5) have pointed out that
Outerbridge grades II and III do not include a
description of the lesion depth. Other grading sys-
tems such as the Noyes and Stabler classification
fi
Outerbridge scale to grade cartilage lesion
Grade Description
I Softening and swelling
II Fragmentation and fissuring of 0.5 in or less
III Fragmentation and fissuring greater than 0.5
IV Erosion of the cartilage to the subchondral bone
ICRS Classification
Grade Description
I Superficial lesions
II Lesions extending to less than half of the cartilage depth
III Lesions extending to more than half of the cartilage depth
IV Osteochondral defects
Surgical treatment of cartilage tear: principles and results 463
(60) or the Ayral classification
fi (61) combine sev-
eral criteria including articular surface appearance,
lesion depth, lesion diameter, and location, but
because or their simplicity, the Outerbridge and
ICRS systems are the most commonly used today
in practice.
History, principles, and
techniques of surgical treatment
Articular cartilage injuries have been recognized as
early as the 18th Century (3), but the treatment of
such lesions has been limited by the lack of diag-
nostic tools. The first arthroscopic treatment for
chondral injuries has been described in the 1940s
by Magnusson (62) and consist a limited joint
lavage, cartilage debridement, and excision of loose
bodies. Until the recent development of MRI, car-
tilage defects were mostly incidentally discovered
during procedures indicated to address meniscal
or ligament tears. For the past two decades, articu-
lar cartilage has been reliably visualized by MRI.
The existence of reliable diagnostic tools has had
a positive impact on the development and evalu-
dures are presented here for historical purposes.
An abundant literature exists today in favor of
the more recent procedures as well as developing
techniques. However, because most of those tech-
niques are fairly recent, it is difficult
ffi to determine
with certainty which is the most effective
ff and thus
off
ffer a standardized treatment.
Arthroscopic debridement
History
Magnusson (62), in an effort
ff to debride unstable
flaps and debris created by infl
flammation, contrib-
uted to popularize this surgical procedure in the
1940s.
Principle
The concept behind this surgical technique is to
remove inflflammatory tissue which might create
dysfunction of the knee joint, causing pain, lock-
ing, catching, or crepitus. Synovitis and joint effu-
ff
sion may decrease after mechanically unstable
excessive tissue is removed (63–65). The question
is whether or not shaving should be included in
this technique. There
Th has been no evidence that
such an addition to simple debridement actually
stimulates repair (66,67). On the contrary, shav-
ing might be detrimental, causing fi fibrillation and
necrosis in adjacent cartilage (68).
464 The Traumatic Knee
Marrow-stimulating techniques by perforation of
subchondral bone
Signifi
ficant partial-thickness chondral lesion is not
spontaneously replaced by normal articular sur-
face, because healing requires vascular ingrowth
into the area of injury.
Penetration of subchondral plate induces bleed-
ing thus triggering infl flammatory response such
as fi
fibrin clot, blood and marrow cells, cytokines,
growth factors, and vascular invasion (69). Pluri-
potent mesenchymal cells migrate into the clot,
multiply and diff fferentiate into chondrocytes
(70,71) which synthesize fibrocartilaginous repair
tissue to fill in the defect within 6–8 weeks (69).
Marrow-stimulating techniques described here
aim to encourage this vascular ingrowth leading to
the synthesis of repair tissue.
Drilling
History
Pridie (72), in 1959, was the first
fi to describe drill-
ing of denuded areas of articular cartilage. Th
This
technique was then popularized by Steadman et al.
in the 1970s (73).
Principle
Exposition of subchondral bone is achieved by
microperforations of the chondral surface. This
Th
fairly simple method is a relatively non-invasive
way to trigger the infl
flammatory cascade while
avoiding thermal trauma.
Method
Percutaneous methods were first described before
Dandy (74) described the arthroscopic method in
1981. Rae and Noble (75) then designed a guide
with a long shaft fit
fi to accommodate a drill and
to avoid damaging the articular surface. Loose
articular cartilage at the periphery of the defect
is removed and the base of the crater is removed
before several drill holes can be made in the
subchondral bone by simply repositioning the
guide.
Abrasion arthroplasty
History
Arthroscopic abrasion knee arthroplasty was
described in the 1980s by Insall (76) and John-
son (77) as an alternative to existing open debri-
dement procedures or total knee arthroplasty for
the older patient suff
ffering from arthritis. In the
early 1980s, Johnson (78) described arthroscopic
abrasion arthroplasty, using a motorized instru-
ment to remove 1–3 mm of subchondral bone in
order to expose the blood vessels in the subchon-
dral plate.
The Insall (79)–Pridie (72) procedure which advo-
cated the drilling and/or removal portions of the
subchondral bone plate to encourage the forma-
tion of healing tissue. These
Th open palliative pro-
cedures were not widely performed because of the
morbidity related to the arthrotomy. Th The abrasion
technique became popular with the possibility to
perform the procedure arthroscopically. Initially,
the technique mimicked drilling procedures with
multiple superficial
fi holes created in the subchon-
dral bone, before extending to remove the entire
ficial layer of subchondral bone plate.
superfi
Principle
The concept behind abrasion is to expose the sub-
chondral bone by removing the superfi ficial layer
of it.
Method
Initially, abrasion was performed with a curette,
but more recent instrumentation has enhanced
control and accuracy. Johnson (80) recommends
the use of motorized burrs to remove a thin layer
of cartilage as well as loose articular cartilage
margins of the sclerotic lesion, while Blevins and
Steadman et al. (81) use a hand instrument. Laser
energy has been described, but should be avoided
because it generates local necrosis (80).
Microfracture
History
The surgery was developed in the late 1980s and
early 1990s by Richard Steadman of the Steadman-
Hawkins clinic in Vail, Colorado, after testing the
procedure on animal models including horses.
Principle
The microfracture technique is based on the same
biologic principles as the abrasion arthroplasty
without systematic bone removal. Arthroscopi-
cally, angled awls are used to perforate the sub-
chondral bone of focal articular cartilage surface
lesions (73,81,82).
By avoiding the use of power drilling, the risk for
thermal necrosis is eliminated, and a more con-
trolled subchondral bone perforation depth and
location can be obtained. The perforations should
go as deep as the underlying cancellous bone, in
order to release blood and mesenchymal cells, with
the ultimate formation of reparative tissue. The Th
cells in the resulting “superclot” proliferate and
diff
fferentiate into a fibrous or fibrocartilage mosaic
repair tissue given that they are not submitted to
mechanical stress such as weight bearing (83).
Method
The manual procedure with a small ice pick is
designed to create multiple perforations through
 Surgical treatment of cartilage tear: principles and results 465

the calcifi
fied cartilage layer to access the bone mar-
row cells. The
Th first step in this procedure involves
creating precise perpendicular edges of the lesion
at the transition zone adjacent to the healthy artic-
ular cartilage (Fig. 5). All unstable cartilage should
be removed. Animal studies suggest that remov-
ing the calcifified cartilage greatly enhances the
percentage and quality of defect fill (22) (Fig. 6).
A surgical awl is then used to create holes placed
2–3 mm apart from each other (Fig. 7). Conflu- fl
ence of the holes should be avoided at all cost, as
free fragments might result unstable bone. When Fig. 5 – The first step consists in creating precise perpendicular edges at the
fat droplets can be seen coming from the marrow transition zone adjacent to healthy cartilage while respecting the natural
cavity, the appropriate depth (2–4 mm) has been repaired cartilage positioned at the right and inferior third of this particular
lesion.
reached (84) (Fig. 8).

Fig. 6 – With the help of a specific curette, the calcified layer is removed. Fig. 7 – A surgical awl is then used to “microfracture” the subchondral plate
starting at the periphery of the lesion.

Fig. 8 – By stopping water inflow, the surgeon can control the quality of the bleeding and the formation of the “superclot.”
466 The Traumatic Knee
Cartilage replacement therapy
Periosteal and perichondral grafting
History
In the 1970s (85) and the 1980s (86), animal
experiments showed encouraging results after per-
ichondrium was transplanted to articular cartilage
defects in animals. The transplanted tissue was
histologically similar to articular cartilage with
74% type II collagen (18,87).
In 1972, Skoog et al. (88) described the use of per-
ichondrial cells to repair cartilage defects.
More recently, Coutts et al. (89) have used rib per-
ichondrium to resurface full-thickness defects in
rabbit knees, and report 60% good results using
repair hyaline cartilage tissue analysis as a crite-
rion. Only performed in a limited number of cen-
ters, this procedure works best in younger patients.
Because of the limited use of this procedure, there
are few reported outcomes that widely endorse its
use.
Principle
The principles underlying these procedures are
that the biological environment (circulation of
recipient bed, oxygen tension) is going to direct
the phenotypic expression by the graft.
The idea of using autogenous tissue without the
morbidity associated with the use of articular car-
tilage have led to consider other tissues capable of
chondrogenesis (87,90).
Articular cartilage allografts
History
Lexer first described the procedure in human as
early as 1908, with a reported success rate of 50%
with incorporation of the graft and restoration of
articular function (91,92).
After it was recognized that arthroplasty in young
patients with focal articular cartilage damage
should be avoided because revision for implant
loosening and/or failure is a nearly certain out-
come, osteochondral allograft transfer was recog-
nized in the 1940s and in the 1950s as a biologic
alternative to knee replacement (93). Allograft
tissue-processing techniques have been advancing
rapidly over the past decade (94–99).
Principle
Osteochondral allografts allows the procurement
of orthotopic grafts (grafts of similar size, thick-
ness, contour, and location to the receiving site),
hence increasing graft compliance. Despite this
advantage, there is concern about possible disease
transmission. There has been abundant research
about the potential threat caused by either the
human immunodefi ficiency virus or other viral par-
ticles with long incubation periods. Although there
has been signifi ficant progress in tissue banking
techniques which minimalize the risk to extremely
low levels, concern has not been completely eradi-
cated (100,101).
Immunogenicity constitutes another signifi- fi
cant preoccupation. The issue has been largely
addressed, and cartilage is considered today as an
immunologically privileged tissue. Friedlaender et
al. (102) concluded that immune reactions found
with even massive grafts were self-limited. Stud-
ies conducted by Langer and Gross (103) in 1974
called into question the necessity of immunosup-
pressant drugs in this procedure, since chondro-
cytes, even though they express surface transplan-
tation antigens, are isolated from the host immune
system by the matrix. Macromolecules within the
chondroid matrix are only weakly immunogenic
(104). It has been suggested that the use of immu-
nosuppressants by the recipient might allow a
lighter processing of the allografts and decrease
the host response. However, there is no evidence
today demonstrating a possible benefit fi of such
treatment (105). However, cartilage tissue must
be transplanted with the attached subchondral
bone, which does trigger immunologic response,
and rejection has been documented (106,107).
These concerns make extensive lavage and anti-
biotic treatment necessary, as well as demanding
transient storage conditions before transfer. Th
Those
prerequisites may have a negative effect
ff on chon-
drocytes. Because the success of an osteochondral
graft implantation is intimately related to the per-
centage of viable chondrocytes, fresh allografts are
often privileged today. The viability of chondro-
cytes decreases as soon as 24 h after procurement,
with a sharp drop occurring after 15 days of stor-
age in a physiologic culture medium (108). Freez-
ing represents another option in order to diminish
immunogenicity and disease transmission (109),
but further decreases the viability of the trans-
planted chondrocytes (110,111). Finally, there are
questions regarding allografts’long-term survival.
There is suffi
fficient evidence that cell viability is
greater with autogenous grafts than with allogenic
grafts, probably due to an immunologic response
and/or mechanical factors. Matrix deterioration
and subsidence has been demonstrated in animal
models (112) as well as in humans. Beaver and
Mahomed have also described progressive decline
in the number of donor chondrocytes, the latter
being intimately associated to the gross quality of
cartilage (113,114).
Method
Allografts are harvested within 12 h of death and
transferred to the patient after processing and
donor-recipient matching.

Osteochondral autograft transfer and mosaicplasty
History
Desjardins et al. (115) studied fresh and frozen
autogenous grafts in horses. Cell viability as well
as proteoglycan content was better in fresh grafts
than in frozen grafts. Their research also suggests
that congruence is primordial for cartilage sur-
vival, and deeply recessed grafts were eventually
replaced by fibrous
fi tissue. Both fresh and frozen
grafts displayed rims of fibrocartilage surround-
ing transplants, suggesting potential weakness
susceptible to pull-outs. In 1985, the first
fi results
of autogenous osteochondral grafts for the treat-
ment of osteochondritis dissecans lesions were
published (116). Subsequent clinical experience
with osteochondral autografting has primar-
ily been in ACL-deficient
fi knees with coexistent
chondral damage, using multiple small plugs.
The first arthroscopic treatment using autografts
was reported in 1993, where Matsusue repairs a
15-mm defect in the medial femoral condyle of an
ACL-defificient patient with three osteochondral
autogenous plugs press-fifit into place (117). Many
studies have been published on that growingly
popular procedure, investigating ideal donor site
or and plug size (118–122).
Principle
The key to this technique is the transfer of viable
chondrocytes designed to synthesize and main-
tain a competent matrix with biological and bio-
mechanical properties similar to sound hyaline
cartilage (123). One or two plugs can be used for
small defects, while multiple plugs (mosaicplasty)
are used to address larger chondral defects. Th There
are several principles which support autogenous
grafts. First, immunologic response and transmit-
ted infections are avoided. Second, there is some
evidence that bone union and long-term cell viabil-
ity might be superior with autografts than with
allografts. In addition, autograft transfers consti-
tute a relatively low cost, single-stage procedure
Disadvantages also include potential morbidity of
the donor site. Such morbidity is linked evidently
related to the size of procurement, when mechanical
studies of autograft plugs have demonstrated that
the pull-out strength of press-fi
fit plugs is intimately
related to the size (length and diameter) of the plug
(124). In addition, grafts cannot be orthotopic, and
it is diffi
fficult to morphologically match the graft to
the recipient site. This problem, however, can be
addressed by performing mosaicplasty, using mul-
tiple small plugs, implanted-like tiles, that can con-
tour to the desired surface curve (117).
Furthermore, with autogenous tissue, the age of
chondrocytes being predetermined by the patient,
the latter cannot take advantage of the possibly
Surgical treatment of cartilage tear: principles and results 467
superior quality of juvenile chondrocytes (125).
Last, although there is a potentially unlimited
supply (hence avoiding ordering and waiting for
grafts), there is a limited supply of autogenous tis-
sue in volume (126).
Method
The technique involves a single-stage transfer of
intact hyaline cartilage and subchondral bone plugs
of small size, from a relatively non-weight bearing
region of the knee to a damaged articular surface
(127). Typically, plugs are harvested in the femo-
ral intercondylar notch and the lateral edge of the
lateral femur just proximal to the sulcus termina-
lis (117,118). The plug then gets integrated in the
surrounding recipient tissue (128) (Fig. 9). For
mosaicplasty, small cylindrical osteochondral grafts
(approximately 3–9 mm in diameter) are harvested
from the femoral condyles. The Th use of diff fferent
graft sizes aims to obtain an optimal rate of defect-
filling (Fig. 10). After preparation of the receiving
site, those plugs are transplanted. Hangogy et al.
(129) have described additional abrasion arthro-
plasty or sharp curettage at the base of the defect to
stimulate fibrocartilage grouting. Mosaicplasty can
be performed by way of arthrotomy or arthroscopy.
Small anterior defects in the femoral condyle can
be treated arthroscopically, when large defects and
posterior defects usually require an arthrotomy.
Autologous chondrocyte implantation
History
In 1965, Smith (130) isolated articular cartilage
chondrocytes. Transfer of autologous chondro-
cytes was performed in animal models as early as
1968 (131). Shortly after, Bentley (132) reported
good chondrocyte survival rate with synthesis
of repair tissue which was well integrated in the
lesion. Similar evidence was reported by Grande
(133) with 82% coverage of initial lesion by repair
tissue 12 months after transfer. Furthermore, type
II collagen seemed predominant in the repair tis-
sue. In 1994, Brittberg et al. (134) first reported
autologous chondrocyte implantation (ACI) in
humans. Autologous chondrocyte transplantation
has been recently introduced as a surgical proce-
dure for the repair of damaged or diseased articu-
lar cartilage (135–137). In this chapter, we volun-
tarily omit generation II and III ACI, since these are
evolving techniques still under investigation.
Principle
The concept underlying this procedure is the capacity
of mature chondrocytes to recreate their initial envi-
ronment. The multiple passages allow multiplica-
tion of a limited number of harvested chondrocytes,
although there is no evidence today as to how many
468 The Traumatic Knee

Fig. 9 – (A) MRI of a 22-year-old basketball player suffering from anterior

knee pain for more than a year. (B) The lesion is located at the proximal and
medial aspect of the trochlea. (C) Harvesting of one osteochondral plug.
(D) Autologous transfer of the osteochondral donor plug in the lesion and
engraftment of the bone retrieved from the lesion into the donor site.

Fig. 10 – (A) Stage IV osteochondrosis dissecans of the medial femoral condyle in 18-year-old soccer player. (B) Part of the original cartilage was found in
the joint and fixed back using resorbable pins. Remaining defect was resurfaced with an autologous osteochondral transfer.

passages the cells can withstand before jeopardizing
their phenotypic expression. Mature articular chon-
drocytes remain diff fferentiated through subculture
(138). However, early evidence has demonstrated
their capacity to be infl
fluenced by their environment
(139). After Holtzer (140) in 1960 proposed that
mature chondrocytes could reverse their differen-
ff
tiation under conditions of culture, there has been
evidence that a subpopulation of chondrogenic cells
in articular cartilage could show a phenotypic plas-
ticity that is comparable with that of mesenchymal
stem cells has been available (141). As early as in the
1980s already, Gospodarowicz (142) and Itay (143)
reported some evidence that the phenotypic expres-

sion and diff
fferentiation could be infl
fluenced by their
microenvironment, hence supporting the idea of
localized grafts. Based on observation on animal
models, those authors (143) have described the
sequence of events that occur after chondrocytes
have been implanted. For the first 4 weeks, a “pro-
liferative stage” permits rapid chondrocyte multi-
plication. Between 4 and 8 weeks, chondrocytes
differentiate
ff and synthesize matrix. During this
“maturation stage, cartilage is formed. Finally, dur-
ing the “transformation stage” which can last up to
6 months after transfer, chondrocytes are replaced
by osteons and subchondral bone is restored.
Method
ACI is a two-stage procedure in which normal hya-
line cartilage is harvested, then cultured in vitro.
The resulting chondrocytes are then reimplanted
into a cartilage defect, covered by an autologous
periosteal patch. Autologous chondrocytes are har-
vested arthroscopically or by way of an arthrotomy
from the non-weight bearing area of the superior
intercondylar notch proximal to the sulcus termi-
nalis. Individual chondrocytes are then released
by enzymatic digestion, multiplied in vitro, then
cryopreserved (144).
Following cartilage harvesting, elective reimplan-
tation is scheduled. The receiving site is carefully
debrided in order to obtain sound cartilage mar-
gins. A periosteal flap
fl the size of the defect is har-
vested and sutured to the surrounding stable car-
tilage margins. Th
The periosteal rim is sutured and/
or sealed with autologous or allogenic fibrin glue.
Finally, the cultured chondrocytes are implanted
under the periosteal flap. To ensure viability of
ACI, concomitant adjuvant procedures should be
performed if necessary, including a closing wedge
high tibial osteotomy, ACL reconstruction, menis-
cal repair, and tibial tubercle osteotomy.
In the future, techniques using minimally invasive
implantation will spare the patient the morbidity
of an open arthrotomy. All arthroscopic techniques
have been reported but are still not widely imple-
mented in the surgical community (145). As ACI
technology becomes more widely spread, it might
become a routine technique used to treat joint sur-
faces other than the knee.
Indications and contra indications
Arthroscopic lavage and debridement
Indications
In a few selected cases involving patients with
a history of low-energy trauma, with specificfi
Surgical treatment of cartilage tear: principles and results 469
mechanical symptoms, minimal malalignment,
stable ligaments, and low body mass index,
arthroscopic debridement may be of some use
(146). Arthroscopic debridement and lavage alone
have shown to have no signifi
ficant lasting benefi
fit in
arthritic knees without specific
fi localized mechani-
cal symptoms (147). However, there is little evi-
dence today to support such procedure, and it is
exposed here mainly for historical reasons.
Contraindications
Because these procedures are mainly palliative,
they should not be performed with the goal to
stimulate the growth of repair. They are conse-
quently not applicable for injuries which present a
potential for cartilage restoration.
Marrow-stimulating techniques by drilling and
perforation of subchondral bone abrasion
Indication
Johnson (80) describes abrasion as “an elaborate
description for an extensive multiple tissue debri-
dement for patients seeking an alternative to total
knee replacement.” In patients seeking an alterna-
tive to total knee replacement, the defi
finitive oper-
ation may be avoided or deferred in a high percent-
age of patients as many as 5 years.
Contraindications
Poor outcome was noted in patients treated by
abrasion who concomitantly suffered
ff from severe
malalignment, ligamentous instability, and morbid
obesity; therefore, those conditions have become
contraindications.
Microfractures
Indications
Ideal indications for microfracture treatment
include focal grade III or IV articular surface lesions
without bone loss in a young patient. Blevins et al.
(81) reported microfacture technique for localized
traumatic lesions without exposed bone.
The potential for cartilage repair seems to be bet-
ter in young individuals (81,148). O’Driscoll pos-
tulates the ideal patient for cartilage repair surgery
is younger than 45 years and has a symptomatic
isolated chondral or osteochondral lesion with no
evidence of osteoarthritis (149).
Contraindication
According to Alford and Cole (150), contraindica-
tions include significant
fi subchondral bone loss,
470 The Traumatic Knee
mechanical axis misalignment, bipolar lesions.
Some authors, like Gudas (151), have suggested
that microfactures be used in small lesions, after
obtaining poor results in defects greater than 2
cm2, especially when situated on the medial femo-
ral condyle in the weight-bearing area. Hangody
suggests an age limit of 50 years for microfracture
procedures (121). Due to the decline in sports par-
ticipation over time, this procedure may not be the
defi
finitive procedure for the athlete’s knee (152).
Periosteal and perichondral grafting
We will not discuss here the indications and con-
traindications of these procedures, which were
presented above for historical purposes only.
Osteochondral allograft Transfer
Indications
Fresh osteochondral allograft transplantation pro-
vides large and viable constructs of hyaline carti-
lage with the underlying subchondral bone. It is
thus ideal to address lesions important both in size
and depth. This treatment also allows respecting
anatomy, because an appropriate size and surface
contour can be matched with cadaveric donors.
Osteochondral allograft transfers are indicated
for symptomatic full-thickness cartilage defect in
young patients. Although authors usually recom-
mend an age limit of 40–45 years, others have
extended it to 60 years of age in healthy, active
individuals (153–155).
Mc Culloch recommends this treatment for lesions
of at least 2 cm2 (156).
Contraindications
Because the cartilage surrounding the chondral
defect must be intact, lesions caused by diffuse
ff
osteoarthritis and infl
flammatory arthropathies or
diff
ffuse avascular necrosis should not be treated
with this procedure. The presence of degenerative
changes on the opposing articular surface is also a
contraindication to allografts. Deficient
fi or injured
menisci, ligamentous instability, and mechanical
axis malalignment must be corrected before or con-
comitantly with allograft implantation. ThThe upper
limit of patient age for these procedures remains
an area of controversy.
Osteochondral autograft transfer
Indications
There is some evidence to support the fact that
the size or the location of chondral injuries does
not affffect the result of autograft transfers, when it
seems that important lesions situated on weight-
bearing articular surfaces negatively influence fl
other procedures like microfractures (151). How-
ever, ideal indications include symptomatic, distal
femoral condyle articular cartilage lesions with
intact menisci and tibial cartilage in a non-degener-
ative joint with proper mechanical alignment. Han-
gody (157) believes the ideal lesion size is 1–2 cm
in diameter. Graft limitations tend to limit indica-
tions for lesions up to 3–4 cm in diameter, although
treatment of such lesions remains possible. Accord-
ing to the authors, the treatment of patella or tibial
surface lesions as well as intact but loose ICRS grade
II lesions would be relative indications.
Contraindications
Although old age has not been proven to be
absolute contraindications, several studies show
that the procedure shows better results in young
patients. Gudas (151) obtained signifi ficantly supe-
rior clinical outcome in a group of patients younger
than 30 years. Belvins’study indicates similar fifind-
ings (81). Overall, the limited availability of sites
for harvest and the concern over the healing of the
graft at its margins make osteochondral autografts
a procedure that should be restricted to the treat-
ment of relative small articular surface defects.
Autologous chondrocyte implantation
Indications
For ACI with cells cultured by Genzyme (Cambridge,
MA), the developer of the Carticel Autologous Cul-
tured Chondrocytes procedure, indications for this
surgical technique include small-to-medium sized
hyaline cartilage lesions (1–10 cm2) in patients who
range in ages between 15 and 55 years (Genzyme
Tissue Repair, unpublished information available
from the company) (158). More precisely, indica-
tion includes an isolated and recent lesion (<1
year), size 3–8 cm2, <6 mm in depth, tidemark pre-
served, in a young patient (<45 years old). Michael
et al. (159) conducted a study on 24 patients for
whom surgeons had appealed for the procedure
after it was rejected by insurance companies. TheTh
study shows that for 96% of the cases, the indica-
tions for the procedure were not met or specific fi
contraindications were present. The study hence
underscores the importance of limited application
for ACI in carefully selected patients.
Contraindications
The relative and absolute contraindications for the
procedure include osteoarthritis, age >45 years
old, lesions <1 cm2 and >8 cm2, kissing lesions, a

malalignment >5°, an instability, an infl flammatory
disease, a total meniscectomy, overweight, mul-
tiple operations on the same knee, smokers, a dif-
fuse tricompartmental degeneration, and multiple
small lesions. ACI is a technically challenging proce-
dure, especially when suturing the periosteal flap.
fl
Multiple studies have demonstrated the learning
curve involved in obtaining reproducible results
(160,161). Finally, ACI is an expensive surgical
procedure. Consequently, ACI should be reserved
for carefully selected candidates.
Results and complications
Arthroscopic, lavage, and debridement
Debridement has been described to decrease
these mechanical and infl flammatory symptoms
(162–165). Without debridement, arthroscopic
joint lavage alone provides short-term benefits fi in
50–70% of patients according to Baumgaertner
(64). When combined with lavage and debridement
of friable tissue, marrow stimulation techniques
appear to provide more durable results (166–168).
After these techniques (drilling, abrasion arthro-
plasty, microfracture), the extent of filling is rarely
more than 75% of the total volume of the chon-
dral defect (1). It is believed that small lesions,
less than 1 cm2, have a better prognosis and that
debridement is the procedure of choice in these
cases (11,169). Dzioba (148) noted better results
for debridement and drilling in chondral lesions
of 1–3 cm2 in patients younger than 45 years per-
formed within 3 weeks of injury. If performed lega
artis, those procedure should not present with sig-
nifi
ficant complications. Aggressive debridement
may lead to joint stiffness.
ff When accompanied
by shaving procedures, debridement becomes a
more aggressive treatment. Hence, in the absence
of proven benefi fits, shaving should be avoided,
ever more so that, there has been evidence that it
increased fibrillation and necrosis in neighboring
cartilage (68). Th
The complications of these proce-
dures are also related to their palliative character.
Because arthroscopic lavage, shaving, and debride-
ment do not stimulate the growth of repair tissue
nor restore cartilage, patients’relief is generally
temporary, unless the procedures are coupled with
the correction of underlying cause.
Marrow-stimulating techniques
by perforation of subchondral bone
Marrow-stimulating techniques are relatively non-
invasive, inexpensive procedures and require mini-
Surgical treatment of cartilage tear: principles and results 471
mal hospitalization time. If performed correctly,
they can alleviate symptoms and restore function.
The advantage is that they do not preclude further
surgical options.
Good results have been reported in the short term
(see details below).
However, the long-term response to this therapeutic
approach is somewhat unpredictable. At best, repair
tissue will be composed of predominantly type I
collagen-rich fibrocartilage. Furthermore, healing
tissue is not always stable and some loss after pro-
cedure can occur, which might be detrimental to
the clinical outcome of procedure, even though it
has been reported that the presence of intact fi fibro-
cartilage was not necessarily a predictor of a good
clinical result (163). Experimental animal studies
(170) and clinical trials (78) have reported similar
histologic findings: the initial hyaline-like cartilage
becomes more fibrous over time and subsequently
tends to deteriorate. Some authors have reported
deterioration of symptoms after a transient relief
(164,171,218). Some clinical studies (162,172) even
suggest that such procedures may increase symp-
toms. Overall, the correlation between subchondral
exposure and formation of decreased joint pain
remains to be further demonstrated by prospective
randomized controlled trials.
Drilling
Childers and Ellwood (173) performed 33 opera-
tions on 29 patients suffffering from patellar chon-
dromalacia. The average age was 27 (range 14–53).
After localized chondrectomy and subchondral
bone plate drilling, the authors reported that good
or excellent results were obtained in most patients
younger than 30 years. Insall (79,174) in clinical
studies comparing abrasion plus drilling versus
abrasion alone revealed no diff fference in the sub-
sets, but the abrasion plus drilling group’s defects
were more severe preoperatively than the defects
of the group treated by abrasion alone.
Abrasion arthroplasty
Although the underlying principle justifying abra-
sion arthroplasty is clear, clinical results have been
disappointing. Friedman et al. (175) reported a
retrospective study of 110 patients treated by
arthroscopic debridement of the knee for Outer-
bridge grade IV chondral lesions, with an average
follow-up of 12 months. Seventy-three of a 100
operations included abrasion arthroplasty, 60%
of which showed improvement according to sub-
jective satisfaction criteria. In contrast, only 32%
of the 37 patients operated with debridement and
medial meniscectomy without abrasion showed
similar results. The best results were obtained for
patients younger than 30 years.
472 The Traumatic Knee
In a retrospective review comparing 126 patients
treated for unicompartmental gonarthrosis with
either debridement alone or abrasion therapy com-
bined with debridement, with a mean follow-up of
60 months, Bert et al. (163) show that results for
abrasion therapy are unpredictable. Patients ben-
fiting from that procedure, evaluated with the
efi
Hospital For Special Surgery Knee Scoring System,
worsened with time. The success rate was higher in
groups treated with debridement alone. In a simi-
lar clinical trial, Blevins (81) corroborates theses
findings, with approximately half of the patients
improving for both groups, but with 33% of wors-
ening in the group treated with abrasion arthro-
plasty.
Johnson et al. (71, 78) found 39% early failures in
a series of 49 knees in 44 patients older than 50
years with osteoarthritis, and 47% failures at the
time of follow-up.
Johnson (80) reviewed patients aged 60 years on
average with osteoarthritis after they underwent
abrasion therapy. The original group included 105
patients, who were reviewed at 2 years and again at
5 years. At 2 years, 99 patients responded to ques-
tions and 42 presented for examination. Another
group included 242 patients (248 knees) with 2- to
5-year follow-up who were reviewed by question-
naire. In the original group, 74% of patients said
they were improved and 24% were worse when
compared with their preoperative condition. At 5
years, 73 patients responded by questionnaire of
which 46 presented for examination. Only 24%
of patients with 2- to 5-year follow-up (average,
3 years) by questionnaire did not have any com-
plaints. Most patients in this group had multiple
complaints. In this clinical series, Johnson (80)
found no positive nor negative predictive factors
aff
ffecting abrasion therapy. According to the author,
there were no positive predictive characteristics,
would it be age, gender, existence of previous
surgery, size, and site of the lesion or associated
morbidity. However, there is some evidence that
failure rate of abrasion and drilling increases with
age. Childers and Ellwood (173) noted a significant
fi
diff
fference in failure rates in patients older than 30
years undergoing those procedures. Overall, this
technique-sensitive procedure, where minimal
destruction of subchondral tissue is a challenging
requirement, should be used with care for selected
patients only.
Microfractures
Although positive outcomes have been described
after microfractures by numerous studies, the best
results have been reported for younger patients
with relatively small lesions caused by an identi-
fiable trauma (152). This suggests that the sub-
chondral tissue underlying the lesion might have
higher potential to heal in younger patients. It also
discourages the use of this type of procedure for
degenerative diseases. Excellent early-term results
have been reported. In 2003, Steadman et al. (176)
reported a case series of 72 patients suff
ffering from
traumatic full-thickness chondral defect with no
associated injuries, aged 45 years and younger. At
7 years after surgery, 80% of the evaluated patients
rated themselves as “improved,” with a decrease in
pain and improvement in function (using scores
such as Lysholm, Tegner, SF-36, and WOMAC). In
a multivariate analysis, Steadman showed that age
was a predictor of functional improvement (176).
He states that age superior to 35 constitutes a
negative predicting factor. However, there is con-
cern about the durability of the repair tissue (177).
Steadman et al. (178) showed that even though 76%
National Football League (NFL) players returned to
football the season following microfractures, only
36% of them continued active participation in the
NFL at the last follow-up (mean follow-up of 4.5
years). In evaluating postoperative results, MRI
can contribute to judge the appearance of chondral
lesions treated with microfractures, which evolves
over time (179). Persistent bone marrow edema
and incomplete filling of the lesion suggest surgi-
cal failure.
Cartilage replacement therapy
Perichondral and periosteal grafting
Animal studies (18,85,87,180) have shown prom-
ising results from perichondrium transplantations
to articular cartilage defects, with transplanted
tissue which was histologically resembled articular
cartilage with 74% type II collagen. There
Th is still lit-
tle clinical evidence concerning those procedures,
but some preliminary reports show that periosteal
and osteoperiosteal grafts can induce regenera-
tion of articular cartilage (181–184). Homminga
et al. (135) arthroscopically transferred autologous
perichondrium harvested on ribs in 25 patients,
with 90% good graft integration at the second-
look arthroscopy 3–12 months later. Cross-exam-
ination of the cartilage as well as its microscopic
aspect showed tissue resembling cartilage. How-
ever, there has been evidence that the success of
those procedures declined with age (185). This Th
clinical observation is compatible with the belief
that the number of pluripotent stems cells or their
ability to produce matrix decreases over time.
Osteochondral allograft transfer
There is some clinical evidence that both fresh and
frozen osteochondral allografts transfers carry

positive outcome, with decreased articular pain.
Several clinical series support this procedure.
Mahomed et al. (114) followed 92 fresh allografts
in 91 patients and found that long-term survival
was 76% at 5 years, 69% at 10 years, and 67% at 14
years. Unipolar grafts (on one side of the joint only)
did better than bipolar grafts, and younger patients
(under the age of 60) did better than older ones.
Garrett (186) reported 39 of 40 successes (97%)
in allografts performed for osteochondritis disse-
cans with a 1- to 6-year follow-up. Adverse factors
included absence of menisci, degenerative changes
on the opposing articular surface, and malalign-
ment. Convery et al. (104) observed nine knees in
eight patients during 5–6 years, and reported 89%
good or excellent results. Mahomed et al. (114) fol-
lowed 92 fresh allografts in 91 patients and found
that long-term survival was 76% at 5 years, 69%
at 10 years, and 67% at 14 years. Garrett (187)
reported 97% positive outcomes in a collective of
40 patients suffffering from osteochondrosis disse-
cans with a 1- to 6-year follow-up. In a prospec-
tive study with 25 patients under 50 years of age
(average age 35) who received fresh osteochondral
allografts to repair symptomatic full-thickness
articular cartilage defects of at least 2 cm2 in the
femoral condyle, McCullogh et al. (156) report an
overall subjective satisfaction of 84%, associated
with objective measures of knee range of motion
and quadriceps size comparable to the unaffected
ff
knee.
Ghazavi et al. (188) as well as Gross (189) reported
126 fresh osteochondral allografts used to treat
localized posttraumatic osteoarticular defects
in the knee in 123 patients. Their
Th clinical review
claimed 95% success rate at 5 years, 71% at 10
years, and 66% at 20 years. Factors that increased
the risk of graft failure included patient age of
more than 50 years, articular surface defects on
both sides of the joint and joint malalignment.
Factors critical to success have been identified fi
(104,115). Grafts should be perfectly orthotopic
with a firm attachment. High and low locations
are unfavorable; young donors are preferable.
Furthermore, better results are obtained for uni-
polar defects (limited to one joint surface) than
for lesions on opposing joint surfaces (bipolar or
kissing lesions). In the series, Mc Culloch describes
complications for 2 patients (8%) (156), including
failure secondary to allograft fragmentation and
prolonged pain, albeit manageable with rehabilita-
tion and analgesics. In a comparative study, Flynn
et al. (190) offer
ff conclusions in favor of frozen
allografts, but whether better results are obtained
with fresh or frozen allografts in the long term
remains unclear.
It has been demonstrated that the success of an
osteochondral graft implantation is intimately
Surgical treatment of cartilage tear: principles and results 473
linked to the proportion of viable chondrocytes
after procedure. Bone resorption leading to col-
lapse of the cartilage carries a poor prognosis
(191). As with autografts, however, durable heal-
ing of cartilage adjacent to the graft has not been
established.
It is most likely that evaluation of surgical results
will increasingly use MR imaging. Radiological
studies have suggested that the persistence of
bone edema beyond a period of 12 months, as well
as fluid signal intensity at the interface between
the graft and the receiving site, as well as surface
collapse might correlate with poor clinical outcome
(192,193).
Osteochondral autograft transfer
Several studies report good-to-excellent results
after autograft transplantations. Bobic (118)
reported 83% of good and consistent results after
treating 12 ACL-deficient
fi patients with chondral
defects with multiple osteochondral cylinders.
Outerbridge et al. (194) describe a 100% satisfac-
tion rate for a series of 10 patients suffffering from
large defects secondary to osteochondrosis disse-
cans in femoral condyles, treated with autologous
grafts of 532 mm2 average size, after a mean fol-
low-up of 6.5 years. Gudas et al. (151) in a prospec-
tive study comparing mosaicplasty and microfrac-
ture, in treating 60 young adults for osteochondral
defects of the knee with a mean follow-up of 37
months, show that both groups showed signifi- fi
cant clinical improvement. Comparison based on
the modifi fied Hospital for Special Surgery (HSS)
and ICRS scores, arthroscopic biopsies which were
obtained for 58% of the patients following proce-
dure, radiograph, MRI, and clinical assessment,
reveals signifificant superiority of mosaicplasty
over microfractures. Both groups had significant fi
clinical improvement: 96% of excellent or good
results after mosaicplasty, compared with 52%
for the microfracture procedure according to the
modifified HSS and ICRS scores; 84% versus 57%
showed excellent to good results based on ICRS
arthroscopic criteria; 94% versus 49% according to
criteria based on MRI. Only 52% athletes treated
with microfractures compared with 93% for the
ones treated with mosaicplasty resume their sports
activities. Hangody et al. (195,196) report good-
to-excellent results in 92% of the patients treated
with femoral condylar implantations using the
same evaluation techniques as Gudas (151). Mosa-
icplasty performed with autologous osteochondral
plugs is a good therapeutic option for small carti-
lage defects, but its use is limited by the amount of
available non-articulating cartilage and concerns
about donor site morbidity (197–202).
Here again, the postoperative evaluation might
routinely include MR imaging in the future. Some
474 The Traumatic Knee
evidence suggests that fluid signal intensity at the
graft-host interface is indicative of graft instability
(203). MRI also allows the evaluation of the aspect
of the cartilage surface as well as its curvature.
Complications might affect
ff the donor site as well as
the receiving site. The risk of donor site morbidity
increases as more tissue is harvested. Physiologic
pressure on the donor sites might be responsible
for morbidity after autologous plug transfers.
Most of the known complications for the receiving
site are due to transplant failure linked to mechan-
icals constraints. If graft congruence is incomplete,
plugs incur shear forces and tend to subside and be
covered by fibrous tissue (204,205).
Whiteside (206) also showed that fixation strength
of mosaic autografts bathed in a physiologic solu-
tion in vitro decreased drastically (44%) over a
7-day period. This suggests that implanted plugs
might suffffer from a signifi ficant loss of fixation
strength immediately after the procedure.
The periphery of mosaic reconstructions is the
area which is the most exposed to shear, which
may lead to progression of the lesion or failure of
the implant.
Autologous chondrocyte implantation
Some good clinical mid-term outcome has been
reported in small series. Brittberg and cowork-
ers (134) reported on 23 patients, ranging in age
from 14 to 48 years, who were treated with ACI for
full-thickness cartilage lesions of the knee ranging
from 1.6 to 6.5 cm2. At the 2-year follow-up, 14 of
16 patients who had ACI on the femoral condyle
showed good-to-excellent results. (Results were
more disappointing for the seven patients grafted
in the patella, with only two displaying good-to-ex-
cellent results.) Minas and Nehrer (137) reported
a 90–95% success rate, given that patients match
proper indications for lesions in an isolated weight
bearing condyle (lesions situated in the trochlea
and the tibial plateau were less satisfactory). Fol-
low-up data suggest durable results after proce-
dure as long as 11 years (207,208). ACI may have
results comparable with those of mosaicplasty
(200,209). The global superiority of ACI to other
surgical procedure is not yet ascertained. Knutsen
et al. (210) did not find a signifi
ficant diff
fference in
macroscopic or histologic results between their
ACI and microfracture groups. Other authors such
as Horas (211) using clinical and histologic evalu-
ation, have suggested the superiority of ACI over
mosaicplasty. Complications include the hypertro-
phy of the graft which usually appears between 3
and 7 months after procedure. Th This condition has
been described in 10–63% of studied cases (208)
and can be assessed radiologically. MR imaging
was reported to be useful in evaluation surgical
success (212).
Overall, although several governmental and private
organizations keep an active registry on patients
on whom the procedure is performed, only a one
controlled, randomized, prospective studies are
available today on this procedure (210).
Perspectives
Future developments will most certainly involve
the contribution of tissue engineering as well as
gene therapy. Brittberg coined the expression “bio-
medical surgery” to describe procedures derived
from such interdisciplinary collaboration designed
to procure “true spare parts” (213).
Mesenchymal stem cells transplantation
Pluripotential stem cells would display a better
chondrogenic expression than mature chondro-
cytes, which off ffer a limited capacity to modulate
their phenotypic expression (214). Progenitor
cells are more likely to reproduce the initial car-
tilage architecture, because they are the natural
target of the infl flammatory cascade after injury.
In the 1990s, isolation of pluripotent stem cells
from periosteum and bone marrow was described.
Osteochondral progenitor cells can then be multi-
plied through passages (215–217).
Some experiments have shown that pluripotent
stem cells and chondrocytes retain their capacity
to produce matrix after implantation in chondral
defects (217–220).
Animal studies (221) have assessed the positive
impact obtained by implanted autologous chon-
drocytes when comparing histological results from
periosteal grafts alone, carbon fiber
fi scaff
ffolds and
periosteum, autologous chondrocytes and perios-
teum, and autologous chondrocytes, carbon fi fiber
scaff
ffolds, and periosteum. Wakitani et al. (217)
have compared this procedure to ACI to repair
full-thickness defects in rabbit knees, with results
favorable to the former.
Transfer of stem cells is a promising technique
which has revealed interesting results in animal
models. Despite these encouraging results, the
benefifit of cell transplantation has yet to be prop-
erly demonstrated in patients, and the correlation
between histological findings and clinical outcome
has to be established.
Gene therapy
Studies showed the possibilities represented by
genetically modifi
fied chondrocytes to resurface
injuries (222). Another approach is to transfer

Fig. 11 – (A) Tissue engineered construct carrying autologous chondrocytes in an alginate and agarose gel based scaffold. (B) Trans-
plantation of the construct in an osteochondrosis dissecans lesion of the medial femoral condyle. Courtesy of TBF Génie tissulaire
company, Mions, France.
genes that encode the growth factors to the site
of the injury. Goto et al. (223) suggested that ani-
mal and human chondral cells were all susceptible
to genetic transduction by both adenoviral and
retroviral vectors. Gene expression was, however,
limited in time in vitro. Recently, among others
Smith et al. (224) conducted an in vitro study, in
which he transferred genes encoding for growth
factors (IGF-1, TGF-1, BMP-2) to articular chon-
drocytes, with a subsequent increase of matrix
synthesis. These promising results encourage the
further development of gene therapy for the repair
of damaged cartilage.
Synthetic and biological matrices
Tissue engineering represents a potential response
to the tremendous challenge represented by carti-
lage injury. Synthetic material is grown in vitro.
The concept is to then implant into patient a bio-
degradable scaff ffold supporting transplanted cells,
initially preventing their scattering and death,
and then shielding their phenotypic expression
designed to synthesize matrix (225,226) (Fig. 11).
The local introduction of growth factors at the site
of chondral injury also requires at least transient
stabilization by some kind of a matrix. In addition,
artifi
ficial matrices may also stimulate host cells
into producing matrix. They could also contribute
to the integration of transplanted tissue and cells
into the host (164,218,227).
Although their comparative benefits fi are still
unclear, non-exhaustive candidate substances for
such scaffffolds include fibrinogen-based materials
combined or not with thrombin or antiprotease
elements, collagen gels, polylactic and polyglycolic
acid, polylactic acid, and hyaluronic acid-based
products.
Surgical treatment of cartilage tear: principles and results 475
Numerous challenges remain, involving biocom-
patibility, mechanical constraints (capacity to
mould the implants to a morphological fit), dura-
bility, and price.
Growth factors and pharmacologic modulation
The principle behind local treatment with growth
factors is the stimulation of normal cartilage syn-
thesis by chondrocytes at the site of the lesion.
Cells and platelets present in articular cartilage or
subchondral bone release many factors when after
exposure to trauma. In turn, many cytokines and
biological molecules are known to influence
fl those
cells. FGFs, insulin growth factors (IGFs), and
TGFs are implicated in chondrocyte metabolism
and chondrogenesis (164,232).
TGF, IGF, bone morphogenetic protein (BMP),
PDGFs, amongst others, are expressed in bone
matrix (232,233). In the 1980s, Sato (234)
reported on the effect
ff of BMP on cultured chon-
dral stem cells, with subsequent production of
matrix. The role of sulfate proteoglycan in rela-
tion to matrix production was studies by Rosen-
berg (235). Howell (236) showed partial healing in
injured canine cartilage after it was treated with
protease inhibitor. TGF- (237) and FGF (238)
have shown to have beneficialfi eff
ffect on matrix
synthesis. Some data suggest, again, that the
eff
ffects of cytokines on local cells might decline
with age (239–242).
Many other chondroprotective bioactive mol-
ecules are being investigated and may lead to the
engineering of “bioactive scaffold”
ff with or without
cells. They represent an interesting option when
addressing cartilage injuries. However, because the
precise eff
ffects of those factors on cartilage remain
476 The Traumatic Knee
incompletely identified,
fi the use of such substances
in a single strategy remains investigational.
Conclusion
Based on animal and clinical studies, algorithms
for surgical treatment of chondral injuries have
been proposed. However, guidelines regarding
ideal patient age and lesion size vary according to
the cartilage repair method discussed. The Th scien-
tifi
fic support which would be necessary to off ffer sys-
tematic recommendations is currently missing.
Comparisons between surgical options are dif-
ficult, for reasons related to the heterogeneity of
the patients and the complex nature of cartilage
disease. When treating patients suff ffering from
trauma, osteoarthritis or both combined, it is
important to recall that those affections
ff are slow-
evolving conditions with correlated symptoms
which are unevenly related to gross and histological
damages. Epidemiology and outcome are difficult,ffi
if not impossible to assess, because asymptomatic
patients will not seek medical advice, and second-
look procedures after treatment can be difficult
ffi to
accept for the patients. Over more, many patients
have undergone previous treatments before being
evaluated by a surgeon. Peterson (244) showed
that the average patient presenting for cartilage
restoration had 2.1 previous treatments.
A comparison between treatment options is intri-
cate, also for reasons related to the procedures per
se. Each technique can be performed in a variety
of manners, which can create possible biases in
the difffferent comparative studies. For instance,
ACI can be performed after arthrotomy as well as
arthroscopy; for mosaicplasty, surgeons use dif-
ferent sizes of plugs which they implant with dif-
ferent patterns on the injured chondral surface.
These diff
Th fferences in techniques might account for
discrepancies in comparatives clinical trials: Pri-
die’s (72) result for drilling procedures in 1959
might have been compromised by arthrotomy and
the ensuing knee stiff ffness; Gudas (151) found dif-
ferences in histologic quality of the transplanted
tissue in favor of autografts when compared with
microfractures, showing results inconsistent with
the ones revealed by Bentley et al. (245).
The variety of techniques for judging results con-
Th
tributes to the diffi fficulty when evaluating the
comparative advantages of surgical techniques.
Currently, clinical satisfaction scores, histologi-
cal analysis, radiographic and MRI imaging, and
arthroscopic scales are being used, none of which
are perfectly correlated to the natural evolution
of osteochondral disease. In addition, it is difficult
ffi
to evaluate the contribution of a single technique
when debridement and lavage which are associated
to most of the procedures (246,247), and even pos-
sibly a placebo effffect (248), might alone benefi
fit the
patients.
Furthermore, treating physicians and surgeons
need to be aware that follow-up has been modest
for most of the procedures. It is difficult
ffi to assert
whether the sometimes disappointing result of
surgery in the middle postoperative period is due
to the transient nature of surgical benefitsfi or to a
long recovery period. Steadman (176) supports the
latter supposition, based on second-look arthros-
copies performed at 3, 6, and 12 months after ini-
tial procedure, showing progressive, albeit varying,
defect filling. Chondral healing over time has been
described by Brittberg (134), Hangody (120), and
Czitrom (95). Newman (249) points out that “the
path to successful cartilage repair is strewn with
early reports of good results with new techniques,
only to be followed by later reports of failures after
longer “investigation”.
One has to keep in mind that general contraindica-
tions for all surgical procedure include the presence
of active infection or the inability of the patient to
comply with postoperative and rehabilitation pro-
tocols, which often include non-weight bearing
requirements.
Even though caution must be necessary, progress
in the field of cartilage repair is undeniable. New
techniques as well as combinations of existing
techniques show promising results and will have
to be properly documented in the near future.
The scientifific, clinical, and financial implications
linked with cartilage repair techniques are tremen-
dous. At the present time, a great effort
ff of research
should be directed toward the early depiction of
partial or full-thickness cartilage injuries. On the
other hand, it has been demonstrated that age is
a negative predicting factor in many procedures.
Therefore, emphasis needs also to be put on treat-
ment modalities in older patients.
Important challenges remain regarding the devel-
opment of new techniques as well as demonstra-
tion that existing techniques can ensure durable
eff
ffects and prevent joint degeneration.
References
1. Buckwalter JA, Mow VC, Ratcliff ffe A (1994) Restoration
of injured or degenerated articular cartilage. J Am Acad
Orthop Surg 2:192–201
2. Aaron RK, Boyan BD, Ciombor DM, et al. (2004) Stimula-
tion of growth factor synthesis by electric and electromag-
netic fields [review]. Clin Orthop 419:30–37
3. Hunter W: On the structure and diseases of articulating
cartilages. Philos Trans R Soc Lond 42B:514–521
4. Buckwalter JA, Hunziker E, Rosenberg L, et al. (1988)
Articular cartilage: composition and structure. In Woo
SL-Y, Buckwalter JA, editors. Injury and repair of the mus-
culoskeletal soft tissues. Park Ridge, IL: AAOS:405–425

5. Brittberg M, Winalski CS (2003) Evaluation of carti-
lage injuries and repair. J Bone Joint Surg Am 85(suppl
2):58–69
6. Mankin HJ (1982) The response of articular cartilage to
mechanical injury. J Bone Joint Surg Am 64:460–466
7. Meachim G, Roberts C (1971) Repair of the joint sur-
face from subarticular tissue in the rabbit knee. J Anat
109:317–327; J Bone Joint Surg 64A:460–466, 1982
8. Thompson RC (1975) An experimental study of surface
injury to articular cartilage and enzyme responses within
the joint. Clin Orthop 107:239–248
9. Sahlstrom A, Johnell O, Redlund-Johnell I (1977) Th The
natural course of arthrosis of the knee. Clin Orthop
340:152–157
10. Linden B (1977) Osteochondritis dissecans of the femoral
condyles: a long-term follow-up study. J Bone Joint Surg
Am 59:769–776
11. Messner K, Maletius W (1996) The long-term prognosis
for severe damage to weight-bearing cartilage in the knee:
a 14-year clinical and radiographic follow-up in 28 young
athletes. Acta Orthop Scand 67:165–168
12. Shelbourne KD, Jari S, Gray T (2003) Outcome of untreated
traumatic articular cartilage defects of the knee: a natural
history study. J Bone Joint Surg Am 85(suppl 2):8–16
13. Brittberg M, Sjogren-Jansson E, Lindahl A, et al. (1997)
Infl
fluence of fibrin sealant (Tisseel) on osteochondral
defect repair in the rabbit knee. Biomaterials 18:235–
242
14. Brittberg M, Peterson L, Sjogren-Jansson E (2003) Articu-
lar cartilage engineering with autologous chondrocyte
transplantation: a review of recent developments. J Bone
Joint Surg Am 85(suppl 3):109–115
15. Furukawa T, Eyre DR, Koide S, Glimcher MJ (1980) Bio-
chemical studies on repair cartilage resurfacing experi-
mental defects in the rabbit knee. J Bone Joint Surg Am
62:79–89
16. Convery FR, Akeson WH, Keown GH (1972) The Th repair
of large osteochondral defects. An experimental study in
horses. Clin Orthop 82:253–262
17. Moran ME, Kim HK, Salter RB (1992) Biological resurfac-
ing of full-thickness defects in patellar articular cartilage
of the rabbit. Investigation of autogenous periosteal grafts
subjected to continuous passive motion. J Bone Joint Surg
74B:659–667
18. O’Driscoll SW, Keeley FW, Salter RB (1988) Durability of
regenerated articular cartilage produced by free autog-
enous periosteal grafts in major full thickness defects in
joint surfaces under the influence
fl of continuous passive
motion. A follow-up report at one year. J Bone Joint Surg
70A:595–606
19. O’Driscoll SW, Salter RB (1986) The repair of major osteo-
chondral defects in joint surfaces by neochondrogenesis
with autogenous osteoperiosteal grafts stimulated by con-
tinuous passive motion. An experimental investigation in
the rabbit. Clin Orthop 208:131–140
20. O’Driscoll SW, Salter RB (1984) The
Th induction of neochon-
drogenesis in free intra-articular periosteal autografts
under the infl fluence of continuous passive motion: An
experimental investigation in the rabbit. J Bone Joint
Surg 66A:1248–1257
21. Nevo Z, Robinson D, Halperin N, et al. (1990) Culturing
chondrocytes for implantation In: Maroudas A, Kuettner
K, editors) Methods in cartilage research. London: Aca-
demic Press:98–100
22. Frisbie DD, Trotter GW, Powers BE, et al. (1999)
Arthroscopic subchondral bone plate microfracture tech-
nique augments healing of large chondral defects in the
radial carpal bone and medial femoral condyle of horses.
Vet Surg 28:242–255
23. Steadman JR, Briggs KK, Rodrigo JJ, et al. (2003) Out-
comes of microfracture for traumatic chondral defects of
Surgical treatment of cartilage tear: principles and results 477
the knee: average 11 year follow-up. Arthroscopy 19:477–
484
24. Repo RU, Finlay JB (1977) Survival of articular cartilage
after controlled impact. J Bone Joint Surg 59A:1068–
1075
25. Haut RC (1989) Contact pressures in the patellofemoral
joint during impact loading on the human flexedfl knee. J
Orthop Res 7:272–280
26. Zimmerman NB, Smith DG, Pottenger LA, Cooperman DR
(1988) Mechanical disruption of human patellar cartilage
by repetitive loading in vitro. Clin Orthop 229:302–307
27. Weightman B (1976) Tensile fatigue of human articular
cartilage. J Biomech 9:193–200
28. Chen AC, Nagrampa JP, Schinagl RM, et al. (1997) Chon-
drocyte transplantation to articular cartilage explants in
vitro. J Orthop Res 15:791–802
29. Buckwalter JA (1992) Mechanical injuries of articular car-
tilage. In: Finerman G, editor. Biology and biomechanics
of the traumatized synovial joint. Park Ridge, IL: Ameri-
can Academy of Orthopaedic Surgeons:83–96
30. Loening AM, James IE, Levenston ME, et al. (2000) Injuri-
ous mechanical compression of bovine articular cartilage
induces chondrocyte apoptosis. Arch Biochem Biophys
381:205–212
31. Zang H, Vrahas MS, Baratta RV, Rosler DM (1999) Dam-
age to rabbit femoral articular cartilage following direct
impacts of uniform stresses: An in vitro study. Clin Bio-
mech 14:543–548
32. Gooodfelow J (1982) Cartilage lesions and chondromala-
cia. In: Pickett JC, Radin EL, editors. Chondromalacia of
the patella, ed. 1. Baltimore/London: Williams & Wilkins:
43–50
33. Insall J (1982) Patellar Pain. J Bone Joint Surg 64-A:147
34. Kettelkamp D, Jacobs A (1972) Tibiofemoral contact
area—determination and implications J Bone Joint Surg
54-A:349–356
35. Frankel V, Burstein A, Brooks D (1971) Biomechanics
of internal derangement of the knee. J Bone Joint Surg
53-A:945
36. Hjelle K, Solheim E, Strand T et al. (2002) Articular car-
tilage defects in 1,000 knee arthroscopies. Arthroscopy
18:730–734
37. Curl W, Krome J, Gordon E et al. (1997) Cartilage inju-
ries: a review of 31,516 knee arthroscopies. Arthroscopy
13:456–460
38. Casscells S (1985) The torn meniscus, the torn anterior
cruciate ligament, and their relationship to degenerative
joint disease. Arthroscopy 1:28
39. Casscells S (1978) The torn or degenerate meniscus and its
relationship to degeneration of the weight-bearing areas
of the femir. Clin Orthop Rel Res 132:196
40. Noble J, Hamblem D (1975) The pathology of the degener-
ate meniscal lesion. J Bone Joint Surg 57-B:180
41. Dandy D, Jackson R (1975) Meniscectomy and chon-
dromalacia of the femoral condyle. J Bone Joint Surg
57-A:1116
42. Zamber RW, Teitz CC, McGuire DA, et al. (1989) Articular
cartilage lesions of the knee. Arthroscopy 5:258–268
43. Levy AS, Lohnes J, Sculley S, et al. (1996) Chondral delam-
ination of the knee in soccer players. Am J Sports Med
24:634–639
44. Mithöfer K, Peterson L, et al. (2005) Articular cartilage
repair in soccer players with autologous chondrocyte
transplantation functional outcome and return to compe-
tition. Am J Sports Med 33(11):1639–1646
45. Mithöfer K, Minas T, Micheli J, et al. (2005) Functional
outcome of knee articular cartilage repair in adolescent
athletes. Am J Sports Med 33:1147
46. Felson DT (2004) TheTh eff
ffect of body weight on progression
of knee osteoarthritis is dependent on alignment. Arthri-
tis Rheum 50(12):3904–3909
478 The Traumatic Knee
47. Johnson DL, Urban WP, Caborn DN, et al. (1998) Articular
cartilage changes seen with magnetic resonance imaging-
detected bone bruises associated with anterior cruciate
ligament rupture. Am J Sports Med 26:409–414
48. Rubin DA, Harner CD, Costello JM (2000) Treatable chon-
dral injuries of the knee: frequency of associated focal sub-
chondral edema. Am J Roentgenol 174:1099–1106
49. Potter H, Linklater J, Allen A et al. (1998) Magnetic reso-
nance imaging of articular cartilage in the knee: an evalua-
tion with use of fast-spin-echo imaging. J Bone Joint Surg
80A:1276–1284
50. Burstein D, Bashir A, Gray ML (2000) MRI techniques in
early stages of cartilage disease. Invest Radiol 35:622–638
51. McCauley T, Disler D (2001) Magnetic resonance imaging
of articular cartilage of the knee. J Am Acad Orthop Surg
9:2–8
52. Recht MP, Piraino DW, Paletta GA, et al. (1996) Accuracy
of fat suppressed three-dimensional spoiled gradient-echo
FLASH MR imaging in the detection of patellofemoral
articular cartilage abnormalities. Radiology 198:209–212
53. Kawahara Y, Uetani M, Nakahara N, et al. (1998) Fast spin-
echo MR of the articular cartilage in the osteoarthrotic
knee. Correlation of MR and arthroscopic findings. Acta
Radiol 39:120–125
54. Bredella MA, Tirman PF, Peterfy CG, et al. (1999) Accuracy
of T2-weighted fast spin-echo MR imaging with fat satura-
tion in detecting cartilage defects in the knee: compari-
son with arthroscopy in 130 patients. Am J Roentgenol
172:1073–1080
55. Gagliardi JA, Chung EM, Chandnani VP, et al. (1994)
Detection and staging of chondromalacia patellae: relative
effi
fficacies of conventional MR imaging, MR arthrography,
and CT arthrography. AJR Am J Roentgenol 163:629–
636
56. Disler DG, McCauley TR, Kelman CG, et al. (1996) Fat-
suppressed three-dimensional spoiled gradient-echo MR
imaging of hyaline cartilage defects in the knee: compari-
son with standard MR imaging and arthroscopy. AJR Am
J Roentgenol 167:127–132
57. Bauer M, Jackson RW (1988) Chondral lesions of the
femoral condyles: a system of arthroscopic classification.
fi
Arthroscopy 4:97–102
58. Insall J (1961) Patellar pain. J Bone Joint Surg Am
64:147–152
59. Outerbridge RE (1961) The etiology of chondromalacia
patellae. J Bone Joint Surg Br 43:752–759
60. Noyes F, Stabler C (1989) A system for grading articular
cartilage lesions at arthroscopy. Am J Sports Med 17:505–
513
61. Ayral X, Dougados M, Listrat V, et al. (1993) Chondros-
copy: a new method for scoring chondropathy. Semin
Arthritis Rheum 22:289–297
62. Magnusson PB (1946) Technique of debridement of the
knee joint for arthritis. Surg Clin North Am 26:226–249
63. Evans CH, Mazzocchi RA, Nelson DD, et al. (1984) Experi-
mental arthritis induced by intraarticular injection of allo-
genic cartilaginous particles into rabbit knees. Arthritis
Rheum 27:200–207
64. Baumgaertner MR, Cannon WD Jr, Vittori JM, et al.
(1990) Arthroscopic debridement of the arthritic knee.
Clin Orthop 253:197–202
65. Bert JM, Maschka K (1989) The arthroscopic treatment
of unicompartmental gonarthrosis: a five-year follow-up
study of abrasion arthroplasty plus arthroscopic debride-
ment and arthroscopic debridement alone. Arthroscopy
5:25–32
66. Kim HKW, Moran ME, Salter RB (1991) The potential
for regeneration of articular cartilage in defects cre-
ated by chondral shaving and subchondral abrasion. An
experimental investigation in rabbits. J Bone Joint Surg
73A:1301–1315
67. Mitchell N, Shepard N (1987) Eff ffect of patellar shaving in
the rabbit. J Orthop Res 5:388–392
68. Schmid A, Schmid F (1987) Results after cartilage shav-
ing studied by electron microscopy. Am J Sports Med
15:386–387
69. Shapiro F, Koide S, Glimcher MJ (1993) Cell origin and
diff
fferentiation in the repair of full-thickness defects of
articular cartilage. J Bone Joint Surg 75A:532–553
70. Buckwalter JA, Rosenberg LA, Hunziker EB (1990) Artic-
ular cartilage: composition, structure, response to injury,
and methods of facilitation repair. In: Ewing JW, editor.
Articular cartilage and knee joint function: basic science
and arthroscopy. New York: Raven Press:19–56
71. Johnson LL (1990) The sclerotic lesion: pathology and the
clinical response to arthroscopic abrasion arthroplasty.
In: Ewing JW, editor. Articular cartilage and knee joint
function: basic science and arthroscopy. New York: Raven
Press:319–333
72. Pridie KH (1959) A method of resurfacing osteoarthritic
knee joints. J Bone Joint Surg 41B:618–619
73. Steadman JR, Rodkey WG, Singleton SB, et al. (1997)
Microfracture technique for full-thickness chondral
defects: technique and clinical results. Oper Tech Orthop
7:300–304
74. Dandy DJ (1981) Arthroscopic surgery of the knee. Edin-
burgh: Churchill Livingstone
75. Rae PJ, Noble J (1989) Arthroscopic drilling of osteochon-
dral lesions of the knee. J Bone Joint Surg 71B:534
76. Insall JN, Hood RW, Flawn LB, et al. (1983) The Th total con-
dylar knee prosthesis in gonarthrosis. J Bone Joint Surg
65A:619–628
77. Johnson LL (1986) Arthroscopic surgery, principles and
practice. St Louis, MO: CV Mosby Co.: 737–773
78. Johnson LL (1986) Arthroscopic abrasion arthroplasty
historical and pathologic perspective: present status.
Arthroscopy 2:54–69
79. Insall JN (1967) Intra-articular surgery for degenerative
arthritis of the knee: a report of the work of the late HR
Pridie. J Bone Joint Surg 49B:211–228
80. Johnson L (2001) Arthroscopic abrasion arthroplasty: a
review. Clin Orthop Relat Res 391 (suppl): S306–S317.
Review
81. Blevins FT, Steadman JR, Rodrigo JJ, et al. (1998) Treat-
ment of articular cartilage defects in athletes: an analysis
of functional outcome and lesion appearance. Orthope-
dics 21:761–767
82. Gill T (2000) The role of the microfracture technique in the
treatment of full thickness chondral injuries. Oper Tech
Sports Med 8:138–140 [Gill T, Macgillivray J (2001) Th The
technique of microfracture for the treatment of articular
cartilage defects in the knee. Oper Tech Orthop 2:105–
107]
83. Freedman KB, Nho SJ, Cole BJ (2003) Marrow stimulat-
ing technique to augment meniscus repair. Arthroscopy
19:794–798
84. Steadman JR, Rodkey WG, Rodrigo JJ (2001) Microfrac-
ture: surgical technique and rehabilitation to treat chon-
dral defects. Clin Orthop 391(suppl): S362–S369
85. Ritsila VA, Santavirta S, Alhopuro S, et al. (1994) Periosteal
and perichondral grafting in reconstructive surgery. Clin
Orthop 302:259–265
86. Jaroma H, Ritsila V (1987) Reconstruction of patellar
cartilage defects with free periosteal grafts. Scand J Plast
Reconstr Surg 21:1987
87. Homminga GN, Bulstra SK, Kuijer R, van der Linden AJ
(1991) Repair of sheep articular cartilage defects with
a rabbit costal perichondrial graft. Acta Orthop Scand
62:415–418
88. Skoog T, Ohlsen L, Sohn SA (1972) Perichondrial poten-
tial for cartilaginous regeneration. Scand J Plast Reconstr
Surg 6:123–125

89. Coutts RD, Woo SL, Amiel D, et al. (1992) Rib perichon-
drial autografts in full-thickness articular cartilage defects
in rabbits. Clin Orthop 275:263–273
90. Chu CR, Coutts RD, Yoshioka M, et al. (1995) Articular
cartilage repair using allogeneic perichondrocyte-seeded
biodegradable porous polylactic acid (PLA): a tissue-engi-
neering study. J Biomed Mater Res 29:1147–1154
91. Lexer E (1908) Substitution of whole or half joints from
freshly amputated extremities by free plastic operation.
Surg Gynecol Obstet 6:601–607
92. Lexer E (1925) Joint transplantations and arthroplasty.
Surg Gynecol Obstet 40:782–809
93. Fitzpatrick PL, Morgan DA (1998) Fresh osteochondral
allografts: a 6–10-year review. Aust N Z J Surg 68:573–579
94. Amiel D, Harwood FL, Hoover JA, Meyers M (1989) A his-
tological and biomechanical assessment of the cartilage
matrix obtained from in vitro storage of osteochondral
allografts. Connect Tissue Res 23:89–99
95. Czitrum AA, Keating S, Gross AK (1990) The viability of
articular cartilage in fresh allografts after clinical trans-
plantation. J Bone Joint Surg Am 72:574–581
96. Mankin HJ, Fogelson FS, Th Thrasher AZ, Jaff ffer F (1976)
Massive resection and allograft transplantation in the
treatment of malignant bone tumors. N Engl J Med
294:1247–1253
97. Manlin TI, Mnaymneh W, Lo HF (1994) Cryopreservation
of articular cartilage: ultrastructural observations and
long term results of experimental distal femoral trans-
plantation. Clin Orthop 303:18–32
98. Rassmussen TJ, Feder SM, Butler DL, Noyes FR (1994)
The effffects of 3 Mrad of gamma irradiation on the ini-
tial mechanical properties of bone–patellar tendon–bone
grafts. Arthroscopy 10:188–197
99. Sammarco VJ, Gorab R, Miller R, Brooks P (1997) Human
articular cartilage storage in cell culture medium: guide-
lines for storage of fresh osteochondral allografts. Ortho-
pedics 20:497–500
100. Asselmeier MA, Caspari RB, Bottenfi field S (1993) A review
of allograft processing and sterilization techniques and
their role in transmission of the human immunodefi ficiency
virus. Am J Sports Med 21:170–175
101. Buck BE, Resnick L, Shah SM, et al. (1990) Human immu-
nodefificiency virus cultured from bone. Implications for
transplantation. Clin Orthop 251:249–253
102. Friedlaender GE, Strong DM, Sell KW (1984) Studies on
the antigenicity of bone, II: donor-specific fi anti-HLA anti-
bodies in human recipients of freeze-dried allografts. J
Bone Joint Surg Am 66:107–112
103. Langer F, Gross AE (1974) Immunogenicity of allograft
articular cartilage. J Bone Joint Surg Am56:297–304
104. Convery FR, Meyers MH, Akeson WH (1991) Fresh osteo-
chondral allografting of the femoral condyle. Clin Orthop
273:139–145
105. Rodrigo JJ, Schnaser AM, Reynolds HM Jr, et al. (1989)
Inhibition of the immune response to experimental fresh
osteoarticular allografts. Clin Orthop 243:235–253.
106. Czitrom AA, Axelrod T, Fernandes B (1985) Antigen pre-
senting cells and bone allotransplantation. Clin Orthop
197:27–31
107. Langer F, Czitrom A, Pritzker KP, et al. (1975) The Th immu-
nogenicity of fresh and frozen allogeneic bone. J Bone
Joint Surg 57A:216–220
108. Williams SK, Amiel D, Ball ST, et al. (2003) Prolonged stor-
age eff
ffects on the articular cartilage of fresh human osteo-
chondral allografts. J Bone Joint Surg Am 85:2111–2120
109. Friedlander GE (1983) Immune responses to osteochon-
dral allografts. Current knowledge and future directions.
Clin Orthop 174:58–68
110. Schachar NS, McGann LE (1986) Investigations of low-
temperature storage of articular cartilage for transplanta-
tion. Clin Orthop 208:146–150
Surgical treatment of cartilage tear: principles and results 479
111. Tomford WW, Duff ff GP, Mankin HJ (1985) Experimen-
tal freeze-preservation of chondrocytes. Clin Orthop
197:11–14
112. Jackson DW, Halbrecht J, Proctor C, et al. (1996) Assess-
ment of donor cell and matrix survival in fresh articular
cartilage allografts in a goat model. J Orthop Res 14:255–
264
113. Beaver RJ, Mahomed M, Backstein D, et al. (1992) Fresh
osteochondral allografts for post-traumatic defects in the
knee. A survivorship analysis. J Bone Joint Surg 74B:105–
110
114. Mahomed MN, Beaver RJ, Gross AE (1992) The long-term
success of fresh, small fragment osteochondral allografts
used for intraarticular post-traumatic defects in the knee
joint. Orthopedics 15:1191–1199
115. Desjardins MR, Hurtig MB, Palmer NC (1991) Heterotopic
transfer of fresh and cryopreserved autogenous articular
cartilage in the horse. Vet Surg 20:434–445
116. Yamashita F, Sakakida K, Suzu F (1985)Th The transplanta-
tion of an autogenic osteochondral fragment for osteo-
chondritis dissecans of the knee. Clin Orthop 201:43–50
117. Matsusue Y, Yamamuro T, Hama H (1993) Arthroscopic
multiple osteochondral transplantation to the chondral
defect in the knee associated with anterior cruciate liga-
ment disruption. Arthroscopy 9:318–321
118. Bobic V (1996) Arthroscopic osteochondral autograft
transplantation in anterior cruciate ligament reconstruc-
tion: a preliminary clinical study. Knee Surg Sports Trau-
matol Arthrosc 3:262–264
119. Hangody L, Feczko P, Bartha L, et al. (2001) Mosaicplasty
for the treatment of articular defects of the knee and ankle
[review]. Clin Orthop 391(suppl): S328–S336
120. Hangody L, Kish G, Karpati Z, et al. (1997) Arthroscopic
autogenous osteochondral mosaicplasty for the treatment
of femoral condylar articular defects: a preliminary report.
Knee Surg Sports Traumatol Arthrosc 5:262–267
121. Hangody L, Kish G, Karpati Z, et al. (1998) Mosaicplasty
for the treatment of articular cartilage defects: application
in clinical practice. Orthopedics 21:751–756
122. Outerbridge HK, Outerbridge AR, Outerbridge RE (1995)
The use of a lateral patellar autologous graft for the repair
of a large osteochondral defect in the knee. J Bone Joint
Surg Am 77:65–72
123. Buckwalter JA (1997) Were the Hunter brothers wrong?
Can surgical treatment repair articular cartilage? Iowa
Orthop J 17:1–13
124. Duchow J, Hess T, Kohn D (2000) Primary stability of
press-fi
fit-implanted osteochondral grafts: infl fluence of
graft size, repeated insertion, and harvesting technique.
Am J Sports Med 28:24–27
125. Noguchi T, Oka M, Fujino M, et al. (1994) Repair of osteo-
chondral defects with grafts of cultured chondrocytes.
Comparison of allografts and isografts. Clin Orthop
302:251–258
126. Vangsness CT Jr, Triff ffon MJ, Joyce MJ, Moore TM (1996)
Soft tissue for allograft reconstruction of the human knee:
a survey of the American Association of Tissue Banks. Am
J Sports Med 24:230–234
127. Kish G, Modis L, Hangody L (1999) Osteochondral mosai-
cplasty for the treatment of focal chondral and osteochon-
dral lesions of the knee and talus in the athlete: ration-
ale, indications, techniques, and results. Clin Sports Med
18:45–66
128. Hangody L, Kish G, Karpati Z (1997) Autogenous osteo-
chondral graft technique for replacing knee cartilage
defects in dogs. Orthop Int 5:175–181
129. Hangody L, Ráthonyi G, Duska Z, et al. (2003) Autologous
osteochondral mosaicplasty. Surgical Technique JBJS
85-A(suppl 2):25–32
130. Smith AU Survival of frozen chondrocytes isolated from
cartilage of adult mammals. Nature 205:782–784, 165.
480 The Traumatic Knee
131. Chesterman PJ, Smith AU (1968) Homotransplanta-
tion of articular cartilage and isolated chondrocytes.
An experimental study in rabbits. J Bone Joint Surg
50B:184–197
132. Bentley G, Greer RB III (1971) Homotransplantation of
isolated epiphyseal and articular cartilage chondrocytes
into joint surfaces of rabbits. Nature 230:385–388
133. Grande DA, Pitman MI, Peterson L, et al. (1989) The repair
of experimentally produced defects in rabbit articular
cartilage by autologous chondrocyte transplantation. J
Orthop Res 7:208–218
134. Brittberg M, Lindahl A, Nilsson A, et al. (1994) Treat-
ment of deep cartilage defects in the knee with autolo-
gous chondrocyte transplantation. N Engl J Med
331:889–895
135. Homminga GN, Bulstra SK, Bouwmeester PSM, et al.
(1990) Perichondral grafting for cartilage lesions of the
knee. J Bone Joint Surg 72B:1003–1007
136. Jackson DW, Simon TM (1996) Chondrocyte transplanta-
tion [current concepts]. Arthroscopy 12:732–738
137. Minas T, Nehrer S (1997) Current concepts in the treat-
ment of articular cartilage defects. Orthopedics 20:525–
538
138. Coon HG (1966) Clonal stability and phenotypic expres-
sion of chick cartilage cells in vitro. Proc Natl Acad Sci U
S A 55:66–73
139. Eyre DR, Muir H (1975) The Th distribution of diff fferent
molecular species of collagen in fibrous, elastic, and hya-
line cartilages of the pig. Biochem J 151:595–602
140. Holtzer H, Abbott J, Lash J, et al. (1960) The loss of phe-
notypic traits by differentiated
ff cells in vitro. I. Dedif-
ferentiation of cartilage cells. Proc Natl Acad Sci U S A
46:1533
141. Tallheden T, Dennis JE, Lennon DP, et al. (2003) Pheno-
typic plasticity of human articular chondrocytes. J Bone
Joint Surg Am 85(suppl 2):93–100
142. Gospodarowicz D, Delgado D, Vlodavsky I (1980) Premis-
sive eff
ffects of the extracellular matrix on cell proliferation
in vitro. Proc Natl Acad Sci U S A 77:4094–4098
143. Itay S, Abramovici A, Nevo Z (1987) Use of cultured embry-
onal chick epiphyseal chondrocytes as grafts for defects in
chick articular cartilage. Clin Orthop 220:284–303
144. Green WT Jr. (1977) Articular cartilage repair: behavior of
rabbit chondrocytes during tissue culture and subsequent
allografting. Clin Orthop 124:237–250
145. Duchow J, Hess T, Kohn D (2000) Primary stability of
press-fifit-implanted osteochondral grafts: infl fluence of
graft size, repeated insertion, and harvesting technique.
Am J Sports Med 28:24–27
146. Harwin (1999) Arthroscopic debridement for osteoarthri-
tis of the knee: predictors of patient satisfaction. Arthros-
copy 15:142–146
147. Moseley JB, O’Malley K, Petersen NJ, et al. (2002) A con-
trolled trial of arthroscopic surgery for osteoarthritis of
the knee. N Engl J Med 347:81–88
148. Dzioba RB (1988) The Th classifi
fication and treatment of acute
articular cartilage lesions. Arthroscopy 4:72–80
149. O’Driscoll SW (1998) The healing and regeneration of
articular cartilage. J Bone Joint Surg Am 80:1795–1812
150. Alford
l d JM, Cole l B (2005)
( ) Cartilage restoration, part 1:
Basic science, historical perspective, patient evaluation,
and treatment options. Am J Sports Med 33(2):295–306
Review; and Alford JW and Cole B (2005) Cartilage res-
toration, part 2: Techniques, outcomes, and future direc-
tions. Am J Sports Med 33(3):443–460. Review, Am J
Sports Med 33:443
151. Gudas R, Kalesinskas R, Smailys A (2005) A prospec-
tive randomized clinical study of mosaic osteochondral
autologous transplantation versus microfracture for the
treatment of osteochondral defects in the knee in young
athletes. Arthroscopy 21(9):1066–1075
152. Gobbi A, Nunag P, Malinowski K (2004) Treatment of full
thickness chondral lesions of the knee with microfrac-
ture in a group of athletes. Knee Surg Sports Traumatol
Arthrosc 3:213–221
153. Locht RC, Gross AE, Langer F (1984) Late osteochondral
allograft resurfacing for tibial plateau fractures. J Bone
Joint Surg Am 66:328–335
154. Meyers MH, Akeson W, Convery FR (1989) Resurfacing of
the knee with fresh osteochondral allograft. J Bone Joint
Surg Am 71:704–713
155. Zukor DJ, Oakeshott RD, Gross AE (1989) Osteochondral
allograft reconstruction of the knee, part 2: Experience
with successful and failed fresh osteochondral allografts.
Am J Knee Surg 2:182–191
156. McCulloch PC, Kang RW, Cole J, et al. (2007) Prospective
evaluation of prolonged fresh osteochondral allograft
transplantation of the femoral condyle: minimum 2-year
follow-up Am J Sports Med 35:411
157. Hangody L, Kish G, Karpati Z, et al. (1997) Osteochon-
dral plugs: autogenous osteochondral mosaicplasty for the
treatment of focal chondral and osteochondral articular
defects. Oper Tech Orthop 7:312–322
158. Mont MA, Jones LC, Vogelstein BN, Hungerford DS
(1999) Evidence of inappropriate application of autolo-
gous cartilage transplantation therapy in an uncontrolled
environment. Am J Sports Med 27:617–620
159. Michael A. Mont, Lynne, et al. (1999) Evidence of inap-
propriate application of autologous cartilage transplanta-
tion therapy in an uncontrolled environment. Am J Sports
Med 27(5).
160. Callaghan JJ, Heekin RD, Savory CG, et al. (1992) Evalu-
ation of the learning curve associated with uncemented
primary porous-coated anatomic total hip arthroplasty.
Clin Orthop 282:132–144
161. Huiskes R (1993) Failed innovation in total hip replace-
ment: diagnosis and proposals for a cure. Acta Orthop
Scand 64:699–716
162. Bert JM (1993) Role of abrasion arthroplasty and debri-
dement in the management of osteoarthritis of the knee.
Rheum Dis Clin North Am 19:725–739
163. Bert JM, Maschka K (1989) The arthroscopic treatment of
unicompartmental gonarthrosis: a five-year follow-up study
of abrasion arthroplasty plus arthroscopic debridement and
arthroscopic debridement alone. Arthroscopy 5:25–32
164. Buckwalter JA, Lohmander S (1994) Operative treatment
of osteoarthritis. Current practice and future develop-
ment. J Bone Joint Surg 76A:1405–1418
165. Rand JA (1991) Role of arthroscopy in osteoarthritis of
the knee. Arthroscopy 7:358–363
166. Hubbard M (1996) Articular debridement versus washout
for degeneration of the medial femoral condyle. J Bone
Joint Surg Br 78:217–219
167. Jackson R, Marans H, Silver R (1988) Arthroscopic treat-
ment of degenerative arthritis of the knee. J Bone Joint
Surg Am70:332.
168. Merchan E, Galindo E (1993) Arthroscope-guided sur-
gery versus nonoperative treatment for limited degenera-
tive arthritis of the femorotibial joint in patients over 50
years of age: a prospective comparative study. Arthroscopy
9:663–667
169. Minas T (2000) A practical algorithm for cartilage repair.
Oper Tech Sports Med 8:141–143.
170. Mitchell N, Shepard N (1976) The resurfacing of adult rab-
bit articular cartilage by multiple perforations through the
subchondral bone. J Bone Joint Surg 58A:230–233
171. Buckwalter JA, Rosenberg L, Coutts R, et al. (1988) Artic-
ular cartilage: injury and repair. In: Woo SL-Y, Buckwalter
JA, editors. Injury and repair of the musculoskeletal soft
tissues. Park Ridge, IL: AAOS; 465–482
172. Bert JM (1979) Abrasion arthroplasty. Oper Tech Orthop
7:294–299

173. Childers J, Stephen C, Ellwood C (1979) Partial chon-
drectomy and subchondral bone. Clin Orthop Relat Res
(144):114–120
174. Insall JN (1974) The Pridie debridement operation of
osteoarthritis of the knee. Clin Orthop 101:61–67
175. Friedman M, Berasi C, Fox J, et al. (1984) Preliminary
result with abrasion arthroplasty in the osteoarthritic
knee. Clin Orthop Relat Res182:200–205
176. Steadman JR, Briggs KK, Rodrigo JJ, et al. (2003) Out-
comes of microfracture for traumatic chondral defects of
the knee: average 11 year follow-up. Arthroscopy 19:477–
484
177. Hunziker EB (2002) Articular cartilage repair: basic sci-
ence and clinical progress: a review of current status and
prospects. Osteoarthritis Cartilage 10:432–463
178. Steadman JR, Miller BS, Karas SG, et al. (2003) TheTh micro-
fracture technique in the treatment of full-thickness
chondral lesions of the knee in National Football League
players. J Knee Surg 16:83–86
179. Choi YS, Potter HG, Chun TJ (2008) MR imaging of car-
tilage repair in the knee and the ankle. Radiographics
28:1043–1059
180. Jaroma H, Ritsila V (1987) Reconstruction of patellar
cartilage defects with free periostal grafts. Scand J Plast
Reconstr Surg 21:1987
181. Argun M, Baktir A, Turk CY, et al. (1993) The Th chondro-
genic potential of free autogenous periosteal and fascial
grafts for biological resurfacing of major full-thickness
defects in joint surfaces (an experimental investigation in
the rabbit). Tokai J Exp Clin Med 18(3–6):107–116
182. Curtin WA, Reville WJ, Brady MP (1992) Quantitative
and morphological observations on the ultrastructure of
articular tissue generated from free periosteal grafts. J
Electron Miscrosc (Tokyo) 41:82–90
183. Korkala O, Kuokkanen H (1991) Autogenous osteope-
riosteal grafts in the reconstruction of full-thickness joint
surface defects. Int Orthop 15:233–237
184. Kreder HJ, Moran M, Keeley FW, et al. (1994) Biologic
resurfacing of a major joint defect with cryopreserved
allogeneic periosteum under the influence
fl of continuous
passive motion in a rabbit model. Clin Orthop 300:288–
296
185. Seradge H, Kutz JA, Kleinert HE, et al. (1984) Perichon-
drial resurfacing arthroplasty in the hand. J Hand Surg
9A:880–886
186. Garrett JC (1994) Fresh osteochondral allografts for treat-
ment of articular defects in osteochondritis dissecans of the
lateral femoral condyle in adults. Clin Orthop 303:33–37
187. Garrett JC (1993) Osteochondral allografts. Instr Course
Lect 42:355–358
188. Ghazavi MT, Pritzker KP, Davis AM, Gross AE (1997) Fresh
osteochondral allografts for posttraumatic osteochondral
defects of the knee. J Bone Joint Surg 79B:1008–1013.
189. Gross AE (1997) Fresh osteochondral allografts for post-
traumatic knee defects: surgical technique. Oper Tech
Orthop 7:334–339
190. Flynn JM, Springfi field DS, Mankin HJ (1994) Osteoar-
ticular allografts to treat distal femoral osteonecrosis. Clin
Orthop 303:38–43
191. Williams RJ III, Dreese JC, Chen CT (2004) Chondrocyte
survival and material properties of hypothermically stored
cartilage: an evaluation of tissue used for osteochondral
allograft transplantation. Am J Sports Med 32:132–139
192. Verstraete K, Almqvist F, Verdonk P, et al. (2004) Mag-
netic resonance imaging of cartilage repair. Clin Radiol
59:674–689
193. Potter H, Foo L (2006) Magnetic resonance imaging of
articular cartilage: trauma, degeneration, and repair. Am
J Sports Med 34:661–677
194. Outerbridge KK, Outerbridge AR, Outerbridge RE (1995)
The use of a lateral patellar autologous graft for the repair
Surgical treatment of cartilage tear: principles and results 481
of a large osteochondral defect in the knee. J Bone Joint
Surg 77A:65–72
195. Hangody L, Füles P (2003) Autologous osteochondral
mosaicplasty for the treatment of full-thickness defects of
weight-bearing joints: ten years of experimental and clini-
cal experience. J Bone Joint Surg Am 85:25–32
196. Hangody L, Rathonyi GK, Duska Z, et al. (2004) Autolo-
gous osteochondral mosaicplasty. Surgical technique. J
Bone Joint Surg Am 86(suppl 1):65–72
197. Delcogliano A, Caporaso A, Menghi A, et al. (2002) Results
of autologous osteochondral grafts in chondral lesions of
the knee. Minerva Chir 57:273–281
198. Garretson RB III, Katolik LI, Verma N, et al. (2004) Con-
tact pressure at osteochondral donor sites in the patel-
lofemoral joint. Am J Sports Med 32:967–974
199. Guettler JH, Demetropoulos CK, Yang KH, Jurist KA
(2005) Dynamic evaluation of contact pressure and the
eff
ffects of graft harvest with subsequent lateral release
at osteochondral donor sites in the knee. Arthroscopy
21:715–720
200. Jakob RP, Franz T, Gautier E, Mainil-Varlet P (2002)
Autologous osteochondral grafting in the knee: indica-
tion, results, and refl
flections. Clin Orthop 401:170–184
201. LaPrade RF, Botker JC (2004) Donor-site morbidity after
osteochondral autograft transfer procedures. Arthroscopy
20: e69–e73
202. Wang CJ (2002) Treatment of focal articular cartilage
lesions of the knee with autogenous osteochondral grafts:
a 2- to 4-year follow-up study. Arch Orthop Trauma Surg
122:169–172.
203. Alparslan L, Winalski C, Boutin R, Minas T (2001) Post-
operative magnetic resonance imaging articular cartilage
repair. Semin Musculoskelet Radiol 5:345–363
204. Pearce SG, Hurtig MB, Clarnette R, et al. (2001) An investi-
gation of 2 techniques for optimizing joint surface congru-
ency using multiple cylindrical osteochondral autografts.
Arthroscopy 17:50–55
205. Sgaglione NA, Miniaci A, Gillogly SD, Carter TR (2002)
Update on advanced surgical techniques in the treatment
of traumatic focal articular cartilage lesions in the knee.
Arthroscopy 18(suppl 1):9–32
206. Whiteside RA, Bryant JT, Jakob RP, et al. (2003) Short-
term load bearing capacity of osteochondral autografts
implanted by the mosaicplasty technique: an in vitro por-
cine model. J Biomech 36:1203–1208
207. Peterson L, Brittberg M, Kiviranta I, et al. (2002) Autolo-
gous chondrocyte transplantation: biomechanics and long
term durability. Am J Sports Med 30:2–12
208. Peterson L, Minas T, Brittberg M, et al. (2000) Two-to
9-year outcome after autologous chondrocyte transplan-
tation of the knee. Clin Orthop Relat Res 374:212–234
209. Smith GD, Richardson JB, Brittberg M, et al. (2003) Autol-
ogous chondrocyte implantation and osteochondral cylin-
der transplantation in cartilage repair of the knee joint. J
Bone Joint Surg Am 85:2487–2488
210. Knutsen G, Engebretsen L, Ludvigsen TC, et al. (2004)
Autologous chondrocyte implantation compared with
microfracture in the knee. A randomized trial. J Bone
Joint Surg Am 86:455–464
211. Horas U, Pelinkovic D, Herr G, et al. (2003) Autologous
chondrocyte implantation and osteochondral cylinder
transplantation in cartilage repair of the knee joint. A
prospective, comparative trial. J Bone Joint Surg Am
5:185–192
212. Marlovits S, Striessnig G, Resinger C, et al. (2004) Defini-
fi
tion of pertinent parameters for the evaluation of articu-
lar cartilage repair tissue with high-resolution magnetic
resonance imaging. Eur J Radiol 52(3):310–319
213. Brittberg M, Tallheden T, Sjögren-Jansson E, et al.
(2001) Autologous chondrocytes used for articular carti-
lage repair: an update in clinical orthopedics and related
482 The Traumatic Knee
research. Lippincott Williams & Wilkins; Number 391S:
S337–S348.
214. Caplan AI (1991) Mesenchymal stem cells. J Orthop Res
9:641–650
215. Caplan AI, Goto T, Wakitani S, et al. (1992) Cell-based
technologies for cartilage repair. In: Finerman GAM,
Noyes FR, editors. Biology and biomechanics of the trau-
matized synovial joint: the Knee as a model. Rosemont,
IL: AAOS:111–122
216. Nakahara H, Goldberg VM, Caplan AI (1991) Culture-ex-
panded human periosteal-derived cells exhibit osteochon-
dral potential in vivo. J Orthop Res 9:465–476
217. Wakitani S, Goto T, Pineda SJ, et al. (1994) Mesenchymal
cell-based repair of large, full-thickness defects of articu-
lar cartilage. J Bone Joint Surg 76A:579–592
218. Buckwalter JA, Mankin HJ (1997) Articular cartilage II:
Degeneration and osteoarthrosis, repair, regeneration and
transplantation. J Bone Joint Surg 79A:612–632
219. Wakitani S, Kimura T, Hirooka A, et al. (1988) Repair
of rabbits’articular surfaces by allograft of chondro-
cytes embedded in collagen gels. Trans Orthop Res Soc
13:440
220. Wakitani S, Kimura T, Hirooka A, et al. (1989) Repair
of rabbit articular surfaces with allograft chondrocytes
embedded in collagen gel. J Bone Joint Surg 71B:74–80;
116–118
221. Brittberg M, Nilsson A, Lindahl A, et al. (1996) Rabbit
articular cartilage defects treated with autologous cul-
tured chondrocytes. Clin Orthop 326:270–283
222. Doherty PJ, Zhang H, Tremblay L, et al. (1998) Resurfac-
ing of articular cartilage explants with genetically modi-
fied human chondrocytes in vitro. Osteoarthritis cartilage
6:153–159
223. Goto H, Shuler FD, Lamsam C, et al. (1999) Transfer of
lacZ marker gene to the meniscus. J Bone Joint Surg Am
81:918–25
224. Smith P, Shuler FD, Georgescu HI, et al. (2000) Genetic
enhancement of matrix synthesis by articular chondro-
cytes: comparison of diff fferent growth factor genes in the
presence and absence of interleukin-1. Arthritis Rheum
43:1156–1164
225. Freed LE, Vunjak-Novakovic G (1997) Tissue culture bio-
reactors: chondrogenesis as a model system. In: Lanza R,
Langer R, Chick W, editors. Principles of tissue engineer-
ing. Austin, TX, RG Landes Company: 151–165
226. Freed LE, Vunjak-Novakovic G, Biron RJ, et al. (1994) Bio-
degradable polymer scaff ffolds for tissue engineering. Bio-
technology 12:689–693
227. Paletta GA, Arnoczky SP, Warren RG (1992) The Th repair of
osteochondral defects using an exogenous fi fibrin clot: an
experimental study in dogs. Am J Sports Med 20:725–
731
228. Muckle DS, Minns RJ (1990) Biological response to woven
carbon fiber pads in the knee. A clinical and experimental
study. J Bone Joint Surg 72B:60–62
229. Muckle DS, Minns RJ, Sunter JP (1988) The Th synovium
before and after intraarticular implantation of woven car-
bon fiber patches into osteochondral defects. J Bone Joint
Surg 70B:152
230. Hemmen B, Archer CW, Bentley G (1991) Repair of articu-
lar cartilage defects by carbon fiber plugs loaded with
chondrocytes. Trans Orthop Res Soc 16:278
231. Brittberg M, Faxen E, Peterson L (1994) Carbon fiber fi
scaff
ffolds in the treatment of early knee osteoarthritis. A
prospective 4-year follow-up of 37 patients. Clin Orthop
307:155–164
232. Buckwalter JA, Einhorn TA, Bolander ME, Cruess RL
(1996) Healing of musculoskeletal tissues. In: Rockwood
CA, Green D, editors. Fractures. Philadelphia, PA; Lippin-
cott 261–304
233. Buckwalter JA, Glimcher MM, Cooper RR, Recker R (1995)
Bone biology II: Formation, form, modeling and remod-
eling. J Bone Joint Surg 77A:1276–1289
234. Sato K, Urist MR (1984) Bone morphogenetic protein-
induced cartilage development in tissue culture. Clin
Orthop 183:180–187
235. Rosenberg L, Hunziker EB (1995) Cartilage repair in oste-
oarthritis: the role of dermatan sulfate proteoglycans. In
Kuettner KE, Goldberg VM, editors. Osteoarthritic disor-
ders. Rosemont, IL: AAOS:341–356
236. Howell DS, Altman RD (1993) Cartilage repair and con-
servation in osteoarthritis. A brief review of some experi-
mental approaches to chondroprotection. Rheum Dis Clin
North Am 19:713–724
237. Hunziker EB, Rosenberg L (1994) Induction of repair
in partial thickness articular cartilage lesions by timed
release of TGF-beta. Trans Orthop Res Soc 19:236
238. Fujisato T, Sajiki T, Liu Q, et al. (1996) Effect
ff of basic
fibroblast growth factor on cartilage regeneration in
chondrocyte-seeded collagen sponge scaffold. ff Biomateri-
als 17:155–162
239. Buckwalter JA, Woo SL-Y, Goldberg VM, et al. (1993) Soft
tissue aging and musculoskeletal function. J Bone Joint
Surg 75A:1533–1548
240. Martin JA, Buckwalter JA (1996) Fibronectin and cell
shape affffect age related decline in chondrocyte synthetic
response to IGF-I. Trans Orthop Res Soc 21:306
241. Martin JA, Ellerbroek SM, Buckwalter JA (1997) The age
related decline in chondrocyte response to insulin like
growth factor-I: the role of growth factor binding proteins.
J Orthop Res 15:491–498
242. Pfeilschifter J, Diel I, Brunotte K, et al. (1993) Mitogenic
responsiveness of human bone cells in vitro to hormones
and growth factors decreases with age. J Bone Miner Res
8:707–717
243. Hunziker EB (2003) Articular cartilage repair: basic sci-
ence and clinical progress. A review of the current status
and prospects. Osteoarthritis Cartilage 10:432–463
244. Peterson L, Minas T, Brittberg M, Lindahl A (2003) Treat-
ment of osteochondritis dissecans of the knee with autol-
ogous chondrocyte transplantation: results at two to ten
years. J Bone Joint Surg Am 85(suppl 2):17–24
245. Bentley G, Biant LC, Carrington RW, et al. (2003) A pro-
spective, randomized comparison of autologous chondro-
cyte implantation versus mosaicplasty for osteochondral
defects in the knee. J Bone Joint Surg Br 85:223–230
246. Livesley PJ, Doherty M, Needoff ff M, Moulton A (1991)
Arthroscopic lavage of osteoarthritic knees. J Bone Joint
Surg 73B:922–926
247. Gibson JNA, White MD, Chapman VM, Strachan RK
(1992) Arthroscopic lavage and debridement for osteoar-
thritis of the knee. J Bone Joint Surg 74B:534–537
248. Moseley JB, Wray NP, Kuykendall D, et al. (1996) Arthro-
scopic treatment of osteoarthritis of the knee: a prospec-
tive, randomized, placebo controlled trial: results of a pilot
study. Am J Sports Med 24:28–34
249. Newman AP (1998) Articular cartilage repair. Am J Sports
Med 26(2):309–324

A. Miniaci, L.D. Farrow Technique of mosaicplasty
Defifinition
M
osaicplasty (osteochondral autograft trans-
plantation surgery) refers to the process
of obtaining small osteochondral cylinders
from non-weight bearing regions at the periphery
of the femoral condyles and transferring them to
prepared recipient sites on weight bearing surfaces
(1). This technique was originally developed for the
treatment of patients with full-thickness osteochon-
dral lesions of the weight bearing articular surface.
The mosaicplasty technique has also been utilized
successfully for the stabilization and treatment of
osteochondral fragments such as osteochondritis
dissecans (OCD) lesions (2).
History
Management of the patient with a full-thickness
chondral or osteochondral defect of the knee is a
very challenging problem for the orthopedic sur-
geon. When lesions involve the weight bearing
articular surfaces, they can be very symptomatic.
Articular cartilage serves a vital role in load trans-
mission and reduction of friction across weight
bearing surfaces. Once damaged, articular cartilage
has no capacity for regeneration. Th The natural his-
tory of untreated lesions demonstrates progressive
degenerative changes and deterioration in func-
tional outcome scores. Many treatment options
are available, each with variable indications and
outcomes. Historically, treatment options focused
on marrow stimulation techniques, also known
as reparative techniques. Reparative techniques
attempt to promote a vascular healing response
through penetration of subchondral bone. The goal
is to resurface the articular defect with fibrocarti-
lage repair tissue. Magnuson originally reported
on his experience with open arthrotomy, debride-
ment, and drilling in 1941 (3). Since that time less
invasive, arthroscopic techniques have been devel-
oped and include subchondral drilling, microfrac-
ture, and abrasion arthroplasty. Th
These arthroscopic
reparative techniques initially yielded very promis-
Chapter 40
ing short-term results, but long-term studies show
less predictable outcomes, possibly related to the
poor biomechanical characteristics of the repara-
tive fibrocartilage (1,4,5).
Alternative treatment options have emerged
in order to address the limitations of marrow
stimulation techniques. Autologous chondrocyte
implantation (ACI) and mosaicplasty, collectively
classifi
fied as reconstructive techniques, were intro-
duced in hopes of repairing full-thickness defects
with hyaline cartilage. ACI is a relatively new, bio-
logic technique that involves transplantation of
viable autologous articular chondrocyte suspen-
sion beneath a tightly sealed periosteal flap (6).
In this technique, autologous chondrocytes are
harvested from the patient, expanded in culture,
and finally reimplanted into the defect under a
periosteal flap during a second operative proce-
dure. Brittberg et al. originally reported on this
procedure in 1994 (7). At second-look arthroscopy,
these authors found hyaline-like cartilage in 11 of
15 treated femoral lesions. In another study of 891
transplantations, good-to-excellent results were
seen in 86% of patient’s objectively and 79% sub-
jectively at a minimum of 2 years follow-up (8). TheTh
failure rate with ACI was noted at 2%. ACI is thus
a viable option for the treatment of full-thickness
cartilage defects. The
Th benefi fits of this technique are
that it allows for filling of large defects with mini-
mal donor site morbidity (6). ACI’s disadvantages
are that it is an expensive, two-stage procedure
that can require a long time for cartilage matura-
tion (6).
The experimental use of osteochondral tissue for
grafting dates back to the early twentieth century
(9). In 1985, Yamashita et al. initially described
transplantation of large autologous osteochondral
grafts for the treatment of large osteochondral
defects (10). However, the potential donor site
morbidity and diffifficulty with restoration of proper
articular surface contour make large osteochondral
autograft surgery an impractical treatment option.
Osteochondral allograft surgery is another option
for treatment of large defects, but the potential for
infection and immune graft rejection is a very real
concern (11).
484 The Traumatic Knee
To address these concerns for donor site morbid-
ity and proper restoration of articular surface
contour, the mosaicplasty concept was developed.
The use of multiple small osteochondral autograft
plugs allows for transplantation of a larger amount
of tissue with less potential for donor site morbid-
ity as well as progressive contouring of the recon-
structed articular defect. Initially, the mosaic-
plasty technique was tested in German Shepards
and equine species with promising results (1).
Macroscopic, histologic, and magnetic resonance
imaging (MRI) has confirmedfi implant survival
posttransplantation. Lane et al. demonstrated in a
goat model complete incorporation of the osteo-
chondral plug into the surrounding recipient sub-
chondral bone. In this study, they demonstrated
86% cellular viability of the transplanted chondro-
cytes at 6-month follow-up (12). Backed by sound
experimental data, the mosaicplasty technique
was expanded to clinical use in 1992. Since that
time, the long-term results of the mosaicplasty
technique have been reported, demonstrating high
rates of success.
Indications
Th ideal candidate for mosaicplasty has a focal,
The
full-thickness unicompartmental chondral or
osteochondral defect of the stable, normally aligned
knee (2). The
Th defect should measure between 1 and
4 cm2 in diameter and extend less than 10 mm into
subchondral bone. This size limitation is mainly
determined by donor site availability. Although
recipient sites of up to 8–9 cm2 in certain salvage
situations can be treated using this technique,
donor-site morbidity is a serious concern (1).
Larger defects should be managed with alternative
techniques. No clinical effi
fficacy has been shown
with respect to treating lesions smaller than 1 cm2.
Clinical evidence suggests that patients should be
younger than 50 years (10). In patients older than
50 years, alternative techniques (i.e., unicompart-
mental or total knee arthroplasty) are available. Th
The
ability of the patient to comply with weight bear-
ing restrictions and postoperative rehabilitation
are also of utmost importance. Finally, all concur-
rent pathology should be addressed to increase the
chances of a successful outcome. Specififically, mala-
lignment, instability, ligament tears, and meniscal
pathology should all be addressed accordingly.
Contraindications
Absolute
1. Infection
2. Tumor
3. Generalized osteoarthritis
4. Rheumatoid arthritis
5. Lack of appropriate donor site
6. Defect larger than 8 cm2
7. Defect deeper than 10 mm
8. Noncompliant patient
Relative
1. Defect 4–8 cm2
2. 40–50 years of age
3. Mild arthritic changes
Preoperative physical examination
The clinical presentation of the patient with full-
thickness chondral and osteochondral lesions is
often nonspecifific in nature. Occasionally, symp-
toms may be related to an acute injury with a
resultant knee eff
ffusion. More commonly, patients
present with a more insidious onset of symptoms.
Patients may present with swelling, clicking, lock-
ing, or giving way. These mechanical symptoms
may be created by chondral fl flaps, loose bodies, or
concurrent pathology such as meniscus tears. Clin-
ical assessment should begin with observation of
the patient’s gait and overall limb alignment. Spe-
cial note should be made of excessive varus or val-
gus malalignment as well as any appreciable varus/
valgus knee thrust. Palpation of the knee should
evaluate for effffusion, crepitance, and localized
tenderness. Range of motion of the knee joint and
patellofemoral tracking are also noted. Focused
examination and special tests for ligamentous lax-
ity or meniscal pathology should also be carefully
performed.
Preoperative imaging (Table 1 )
Table 1 – Imaging studies.
Modality Clinical importance
Plain films
Standing anteroposterior knee Evaluate tibiofemoral joint
Standing 45° posteroanterior Evaluate weight bearing region of
knee (Rosenberg) tibiofemoral joint
Lateral knee Evaluate tibiofemoral and
patellofemoral joints
Patellar merchant Evaluate patellofemoral joint
Standing full-length extremity Evaluate lower extremity alignment
(optional)
Magnetic resonance imaging Evaluate lesion size
Evaluate extent of arthrosis
Evaluate other anatomic structures
Computed tomography Little utility

Fig. 1 – Operative set-up. The unaffected extremity is left free. A lateral
post is used for the operative extremity. The set-up should allow at least
120 degrees of knee flexion.
Surgical technique
Preoperative planning
In general, lesions of the articular surface are
usually defifined only during the arthroscopic pro-
cedure. If the preoperative history and physical
exam is suggestive of a cartilage lesion, the patient
should be counseled on the possibility of mosaic-
plasty. In case the lesion is inaccessible by arthros-
copy, the patient should also be made aware of
the possibility of an open procedure. This may be
the case with patellar lesions or posterior lesions
on the femoral condyle where the knee cannot be
suffi
fficiently flexed to reach the lesion. Ultimately,
a decision on whether the lesion can be addressed
arthroscopically or open is determined by lesion
size and location, as well as surgeon experience.
The decision to perform mosaicplasty intraopera-
tively could result in altered weight bearing status
postoperatively and/or an overnight hospital stay.
In some circumstances, large lesions could require
donation from the contralateral limb for sufficient
ffi
graft tissue. All of these possibilities should be dis-
cussed with the patient preoperatively. We recom-
mend tourniquet control under general or regional
anesthesia. Prophylactic antibiotics are left to the
discretion of the treating surgeon, but are gener-
ally recommended.
Patient positioning – arthroscopic technique
Patient positioning is primarily dependent on sur-
geon preference as well as the location of the artic-
ular defect. In general, the patient should be placed
in the supine position. The knee should be capable
Technique of mosaicplasty 485
of 120° of flexion to ensure perpendicular access
to lesions which are more posterior on the femo-
ral condyle. We leave the contralateral extremity
free and utilize a lateral post for the operative leg
to perform the arthroscopic portion of the proce-
dure (Fig. 1). Alternatively, a surgical leg holder
can be utilized and the contralateral extremity
can be placed into a well-leg stirrup/holder. If you
are planning on using multiple plugs, sometimes
it is important to drape the opposite extremity to
allow for harvest of grafts from that knee to ensure
enough donor sites are available.
Approach – arthroscopic technique
Perpendicular access to the lesion is of utmost
importance. An 18-guage spinal needle or 1.2 mm
K-wire inserted percutaneously will help to
assess the optimal position for portal placement
prior to making the incision (Fig. 2). Due to the
inward curvature of the femoral condyle, portal
placement may be more central than the stan-
dard arthroscopic portals. On some occasions, a
transpatellar tendon portal is necessary to gain
perpendicular access to the lesion. OCD lesions
of the medial femoral condyle can be approached
through a lateral portal, but most often through
a transpatellar tendon portal. We prefer verti-
cal incisions for the arthroscopic portals. Vertical
incisions can be incorporated into an arthrotomy
incision if needed. Vertical incisions also allow for
better proximo-distal excursion of the harvesting
chisel. The anteromedial and anterolateral portals
are made approximately 1 cm off ff the medial and
lateral borders of the patellar tendon, respectively
(Fig. 3). Beginning with these incisions, three to
four 4.5 mm grafts can be harvested. If more plugs
are needed, more proximal accessory incisions can
be utilized to collect nine to twelve plugs from each
knee depending on knee size.
Step-by-step description – arthroscopic
technique
There are multiple instrument sets available from
various companies to perform the osteochondral
autologous transplantation/mosaicplasty tech-
nique. Reusable and disposable trays are also avail-
able. Each system has its respective pros and cons
and the choice of which system to use is left solely
to the discretion of the treating surgeon.
After the defect is identifified and perpendicular
access is confi
firmed, the defect edges are sharply
debrided back to a good, stable hyaline cartilage rim
486 The Traumatic Knee

B
Fig. 2 – A. Optimal portal position is determined with an 18-gauge spinal needle or 1.2 mm Kirschner
wire. (Courttesy Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis L. Autologous Osteochondral
Mosaicplastty. Surgical Technique. J Bone Joint Surg Am. 2004 ; 86 : 65-72.)
B. Perpendicular access to lesion is verified. (Courtesy Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G,
Fules P, Moddis L. Autologous Osteochondral Mosaicplasty. Surgical Technique. J Bone Joint Surg Am. 2004 ;
A 86 : 65
65-72.)
72.)

Fig. 3 – Standard arthroscopic portals. Anteromedial and anterolateral por-

tals made 1 cm off of patellar tendon.
B
oriented at a 90° angle. This
Th can be accomplished
with an arthroscopic resector blade, curette, or
knife blade (Fig. 4).
The base of the lesion is then debrided with a rasp
or burr down to subchondral bone (Fig. 5). Th This
preparation of the base should result in subsequent
fibrocartilage in-growth between the mosaicplasty
plugs to act as a biologic grout.
The appropriately sized graft harvesting chisel
(2.7, 3.5, 4.5, 6.5, and 8.5 mm in diameter) is
placed in the lesion and gently tapped in order
to score the lesion’s base (Fig. 6A). This
Th creates a
template to estimate the positioning of the graft
plugs (Fig. 6B). In addition, fine markings will be Fig. 4 – Edges of the lesion are debrided back to a stable articular cartilage
left behind for later referencing. This
Th step also rim. (Courtesy Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis
allows the surgeon to estimate the number of plugs L. Autologous Osteochondral Mosaicplasty. Surgical Technique. J Bone Joint
needed to fill the defect. Use of equal sized chisels Surg Am. 2004 ; 86 : 65-72.)
 Technique of mosaicplasty 487

to fill the defect can result in a 70–80% fill rate held steady and firm as the chisel may shift when
(Fig. 7). Alternatively, the use of different
ff sized contacting subchondral bone. This Th could poten-
chisels as well as cutting into adjacent grafts can tially result in a misshapen graft. Calibrated laser
result in a 90–100% fill rate (Fig. 7). At this time, marks on each chisel aid with monitoring of the
the depth of the defect should also be measured depth of insertion. Ideally, harvested grafts should
with the dilator. be between 15 and 25 mm in length. As a general
The preferred donor sites are at the periphery of rule, the length of the graft should be at least twice
the medial and lateral femoral condyles above the
level of the intercondylar notch and away from the
tibiofemoral articulation. Alternatively, the femo-
ral notch area may be utilized for graft harvest A
(Fig. 8). Th
The femoral notch area is less desirable
due to the concave shape of the cartilage surface,
the thin cartilage in this area, and the less elastic
nature of the subchondral bone.
The arthroscope is used to confi firm perpendicular
access to the donor site. The standard portal is
often too far from the periphery of the joint mar-
gins, and this should be considered when estab-
lishing these portals at the beginning of a mosa-
icplasty procedure. It sometimes does not allow
perpendicular access to the most superior donor
sites, so more proximal accessory portals often
need to be established. A spinal needle or K-wire
can be used to confi firm proper positioning of this
additional portal.
Once perpendicular access is confirmed,
fi the contral-
ateral portal usually provides the best view for graft
harvest. With the knee in the extended position,
the cylindrical cutting chisel is inserted perpendic-
ular to the articular surface (Fig. 9). We prefer the
manual punch technique over power harvesting,
as power harvesting has been shown to decrease
chondrocyte viability and is more technically dif-
ficult to perform (13). A mallet is used to impact B
the chisel to the desired depth. The
Th chisel should be

Fig. 6 – A. Creation of mosaicplasty template. An appropriately sized graft

Fig. 5 – An arthroscopic burr is used to debride the base of lesion down to
subchondral bone. (Courtesy Hangody L, Rathonyi GK, Duska Z, Vasarhelyi
G, Fules P, Modis L. Autologous Osteochondral Mosaicplasty. Surgical Tech-
nique. J Bone Joint Surg Am. 2004 ; 86 : 65-72.)
harvesting chisel is utilized to score to base of the lesion. (Courtesy Hangody
L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis L. Autologous Osteo-
chondral Mosaicplasty. Surgical Technique. J Bone Joint Surg Am. 2004 ; 86 :
65-72.)
B. Fine markings are left behind for later referencing. (Courtesy Hangody
L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis L. Autologous Osteo-
chondral Mosaicplasty. Surgical Technique. J Bone Joint Surg Am. 2004 ; 86 :
65-72.
488 The Traumatic Knee

Fig. 7 – Varying plug size can result in 70 – 100 percent fill rate. (Courtesy
Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis L. Autolo-
gous Osteochondral Mosaicplasty. Surgical Technique. J Bone Joint Surg
Am. 2004 ; 86 : 65-72.)

its diameter. Fifteen millimeter grafts are typically

used to resurface chondral lesions. Plugs ≥20 mm
are utilized for deeper defects and for stabiliza-
tion of OCD lesions. By flexing the knee, additional Fig. 8 – Multiple donor sites are available (shaded areas). (Courtesy
donor sites can be accessed. As mentioned above, Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis L. Autolo-
the lowest site of harvest should be at the level of gous Osteochondral Mosaicplasty. Surgical Technique. J Bone Joint Surg
the intercondylar notch or sulcus terminalis. Once Am. 2004 ; 86 : 65-72.)
the chisel has been driven to the appropriate depth,
it is toggled back and forth to break the graft free
(Fig. 10A). Inserting a harvesting tamp into the
cross holes of the chisel aid with this step. Special
care should be taken not to rotate the chisel as this
may result in the inability to remove the graft. Once
the graft is free, it can be delivered from the chisel
by placing the appropriate chisel guard over the
cutting end followed by the tamp (Fig. 10B). This Th
pushes the graft out from the cancellous bone end
and avoids pushing against the cartilage cap. At this
time, the graft is carefully inspected to evaluate for
fracture as well as any deformity caused during har-
vesting. The cartilage cap is also carefully examined
to ensure that there is not too much obliquity pres-
ent. This step is crucial as a fractured or misshapen
graft or cartilage cap could potentially jeopardize
the ability to obtain the proper articular surface
Fig. 9 – The cutting chisel should be oriented perpendicular to the articular
contour during implantation. Finally, the graft is surface. Non-perpendicular graft harvest may result in a misshapen graft.
measured and then carefully stored – keep them
moist only. This
Th can be accomplished in a saline-
moistened gauze to prevent cartilage desiccation. I perpendicular access to the recipient site. Adequate
have noticed swelling after a certain period of soak- joint distention aids visualization during this step in
ing. This swelling could potentially cause diffi fficulty the procedure. It is imperative to maintain a perpen-
with later graft insertion. dicular orientation of the plugs with respect to the
Once the appropriate number of grafts has been articular surface. The appropriate angle of insertion
obtained, attention may then be directed to the can once again be confirmed
fi with a K-wire or spinal
recipient site. The knee is now flexed in order to allow needle. Using the dilator as a blunt obturator, the drill
 Technique of mosaicplasty 489

guide is inserted into the knee joint. Th The laser marks
on the drill guide help ensure the proper orientation.
Once perpendicular access is confi firmed, the cutting
edge of the drill guide is tapped a few millimeters
into subchondral bone. The appropriately sized drill
bit is introduced into the drill guide and drilled to the
desired depth (Fig. 11A and B). Th The depth should be
similar to the length of the graft minus the amount
it needs to sit proud of the subchondral bone so that
it sits at the level of the joint surface.
The drill is then removed and the dilator is inserted
Th
while maintaining the appropriate alignment of
the drill guide (Fig. 12A and B). The
Th conical dilator
is then used to dilate the hole 0.1–0.2 mm. In gen-
eral, stiff
ff bone requires more dilation than normal
or soft bone in order to help with ease of insertion.
This will also ensure proper press-fi
fit technique and
help to avoid excessive insertion pressure on the
cartilage cap. The drill guide is held firmly as the
dilator is removed.
Next the graft is inserted into the recipient hole.
The insertion tamp handle is adjusted in order to
allow the graft to sit slightly proud with respect
to the surrounding cartilage surface. Th The infl
flow

Fig. 10 – A. The harvesting chisel is toggled to liberate the bone plug. (Courtesy Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis L. Autologous
Osteochondral Mosaicplasty. Surgical Technique. J Bone Joint Surg Am. 2004 ; 86 : 65-72.)
B. The chisel guard is placed over the cutting end of the chisel and the tamp is used to remove the graft. The tamp pushes the graft from the cancellous bone
end, avoiding the articular cartilage. (Courtesy Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis L. Autologous Osteochondral Mosaicplasty.
Surgical Technique. J Bone Joint Surg Am. 2004 ; 86 : 65-72.)

Fig. 11AB – The selected drill bit is drilled to the appropriate depth. (Courtesy Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P,P Modis L. Autologous
Osteochondral Mosaicplasty. Surgical Technique. J Bone Joint Surg Am. 2004 ; 86 : 65-72.)
490 The Traumatic Knee

should be stopped to prevent ejection of the graft flush with the surrounding articular surface. The
from the delivery tube. The graft is then delivered drill guide is removed and the inserted graft is
through the drill guide into the recipient site under inspected to confi
firm appropriate insertion depth
direct visualization. Next, the handle of the tamp is (Fig. 13). If proud, the graft is further recessed
rotated counterclockwise and the graft is inserted with the appropriate tamp.

Fig. 12AB – Conical dilator is used to dilate the recipient hole. (Courtesy Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis L. Autologous Osteo-
chondral Mosaicplasty. Surgical Technique. J Bone Joint Surg Am. 2004 ; 86 : 65-72.)

A B

C D

Fig. 13 – The graft is inserted flush with the surrounding articular cartilage. (Courtesy Hangody L, Rathonyi GK, Duska Z, Vasarhelyi G, Fules P, Modis L.
Autologous Osteochondral Mosaicplasty. Surgical Technique. J Bone Joint Surg Am. 2004 ; 86 : 65-72.)

Fig. 14AB – Incorrect graft orientation fails to fully restore the normal contour
(A) and curvature (B) of the articular surface. Recreating the normal contour and
curvature of the articular surface requires slightly oblique graft placement (C).
Implantation of additional grafts continues by
repeating the same steps. Methodical insertion of
subsequent grafts should occur adjacent to previ-
ous grafts to achieve a high filling rate. In addi-
tion, subsequent dilatation of adjacent drill holes
help to impact cancellous bone around previously
implanted grafts. This actually helps to achieve the
desired press-fit
fi fixation. Using this technique, the
fill rate is usually 70–80%. By cutting into previ-
fi
ously placed grafts and utilizing variable graft
sizes, the fill
fi rate can be increased to 90–100%. To
recreate the normal convex contour of the articu-
lar surface, the peripheral plugs should be inserted
first, followed by the more central plugs. This
fi
usually requires that the central grafts be seated
slightly higher to avoid recreating a fl
flat contour for
the articular surface (Fig. 14A–C).
Once all the grafts have been inserted, a fi final
inspection of the filled
fi defect is undertaken. The
stability of the inserted grafts should be tested and
the knee should be taken through a gentle range
of motion. Range of motion should be fluid, fl con-
firming congruency of the implanted grafts. The
arthroscopy portals are closed. A suction drain can
be inserted. A soft dressing and elastic bandage
may help with postoperative hemostasis.
Pearls and pitfalls – arthroscopic technique
Perpendicular graft harvest and implantation is
one of the basic requirements for mosaicplasty.
Non-perpendicular graft harvest and insertion is
one of the major complications encountered dur-
ing mosaicplasty. Non-perpendicular graft harvest
Technique of mosaicplasty 491
or insertion can result in step-offff at the articular
surface. During graft harvest, failure to hold the
cutting tool firmly as subchondral bone is encoun-
tered may result in a misshapen graft. Failure to
adequately visualize the donor/recipient site dur-
ing harvest and insertion can also result in non-
perpendicular graft harvest/insertion. Multiple
viewing angles, adequate joint distension, firm fi
handling of the cutting guide, and close monitor-
ing during graft insertion/harvest help to avoid
this potential pitfall.
Graft sinkage below the surface of the surround-
ing normal cartilage should also be avoided. Th This
leads to step-off
ff at the articular surface. Huang
et al. demonstrated in a sheep model that mini-
mal incongruencies (1 mm) have the ability to
remodel and become smooth. Incongruencies of
2 mm underwent cartilage necrosis and fi fibrous
overgrowth (14). Excessive graft sinkage is usually
caused by inappropriate use of the delivery tamp.
This pitfall can be avoided by proper usage of the
delivery tamp. This can also be avoided by making
the recipient hole the correct depth.
An easily avoidable pitfall is premature weight
bearing after mosaicplasty. This can result in graft
subsidence. This can either be seen in a noncom-
pliant patient, or in a patient or physical therapist
that has not been appropriately educated about
the expected postoperative weight bearing restric-
tions. Proper patient selection, screening, and edu-
cation are of utmost importance. A well-trained,
educated physical therapist who is familiar with
the expected postoperative protocol is an invalu-
able asset to the care of the patient.
Finally, grafting a defect which is too large can be
very problematic. This may result in the inability to
492 The Traumatic Knee
restore the proper contour of the articular surface
due to lack of suffi
fficient graft material. The need
for more grafts may result in donor site morbid-
ity of the involved knee in an attempt to harvest
enough grafts to fill the defect. Alternatively, this
may require that grafts be obtained from the con-
tralateral knee to obtain enough grafts to fi fill the
defect. This is why the patient should be counseled
about contralateral harvest in the preoperative
period. The usual cause for this pitfall is improper
estimation of the size of the lesion. Advanced
imaging (i.e., MRI) and accurate measurement of
the defect intraoperatively can help to avoid this
potential pitfall.
Alternative technique I – open mosaicplasty
The need for open mosaicplasty is determined by
surgeon experience, the location of the defect,
and the ability to fl
flex the knee at 120°. Preopera-
tive planning is essentially the same except that
the patient should be made aware of the need for
open arthrotomy. Patient positioning is essen-
tially the same as for the arthroscopic technique.
The approach is commonly through a vertical
mini-arthrotomy made either anterolaterally or
in the medial parapatellar region, depending on
the location of the defect. Alternatively, a stan-
dard medial parapatellar approach can be utilized
for tibial or patellar lesions. Once the approach is
made, the technique is essentially the same as for
arthroscopic mosaicplasty.
Alternative technique II – osteochondritis
dissecans
Treatment of the unstable OCD lesion is a very
challenging problem. Patients typically present
with pain, swelling, and recurrent effusions.
ff Loose
osteochondral fragments can produce mechanical
symptoms such as locking, clicking, popping, and
giving way. Physical examination and preoperative
planning are similar to that described for cartilage
lesions. Operative internal fixation
fi of the unstable
OCD lesion has been described and can be carried
out with Herbert screws, K-wires, corticocancel-
lous bone pegs, and synthetic absorbable pins. TheTh
mosaicplasty technique can also be utilized to sta-
bilize these lesions. The benefifit of mosaicplasty is
that it off
ffers a biologic fixation option that does
not require implant removal at a later date. In
addition, penetration of subchondral bone at the
recipient site may act to stimulate vascularization
of the surrounding subchondral bone.
Positioning
Patient positioning is the same as that for
arthroscopic or open mosaicplasty. The
Th patient is
placed supine on the operative table and at least
120° of knee flexion should be possible. Prepping
and draping proceeds in the usual, sterile fashion.
Approach
Stabilization of OCD lesions of the medial femo-
ral condyle usually will require an accessory
medial portal placed through the patellar tendon
(most often) or utilization of the anterolateral
arthroscopic portal. Perpendicular access is con-
firmed with a spinal needle or K-wire.
Step-by-step description
Arthroscopic assessment of the lesion is fi first
undertaken (Fig. 15A and B). These Th lesions are
often fragmented. Fragmented portions of the
lesion and those lesions without an osseous base
should be excised. Stability of the lesion is assessed
with an arthroscopic probe.
Stable lesions can be stabilized with a central osteo-
chondral plug and several circumferential plugs uti-
lizing the previously described mosaicplasty tech-
nique (Fig. 16 A and B). Grafts measuring 20 mm
in length is usually sufficient
ffi to fix osteochondral
lesions that are 1 cm in thickness.
Unstable lesions and loose bodies can first be fixed
with a central screw in order to provide compres-
sion and maintain reduction. Peripheral plugs are
then placed. Finally, the central screw is replaced
with an osteochondral plug once peripheral fi fixa-
tion is obtained.
For partially fragmented lesions, the fragmented
portion is removed and a hybrid technique is then
utilized. In the hybrid technique, the main frag-
ment is secured as previously described for OCD
lesions. The defect remaining after excision of the
fragmented portion is grafted utilizing the standard
mosaicplasty technique for osteochondral defects.
Postoperative care
Postoperatively, a soft, compressive bandage is
used to aid in hemostasis and to control swelling.
The surgery can be done on an outpatient basis and
patients may go home following the procedure. If
the patient stays overnight, the suction drain can
be left overnight and removed before discharge if
placed at the time of surgery. Pain control is based
on surgeon preference. We prefer to begin pain

A B
Fig. 15 – Illustration of OCD lesion (A). Arthroscopic view of OCD
lesion (B).
A B
Fig. 16 – Illustration of fixation of OCD lesion. Arthroscopic view
of OCD lesion.
management preoperatively. Th The anesthesia team
typically places a regional nerve block (femoral
and/or sciatic) in the preoperative holding area.
This not only diminishes the amount of inhalation
and narcotic medication required intraoperatively,
it also helps with pain control in the early postoper-
ative period. Alternatively, if the patient is staying
overnight, a spinal/epidural anesthetic can also be
utilized. We typically do not utilize medications for
deep venous thrombosis (DVT) prophylaxis. Th This is
best left to the discretion of the treating surgeon.
Oral narcotic pain medication is prescribed for
home-going. Anti-infl flammatory medication can
be utilized for break through pain. Frequent ice
packs or a portable continuous cooling unit may be
utilized in the early postoperative period to help
control pain and swelling.
Some centers utilize a continuous passive motion
(CPM) machine in the postoperative period. We
do not utilize a CPM machine. However, we do
encourage passive range of motion. The Th patient is
allowed to ambulate with crutches and toe-touch
weight bearing initially. We recommend toe-touch
weight bearing precautions for 6 weeks. Th The patient
is encouraged to perform isometric quadriceps
exercises, calf pumps, and straight leg raises in the
Technique of mosaicplasty 493
immediate postoperative period. A stationary bike
is begun once the patient is comfortable and able to
tolerate it. A gradual strengthening program is also
begun at this time. At 6 weeks, gradual weight bear-
ing is begun if the plain films are satisfactory. The
criteria for return to sports include near full range
of motion, recovery of quadriceps strength to within
80% of the contralateral side, minimal eff
ffusion, and
evidence of graft incorporation on follow-up MRI.
Outcomes
Since beginning clinical application in 1992, there
have been only a few studies looking at the long-term
outcome of the mosaicplasty technique. TheTh subjec-
tive and objective results of these studies are quite
encouraging. Hangody et al. recently reported on
their 10-year experience utilizing the mosaicplasty
technique. Seven-hundred and forty out of their
831 mosaicplasties in this study were performed in
the knee joint. Patients who had mosaicplasty per-
formed for femoral condyle lesions demonstrated
92% good-to-excellent scores based on clinical out-
comes. Patients with tibial resurfacing and patel-
494 The Traumatic Knee
lar and/or trochlear mosaicplasties fared slightly
worst with 87% and 79% good-to-excellent results,
respectively. Only 3% of patients had donor site dis-
turbances in this series. Eighty-three patients had
arthroscopic follow-up of their surgery. Sixty-nine
of these patients demonstrated good gliding sur-
faces, survival of the transplanted hyaline cartilage,
and fibrocartilage coverage of the donor sites. Most
of the transplanted cartilage demonstrated similar
ffness to the surrounding normal cartilage on
stiff
arthroscopic indentation testing (15).
Jakob et al. reported on 52 consecutive patients
undergoing the mosaicplasty technique for carti-
laginous defects of the knee. Forty-two patients
were available for follow-up. Subjectively, 93% had
no or slight limitations of knee function with daily
activities. Fifty-two percent had an increased level
of sporting activity. Eighty-eight percent were sat-
isfi
fied and 12% regretted having the surgery. At
latest follow-up, objective grading demonstrated
that 92% of patients had improved function.
Arthroscopic examination revealed that donor
sites were filled with fibrocartilage. In the absence
of graft failure, the recipient site was normal or
near normal in all knees. A demarcation between
the grafted surface and the surrounding normal
cartilage was always seen. On histologic analysis,
the transplanted hyaline cartilage retained its hya-
line character. There was no delamination at the
articular surface. The intervening space between
the bone plugs was filled
fi with fibrocartilage, and
there was no lateral integration with the surround-
ing normal cartilage (16).
Koulalis et al. reported their results in 18 patients
with grade IV (Outerbridge classification)
fi articu-
lar cartilage lesions of the knee. MRI follow-up
at 1 year showed cartilage coverage of the defect
in all patients. All patients had complete osseous
integration of the transplant by 6 months. Repeat
arthroscopy in four patients demonstrated color
and hardness of the transplanted cartilage simi-
lar to the surrounding normal cartilage. Objective
scoring revealed that 12 patients were normal and
the remaining 6 were nearly normal (17).
Several smaller studies have also demonstrated high
rates of good-to-excellent results after mosaicplasty.
Ozturk et al. demonstrated 85% good-to-excellent
results at 2–7 years of follow-up in their study of
19 patients undergoing the mosaicplasty technique
for full-thickness cartilage lesions of the knee (18).
Marcacci et al. performed a prospective evaluation of
their mosaicplasty experience in 37 active patients
younger than 50 years. At 2-year follow-up, objec-
tive scoring yielded 78% good-to-excellent results.
Twenty-seven of 37 patients returned to activity
at the same level. Results were much better for
lateral condyle lesions compared with medial con-
dyle lesions which showed 100% and 65% good-to-
excellent results, respectively. Acute lesions faired
slightly better than chronic lesions (19).
These studies illustrate that when a good, stan-
dardized protocol is followed and when the afore-
mentioned surgical indications are strictly adhered
to, good-to-excellent long-term results can be
expected in the majority of patients following
mosaicplasty.
Complications
Major complications after mosaicplasty are fairly
infrequent. The most frequently reported compli-
cation after this procedure is painful hemarthrosis.
Painful hemarthrosis is most likely the result of
bony bleeding from the osteochondral plug donor
sites. This complication can potentially be avoided
by placement of a suction drain intraoperatively.
Filling of the donor site with various biodegrad-
able materials has also been shown to decrease
postoperative bleeding (20). Ultimately, patients
with symptomatic eff ffusion may require aspira-
tion or operative debridement (arthroscopic or
open) for relief of symptoms. In their evaluation
of 831 mosaicplasties, Hangody et al. found a 4%
incidence of postoperative hemarthrosis. Nine of
these hemarthroses required operative debride-
ment (15). Jakob et al. reported a 2% incidence of
painful postoperative hemarthrosis (16).
Donor site morbidity is reported infrequently.
Peripheral graft harvest and the relatively smaller
graft sizes utilized in the mosaicplasty technique
ensure that areas of minimal weight bearing are
utilized. In general, graft sizes less than 5 mm in
diameter should be used to decrease donor site
morbidity. Jakob et al. noted that crepitance was
noted in 15/15 knees when more than 6 osteo-
chondral plugs of 6–7 mm in diameter were har-
vested (16). None of these knees were painful
however. In addition, correct estimation of recipi-
ent site size may avoid donor site morbidity when
mosaicplasty is utilized to treat defects that are
too large. The large number of plugs needed to
fill larger defects may necessitate excessive graft
harvest from the ipsilateral knee or the need to
obtain grafts from the contralateral normal knee.
Other treatment options should be entertained
in patients with larger defects. When donor site
symptoms do occur, they appear to be transient in
the vast majority of affected
ff patients.
Less frequent complications include deep infection
and thromboembolic phenomenon. The Th rate of seri-
ous postoperative infection is less than 2% (15,16).
We administer intravenous antibiotics with gram-
positive coverage to all patients within 1 h before
surgery for perioperative prophylaxis. When infec-

tion does occur, it can usually be managed with anti-
biotics and either open or arthroscopic debridement.
DVT after mosaicplasty is very rare. We do not utilize
any thromboembolism prophylaxis in our patients.
In their review of 831 mosaicplasties, Hangody et al.
had four patients with deep infection (<1%) and two
patients with thromboembolic phenomenon (15).
Mosaicplasty is a relatively safe procedure with low
rates of serious postoperative complications.
References
1. Hangody L, Fecko P, Bartha L, Bodo G, Kish G (2001)
Mosaicplasty for the treatment of articular cartilage
defects of the articular defects of the knee and ankle. Clin
Ortho Relat Res 391S: S328–S336
2. Morelli M, Nagamori J, Miniaci A (2002) Management of
chondral injuries of the knee by osteochondral autologous
transplantation (mosaicplasty). J Knee Surg 15(3):185–
190
3. Magnuson PB (1941) Joint debridement: surgical treat-
ment of degenerative arthritis. Surg Gynecol Obstet 73:1
4. Buckwalter JA, Mankin HJ (1998) Articular cartilage
repair and transplantation. Arthritis Rheum 41:1331
5. Insall JN (1974) The Pridie debridement operation for
osteoarthritis of the knee. Clin Ortho 101:61–67
6. Dozin B, Malpeli M, Cancedda R, et al. (2005). Compara-
tive evaluation of autologous chondrocyte implantation
and mosaicplasty. A multicentered randomized clinical
trial. Clin J Sports Med 15:220–226
7. Brittberg M, Lindahl A, Nilsson A, et al. (1994) Treatment
of deep cartilage defects in the knee with autologous chon-
drocyte transplantation. N Eng J Med 331:889–895
8. Browne JE, Branch TP (2000) Surgical alternatives for the
treatment of articular cartilage lesions. J Am Acad Orthop
Surg 8:180–189
Technique of mosaicplasty 495
9. Lexer E (1908) Substitution of whole or half joints from
freshly amputated extremities by free plastic operation.
Surg Gynecol Obstet 6:601–607
10. Yamashita F, Skakida K, Suzu F, Takai S (1985) Th The trans-
plantation of an autogenic osteochondral fragment for
osteochondritis of the knee. Clin Orthop Rel Res 210:43–50
11. Bugbee WD, Convery FR (1995) Osteochondral allograft
transplantation. Clin Sports Med 18:67–75
12. Lane JG, Massie JB, Ball ST, et al. (2004) Follow-up of
osteochondral plug tranfers in a goat model. A 6-month
study. Am J Sports Med 32(6):440–1450
13. Evans PJ, Miniaci A, Hurtig MB (2004). Manual punch
versus power harvesting of osteochondral grafts. Arthros-
copy 20:306–310
14. Huang FS, Simonian PT, Norman AG, Clark JM (2004)
Eff
ffects of small incongruencies in a sheep model of osteo-
chondral allografting. Am J Sports Med 32(8):1–7
15. Hangody L, Fules P (2003) Autologous osteochondral
mosaicplasty for the treatment of full-thickness defects of
weight-bearing joints: ten years of experimental and clini-
cal experience. J Bone Joint Surg 85:25–32
16. Jakob RP, Torsten F, Gautier E, Mainil-Varlet P (2002)
Autologous osteochondral grafting in the knee: indications,
results, and refl
flections. Clin Orthop Relat Res 401:170–184
17. Koulalis D, Schultz W, Heyden M, Konig F (2004). Autolo-
gous osteochondral grafts in the treatment of cartilage
defects of the knee joint. Knee Surg Sports Traumatol
Arthrosc 12:329–334
18. Ozturk A, Ozdemir MR, Ozkan Y (2006) Osteochondral
allografting (mosaicplasty) in grade IV cartilage defects
in the knee joint: 2 to 7-year results. Int Orthop 30:200–
204
19. Marcacci M, Kon E, Zaff ffagnini S, et al. (2005) Multiple
osteochondral arthroscopic grafting (mosaicplasty) for
cartilage defects of the knee: prospective study results at 2
year follow-up. Arthroscopy 21:462–470
20. Feczko P, Hangody L, Varga J, et al. (2003). Experimental
results of donor site filling for autologous osteochondral
mosaicplasty. Arthroscopy 19:755–761

M.J. DeFranco,
A.G. McNickle, B.J. Cole
Allograft osteoarticular resurfacing
Strategy
O
steochondral allograft transplantation is
a surgical technique that relies on obtain-
ing tissue from cadaveric “living” donors.
The objective is to procure healthy articular carti-
lage from a donor and transfer it to the damaged
area of the recipient’s knee. Using cadaveric tis-
sue eliminates the donor site morbidity associated
with osteochondral autografting and allows for the
treatment of larger and more aggressive lesions
in virtually any joint. Th The technique also allows
for the ability to implant fully formed articular
cartilage without specific fi limitation with respect
to defect size, and it can be completed as a single-
stage procedure. Issues regarding cost, graft avail-
ability, cell viability, immunogenicity, and risk of
disease transmission are some of the factors that
may limit the use of this technique.
The ideal patient for an osteochondral allograft is a
Th
younger patient with an isolated traumatic lesion or
osteochondritis dissecans (OCD). TheTh lesions should
be at least 2–3 cm2 and can have associated bone
loss or compromise due to dysvascular changes (i.e.,
avascular necrosis, AVN). This technique may be
used for larger defects – 3 cm2 up to an entire hemi-
condyle. These grafts are most commonly used for
the femoral condyle but may also be used for patella,
trochlea, and tibial plateau lesions. Because the
allograft contains bone, any disorder with associ-
ated bone loss (AVN, osteochondral fracture, OCD)
may also be restored with this surgical technique.
Prior to surgery, all patients should be evaluated for
relevant comorbidities such as malalignment, liga-
mentous instability, and meniscal defi ficiency.
Availability of graft tissue varies by institution
and geographic location. Most transplanted grafts
are considered “fresh tissue grafts” meaning that
they are procured within 24–48 h of the donor’s
death, processed and serologically screened within
14 days of procurement, and transplanted within
28 days without the need for deep-frozen stor-
age. Frozen grafts can be stored and shipped on
demand, potentially alleviating scheduling issues,
but these grafts lack cell viability. Prolonged cold
storage method increases the “shelf-life” of the
Chapitre 41
graft to at least 28 days and alleviates scheduling
diffi
fficulties while maintaining cell viability, but
chondrocyte suppression continues to be an issue.
Overall, fresh osteochondral tissue demonstrates
greater than 60% donor chondrocyte viability at
biopsy (1–3).
Incorporation and healing of the allograft depends
on creeping substitution of host bone to allograft
bone, although the bone may also undergo some
degree of necrosis and fail to defifinitively incorpo-
rate (4,5). The main source of graft immunogenicity
is the blood or bone marrow elements within the
subchondral bone of the donor tissue. At the time
of procurement, these elements are pulse-lavaged
from the donor tissue to minimize the chance of
immune reaction. Even though immune reaction
may occur, they are self-limited and do not limit
graft success (6). In order to decrease the risk of
disease transmission, tissue banks must adhere to
strict protocols of donor screening, sterile process-
ing, and serological testing. When a size- and side-
matched graft becomes available, the patient is
notifified and expeditiously scheduled for surgery.
Patient selection
Indications
– Localized, grade III and IV unipolar lesion of the
femoral condyle, trochlea, or patella
– Defects due to trauma, OCD, AVN, or intra-artic-
ular tibial plateau fractures
– Young, high demand patients who are not candi-
dates for joint replacement
– Moderate-to-large cartilage lesions 15–35 mm in
diameter
– Pain and symptoms localized and due to the dam-
aged region
Relative contraindications
– Body mass index >30 kg/m2
– Age greater than 50 years
498 The Traumatic Knee
– Bipolar lesions
– Uncorrected malalignment, ligament insuffi-
ffi
ciency, or meniscus defi
ficiency
Absolute contraindications
– Rheumatoid or osteoarthritis and corticosteroid-
induced osteonecrosis
– Tumor or infection
– Medical conditions that may affectff incorporation
of allograft tissue (i.e., insulin-dependent diabe-
tes mellitus)
– Unwillingness or inability to follow rehabilita-
tion regimen
Preoperative evaluation generally includes com-
prehensive history, physical exam, radiographs,
magnetic resonance imaging (MRI), and diagnos-
tic arthroscopy. Historical information should
include prior injuries and mechanism of injury,
symptom onset, and previous surgical interven-
tion. Acute injuries may present with mechani-
cal symptoms or potentially a loose body, while
chronic cartilage damage may result in activity-
related swelling, pain, and mechanical symptoms
(locking or catching). Range of motion is gener-
ally preserved in patients with focal defects; how-
ever, gait alterations are possible to reduce load-
ing across the defect (toeing-in or toeing-out).
Depending on the location of the lesion, palpa-
Fig. 1 – Imaging prior to osteochondral allografting. (A) Right knee A-P radiograph for sizing with a 10 cm opaque marker to correct for magnification. The
osteochondral lesion has disrupted the normal contour of the lateral femoral condyle (arrow). (B) Coronal T1 image of demonstrating an area of decreased
signal intensity in the subchondral bone of the lateral femoral condyle.
tion may reveal joint line or peripatellar tender-
ness. A radiographic series should include long-
axis weight bearing, 45° posterior to anterior
flexion weight bearing, lateral non-weight bear-
ing, and patellofemoral (sunrise) views with siz-
ing markers (Fig. 1A). All compartments should
be evaluated for joint-space narrowing, osteo-
phyte formation, and subchondral changes (scle-
rosis or cysts). Long axis radiographs are useful
for assessing alignment and Q-angle to establish
the need for concurrent osteotomy. Anteropos-
terior and lateral films with markers are utilized
to determine the appropriate medial-lateral and
anterior-posterior dimensions of the donor graft.
MRI functions to evaluate the overall status of
the knee (i.e., meniscal or ligament pathology).
Fat-suppressed sequences are useful in detecting
bone injury – sclerosis, cysts, or edema (Fig. 1B).
Subchondral involvement could help preclude the
use of other modalities such as autologous chon-
drocyte implantation.
Surgical technique
The patient is placed in the supine position and
anesthetized via general endotracheal, epidural,
spinal, or regional anesthesia. A proximal thigh
tourniquet is applied prior to prepping and drap-

ing for a standard knee arthrotomy. The leg is
exsanguinated and the tourniquet inflated fl to
maintain hemostasis during the procedure. Th The
articular lesion is exposed through a medial or
lateral parapatellar mini-arthrotomy, depending
on the location of the lesion (Fig. 2A). The
Th diam-
eter of the defect is assessed using a cannulated
sizing cylinder from a commercially available
instrumentation system (Arthrex Inc., Naples,
FL). The cylinder is centered over the lesion and
oriented perpendicular to the cartilage surface. A
guide pin is drilled perpendicularly through the
center of the lesion to a depth of 2–3 cm. A can-
nulated reamer is used to excavate the lesion to a
depth of 6–8 mm. Adequate fi fixation is achieved at
this depth while minimizing the amount of donor
subchondral bone – the most immunogenic com-
ponent of the graft. The guide pin is removed and
the 12 o’clock position is marked on margin of
recipient socket. The edges of the socket are deb-
Fig. 2 – (A) An Outerbridge grade IV lesion of the lateral femoral condyle. Note the full thickness loss of cartilage and subchondral bone exposure. (B)
Prepared recipient socket of 25 mm in diameter and 6–8 mm in depth. Holes are drilled in the base of the socket to create vascular channels and enhance
graft incorporation.
Allograft osteoarticular resurfacing 499
rided to a sharp, clean edge using a no. 15 scalpel
blade. To facilitate graft incorporation, vascular
channels are created in the base of the lesion by
drilling multiple small holes using a small drill bit
or Kirshner wire (Fig. 2B). TheTh depth of the recipi-
ent socket is assessed in all four quadrants to cus-
tomize the graft fifit.
The donor osteochondral allograft plug is harvested
from a full femoral hemicondyle. If the hemicondyle
is provided en bloc, it is first trimmed with a power
saw to fit securely into the allograft workstation
(Fig. 3). Th
The curvature of the harvest site is matched
to the curvature of the patient’s recipient socket
using topographic markings. The Th 12 o’clock position
of the graft is marked and the bushing of the corre-
sponding size is secured over the graft to match the
location and size of the recipient socket. The graft is
drilled perpendicularly throughout the entire thick-
ness of the hemicondyle while using cold irrigation
solution and carefully extracted to avoid damaging
Fig. 3 – A hemicondyle is secured within the allograft workstation
prior to cutting the osteochondral plug. Initially, the hemicondyle was
trimmed with an osteotome to create a flat base.
500 The Traumatic Knee
the articular surface (Fig. 4). ThThe osteochondral
plug is placed in the holding forceps and trimmed to
match the depth of the recipient socket in the four
quadrants (Fig. 5A). The allograft plug is then power-
washed with pulsatile lavage to remove any residual
marrow elements and decrease the risk of disease
Fig. 4 – The drill guide is attached to the allograft workstation – aligned
to match graft curvature to the recipient site. A full thickness osteochondral
plug is drilled through the guide with lavage.
Fig. 5 – (A) A full-thickness osteochondral plug is marked to match the depth in all four quadrants of the recipient socket. (B) The plug is rinsed thoroughly
with pulsatile lavage to remove immunogenic marrow elements remaining in the graft.
transmission and immune response (Fig. 5B). If the
lesion is not amendable to a circular graft, a shell
graft can be fashioned free hand in a trapezoidal
confifiguration that matches a hand-prepared defect
bed using a motorized burr and oscillating saw with
cold irrigation. Freehand sizing of the graft is more
time-consuming and often requires fi fixation because
the fit is less precise.
Before graft placement, a calibrated dilator is used
to dilate the recipient socket an additional 0.5 mm.
The graft is press-fi fit into the socket with careful
attention to graft orientation (Fig. 6A). Once the
graft has preliminary fit in the socket, it is gently
impacted with the use of an oversized tamp to seat
it completely. If the graft is particularly uncontained
and or a minimum of 20 mm in diameter, fi fixation
can be achieved with headless bioabsorbable com-
pression screws (Arthrex Inc.) or metal screws
(Fig. 6B). These steps should result in a graft that
is securely positioned, well seated, and matches the
contour of the neighboring host articular cartilage.
The incision is closed in standard fashion with
no. 1 Vicryl or no. 2 Ethibond for the arthrotomy
and no. 2 Vicryl for the subcutaneous tissue and a
standard skin closure. Drain placement is usually
unnecessary after osteochondral allografting. Th The
knee is bandaged and braced in full extension. Cry-
otherapy is initiated immediately after surgery.
Postoperative rehabilitation
The outcome of osteochondral allograft transplan-
tation relies on time-dependent maturation and
remodeling of the subchondral bone. In order to

achieve this goal, patients must be compliant with
the postoperative rehabilitation protocol. Postop-
eratively, weight bearing is limited for a minimum
of 8 weeks. Continuous passive motion is initiated
early to regain range of motion and facilitate heal-
ing. It provides mechanical stimulation for chon-
drocyte growth and orientation, while prevent-
ing premature overload of the graft. Subchondral
collapse of the graft may occur if it is prematurely
loaded. For that reason, high-impact sports are
often limited following osteoarticular allografting
because of concerns for graft collapse and graft
deterioration (7).
Surgical outcome
Osteochondral allografting to the knee has been
reported in the literature for more than two
decades. Outcomes of femoral condyle allografting
represent a signifi
ficant segment of published stud-
ies with a consensus of 70–80% success. Patients
with OCD in the condyle had significant
fi improve-
ment in their D’Aubigne & Postel and Subjective
Knee Function scores at a mean of 7.7 years after
implantation (8). McCulloch et al.’s patient popula-
tion had an 84% satisfaction rate with significant
fi
improvements in Lysholm, IKDC, and KOOS scores
(9). Graft survivorship in the femoral condyles is
estimated to be 95% at 5 years and 85% at 10 years
(10). Etiology (posttraumatic vs. osteochondritis
dessicans) and condyle location do not appear to
aff
ffect the outcome.
Allografting to the tibial plateau, trochlea, and
patella occurs less frequently; consequently, lim-
ited reports are available on the success and dura-
Fig. 6 – (A) A press-fit 25 mm osteochondral plug to the medial femoral condyle. (B) Fixation of a 25 mm osteochondral plug to the lateral femoral condyle
is achieved with a bioabsorbable screw (arrow) through the graft.
Allograft osteoarticular resurfacing 501
bility of these grafts. In 65 unilateral tibial grafts,
Kaplan Meier survival was 80% at 10 years with
21 knees converting to total arthroplasty at an
average of 9.7 years (11). At a mean of 7.5-year
follow-up, Ghazavi et al. had 86% good-to-excel-
lent results and a 10-year survival rate of 71%
(2). Bipolar resurfacing of the tibiofemoral joint
as a salvage procedure to delay arthroplasty has
had limited clinical success. In one cohort of six
reciprocal transplants, articular allograft failure
occurred in all three lateral and one of three medial
transplants (12).
Success of patellar and combined patellar and
trochlear allografting has been variable in small
patient cohorts. In 8 isolated patellar and 12 com-
bined grafts, 12 patients had good-to-excellent
ratings compared with 5 grafts failures (2 patel-
lar, 3 combined). Graft survival in this cohort was
calculated to be 67% at 10 years (13). Elsewhere,
bipolar patellofemoral resurfacing has had good or
excellent results in 58–75% of patients. Isolated
low volume reports of patellar allografting are con-
tradictory with both high rates of success and fail-
ure (12,14). In actuality, the frequency of success is
likely to be intermediate – undoubtedly lower than
condylar allografts.
Treatment options for a failed osteochondral
allograft are limited to reallografting or conver-
sion to a unicompartmental or total arthroplasty.
Factors that increase the frequency of graft failure
include reciprocal defects, malalignment, worker’s
compensation patients, higher body mass index,
and older age (2). Concurrent meniscal allograft
transplantation or realignment are widely rec-
ognized and employed for risk modification.
fi For
patellar and tibial allografts, the “salvage” nature
502 The Traumatic Knee

Table 1 – Published reports on osteochondral allografts

Follow-up Good/excellent results Survival (10
Author Number Graft failure
time (year) (scale) years)

Emmerson et al. (8) 7.7 (2–22) 66 FC 47/65 (72%) D’Aubigne & Postel 76% 10

Gross et al. (10) 10 (45–22) 60 FC 40/60 (67%) HSS score 85% 12

Shasha et al. (11) 12 (5–24) 65 TIB HSS score 80% 21

63 TIB 54/63 (86%) HSS score 7

Ghazavi et al. (2) 7.5 (2–20) 71%
8 FC+TIB 4/8 (50%) HSS score 4
6 FC+TIB 2/6 (33%) D’Aubigne & Postel 4
Chu et al. (12) 6.3 (1–12) 5 PT 5/5 (100%) D’Aubinge & Postel n/a 0
4 TR+PT 3/4 (75%) D’Aubigne & Postel 1
2 PT 0/2 (0%) KSS & Lysholm 2
Torga Spak and Teitge (14) 10 (3–18) 71%
12 TR+PT 7/12 (58%) KSS & Lysholm 4
8 PT
Jamali et al. (13) 7.8 (2–18) 12/20 (60%) D’Aubigne & Postel 67% 5
12 TR+PT

of the procedure should be acknowledged by both
surgeon and patient.
The role of osteochondral allografting in articu-
lar cartilage restoration – especially to the femo-
ral condyle – is widely validated in the literature.
With adequate technical profificiency on the part of
the surgeon and compliance to the rehabilitation
protocols, nearly 80% of patients will achieve clini-
cal success – improvements in pain and function.
Overall, the survivorship of these grafts is nearly
90% at 5 years and 80% at 10 years.
Pearls
– Patient selection: young, high demand individual
with a localized, symptomatic, unipolar lesion
(grade III–IV) of the femoral condyle
– Evaluate and treat comorbidities: evaluate for the
presence of malalignment, meniscal defi ficiency,
or ligamentous instability requiring correction
– Imaging: long axis films to assess alignment and
sizing films for donor matching
– Prepare recipient site: create a perpendicular, shal-
low (6–8 mm) cylindrical socket – removing all
fibrous tissue and sclerotic bone to form a viable
fi
allograft bed
– Construct graft: trim to the appropriate depth in
all four quadrants of the socket and rinse with
pulsatile lavage to decrease immunogenicity
– Implant: press-fi
fit to minimize damage to articu-
lar surface; otherwise, utilize an oversized tamp
to gently impact the allograft
– Rehabilitate: obtain range of motion early via con-
tinuous passive motion and limit weight bearing
for 6–8 weeks to protect the articular cartilage
surface
References
1. Bugbee WD (2002) Fresh osteochondral allografts. J Knee
Surg 15:191–195
2. Ghazavi MT, Pritzker KP, Davis AM, et al. (1997) Fresh
osteochondral allografts for post-traumatic osteochon-
dral defects of the knee. J Bone Joint Surg Br 79:1008–
1013
3. Williams RJ, III, Dreese JC, Chen CT (2004) Chondrocyte
survival and material properties of hypothermically stored
cartilage: an evaluation of tissue used for osteochondral
allograft transplantation. Am J Sports Med 32:132–139
4. Jamali AA, Hatcher SL, You Z (2007) Donor cell survival
in a fresh osteochondral allograft at twenty-nine years. A
case report. J Bone Joint Surg Am 89:166–169
5. Maury AC, Safirfi O, Heras FL, et al. (2007) Twenty-fi
five-year
chondrocyte viability in fresh osteochondral allograft. A
case report. J Bone Joint Surg Am 89:159–165
6. Friedlaender GE, Strong DM, Sell KW (1984) Studies on
the antigenicity of bone. II. Donor-specificfi anti-HLA anti-
bodies in human recipients of freeze-dried allografts. J
Bone Joint Surg Am 66:107–112
7. Nehrer S, Spector M, Minas T (1999) Histologic analysis of
tissue after failed cartilage repair procedures. Clin Orthop
Relat Res 365:149–162
8. Emmerson BC, Gortz S, Jamali AA, et al. (2007) Fresh
osteochondral allografting in the treatment of osteochon-
dritis dissecans of the femoral condyle. Am J Sports Med
35:907–914
9. McCulloch PC, Kang RW, Sobhy MH, et al. (2007) Prospec-
tive evaluation of prolonged fresh osteochondral allograft
transplantation of the femoral condyle: minimum 2-year
follow-up. Am J Sports Med 35:411–420

10. Gross AE, Shasha N, Aubin P (2005) Long-term fol-
low-up of the use of fresh osteochondral allografts
for posttraumatic knee defects. Clin Orthop Relat Res
435:79–87
11. Shasha N, Aubin PP, Cheah HK, et al. (2002) Long-term
clinical experience with fresh osteochondral allografts for
articular knee defects in high demand patients. Cell Tissue
Bank 3:175–182
Allograft osteoarticular resurfacing 503
12. Chu CR, Convery FR, Akeson WH, et al. (1999) Articular
cartilage transplantation. Clinical results in the knee. Clin
Orthop Relat Res: 159–168
13. Jamali AA, Emmerson BC, Chung C, et al. (2005) Fresh osteo-
chondral allografts. Clin Orthop Relat Res 437:176–185
14. Torga Spak R, Teitge RA (2006) Fresh osteochondral
allografts for patellofemoral arthritis: long-term fol-
low-up. Clin Orthop Relat Res 444:193–200

S. Zaffagnini, E. Kon,
G. Filardo, G. Giordano,
Technique of chondrocytes
M. Delcogliano,
G.M. Marcheggiani implantation
Muccioli, M. Marcacci
Defifinition
A
biodegradable, hyaluronian-based biocom-
patible scaff
ffold is used for autologous chon-
drocyte implantation (ACI) for the treatment
of articular cartilage lesions. This
Th procedure con-
sists of two steps: the first one is an arthroscopic
biopsy of healthy cartilage for chondrocyte cell
culture. After 6 weeks, the bioengineered tissue
obtained can be implanted trough a mini-open
procedure or arthroscopic technique.
History
The research of an effi
fficient treatment for full thick-
ness articular surface lesion in the knee remains a
challenge for the orthopedic surgeon.
The marked increase in sports participation and
increased emphasis on physical activity in all age
groups has also increased the incidence of these
lesions and the recovery expectations of the
patients.
However, articular cartilage lesions are difficult
ffi to
treat due to the distinctive structure and function
of hyaline cartilage and by the diffi
fficulty in deter-
mining which lesion will be symptomatic and will
evolve in degenerative joint changes.
ACI has been developed as a reconstructive tech-
nique with the purpose to restore the cartilage
lesions with a bioengineered cartilage tissue in
order to restore a normal joint function. The
Th clini-
cal use of ACI was introduced in Sweden in 1987 to
treat patients with chronic symptoms of cartilage
defects. The first clinical report in 1994 showed
highly satisfactory results clinically and with
biopsy samples showing hyaline-like cartilage (1).
More recent studies confi firm the clinical outcome
achieved and demonstrate the durability of the
results obtained (2,3).
However, good results have to be weighed
against the number of problems that can be
observed with first-generation ACI methods: the
difficulty in handling a delicate liquid suspen-
sion of chondrocytes at implantation surgery,
Chapter 42
the need to make an hermetic periosteum seal
using sutures, the requirement of a second open
surgery operation, the very long rehabilitation
period and possible complications associated
with the use of a periosteal flap, like the fre-
quent occurrence of periosteal hypertrophy, and
large joint exposure (4).
To address the limitations related to the complex-
ity and the morbidity of the surgical procedure,
second-generation ACI has been developed. Bio-
degradable polymers as temporary scaffolds ff for
the in vitro growth of living cells and their sub-
sequent transplantation onto the defect have
become widely used (5,6). One of the most utilized
ffold for ACI (HYAFF® 11, Fidia Advanced Bio-
scaff
polymers Laboratories, Padova, Italy) is entirely
based on the benzylic ester of hyaluronic acid
and consists of a network of 20-μm-thick fi fibers
with interstices of variable sizes, which has been
demonstrated to be an optimal physical support
to allow cell-cell contacts, cluster formation, and
extracellular matrix deposition (7,8). The Th cells
harvested from the patient are expanded and
then seeded onto the scaff ffold to create the tissue-
engineered product Hyalograft C. Seeded on the
ffold, the cells are able to rediff
scaff fferentiate and to
retain a chondrocytic phenotype even after a long
period of in vitro expansion in monolayer culture
(8–10).
The clinical utilization of this three-dimensional
scaff
ffold for autologous chondrocyte culture can
overcome some of the diffi fficulties of the classic
ACI surgical technique. Hyalograft® C was intro-
duced into clinical practice in a number of Euro-
pean countries in 1999 for the treatment of full-
thickness cartilage defects (11–13). Hyalograft C
constructs can be implanted by pasting directly
into the lesion, avoiding suturing to surrounding
cartilage and obviating the need for a periosteal
flap. The features of this device have also permit-
ted the development of an arthroscopic surgical
technique for implantation of autologous chon-
drocytes on a hyaluronic acid support with the
aim of reducing patient morbidity, surgical time
and recovery, and complications related to open
surgery (14,15).
506 The Traumatic Knee
Indications
The autologous chondrocytes implantation is used to
treat symptomatic patients between 16 and 50 years
with chondral lesions (Outerbridge grade III–IV) of
the femoral condyles, trochlea, and patella from 2.0
to 5.0 cm2. Osteochondritis dissecans of the medial
or lateral femoral condyles are also included.
Contraindications
The exclusion criteria included chondral lesions
greater than 5.0 cm2, tibial plateau chondral lesions,
ffused arthritis or bipolar (kissing) lesions, non-cor-
diff
rected axial deviation, or knee instability. Also infec-
tions, tumors, and metabolic and infl flammatory dis-
eases represent contraindications for this treatment.
Preoperative physical findings
fi
Patients are evaluated clinically and with imaging pro-
cedures. Typically, patients present a history of pain
related to the weight bearing or even sitting with the
knee flexed for patellar lesions. Sometimes, swelling,
crepitus, and a reduced range of motion complete the
clinical findings; stiff
ffness or articular block are less
common expressions of cartilage damage.
Imaging and other diagnostic studies
Magnetic resonance imaging represents the most
accurate non-invasive technique to investigate the
chondral defects. It is a reliable, reproducible, and
an accurate tool to asses the cartilage condition.
We also complete the examination with an x-ray
analysis to evaluate axial deformity. Anyway, the
Fig. 1 – Schematic representation of mini-open technique: (A) cleaning of the lesion; (B) sizing of the lesion; (C) implant of the graft without periostal flap.
real quantifi
fication of the chondral damage and the
indications of the more suitable treatment are pos-
sible only trough an arthroscopic view.
Surgical technique
The arthroscopic biopsy of healthy cartilage for cell
culture remains mandatory to evaluate the site of
the lesion and cartilage quality. A 150–200 mg car-
tilage biopsy is taken with a sharp edge curette from
a non-weight bearing site of the articular surface
(intercondylar notch) and sent to the processing
center in a serum-free nutritional medium. At this
time, associated procedures as ACL reconstruction
or meniscal surgeries are usually performed. After
6 weeks, the bioengineered tissue Hyalograft C® is
ready to be implanted and the second step can be
performed.
Mini-open technique
The patient is placed in the supine position on the
operating table. A pneumatic tourniquet is placed
as high as possible around the proximal part of the
thigh. For condyle lesions, a medial or lateral parap-
atellar arthrotomy is performed to access the joint.
When the lesion is too posterior, a meniscal take-
down is required to facilitate adequate visualization
and debridement of the lesion. Patellar and selected
trochlear lesions, arthroscopically inaccessible, are
also transplanted, after a midline incision of the
skin, through a mini-arthrotomy approach (lateral
or medial parapatellar arthrotomy). This damaged
area is prepared using a handheld curette: non-via-
ble cartilage tissues are removed to create a stable
shoulder for the articular lesion. The lesion is tem-
plated using an aluminum foil, to obtain the exact
size of the graft needed to cover the entire defect.
The template is then used to prepare the graft that

is implanted through a press-fi fit technique (Fig. 1).
Because of the intrinsic adhesive properties of this
scaff
ffold, additional fixation devices are not neces-
sary. However, after the tourniquet removal, stabil-
ity is tested with cyclic bending of the knee while
visualizing the graft (Fig. 2). In big lesions some-
times, the stability of the patch can be increased by
adding fibrin glue at the margin of the defect.
If meniscal takedown is performed, it is neces-
sary to suture it with a number 2 non-absorbable
braided. Suction drains are not placed intra-articu-
lar to avoid injuries of the graft. Th
The wound is then
closed in layers.
Arthroscopic technique
The easy handling of this new bioengineered scaf-
fold permitted the development of an arthroscopic
surgical approach for the implantation of autolo-
gous chondrocytes, reducing patient morbidity,
surgical time and recovery, and complications
related to open surgery (14,15).
The arthroscopic implant has been developed for
medial or lateral condyle lesion. With improving
expertise and long learning curve, we are now able
to address almost every localization of grade IV
Fig. 2 – Mini-open procedure: (A) cleaning of the lesion; (B) sizing of the lesion; (C) preparation of the graft according to size; (D) implant of the graft without
periostal flap.
Technique of chondrocytes implantation 507
defect, which can have a wide extension, except for
patella location.
The patient is placed in the supine position on the
operating table. A pneumatic tourniquet is placed
as high as possible around the proximal part of the
thigh. A support is placed laterally at the upper level
of the knee to stress the joint during arthroscopic
evaluation. After preparation and draping of the
leg, the arthroscopic portals are performed (super-
omedial portal for the inflow fl cannula, an antero-
lateral portal for the camera, and an anteromedial
portal for instruments). After the visualization
of the damaged area, the toilette of the chondral
lesion is performed removing all the fi fibrous tissue
from its surface with a motorized shaver.
A flipped cannula is used to retract the fat pad and
have a white view of the lesion. Into this cannula, a
delivery device of variable diameter (6.5–8.5 mm)
with a sharp edge is introduced to evaluate, map,
and size the defect. A cannulated trocar is then
inserted to introduce a Kirschner wire (0.9 mm
diameter), to guide a specifi fically designed can-
nulated low profi file drill (6.5–8.5 mm), positioned
according to the mapping previously performed.
This drill, with a safety stop at 2 mm, was developed
specifi
fically to avoid lesion to the subchondral bone
plate, which must remain intact during debride-
508 The Traumatic Knee
Fig. 3 – Schematic representation of arthroscopic technique: (A) mapping of the lesion with sharp trocar; (B) a Kirschner wire guides a cannulated reamer
according to the mapping previously performed; (C) final preparation of the lesion; (D) harvesting of the patches according to size; (E) patches implanted
inside the lesion.
ment of the lesion. The low-speed drilling of the car-
tilage surface allows creation of the predetermined
circular area with regular margins for the graft. The
Th
procedure is repeated to prepare the entire defect
surface according to the previous sizing. After drill-
ing, a joint lavage is performed with motorized
shaver. The infl
flow is then closed, and suction from
the cannula inserted in the anteromedial portal is
applied to create a dry joint surface. The delivery
system with sharp edge is beat on the hyaluronic
acid patch containing the autologous chondrocyte
culture. The stamp obtained remains automatically
in the sheath of the delivery system, which is then
transported through the flipped
fl cannula and posi-
tioned in the prepared area. The delivered stamp is
pushed to plug precisely the defect. TheTh procedure
is repeated until the defect is entirely filled (Fig. 3).
It is important to cover as much as possible of the
prepared area without covering the margin of the
defect with the implanted stamps. In this manner,
the stamps do not move from the defect. Under
arthroscopic control, the stability of implanted
stamps is evaluated with a blunt probe (Fig. 4).
The tourniquet is released, and the graft swelling is
observed and stability reevaluated. With the scope
still in the joint, a cyclic bending of the knee is per-
formed and possible movement of the grafts from
the prepared defect is checked.
Postoperative care
A proper rehabilitation program may signifi ficantly
aff
ffect the cartilage repair and maturation, the
eventual chondrocyte death, the functional recov-
ery, and the capacity to prevent the risk of re-in-
jury. The postoperative protocol can be divided in
three subsequent phases (16).
The first stage concerns implant protection and
recovery of walk (0–10 weeks or more).
The treatments are focused on controlling pain,
eff
ffusion, loss of motion, and muscle atrophy and
the main goal in this phase is to protect the trans-
plant, preventing the weight bearing for about 3–4
weeks. The management of the postoperative pain
allows early mobilization that contributes to a faster
resolution of swelling to promote defect healing and
joint nutrition and to prevent the development of
adhesions. On the second postoperative day, self-as-

Fig. 4 – Arthroscopic view: (A) prepared lesion and (B) patches implanted.
sisted mobilization of the knee or continue passive
motion 6 h daily with 1 cycle per minute is recom-
mended until 90° of flexion is reached. Early isomet-
ric and isotonic exercises and controlled mechanical
compression are performed. Muscular voluntary
contraction and neuromuscular electrical stimu-
lation is indicated and can be started at discharge
of the patient. In the third or fourth week, weight
touch down with crutches is allowed and should
be usually completed within the eighth week after
surgery. Gait training in a swimming pool facilitates
the recovery of normal gait phases.
In the second stage, the rehabilitation goal is the
return to a correct running pathway by propriocep-
tive, strength, and endurance exercises and aerobic
training. Exercises with closed and open kinetic chain
with progressive increments of the articular load
are gradually introduced. Proprioceptive exercises
of increased diffi
fficulty are performed in this stage,
using unstable surfaces and perturbation devices.
After 30–32 weeks of surgery, when the rehabilita-
tion progresses without complications, the patient
can join the last stage. In order to complete the
athletic recovery proprioceptive, eccentric and
reconditioning exercises are performed.
Strengthening and endurance exercises for the
muscular groups of the lower limbs are performed
Technique of chondrocytes implantation 509
in the gymnasium and on the field
fi where it is pos-
sible to reproduce the metabolic and technical
characteristics of the sports activity of the patient.
They prepare the athlete to return to high impact
sports that need to be avoided for 10–12 months
after surgery.
Outcomes
Second-generation ACI with the use of Hyalograft
C has been developed in 1999. Arthroscopic tech-
nique has been ideated and used in our institute
since 2001 (15). We have participated to a mul-
ticenter investigation to evaluate the long-term
clinical outcomes of the treatment with Hyalograft
C®. In this study, we analyzed clinical results on
the cohort of 141 patients with follow-up assess-
ments ranging from 2 to 5 years (average follow-up
time: 38 months) (11). The patients were treated
with mini-open technique or, when indicated,
arthroscopically. Of the patients, 71.4% reported
that they could do everything or nearly everything
that they want to do with their joint compared
with the 4.3% prior to surgery. There was a signifi fi-
cant improvement in knee function, symptoms,
and patient’s activity level, with a mean IKDC score
that increased from 39.3 to 71.9 postoperatively.
Of the patients, 91.5% had an improvement with
respect to their presurgery status according to this
scoring system. Improvement was not related to
the lesion characteristics analyzed, that is, diagno-
sis, size and type, or location; however, significant
fi
improvements were observed in all of the patients
subgroups categorized according to these charac-
teristics. There was a signifi
ficant increase in health-
related quality of life in the 3-year average study
period with 86.4% of patients improved (EuroQol
EQ-5D questionnaire).
In our experience, we have treated arthroscopically
from 2001 more than 150 patients (14). The good
results obtained at short-term follow-up have been
confifirmed by the analysis at medium follow-up of
40 patients treated by arthroscopic technique. A
statistically significant
fi improvement was observed,
showing 90% of normal or nearly normal knees at
5-year follow-up. There was a signifificant subjective
improvement too, with a mean IKDC score of 80.2.
The level of sport activity was improved and main-
tained from 2 to 5 years follow-up.
We also evaluated 32 patients with patellofemoral
full-thickness chondral defects, treated with the
open approach (12). A significantfi improvement
was achieved at 2-year follow-up in these patients
too, showing 90% of normal or nearly normal
knees and a subjective evaluation of 73.6 using the
IKDC score.
510 The Traumatic Knee
Complications
No complications related to the implant or serious
adverse events were observed during the treat-
ment and follow-up period.
Conclusions
The results of our series using Hyalograft C® are
comparable with the ones of the original ACI tech-
nique. The arthroscopic implant also has reduced
the morbidity for the patient, the recovery time,
and the rehabilitation protocol. Our results sug-
gest that this method also may be used for the
treatment of large cartilage lesions in highly com-
petitive athletes, but long-term follow-up and ran-
domized studies will be needed to confirm
fi the reli-
ability of this procedure.
Several improvements are soon expected, as the
result of the rapidly growing knowledge on cell cul-
ture and chondrocyte behavior, leading to a more
reliable surgical technique and better clinical out-
come.
References
1. Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O,
Peterson L (1994) Treatment of deep cartilage defects in
the knee with autologous chondrocyte transplantation. N
Engl J Med 331(14):889–895
2. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl
A (2002) Autologous chondrocyte transplantation. Biome-
chanics and long-term durability. Am J Sports Med 30:2–12
3. Brittberg M, Peterson L, Sjögren-Jansson E, Tallheden T,
Lindahl A (2003) Articular cartilage engineering with autolo-
gous chondrocyte transplantation. A review of recent devel-
opments. J Bone Joint Surg Am 85-A(suppl 3):109–115
4. Sgaglione NA, Miniaci A, Gillogly SD, Carter TR (2002)
Update on advanced surgical techniques in the treatment
of traumatic focal articular cartilage lesions in the knee.
Arthroscopy 18(2, suppl 1):9–32
5. Steinwachs M, Kreuz PC (2007) Autologous chondrocyte
implantation in chondral defects of the knee with a type I/
III collagen membrane: a prospective study with a 3-year
follow-up. Arthroscopy 23(4):381–387.
6. Behrens P, Bitter T, Kurz B, Russlies M (2006) Matrix-
associated autologous chondrocyte transplantation/
implantation (MACT/MACI) – 5-year follow-up. Knee
13(3):194–202
7. Brun A, AbatangeloG, Radice M, Zacchi V, Guidolin D,
Daga Gordini D, Cortivo R (1999) Chondrocyte aggrega-
tion and reorganization into three-dimensional scaffolds.
ff
J Biomed Mater Res 46(3):337–346
8. Grigolo B, Lisignoli G, Piacentini A, Fiorni M, Gobbi P,
Mazzotti G, Duca M, Pavesio A, Facchini A (2002) Evi-
dence for rediff
fferentiation of human chondrocytes grown
on a hyaluronan-based biomaterial (HYAff ff 11): molecular,
immunohistochemical and ultrastructural analysis. Bio-
materials 23(4):1187–1195
9. Aigner J, Tegeler J, Hutzler P, Campoccia D, Pavesio A,
Hammer C, Kastenbauer E, Nauman A (1998) Cartilage
tissue engineering with novel nonwoven structured bio-
material based on hyaluronic acid benzyl ester. J Biomed
Mater Res 42(2):172–781
10. Solchaga LA, Dennis JE, Goldberg VM, Caplan AL (1999)
Hyaluronic acid-based polymers as cell carriers for tissue-
engineered repair of bone and cartilage. J Orthop Res
17(2):205–213
11. Marcacci M, Berruto M, Brocchetta D, Delcogliano A,
Ghinelli D, Gobbi A, Kon E, Pederzini L, Rosa D, Sac-
chetti GL, Syefani G, Zanasi S (2005) Articular cartilage
engineering with Hyalograft C:3-year clinical results. Clin
Orthop Relat Res (435):96–105
12. Gobbi A, Kon E, Berruto M, Francisco R, Filardo G, Mar-
cacci M (2006). Patellofemoral full-thickness chondral
defects treated with Hyalograft-C: a clinical, arthroscopic,
and histologic review. Am J Sports Med 34(11):1763–
1773
13. Nehrer S, Domayer S, Dorotka R, Schatz K, Bindreiter U,
Kotz R (2006) Three-year clinical outcome after chondro-
cyte transplantation using a hyaluronan matrix for carti-
lage repair. Eur J Radiol 57(1):3–8
14. Marcacci M, Kon E, Zaff ffagnini S, Filardo G, Delcogliano
M, Neri MP, Iacono F, Hollander AP (2007) Arthroscopic
second generation autologous chondrocyte implantation.
Knee Surg Sports Traumatol Arthrosc 15(5):610–619
15. Marcacci M, Zaff ffagnini S, Kon E, Visani A, Iacono F, Loreti
I (2002) Arthroscopic autologous chondrocyte trans-
plantation: technical note. Knee Surg Sports Traumatol
Arthrosc 10(3):154–159
16. Creta D, Della Villa S, Roi GS (2006) Rehabilitation after
arthroscopic autologous chondrocyte transplantation
with three dimensional hyaluronan-based scaffolds ff of
the knee. In: Brittberg M, Marcacci M, Zanasi S, edi-
tors. Basic science, clinical repair and reconstruction of
articular cartilage defects: current status and prospects.
Timeo Ed.

T. Laumonier, J. Ménétrey Regenerative medicine for cartilage
Abstract
R
egenerative medicine is an emerging multi-
disciplinary field involving biology, medicine,
and engineering that is likely to revolutionize
the ways we improve the health and quality of life
for millions of people by restoring, maintaining,
or enhancing tissue and organ function. This Th field
holds the promise of regenerating damaged tissues
and organs in the body by stimulating previously
irreparable tissues to heal themselves. Regenerative
medicine also includes the capacity to grow tissues
and organs in the laboratory and safely implant
them when the body cannot heal itself, as observed
for cartilage tissue after damage or wear.
To achieve these goals, regenerative medicine
research includes the following areas: a) cells
including cell proliferation and differentiation,
ff
cell source, autologous/allogeneic/xenogeneic
cells, stem cells, and genetically engineered cells;
(b) biomaterials including novel scaffolds
ff that are
designed to improve growth and differentiation
ff of
cells in the process of forming functional tissue;
(c) biomolecules including growth factors, differ-ff
entiation factors, and angiogenic factors.
Introduction
Regenerative medicine focuses on new therapies to
replace lost or damaged tissue with the final goal to
restore tissue function. Following injury or degen-
eration, multicellular organisms restore homeosta-
sis by either of two processes. The
Th first is the pro-
cess of scar formation, a natural part of the healing
response, which consists in the substitution of a
cellular matrix as a patch to immediately reestab-
lish both physical and physiologic continuity to the
injured organ. The second is the process of regenera-
tion. By reactivating developmental pathways, the
architecture of the original organ is recreated. Unlike
regenerated tissue, scar tissue is different
ff and less
perfect than the surrounding tissue it replaces.
Cartilage degeneration caused by congenital
abnormalities, disease, or injury is of great clini-
Chapitre 43
cal consequence, given the limited intrinsic healing
potential of the tissue. In fact, articular cartilage is
an avascular tissue that has a very limited capacity
for self-repair. Because of the lack of blood supply
and subsequent wound healing response, damage
to cartilage results in an incomplete attempt at
repair by local chondrocytes. To prevent progres-
sive cartilage degeneration or to repair damaged
cartilage, the surgical treatment is often the only
option but rarely restore full function of the dam-
aged tissue. Even in the best conditions, surgery
will delay rather than prevent the subsequent pro-
gression of degenerative joint disease. Therefore,
Th
regenerative medicine for the generation of func-
tional cartilage tissue has emerged as an important
field of research. There are diff
fferent approaches for
cartilage regeneration that may help to replace,
repair, or promote tissue healing. Th The use of cells
including chondrocytes and stem cells may rep-
resent a promising approach. These cells may be
included in special biomaterials that provide a 3D
environment that is desirable for the production
of cartilaginous tissue. Finally, delivery of biomol-
ecules such as growth factors directly or using cells
as gene delivery vehicles to the injury site may also
promote cartilage regeneration.
This chapter covers recent advances in regenera-
tive medicine including cell-based regenerative
therapies (chondrocytes and chondrocyte progeni-
tor cells), the use of natural/synthetic scaffolds
ff in
combination or not with growth factors as pos-
sible tools for developing new clinical therapies to
enhance cartilage healing.
Cell-based regenerative therapies
Regenerative medicine helps natural healing pro-
cesses to work faster, but in the case of cartilage, it
involves the use of special cells and/or biomateri-
als to regrow missing or damaged tissue. Th The ideal
cell source for cartilage regenerative medicine is
still being investigated. Chondrocytes are the most
obvious choice for cartilage repair, since they are
found in native cartilage and are known to play a
512 The Traumatic Knee
major role in producing, maintaining, and remod-
eling the cartilage extracellular matrix (ECM). Nev-
ertheless, other cell source may also be used for
cell therapy such as embryonic stem cells (ESCs) or
adult stem cells. Adult stem cells such as bone mar-
row mesenchymal stem cells (BMSCs), adipose-de-
rived stem cells (ADSCs), and muscle-derived stem
cells (MDSCs), which have the advantage to be
isolated from various tissues with a multi-lineage
potential, represent another promising cell source.
Chondrocytes
Chondrocytes, the only cells found in cartilage, are a
natural choice for cartilage repair. Chondrocytes are
growing and proliferating, while cartilage is devel-
oping, but become mostly a quiescent cell popula-
tion during the adult life, with a major behavior, the
production of the ECM. Th The use of cultured autolo-
gous chondrocytes in patients with cartilage injuries
have been explored 14 years ago and have shown
encouraging clinical results in combination with
the regeneration of hyaline cartilage (1). One of the
major challenges in chondrocyte therapy is to obtain
a suffi
fficient cell number to treat a clinically relevant
defect. In fact, chondrocytes are limited in number,
representing 5–10% of cartilage tissue, and thus
need to be expanded in vitro. During proliferation
in vitro, chondrocytes dedifferentiate
ff which is char-
acterized by decreased type II collagen expression,
increased type I collagen expression, and variation
in the expression of matrix modulators, growth fac-
tor, and integrins (2). To prevent this phenomenon,
a variety of substrates and growth factors have been
used in culture such as beta fibroblast growth factor
(FGF) that enhance chondrocyte amplification
fi and
regulate its diff
fferentiation (3). In addition, a variety
of methods have been developed to limit chondro-
cytes dedifffferentiation including the use of 3D cul-
ture (4), the regulation of collagen type II expres-
sion by histone deacetylase (5), or cell expansion
in hypoxic conditions (6). Alternatively, the use of
allogeneic chondrocytes isolated from different
ff ana-
tomical sources would permit an unlimited supply of
cells for cartilage repair or regeneration application
(7). However, chondrocytes, like many other cell
types, are believed to express major histocompatibil-
ity complex antigens on the cell surface, which could
lead to immunologic rejection by the recipient.
Stem cells
Although the use of chondrocytes for applications
of cartilage tissue engineering is prevalent, con-
cerns associated with donor site morbidity, cell
dediff
fferentiation, and the limited life span of these
cells have brought the usage of stem cells to the
forefront of such applications.
Stem cells are defi
fined as cells that can both self-re-
new and give rise to clonal progeny with the ability
to diff
fferentiate (8). There are two major families
of stem cells: ESCs are pluripotent cells capable of
generating all tissues and organs within the devel-
oping fetus. Further differentiation
ff forms multi-
potent, or lineage-specific,
fi stem cells. Hematopoi-
etic stem cells, an example of multipotent cells,
can diff
fferentiate to form any circulating blood cell
but not other tissues.
Embryonic stem cells
The use of ESC is still controversial. They represent
a potential source for cartilage tissue engineer-
ing (9) link to their proliferation capabilities, but
diffi
fficulties in ESC selection and purity, as well as
possible antigenicity and ethical issue, may hinder
their clinical use (10).
Adult stem cells
Adult stem cells may also represent the alternative
to chondrocytes. These
Th cells can be found resident
within a host of musculoskeletal and connective
tissues, and the multipotential nature of adult
stem cells makes them theoretically ideal candi-
dates for repair of cartilage defects.
Bone marrow-derived stem cells
BMSCs represent a promising alternative to the
use of chondrocytes for cartilage repair. First, they
are easy to obtain; BMSC isolation can be achieved
by aspiration of blood from the bone marrow
using local anesthesia, without major side effects.
ff
Second, BMSC can be expanded in culture while
maintaining their differentiation
ff potential. They
undergo chondrogenesis in various culture condi-
tions that often involve induction with growth fac-
tor such as transforming growth factor- (TGF-)
or insulin growth factor-1 (IGF-1) combined with a
3D environment (11). Several recent animal studies
have shown evidence for the potential of BMSC in
improving osteochondral defects (12,13). Recently,
Park et al. demonstrated that 3D constructs includ-
ing TGF-3 or heparin bound TGF-3 mixed with
rabbit MSC allow to enhance chondrogenesis and
to improve neocartilage formation in vivo (14).
Adipose-derived stem cells
Recent studies have identifi
fied the presence of an
abundant source of stem cells in subcutaneous adi-
pose tissue that can diff
fferentiate into osteogenic
and chondrogenic cells (15). These
Th cells, termed
adipose-derived adult stem cells, show character-
istics of multipotent adult stem cells, similar to
those of BMSC, and under appropriate culture con-

ditions, synthesize cartilage-specific
fi matrix pro-
teins that are assembled in a cartilaginous ECM.
The growth and chondrogenic diff fferentiation of
ADSC cells is strongly infl
fluenced by factors in the
biochemical as well as biophysical environment of
the cells (16). Furthermore, there is strong evi-
dence that the interaction between the cells, the
extracellular biomaterial substrate, and growth
factors regulates ADSC cell differentiation
ff and tis-
sue growth. Overall, ADSC cells show significant
fi
promise for the development of functional tissue
replacements for various tissues of the musculo-
skeletal system.
Muscle-derived stem cells
Besides bone marrow and adipose tissue, skeletal
muscle is another source of adult stem cells being
explored for cartilage repair. MDSCs are identi-
fied as a valuable source of postnatal stem cells
that appear to be distinct from satellite cells and
possess the ability to differentiate
ff into other cell
lineages such as the chondrogenic lineage. MDSC
improved the healing of the cartilage defect, with
effi
fficiency equivalent to chondrocyte transplanta-
tion (17). MDSC can also be used as gene delivery
vehicle for proteins. Recently, MDSCs were geneti-
cally engineered to deliver bone morphogenetic
protein-4, and the authors demonstrated that
these cells participated in the repair of cartilage in
rats after transplantation (18).
Biomaterials/scaffolds
ff
When cells are directly transplanted at the cartilage
defect site, one of the major problems is the lack of
cell retention. The rapidly emerging field of tissue
engineering holds great promise for the generation
of functional tissue substitutes. The basic princi-
ple is to utilize a biocompatible, structurally and
mechanically sound scaffold
ff that is seeded with an
appropriate cell source, and is loaded with bioac-
tive molecules to promote cellular differentiation
ff
and/or maturation. Scaff ffolds provide a temporary
3D environment to injected cells that is desirable
for the production of cartilaginous tissue. To be
considered for tissue engineering applications, the
architecture of the scaff ffold should ideally mimic
that of the native tissue to be repaired; addition-
ally, this implantable scaffold
ff should be suited to
facilitate infi
filtration, attachment, proliferation,
and difffferentiation of the desired, individual cell
type. Moreover, ideally, the scaffold
ff should have
a controlled degradation during new tissue regen-
eration and allow for the diffusion
ff of nutrients
and waste products. To date, a wide diversity of
scaff
ffolds has been investigated for cartilage tis-
Regenerative medicine for cartilage 513
sue engineering. This includes the fabrication of
natural and synthetic polymers used as scaffolds ff
for cells, including porous sponges, woven or non-
woven meshes, and hydrogels. The various type of
scaff
ffold used in cartilage tissue engineering are
well documented in a recent review by Chung et
al. (19). Actually, the most commonly used scaf-
folds in cartilage tissue engineering are meshes
made of poly(-hydroxy esters) because of their
capacity to degrade naturally and the US Food and
Drug Administration (FDA) approval for clinical
use. These scaff ffolds [including poly(glycolic acid),
poly(lactic acid), and their copolymer poly(lactic-
co-glycolic acid)] have been investigated for use
as cartilage tissue engineering scaffolds
ff since the
early 1990s (20). Numerous studies have demon-
strated the maintenance of chondrocyte pheno-
type and the production of cartilage-specific fi ECM
in these scaff ffolds (21–23). Other scaff ffolds are
used for cartilage repair such as hydrogel scaffolds
ff
(24). Hydrogel is a soft solid scaff ffold mainly com-
posed of water, which would be easily absorbed by
the body. The unique ability of hydrogel scaff ffolds
to encapsulate cells, rather than promote attach-
ment, keeps cells in a spherical morphology condu-
cive to maintenance of chondrocyte phenotype. In
practice, a cell-polymer suspension is injected into
the body to fill a cavity or defect prior to gelation in
situ, eliminating a separate cell-seeding step post-
scaff
ffold fabrication, and minimizing the need for
invasive surgical procedures.
Biomolecules
Biomolecules, including growth factors, cytokines,
and diff
fferentiation factors are commonly used to
promote tissue growth in regenerative medicine.
These biomolecules, via binding to specifific recep-
tors, activate intracellular signaling pathways,
instruct cells to proliferate, differentiate,
ff and
synthesize ECM during the processes of cartilage
regeneration. The use of growth factors alone or
in combination with cells and/or scaffold
ff seem to
be one of the most promising method for cartilage
repair (25). A number of biomolecules have shown
regulatory effffects on chondrocytes and stem cells
for cartilage tissue engineering. Th This includes
members of the TGF- superfamily (including the
bone morphogenic proteins [BMPs]), IGF and FGF
(26). Among these factors, BMP-2 and TGF-1 may
be the most potent inducers of chondrogenesis
and represent powerful tools to prevent or repair
cartilage damages (27,28). BMP-2 and BMP-7,
which are known to modulate cell phenotype in
cartilage tissue, are commonly used growth factors
for cartilage repair. They have recently received
514 The Traumatic Knee
Fig. 1 – Concept of regenerative medicine: a potential treatment for cartilage repair. Cells isolated from various tissues (cartilage, bone marrow, skeletal
muscle, etc.), or embryonic stem cells, are expanded in vitro. When a suffi
fficient cell number is obtained, cells may be directly injected in the lesion with the
addition or not of growth factors (direct growth factor addition or ex vivo gene therapy). Cells may also be engineered in 2D/3D constructs by combination of
biomaterials and growth factors and injected in the lesion or engineered in bioreactors to accelerate and improve the growth off cartilage to obtain functional
tissue.
approval by the FDA for specifi fic clinical cases (29).
However, BMPs must be used with caution for car-
tilage repair, as they are potent osteogenic induc-
ers (30). Another member of the TGF- superfam-
ily, TGF-1, is very abundant in articular cartilage
(31). It is known to stimulate chondrocytes ECM
synthesis, to have potent anti-infl flammatory prop-
erties, and is an essential mediator in cell prolif-
eration and diff fferentiation (32). TGF-1 acting as
a cartilage reparative factor has been well studied
(27). Besides the members of the TGF- superfam-
ily, other growth factors have been used in carti-
lage repair strategies. FGF-2 has been shown to
enhance chondrocyte proliferation and to regulate
their diff
fferentiation ex vivo (3,33). IGF-1, known
to increase cartilage proteoglycan synthesis and
ECM production (34), has also been well studied
in vivo. The exogenous administration of human
IGF-I has been reported to enhance the cell-based
repair of articular cartilage defects (35). Madry
et al. have demonstrated that transplantation of
IGF-1 transfected chondrocytes in osteochon-
dral defects improved articular cartilage repair
(36) and recently, Nixon and collaborators have
reported that transplantation of IGF-1 genetically
engineered chondrocytes improve equine cartilage
healing (37). As underlined by these in vivo stud-
ies on IGF-1, biomolecules may be added to culture
media in vitro or incorporated into scaffolds
ff for in
vivo delivery to control cellular differentiation
ff and
tissue formation. Nevertheless, many of these bio-
logical agents have a short half-life in vivo, which
limits their effi
fficiency. Gene therapy is an alterna-
tive approach to deliver bioactive molecules for
cartilage tissue engineering (38). Gene therapy can
be defifined as the introduction of genetic material
into cells with the intent of altering cellular func-
tion or structure at the molecular level to improve
a clinical outcome (39). There
Th are two fundamen-
tally diff
fferent gene delivery systems: viral (e.g.,
lentiviruses, adenoviruses, and adeno-associated
viruses) and non-viral (polymers and liposomes).
Both approaches can be carried out in vivo or ex
vivo (40). The in vivo approach involves direct
delivery of genes to the target cell within the living
organism. The ex vivo approach requires removal of
the cells from the host, in vitro cultivation, expan-
sion, and genetic modifi fication followed by implan-
tation back into the tissue. This approach is labo-
rious and more expensive but has the advantage
that selective genetic manipulation of the desired
cell type and quantification
fi of the transfection effi
ffi-
ciency in vitro is possible. Despite greater safety
concerns, viral vectors, which typically have higher
transfection effi
fficiencies, may be the good choice.
For improving cartilage repair cells (stem cells or
chondrocyte), overexpressing growth factor genes
have shown promising results. Proof of concept
has been developed using viral vectors, predomi-
nantly adenovirus, to deliver growth factor genes,
such as BMP-2, TGF-1, and IGF-1 to damaged car-
tilage (41–43). The application of gene-enhanced
tissue engineering will result in the development
of cartilage grafts with the potential for prolonged
synthesis of growth factors after transfer to the in
situ lesion site.

Conclusion
Regenerative medicine including cells, scaffolds,
ff and
growth factors represents a highly promising alter-
native solution for cartilage repair (Fig. 1). Never-
theless, none of the tested cartilage repair strategies
has generated long lasting grafts that meet the func-
tional demands placed upon this tissue in vivo. Key
challenges remains to be addressed such as matrix
degradation, cell diff fferentiation or integration
insuffi
fficiencies, or loss of the transplanted cells and
tissues. It is most probable that successful cartilage
regeneration will depend on future advances in our
understanding of the biology of cartilage, of stem
cells, and of scaffffolds technological development.
Combining cell transplant technology to deliver dif-
ferentiated cells in a minimally invasive way, with
genes that improve matrix formation, may provide a
manageable protocol for a better cartilage healing.
References
1. Brittberg M, Lindahl A, Nilsson A, et al. (1994) Treat-
ment of deep cartilage defects in the knee with autologous
chondrocyte transplantation. N Eng J Med 331:889–895
2. Goessler UR, Bieback K, Bugert P, et al. (2005) Human
chondrocytes diff fferentially express matrix modulators
during in vitro expansion for tissue engineering. Int J Mol
Med 16:509–515
3. Schmal H, Zwingmann J, Fehrenbach M, et al. (2007)
bFGF inflfluences human articular chondrocyte difffferentia-
tion. Cytotherapy 9:184–193
4. Takahashi T, Ogasawara T, Asawa Y, et al. (2007) Three-
Th
dimensional microenvironments retain chondrocyte phe-
notypes during proliferation culture. Tissue Eng 13:1583–
1592
5. Huh YH, Ryu JH, Chun JS (2007) Regulation of type II
collagen expression by histone deacetylase in articular
chondrocytes. J Biol Chem 282:17123–17131
6. Egli RJ, Bastian JD, Ganz R, et al. (2008) Hypoxic expan-
sion promotes the chondrogenic potential of articular
chondrocytes. J Orthop Res
7. Weinand C, Peretti GM, Adams SB, Jr., et al. (2006) Heal-
ing potential of transplanted allogeneic chondrocytes of
three diff
fferent sources in lesions of the avascular zone
of the meniscus: a pilot study. Arch Orthop Trauma Surg
126:599–605
8. Weissman IL (2000) Stem cells: units of development, units
of regeneration, and units in evolution. Cell 100:157–168
9. Jukes JM, Moroni L, van Blitterswijk CA, de Boer J
(2008) Critical Steps toward a tissue-engineered carti-
lage implant using embryonic stem cells. Tissue Eng Part
A 14:135–147
10. Daley GQ, Scadden DT (2008) Prospects for stem cell-
based therapy. Cell 132:544–548
11. Worster AA, Brower-Toland BD, Fortier LA, et al. (2001)
Chondrocytic difffferentiation of mesenchymal stem cells
sequentially exposed to transforming growth factor-beta1
in monolayer and insulin-like growth factor-I in a three-
dimensional matrix. J Orthop Res 19:738–749
12. Shao X, Goh JC, Hutmacher DW, et al. (2006) Repair of
large articular osteochondral defects using hybrid scaf-
folds and bone marrow-derived mesenchymal stem cells
in a rabbit model. Tissue Eng 12:1539–1551
Regenerative medicine for cartilage 515
13. Zhou G, Liu W, Cui L, et al. (2006) Repair of porcine artic-
ular osteochondral defects in non-weightbearing areas
with autologous bone marrow stromal cells. Tissue Eng
12:3209–3221
14. Park JS, Woo DG, Yang HN, et al. (2008) Heparin-bound
transforming growth factor-beta3 enhances neocartilage
formation by rabbit mesenchymal stem cells. Transplanta-
tion 85:589–596
15. Zuk PA, Zhu M, Mizuno H, et al. (2001) Multilineage cells
from human adipose tissue: implications for cell-based
therapies. Tissue Eng 7:211–228
16. Wei Y, Hu Y, Hao W, et al. (2008) A novel injectable scaf-
fold for cartilage tissue engineering using adipose-derived
adult stem cells. J Orthop Res 26:27–33
17. Adachi N, Sato K, Usas A, et al. (2002) Muscle derived, cell
based ex vivo gene therapy for treatment of full thickness
articular cartilage defects. J Rheumatol 29:1920–1930
18. Kuroda R, Usas A, Kubo S, et al. (2006) Cartilage repair
using bone morphogenetic protein 4 and muscle-derived
stem cells. Arthritis Rheumatism 54:433–442
19. Chung C, Burdick JA (2008) Engineering cartilage tissue.
Adv Drug Deliv Rev 60:243–262
20. Vacanti CA, Langer R, Schloo B, Vacanti JP (1991) Syn-
thetic polymers seeded with chondrocytes provide a tem-
plate for new cartilage formation. Plastic Reconstr Surg
88:753–759
21. Hunter CJ, Levenston ME (2004) Maturation and inte-
gration of tissue-engineered cartilages within an in vitro
defect repair model. Tissue Eng 10:736–746
22. Fuchs JR, Hannouche D, Terada S, et al. (2005) Cartilage
engineering from ovine umbilical cord blood mesenchymal
progenitor cells. Stem Cells (Dayton, Ohio) 23:958–964
23. Seidel JO, Pei M, Gray ML, et al. (2004) Long-term culture
of tissue engineered cartilage in a perfused chamber with
mechanical stimulation. Biorheology 41:445–458
24. Vinatier C, Guicheux J, Daculsi G, et al. (2006) Cartilage
and bone tissue engineering using hydrogels. Biomed
Mater Eng 16: S107–S113
25. Goldberg A (2001) Eff ffects of growth factors on articular
cartilage. Ortop Traumatol Rehabil 3:209–212
26. O'Connor WJ, Botti T, Khan SN, Lane JM (2000) The Th use
of growth factors in cartilage repair. Orthop Clin N Am
31:399–410
27. Blaney Davidson EN, van der Kraan PM, van den Berg WB
(2007) TGF-beta and osteoarthritis. Osteoarthritis and
cartilage/OARS. Osteoarthr Res Soc 15:597–604
28. Oshin AO, Stewart MC (2007) The Th role of bone mor-
phogenetic proteins in articular cartilage development,
homeostasis and repair. Vet Comp Orthop Traumatol
20:151–158
29. Bessa PC, Casal M, Reis RL (2008) Bone morphogenetic
proteins in tissue engineering: the road from laboratory
to clinic, part II (BMP delivery). J Tissue Eng Regen Med
2:81–96
30. Luu HH, Song WX, Luo X, et al. (2007) Distinct roles of
bone morphogenetic proteins in osteogenic differentia-
ff
tion of mesenchymal stem cells. J Orthop Res 25:665–
677
31. Morales TI, Joyce ME, Sobel ME, et al. (1991) Transform-
ing growth factor-beta in calf articular cartilage organ cul-
tures: synthesis and distribution. Arch Biochem Biophys
288:397–405
32. Siegel PM, Massague J (2003) Cytostatic and apoptotic
actions of TGF-beta in homeostasis and cancer. Nature
Rev 3:807–821
33. Stewart AA, Byron CR, Pondenis H, Stewart MC (2007)
Eff
ffect of fibroblast growth factor-2 on equine mesenchy-
mal stem cell monolayer expansion and chondrogenesis.
Am J Vet Res 68:941–945
34. Gooch KJ, Blunk T, Courter DL, et al. (2001) IGF-I and
mechanical environment interact to modulate engineered
516 The Traumatic Knee
cartilage development. Biochem Biophys Res Commun
286:909–915
35. Fortier LA, Mohammed HO, Lust G, Nixon AJ (2002)
Insulin-like growth factor-I enhances cell-based repair of
articular cartilage. J Bone Joint Surg 84:276–288
36. Madry H, Kaul G, Cucchiarini M, et al. (2005) Enhanced
repair of articular cartilage defects in vivo by transplanted
chondrocytes overexpressing insulin-like growth factor I
(IGF-I). Gene Ther
Th 12:1171–1179
37. Goodrich LR, Hidaka C, Robbins PD, et al. (2007) Genetic
modifification of chondrocytes with insulin-like growth
factor-1 enhances cartilage healing in an equine model.
Journal Bone Joint Surg 89:672–685
38. Saraf A, Mikos AG (2006) Gene delivery strategies for
cartilage tissue engineering. Adv Drug Deliv Rev 58:592–
603
39. Anderson WF (1998) Human gene therapy. Nature
392:25–30
40. Crystal RG (1995) Transfer of genes to humans: early les-
sons and obstacles to success. Science (New York, NY)
270:404–410
41. Zachos T, Diggs A, Weisbrode S, et al. (2007) Mesenchy-
mal stem cell-mediated gene delivery of bone morphoge-
netic protein-2 in an articular fracture model. Mol Th
Ther
15:1543–1550
42. Pagnotto MR, Wang Z, Karpie JC, et al. (2007) Adeno-
associated viral gene transfer of transforming growth
factor-beta1 to human mesenchymal stem cells improves
cartilage repair. Gene Th
Ther 14:804–813
43. Palmer GD, Steinert A, Pascher A, et al. (2005) Gene-in-
duced chondrogenesis of primary mesenchymal stem cells
in vitro. Mol Ther 12:219-228
Patello-femoral joint

R.P. Grelsamer, J. Gould The biomechanics of the patella
Introduction
A
long with the meniscus, the patella has now
been permanently removed from the ever-
shrinking list of anatomic structures thought
to be expendable at best and a mere source of pain
at worst.
It was Kaufer in 1971 who analyzed what seems
evident today: the patella is part of a lever that
favorably aff
ffects the function of the leg’s extensor
mechanism (1). But what a lever!
The patella as a lever
Th
There are three types of levers, and these are cat-
egorized by the relative location of the fulcrum,
the applied force, and the structure to be dis-
placed. In a type I lever, the fulcrum sits between
the force and the structure (a person lifting a rock
by pushing down on a stick). Distance is sacrificed
fi
for force. Force is multiplied, but at the expense of
displacement. With a type II lever, the structure to
be lifted lies between the fulcrum and the applied
force (the wheelbarrow). In a type III lever, it is the
applied force that lies in between the two others.
Example: the brachioradialis contracting when a
person bends their elbow to lift a weight. Here,
force is sacrifi
ficed for displacement. The applied
force is greater than the weight of the structure
to be moved, but the structure moves a great deal
more than the applied force. A little contraction of
the brachioradialis leads to a greater displacement
of the hand. It is the existence of multiple type III
levers throughout our arms and legs that allow us
to have a relatively compact shape. Imagine what
we would look like if our muscles had to shorten
by one meter to raise our hands by the same dis-
tance!
The extensor mechanism is a type III lever: a short
Th
contraction of the quadriceps leads to a signifi- fi
cantly larger displacement of the foot. This
Th comes
at the expense of a strong contraction of the
quadriceps that is required just to raise our foot.
The problem is compounded by the unfavorable
Th
Chapter 44
angle at which the patellar tendon attaches to the
upper tibia. Without the tuberosity on the upper
tibia and without the patella, this angle would be
close to 0°. This would be the equivalent of trying
to open a door while standing off ff to the side near
the hinges.
By increasing the approach angle of the patellar ten-
don, the patella diminishes the force that needs to
be generated by the quadriceps muscle. Diminish-
ing this force in turn diminishes the stresses across
the femorotibial compartments, which in turn may
diminish the risk of femorotibial arthritis.
Complicating the analysis of the extensor mecha-
nism is the fact that the exact location of the ful-
crum relative to the trochlea is constantly changing:
Indeed only part of the patella is in contact with
the underlying femoral trochlea (trochlear groove),
and the location of this contact area changes with
every degree of flexion (see below). Thus, we have
a rolling fulcrum. Nevertheless, although specific fi
relationships may change, the quadriceps-sparing
function of the patella remains throughout the arc
of motion.
Patellofemoral cartilage
Patellofemoral cartilage diff
ffers in a number of ways
from articular cartilage elsewhere in the body. It is
far thicker, reaching up to 7 mm in the center of
the patella,
a testament to the high forces imparted upon it
(2,3).
The patellofemoral joint is unique to the extent that
cartilage does not follow the contour of the under-
lying subchondral bone (2,4–6). The cartilaginous
apex of the patella (when seen on a transverse cut)
only overlies the bony apex 15% of the time. In
25% of patients, it lies slightly medial to it and in
60% of people, it lies lateral to it (5). Th
Therefore, a
small amount of medial-lateral displacement seen
on a radiograph is not automatically a sign of poor
articular congruence (fit).
fi
The articular surface of the patella features facets
which vary in size, orientation, and magnitude
520 The Traumatic Knee
from person to person (2). Th These facets can be lik-
ened to the fingerprint of the knee. Complement-
ing the bony median ridge, a cartilaginous median
ridge extends from proximal to distal across the
patellar surface. But only in 40% of patients does
this ridge remain purely median: in the remain-
ing 60%, the ridge veers medially as one goes in
a proximal to distal direction (2). A cartilaginous
lesion can therefore lie lateral to the median ridge
and still be on the medial side of the patella. Th The
ridge ranges from quite prominent to hardly vis-
ible. All patellae feature a transverse cartilaginous
ridge across the lateral aspect of the patella (2).
Like any human articular cartilage, patellofemoral
cartilage can be considered a biphasic material – a
freely flowing fluid phase and a porous-permeable,
fiber-reinforced solid phase (7). However, patellar
fi
cartilage is more permeable and more pliable (it
features a greater “compressive aggregate modu-
lus” – a combination of Young’s modulus and Pois-
son’s ratio) than other cartilage, including that of
its mating surface on the trochlea (4,8)! This may
contribute to the greater prevalence of patellar car-
tilage lesions relative to other cartilage surfaces.
The patella is congruent when viewed in the trans-
verse plane, it is incongruent in the sagittal plane
(9) [consider figure].
Patellar cartilage is insensate (10), but pain fi
fibers
are found within the subchondral bone and sur-
rounding soft tissues.
Anatomy, position, and tracking
As the knee actively bends and straightens, the
patella is pulled laterally by the contraction of the
quadriceps muscles. Indeed, when viewed from
the front, the quadriceps’direction of the pull,
the patella, and the patellar tendon do not form
a straight line. They form an angle, imaginatively
called the Q (Quadriceps) angle. As the quadriceps
contract, the patella is pulled laterally, as the exten-
sor mechanism moves to form a straight line.
There is considerable literature pertaining to this
Q angle. Much of the literature of the last 20 years
has seemingly been devoted to deconstructing the
importance of this angle. There
Th are articles point-
ing out the variability of the angle between men
and women (11,12) or not (13–15), the variability
between standing and supine subjects (12), and
articles pointing out the absence of a clear correla-
tion between the value of the Q angle and the pres-
ence/absence of pain (16,17).
Nevertheless, the existence of a Q angle and the
resulting tendency of the patella to move laterally
when the quadriceps contract is not subject to dis-
pute.
The existence of the Q angle is the result of our
bipedal gait: an inwardly directed femur brings
the knees and feet closer to the midline and more
in line with the center of gravity. Th This leads to a
smoother, more effi fficient gait. This is contrast to
the great apes who have no valgus at the knees and
exhibit a more waddling gait.
The normal Q angle measures around 15°, with
a standard deviation of approximately 5°. This Th
applies to both men and women. The small (1–2°)
diff
fference between men and women is simply
attributable to the greater average height of men
(taller people exhibit smaller Q angles) (15).
Three principle structures keep the patella from
slipping out of the trochlea with each contraction
of the quadriceps:
– The lateral wall of the trochlea
– The vastus medialis obliquus (VMO)
– The medial patellofemoral ligament (MPFL)
The lateral wall of the trochlea is higher than the
medial wall (as one proceeds from a proximal to
distal direction, the trochlear groove appears at
the same time as the arch of the femoral condyles).
This provides a rigid barrier to lateral displace-
ment of the patella (incidentally, the trochlea of
the great apes is flat,
fl and there are few reports of
gorillas coming to the doctor for patellar instabil-
ity. Indeed without a Q angle to speak of, great
apes have a patella that tracks eff ffortlessly without
any tendency to move laterally).
Patients with a low-lying lateral trochlea (and/
or flat central portion) are at risk for feeling the
patella slip laterally (“patellar instability,” “sublux-
ation,” “dislocation”). When present, these ana-
tomic variations are most pronounced at the proxi-
mal portion of the patella. Thus, patellar instability
is most manifest in the early degrees of fl flexion.
The VMO is the only dynamic restraint to lateral
translation of the patella (18). It is distinct from
the vastus medialis longus with which it is con-
tiguous. It is usually not easy to see where the
vastus medialis longus ends and where the VMO
begins. In some patients, a thin layer of fat can be
seen separating the two. Th The VMO inserts into the
medial retinaculum and superomedial portion of
the patella. In fact, the normal VMO attaches as
far distally as the upper third or half of the patella,
and its lowermost fibers can be nearly horizontal.
Its tendinous portion is short, broad, and blends in
with the medial retinaculum. It has a line of action
of about 50–65° off ff the long axis of the femur in
the frontal plane – quite a bit less vertical than the
bulk of the quadriceps (18). It is this line of action
that provides the VMO with its ability to resist lat-
eral movement of the patella.
In patients with tracking disorders, the VMO can
be dysplastic: its fibers are oriented more vertically
and fail to reach the upper third of patella. Physi-

cal therapy can only partially offset ff such anatomic
defificiencies. It is, nevertheless, a limited compen-
sation that can sometimes suffi ffice.
Of all the anatomic structures, it is the MPFL that
has received the most attention over the last few
years (19–27). It is a flat ligament that ranges
from 3 to 30 mm in width, meaning that it ranges
from the quasi-invisible to the quite obvious. It
originates between the medial epicondyles and the
adductor tubercle, courses underneath the lower
aspect of the VMO, and inserts into the proximal
half of the medial patellar border. Most stud-
ies indicate that the MPFL is tightest in the early
degrees of flexion,
fl and becomes lax as the knee
flexes. This supports the premise that the MPFL
guides the patella in the early degrees of flexion, fl
prior to its engagement into the friendly confines fi
of the trochlear groove.
Patellar tracking and contact pressures are also
ff
affected by defi
ficiencies of distant structures: weak-
ness and tightness of the “core” musculature about
the hip and pelvis (28–30), torsion of the femoral
neck and femoral shaft, torsion of the upper and
lower ends of the tibia, and abnormal foot and
ankle mechanics (e.g., flatfl feet) (31).
It stands to reason that the normal patella tracks
within the trochlea during fl flexion and extension
of the knee. Controversies have centered over the
variability of the specifi fic tracking pattern from
subject to subject and over the positioning of the
patella when the knee is extended.
It was felt at one point that the patella takes a
highly individualistic, serpentine path down the
trochlea (32,33). This, however, has turned out
to be mostly an artifact of the coordinates chosen
to study the matter (34). In in vitro studies, when
coordinates are centered on the jig used to hold
the knee, each patella can indeed appear to have a
unique course. When the coordinates, however, are
anatomically centered on the patella and femur, all
normal patellae exhibit the same pattern: a slightly
lateralized position in full extension, followed by
immediate medialization within the fi first 20° of
flexion, and an unwavering path for the remainder
of knee flexion (34). This is true for both men and
women.
Patellar modeling still presents challenges and con-
tinues to be the subject of studies (35).
When viewed from the side, the patella lies level
with the origin of the trochlea (or slightly proxi-
mal to that) when the knee is extended to 0°. Th The
patella quickly comes into contact with the articu-
lar cartilage of the trochlea as the knee is flexed.
fl A degrees of flexion (44). As the knee flexes toward
patella that sits considerably proximal to the tro-
chlea and that fails to contact the trochlea in the
early degrees of flexion
fl is called a patella alta. Con-
versely, a patella that sits too low is called patella
baja or patella infera. Collectively, these are known
The biomechanics of the patella 521
as disorders of patellar height. A number of studies
have quantitatively analyzed these relationships
(36,37) and their effects
ff on the biomechanics of
the patella (38).
During most of the arc of fl flexion, the patella is in
contact with both walls of the trochlea. Th This trans-
lates to an imaginary line joining the medial and
lateral borders of the patella being parallel to the
plane of popliteal fossa.
When viewed in the axial plane, a line drawn across
the bottom of the lightly dome-shaped anterior
border of the patella is horizontal. “Tilt” is the term
applied to a patella whose medial side is raised. Tilt
is commonly found in conjunction with a tight lat-
eral retinaculum and can be associated with the
VMO dysplasia described above (39). Tilt can also
occur as a result of advanced trochlear dysplasia,
whereby the proximal trochlea is convex rather
than concave. This by necessity forces the patella
to lie in a tilted fashion.
Increased Q angles, tilt, and disorders of patellar
height all qualify as “malalignment,” though con-
troversies still exist with regard to the exact role
that each plays in the genesis of pain and instabil-
ity (31).
By and large, the patella glides within the trochlear
groove. It is a complex ride, as the size and location
of the patellar contact area constantly changes.
Tracking is infl fluenced by both rigid geometric
parameters as well as the surrounding musculature
(40) and retinacula (41–43). The patella is partly
confi
fined to the femoral (trochlear) groove at the
end of the femur. This is increasingly true as the
knee flexes. In the normal knee, bony geometry
plays no role in extension and in the early degrees
of flexion. In the abnormal knee, a bump can be
present at the origin of the trochlea, which, if any-
thing, makes the patella unstable. This Th accounts
for the clinical observation that patellae dislocate
mainly when a knee is slightly flexed (dancing,
turning to throw a basketball).
The patellofemoral contact area
As far back as 1941, Wiberg recognized that only
part of the patella contacts the trochlea, and that
this part varies with the degree of knee fl flexion.
Goodfellow carried out elegant experiments dem-
onstrating that the distal portion of the patellar
surface articulates with the trochlea in the early
90°, the area of contact shifts proximally. Past 90°,
the contact area moves back toward the center
of the patella. In deepest flexion, the only con-
tact between the medial femoral condyle and the
patella is by of way of the small, vertical cartilagi-
522 The Traumatic Knee
nous facet called the “odd” facet. This facet is pres-
ent in about 80% of subjects (2).
The magnitude of the contact area increases from
0° to 60° (45–47). In everyday activities such as
walking up or down steps, this partially limits the
rise in the compressive stresses associated with
knee flexion. From 60° to 90°, there is still some
disagreement in the literature as to whether the
contact area levels offff (45), diminishes (48), or
continues to increase (44,49,50). Past 90°, some
investigators find a continued rise in the size of
the contact area (51), others see a leveling off
ff (49),
while yet others see a drop-offff (45,52). These dif-
ferences can be accounted for in part by person-
to-person variability, varying measurement tech-
niques, and variations in the magnitude and time
of force (quadriceps) application (46,51). These Th
changes most likely relate to the soft, conforming
nature of patellar cartilage, which leads to a greater
amount of patellar cartilage being in contact with
the trochlea as loads increase.
Another major factor in any discussion of contact
area and stress is the quadriceps tendon. As the
knee flexes past 90°, the quadriceps tendon comes
into contact with the trochlea (53), and in some
ways acts as another patella facet.
Patellofemoral stresses
Shear and compressive stresses impart potential
damage to articular cartilage. These
Th stresses are
the product of forces and contact areas (force/area
in the simplest cases). The stresses experienced by
the patellofemoral articulation at any given degree
of knee flexion depend on whether the knee is
being exercised in an open or closed kinetic chain
mode (the foot off ff or on the ground). Leg curls
and extensions are examples of the former, and
knee bends an example of the latter. In a closed
chain exercise, the contact stresses increase as the
knee flexes from 0° to 90° (53). In an open chain
exercise (leg extension), one might expect the
stresses to increase as the knee extends from 90°
to 0°. Indeed, the quadriceps forces increase and
the size of contact area decreases. However, as the
knee extends, a smaller portion of the quadriceps
force is directed toward the patellar surface. These
Th
factors off
ffset each other to the point where the
contact stresses in an open chain exercise remain
essentially constant from 90° to 0° (54).
Future directions
The purpose of studying patellar mechanics is to
aid us in our treatment of patients with patellar
instability and patellar pain. Th The various patho-
anatomies of instability are rather well under-
stood, and this has led to the development of sur-
gical procedures that specifi fically seek to address
patients’individual deficiencies.
fi The correlation
between altered mechanics and patellar pain,
however, remains incompletely appreciated. As
we come closer to determining what the normal
mechanics of the patella are, our next challenge
will be to determine what role abnormal mechan-
ics play in the genesis of patellar pain.
References
1. Kaufer H (1971) Mechanical function of the patella.
J Bone Joint Surg [Am] 53(8):1551–1560
2. Kwak SD, Colman WW, et al. (1997) Anatomy of the human
patellofemoral joint articular cartilage: surface curvature
analysis. J Orthop Res 15(3):468–472
3. Mow VC, Hayes WC (2004) Basic orthopaedic biomechan-
ics. New York, Lippincott Raven
4. Ateshian GA, Kwak SD, et al. (1994) A stereophotogram-
metric method for determining in situ contact areas in
diarthrodial joints, and a comparison with other methods.
J Biomech 27(1):111–124
5. Staubli HU, Durrenmatt U, et al. (1999) Anatomy and
surface geometry of the patellofemoral joint in the axial
plane. J Bone Joint Surg Br 81(3):452–8
6. van Huyssteen AL, Hendrix MR, et al. (2006) Cartilage-
bone mismatch in the dysplastic trochlea. An MRI study.
J Bone Joint Surg Br 88(5):688–91
7. MowVC, Ratcliff ffe A, et al. (1992) Cartilage and diarthro-
dial joints as paradigms for hierarchical materials and
structures. Biomaterials 13(2):67–97
8. Froimson MI, Ratcliff ffe A, et al. (1997) Diff
fferences in patel-
lofemoral joint cartilage material properties and their sig-
nifi
ficance to the etiology of cartilage surface fibrillation.
Osteoarthritis Cartilage 5(6):377–86
9. Grelsamer RP, McConnell J (1998) The patella – a team
approach. Gaithersburg, Aspen
10. Dye S, Vaupel G, et al. (1998) Conscious neurosensory
mapping of the internal structures of the human knee
without intraarticular anesthesia. Am J Sports Med
26(6):773–777
11. Aglietti P, Insall JN, et al. (1983) Patellar pain and incon-
gruence. I: Measurements of incongruence. Clin Orthop
(176):217–224
12. Woodland LH, Francis RS (1992) Parameters and com-
parisons of the quadriceps angle of college-aged men and
women in the supine and standing positions. Am J Sports
Med 20(2):208–211
13. Hsu RW, Himeno S, et al. (1990) Normal axial alignment
of the lower extremity and load-bearing distribution at
the knee. Clin Orthop Relat Res (255):215–227
14. Skalley TC, Terry GC, et al. (1993) The quantitative mea-
surement of normal passive medial and lateral patellar
motion limits. Am J Sports Med 21(5):728–732
15. Grelsamer RP, Dubey A, et al. (2005) Men and women have
similar Q angles: a clinical and trigonometric evaluation.
J Bone Joint Surg Br 87(11):1498–501
16. Post WR (1999) Clinical evaluation of patients with patel-
lofemoral disorders. Arthroscopy 15(8):841–851
17. Post WR (2005) Anterior knee pain: diagnosis and treat-
ment. J Am Acad Orthop Surg 13(8):534–543
18. Raimondo RA, Ahmad CS, et al. (1998) Patellar stabili-
zation: a quantitative evaluation of the vastus medialis
obliquus muscle. Orthopedics 21(7):791–795

19. Amis AA, Firer P, et al. (2003) Anatomy and biomechanics
of the medial patellofemoral ligament. Knee 10(3):215–
220
20. Bicos J, Fulkerson JP, et al. (2007) Current concepts
review: the medial patellofemoral ligament. Am J Sports
Med 35(3):484–492
21. Elias JJ, Cosgarea AJ (2006) Technical errors during
medial patellofemoral ligament reconstruction could
overload medial patellofemoral cartilage: a computational
analysis. Am J Sports Med 34(9):1478–85
22. Nomura E, Inoue M, et al. (2007) Long-term follow-up and
knee osteoarthritis change after medial patellofemoral
ligament reconstruction for recurrent patellar dislocation.
Am J Sports Med 35(11):1851–8
23. Sharkey NA, Donahue SW, et al. (1997) Patellar strain and
patellofemoral contact after bone-patellar tendon-bone
harvest for anterior cruciate ligament reconstruction.
Arch Phys Med Rehabil 78(3):256–263
24. Smirk C, Morris H (2003) The anatomy and reconstruction
of the medial patellofemoral ligament. Knee 10(3):221–7
25. Smith TO, Walker J, et al. (2007) Outcomes of medial
patellofemoral ligament reconstruction for patellar insta-
bility: a systematic review. Knee Surg Sports Traumatol
Arthrosc 15(11):1301–14
26. Steiner TM, Torga-Spak R, et al. (2006) Medial patell-
ofemoral ligament reconstruction in patients with lateral
patellar instability and trochlear dysplasia. Am J Sports
Med 34(8):1254–61
27. Tuxoe JI, Teir M, et al. (2002) The medial patellofemoral
ligament: a dissection study. Knee Surg Sports Traumatol
Arthrosc 10(3):138–40
28. Arendt EA (2007). Core Strengthening. Instruct Course
Lect 56:379–384
29. Pollard CD, Sigward SM, et al. (2007) Gender differences
ff in
hip joint kinematics and kinetics during side-step cutting
maneuver. Clin J Sport Med 17(1):38–42
30. Willson JD, Dougherty CP, et al. (2005) Core stability and
its relationship to lower extremity function and injury.
J Am Acad Orthop Surg 13(5):316–325
31. Grelsamer R (2000) Patellar malalignment – current con-
cepts review. J Bone Joint Surg 82-A(November):1639–
1650
32. van Kampen A, Huiskes R (1990).The Th three-dimensional
tracking pattern of the human patella. J Orthop Res
8(3):372–82
33. Veress SA, Lippert FG, et al. (1979) Patellar tracking pat-
terns measurement by analytical x-ray photogrammetry.
J Biomech 12(9):639–50
34. Blankevoort L, Kwak SD, et al. (1996) Eff
ffects of global and
anatomic coordinate systems on knee joint kinematics.
Trans Eur Soc Biomech 10:260
35. Powers CM, Chen YJ, et al. (2006) TheTh infl
fluence of patel-
lofemoral joint contact geometry on the modeling of
three dimensional patellofemoral joint forces. J Biomech
39(15):2783–2791
36. Biedert RM, Albrecht S (2006) The patellotrochlear index:
a new index for assessing patellar height. Knee Surg Sports
Traumatol Arthrosc 14(8):707–712
The biomechanics of the patella 523
37. Grelsamer RP, Meadows S (1992) The Th modifified Insall-Sal-
vati ratio for assessment of patellar height. Clin Orthop
(282):170–6
38. Ward SR, Terk MR, et al. (2007) Patella alta: associa-
tion with patellofemoral alignment and changes in con-
tact area during weight-bearing. J Bone Joint Surg Am
89(8):1749–1755
39. Grelsamer R, Stein D (2005) Rotational malalignment
of the patella. Common disorders of the patellofemoral
joint. JP Fulkerson, American Academy of Orthopaedic
Surgeons:19–28
40. Heegaard J, Leyvraz PF, et al. (1995) The
Th biomechanics of
the human patella during passive knee flexion.
fl J Biomech
28(11):1265–79
41. Feller JA, Amis AA, et al. (2007) Surgical biomechanics of
the patellofemoral joint. Arthroscopy 23(5):542–53
42. Powers CM, Chen YJ, et al. (2006) Role of peripatellar
retinaculum in transmission of forces within the extensor
mechanism. J Bone Joint Surg Am 88(9):2042–2048
43. Teitge RA, Faerber WW, et al. (1996) Stress radiographs of
the patellofemoral joint. J Bone Joint Surg Am 78(2):193–
203
44. Goodfellow J, Hungerford DS, et al. (1976) Patello-fem-
oral joint mechanics and pathology. 1. Functional anat-
omy of the patello-femoral joint. J Bone Joint Surg [Br]
58(3):287–90
45. Ahmed AM, Burke DL (1983) In-vitro measurement of
static pressure distribution in synovial joints – Part I:
Tibial surface of the knee. J Biomech Eng 105(3):216–
225
46. Ahmed AM, Burke DL, et al. (1987) Force analysis of the
patellar mechanism. J Orthop Res 5(1):69–85
47. Retaillaud JL, Darmana R, et al. (1989) Experimental bio-
mechanical study of the advancement of tibial tuberosity.
Rev Chir Orthop Reparatrice Appar Mot 75(8):513–523
48. D'Agata SD, Pearsall AW, et al. (1993) An in vitro analysis
of patellofemoral contact areas and pressures following
procurement of the central one-third patellar tendon. Am
J Sports Med 21(2):212–219
49. Huberti HH, Hayes WC (1984) Patellofemoral contact
pressures. The inflfluence of q-angle and tendofemoral con-
tact. J Bone Joint Surg [Am] 66(5):715–24
50. Seedhom BB, Tsubuku M (1977) A technique for the study
of contact between visco-elastic bodies with special refer-
ence to the patello-femoral joint. J Biomech 10(4):253–
260
51. Hehne HJ (1990) Biomechanics of the patellofemoral joint
and its clinical relevance. Clin Orthop (258):73–85
52. Matthews LS, Sonstegard DA, et al. (1977) Load bearing
characteristics of the patello-femoral joint. Acta Orthop
Scand 48(5):511–6
53. Huberti HH, Hayes WC, et al. (1984) Force ratios in the
quadriceps tendon and ligamentum patellae. J Orthop Res
2(1):49–54
54. Cohen Z, Roglic H, et al. (2001) Patellofemoral stresses
during open and closed kinetic chain exercises. An analysis
using computer simulation. Am J Sports Med 29(4):480–
487
 Chapter 45

Y. Carrillon Imaging of the patellofemoral joint

Introduction Lateral or profile

fi view

P
atellofemoral joint is one of the three knee Lateral view can be done either in standing or
compartments with medial and lateral supine position. It can be done in extension or
tibiofemoral joints. Troubles of patellofemo- with 30° of knee flexion.
fl Criterion of success for
ral joint are most often associated with involve- lateral view is the superimposition of the posterior
ment of tibiofemoral joints as in osteoarthritis. edge of the two condyles (1).
Patellofemoral pain syndrome and patellofemoral In patellofemoral pain syndrome, lateral view dem-
osteoarthritis are primitive diseases involving only onstrates patella position and morphology of patel-
patellofemoral joint. lofemoral joint. Patella alta is one of the diagnostic
Patellofemoral pain syndrome is a disease related criterions of patellar instability. Several techniques
to an abnormal positioning of the patella during exist for assessing patellar height (2). Caton and
knee flexion. This syndrome can be moderated, Deschamps technique seems to be the most repro-
revealed by anterior or lateral knee pain with no ducible (3). A Caton-Deschamps index greater than
abnormality at clinical examination or imaging. flects a patella alta (Fig. 1). However, this
1.2 refl
It can be more severe with imaging findings con- index takes no account of patellar engagement,
sistent with abnormal patellar position and patel- since the patella height is defined
fi from the tibia
lofemoral dysplasia. In more severe cases, patellar and not from femoral trochlea. Blackburne-Peel
instability can lead to dislocation. ThThe final evo- and Insall-Salvatti techniques have the same dis-
lution of this disease is primitive patellofemoral advantage. Measurement of patellotrochlear index
degenerative osteoarthritis.
Patellofemoral osteoarthritis is defi
fined by the loss
of articular cartilage from patella and femoral tro-
chlea. Cartilage loss is most often due to mechani-
cal wear. In certain cases, cartilage wear can be
due to inflflammatory or metabolic process, as in
chondrocalcinosis. Osteoarthritis can be isolated
and primitive, as in patellofemoral pain syndrome,
aff
ffecting only the patellofemoral compartment,
sparing medial and lateral tibiofemoral joints. It
can be consecutive to prior tibiofemoral osteoar-
thritis.
Imaging plays an important role in the identifica-
fi
tion and assessment of the diff
fferent patellofemoral
diseases. The purpose of this article is to analyze
the diff
fferent techniques used for imaging the knee
and give their results in patellofemoral pathology.

X-rays
Lateral and axial views of the patella are the main
x-rays examination technique for imaging patel-
lofemoral joint. AP view does not allow a direct Fig. 1 – True profile with 30° of knee flexion. Caton-Deschamps index is the ratio
study of this joint. measured by a/b. Patella is considered as high when the index is superior to 1.2.
526 The Traumatic Knee

Fig. 3 – True profile of the knee demonstrates smooth subchondral patellar

irregularities due to osteoarthritis.

Fig. 2 – True profile in a patient with patellar instability. Patellofemoral

dysplasia with overlapping of the three lines representing lateral, medial
edges of the trochlea, and trochlear groove (arrow). Arthritis is demon-
strated by narrowing of patellofemoral joint with tilting of the patella.

seems more logical because this index is calculated

from femoral trochlea.
Tilt and subluxation of the patella can be detected
on lateral view. With the knee fl flexed in less than
30°, the engagement can be studied and patellar tilt
evaluated in analyzing the three lines that represent
the ridge and medial and lateral edges of the patella.
Overlapping of these lines reflflects patellar tilt (4).
Patellofemoral dysplasia is easily depicted on lat-
eral view. Dejour and colleagues have described the
appearance of trochlea dysplasia on lateral view Fig. 4 – Axial view of the patella with 30° of knee flexion demonstrating
(5). Crossing, at the top of femoral trochlea, of the chronic subluxation of the patella with osteoarthritis. There is a bony notch
three lines corresponding respectively to trochlear on the medial edge of the patella due to prior dislocation.
groove, medial and lateral edges of trochlea deter-
mines trochlea flattening, a major sign of dyspla-
sia (Fig. 2). Th
The additional presence of a supra tro-
chlear bump refl flects a more severe dysplasia.
In osteoarthritis, lateral view is not decisive. In
some cases, it may show subchondral abnormali-
ties, indirect signs of cartilage damage (Fig. 3).

Axial view of the patella

Axial view of the patella, also known as Merchant or
skyline view, allows a patellofemoral joint analysis in
a perpendicular plane to the axis of patellar engage-
ment. This view is usually performed in supine posi- Fig. 5 – This x-ray axial view of patellofemoral joint with 30° of knee flexion
tion, both knees bent 3090°, x-ray beam tangent to demonstrates patellofemoral osteoarthritis stage 4 (Iwano classification).

patellofemoral joint (6). Axial view may also be per-
formed in standing position with a vertical orienta-
tion of the x-ray beam. With 30° of knee flexion,
fl axial
view demonstrates femoral trochlea at approximately
15 mm from the upper point of patella engagement.
Analysis of the upper part of the trochlea would
require a knee flexion of less than 30°, not technically
feasible with conventional radiography. Application
of a lateral rotation of the leg during the execution of
the film increases lateral forces and tendency to sub-
luxation and tilt of the patella (7) (Fig. 4).
On axial view, sulcus angle measurement enables
an assessment of trochlear dysplasia. Patella dys-
plasia, occasionally associated with trochlea dys-
plasia, was described by Wyberg on axial views (8).
Then, axial view may demonstrate complications
of patellar dislocation such as bony fractured frag-
ment attached to the medial side of the patella.
Axial view is the most accurate x-ray technique
for analysis patellofemoral osteoarthritis (9,10).
Iwano classifi fication (11) allows a quantitative
assessment of patellofemoral osteoarthritis. Stage
1 is a joint space narrowing of more than 3 mm,
stage 2 a joint space narrowing of less than 3 mm,
stage 3 a complete joint space narrowing covering
less than one-fourth of the total length of joint
space, and stage 4 a complete join space narrow-
ing covering more than one-fourth of joint space
(Fig. 5). Joint space narrowing may be sometimes
diffi
fficult to assess due to overlapping of articular
surfaces in case of inappropriate technique.
Fig. 6 – CT-scanner in a 20-year-old patient with patellar instability. In A,
images are performed with quadriceps relaxation. In B, quadriceps con-
traction increases patella lateralization and tilting. Patella tilt is the angle
formed by a line passing tangentially through the anterior surface of the
patella and a line passing by the two posterior condyles.
Imaging of the patellofemoral joint 527
Ultrasound
Ultrasound technique is inexpensive and non-in-
vasive. It allows examination of soft parts around
the knee. It also allows dynamic study. In routine
examination, ultrasound is not widely accepted as an
interested technique for imaging the knee. In patell-
ofemoral pain syndrome, ultrasound allows a partial
assessment of dysplasia and sulcus angle. It can also
analyze patellofemoral ligaments and the possible
consequences of failure due to episodes of disloca-
tion. Some authors have studied ultrasound anat-
omy of vastus medialis obliquus muscle, considered
fficient in patellar instability (12). Except for
insuffi
identifi
fication of a possible joint eff
ffusion or popliteal
cyst, ultrasound shows no interest in osteoarthritis.
CT-scanner
CT-scanner is the ideal technique for analyzing
patellofemoral joint in the axial plane. Entire patel-
lar and trochlear joint surfaces are perfectly delin-
eating even the knee in total extension. Patella
engagement and position can be also studied when
positioning the knee in small flexion (less than
15°) or with quadricipital contraction. Further-
more, CT-scanner allows images superimpositions,
enabling calculation of limb rotational angles.
Fig. 7 – CT-scanner in a patient with trochlear dysplasia in a context of
patellar instability. In image A, supra trochlear surface is replaced by a
bump. In image B, lateral trochlear facet is oriented horizontally.
528 The Traumatic Knee
Fig. 9 – MRI with axial slices. In A, fast spin-echo T2-weighted sequence
with fat saturation technique. In B, 3D DESS sequence. Both sequences pro-
vide accurate information on the quality of articular cartilage.
In patellofemoral pain syndrome, CT-scanner
demonstrates patellofemoral morphology and
patella position of the knee in total extension. It
is thus possible to analyze areas of the joint not
shown on the axial view of patella. By perform-
ing a quadricipital contraction increasing lateral
forces, patellar tilt is increased (Fig. 6) (13,14). A
tilt greater than 20° can be regarded as abnormal.
Trochlea dysplasia is fully assessed on CT-scanner.
Measurement of the lateral inclination of patella
is an important quantitative criterion of dysplasia
Fig. 8 – Summation of two CT-scan-
ner axial slices performed the knee
extended; the first passing through
tibial tuberosity (TT), the second on
the deeper portion of the trochlear
groove (TG). TT-GT distance is calcu-
lated from two lines perpendicular
to posterior bicondylar line, the first
passing through the centre of the TT,
the second passing at the centre of GT.
When superior to 20 mm, TT-TG dis-
tance is considered as abnormal.
(Fig. 7). When lateral inclination is less than 10°,
there is a mild trochlear dysplasia. A lateral inclina-
tion less than 4° indicates a marked dysplasia. One
other important dysplasia component is TT-GT
measurement. This measure defi fines the lateraliza-
tion of the tibial tuberosity (TT) relative to the tro-
chlea groove (GT). ThisTh measure is correlated with
the Q angle. A TT-GT distance greater than 20 mm
in extension is abnormal (Fig. 8). It represents one
of the cardinal signs of patellar instability. Femoral
and tibial torsions are other angles that could be
abnormal in patellar instability. They can be reli-
ably measured with CT-scanner using image super-
imposition technique.
In osteoarthritis, theoretically, CT-scanner allows a
better analysis of patellofemoral joint space narrow-
ing than plain film.
fi However, it is not used in practice.
If necessary, it is replaced by arthro CT-scanner.
Magnetic resonance imaging
Magnetic resonance imaging (MRI) is the imaging
technique of reference for studying knee injuries.
In patellofemoral pathology, this technique allows
a three-dimensional assessment of all anatomic
components: bone, cartilage, ligaments, muscles,
tendons, etc. Diff
fferent types of MR sequences had
been proposed to explore the knee. In routine,
T2-weighted sequences with fat suppression are
best suited to an overall analysis of patellofemoral
joint. For the analysis of cartilage, there are other
types of sequences that can more accurately assess
the loss of substance and quality of cartilage. 3D
FISP sequences or DESS appear particularly suited
to the study of cartilage (Fig. 9) (15). In addition,
MRI can be used, as CT-scanner, to visualize the
entire patellofemoral joint without overlapping.
MRI also studies soft tissues, edema, and cartilage
that cannot reliably explore CT-scanner. Moreover,

Fig. 10 – MRI: T2-weighted sequence in axial plane and fat saturation tech-
nique demonstrates recent patellar dislocation with bone edema on lateral con-
dyle (red arrow) and tears of medial patellofemoral ligaments (green arrow).
Fig. 12 – MRI with T2-weighted axial image and fat suppression technique
demonstrates patellofemoral osteoarthritis with severe stage 4 lesions.
it is possible with MRI to make images superimpo-
sition in order to calculate limb torsion angles as
CT-scanner.
MRI appears to be very accurate in patellofemoral
pain syndrome. In acute patella dislocation, MRI
can demonstrate bony fragments, ligaments tears,
and lateral condyle bone bruise relative to patella
impaction (Fig. 10 and 11).
Imaging of the patellofemoral joint 529
Fig. 11 – Transverse MR T2-weighted sequence with fat suppression technique
demonstrates recent patellar dislocation with bone bruise and patellofemoral
dysplasia with horizontalization of the lateral trochlear facet (angle a < 10°).
MRI evaluates patellofemoral dysplasia with a
three-dimensional analysis. In patellar instabil-
ity, Pfi
firrmann and colleagues have proposed to
analyze patellofemoral dysplasia on MRI from
a mid-sagittal slice and an axial slice located 3
cm above the joint line (16). These
Th slices allow a
precise analysis of dysplasia and patellar height.
Measuring the inclination of lateral trochlea
allows a quantitative assessment of dysplasia
(17). Patella position may also be assessed by
measuring patella tilting and lateralization as in
CT-scanner. Moreover, MR dynamic sequences
allow analysis of patella engagement during knee
flexion (18). Although this technique is rarely
used for this purpose, TT-GT calculation and limb
angles evaluation can be reliably done on MRI as
in CT-scanner. As ultrasound, MRI is a good tech-
nique for analyzing muscle quality and position,
giving the ability to evaluate extensor muscles
dysplasia.
MRI is a good technique to assess damaged patel-
lofemoral arthritis (Fig. 12). In case of large losses
of cartilage substance, MRI is as reliable as arthro
CT-scanner. However, MRI may be insufficient
ffi for
analyzing small lesions where chondromalacia and
small velvety lesions can be confused. In these
cases, arthro CT-scanner can be done in preopera-
tive management.
530 The Traumatic Knee

(Fig. 13). In the context of small cartilage lesions,

arthro CT-scanner appears superior to MRI. As
part of the patellofemoral pathology, this tech-
nique is restricted mainly to the evaluation of car-
tilage lesions requiring a surgical management.
In summary, imaging plays an important role
in the dismemberment of patellofemoral joint
lesions. Standard radiographic examination
remains the most important imaging technique
and must be performed before any other imaging
study. CT-scanner provides excellent information
on patella position, patellofemoral dysplasia, and
lower limb axis. MRI allows a comprehensive study
of all patellofemoral anatomical structures. It gives
information on recent traumatic lesions as well as
patellofemoral dysplasia or patella position. Arthro
CT-scanner is interesting in preoperative manage-
ment of cartilage lesions.

References
Fig. 13 – Arthro CT-scanner in axial plane in three different patients with
cartilage loss on lateral patellar facet in A and B patients and medial patel-
lar facet D in patient.
Arthro CT-scanner
Arthro CT-scanner consists in an iodine joint injec-
tion coupled with a CT-scanner. This technique
has the same advantages as CT-scanner. It allows
an additional analysis of cartilaginous structures
1. Maldague B, Malghem J (1976) La radiographie de profil fi
strict, une nouvelle approche de l'articulation fémoro-pa-
tellaire. Ann Radiol (Paris) 19(6):573–581
2. Barnett AJ, Prentice M, Mandalia V, et al. (2009) Patellar
height measurement in trochlear dysplasia. Knee Surg
Sports Traumatol Arthrosc 17(12):1412-5
3. Rogers BA, Thornton-Bott P, Cannon SR, Briggs TW
(2006) Interobserver variation in the measurement of
patellar height after total knee arthroplasty. J Bone Joint
Surg Br 88(4):484–488
4. Maldague B, Malghem J (1976) The Th true lateral view of the
patellar facets. A new radiological approach of the femoro-
patellar joint (author's translation). Ann Radiol (Paris)
19(6):573–581
5. Dejour H, Walch G, Nove-Josserand L, Guier C (1994)
Factors of patellar instability: an anatomic radiographic
study. Knee Surg Sports Traumatol Arthrosc 2(1):19–26
6. Merchant AC, Mercer RL, Jacobson RH, Cool CR (1974)
Roentgenographic analysis of patellofemoral congruence.
J Bone Joint Surg Am 56:1391–1396
7. Malghem J, Maldague B (1989) Patellofemoral joint: 30°
axial radiograph with lateral rotation of the leg. Radiology
170:566–567
8. Fucentese SF, von Roll A, Koch PP, et al. (2006) The patella
morphology in trochlear dysplasia – a comparative MRI
study. Knee 13(2):145–150
9. Cicuttini FM, Baker J, Hart DJ, Spector TD (1996) Choos-
ing the best method for radiological assessment of patel-
lofemoral osteoarthritis. Ann Rheum Dis 55(2):134–136
10. Buckland-Wright C (2006) Which radiographic techniques
should we use for research and clinical practice? Best Pract
Res Clin Rheumatol 20(1):39–55
11. Iwano T, Kurosawa H, Tokuyama H, Hoshikawa Y (1990)
Roentgenographic and clinical findings of patellofemoral
osteoarthrosis. With special reference to its relationship
to femorotibial osteoarthrosis and etiologic factors. Clin
Orthop Relat Res (252):190–197
12. Lin YF, Lin JJ, Cheng CK, Lin DH, Jan MH (2008) Associa-
tion between sonographic morphology of vastus medialis
obliquus and patellar alignment in patients with patel-
lofemoral pain syndrome. J Orthop Sports Phys Th Ther
38(4):196–202

13. Sasaki T, Yagi T (1986) Subluxation of the patella. Inves-
tigation by computerized tomography. Int Orthop
10(2):115–120
14. Biedert RM, Gruhl C (1997) Axial computed tomogra-
phy of the patellofemoral joint with and without quad-
riceps contraction. Arch Orthop Trauma Surg 116(1–
2):77–82
15. Duc SR, Pfi
firrmann CW, Schmid MR, et al. (2007) Articular
cartilage defects detected with 3D water-excitation true
FISP: prospective comparison with sequences commonly
used for knee imaging. Radiology 245(1):216–223
Imaging of the patellofemoral joint 531
16. Pfi
firrmann CW, Zanetti M, Romero J, Hodler J (2000) Femo-
ral trochlear dysplasia: MR findings. Radiology 216(3):858–
864
17. Carrillon Y, Abidi H, Dejour D, et al. (2000) Patellar insta-
bility: assessment on MR images by measuring the lat-
eral trochlear inclination-initial experience. Radiology
216(2):582–585
18. MacIntyre NJ, Hill NA, Fellows RA, et al. (2006). Patel-
lofemoral joint kinematics in individuals with and with-
out patellofemoral pain syndrome. J Bone Joint Surg Am
88(12):2596–2605

K. F. Almqvist
E. A. Arendt
Anterior knee pain and patellar
instability: diagnosis and treatment
Patellofemoral pain
P
atellofemoral (PF) pain syndrome is not a
diagnosis but a description of the complaints
of the patient. One must try to identify a spe-
cifi
fic cause for the patient’s knee pain since not all
anterior knee pain will be treated in the same way.
PF pain can occur without a history of blunt trauma
or patellar instability, and can be present without
objective anatomical malalignment. The Th pain fre-
quently presents when sitting with fl flexed knees
for a prolonged period or when climbing/descend-
ing stairs. The source of this pain is speculative.
The pain can mechanically be induced by increased
intraosseus pressure, by irritation of peripheral
nerve ends, and/or by chemical production of dif-
ferent cytokines. Due to the loss of tissue homeo-
stasis or altering the envelope of tissue acceptance,
pain can occur (1). Currently some objective tests
exist that support these theories as a potential
source of pain. Absence of tissue homeostasis
can be verifified by the use of technetium scintig-
raphy. The
Th patient with PF pain due to increased
intraosseus pressure may show an increased tech-
netium uptake in the patella (Fig. 1). Altering the
patients’activities can be a therapeutic option to
normalize tissue homeostasis. When an operative
option is used without a clear diagnosis, the result
is often an iatrogenic structural damage, additive
to the pre-operative pain status, often resulting in
even worse pain and dysfunction of the knee.
Fig. 1 – A patient with patellofemoral pain due to increased intraos-
seus pressure with an increased technetium uptake in the patella (black
arrow).
Chapter 46
Patellofemoral instability
The incidence of primary patellar dislocation is
between 5.8 and 7 per 100,000 per year (2, 3).
This prevalence of acute primary patellar disloca-
tion is higher in adolescents and females, with a
prevalence of 33–44 per 100,000 per year (3, 4).
The concern after a primary patellar dislocation,
especially after a sports incident (2), is the risk of
recurrent dislocation.
It is of importance to know the circumstances in
which the patellar dislocation occurred. If the dis-
location took place after a minor trauma, there
probably are one or more anatomical bony abnor-
malities in the knee joint. In this case recurrent
patellar dislocation is much more frequent. The Th
patient with a traumatic primary patellar disloca-
tion will most often present with a swelling of the
knee that is painful, with giving way of the knee
and an extension limitation (5). Less than 10% of
the patients present with a persistent dislocated
patella (6). The patient will frequently mention a
feeling of subluxation of the patella in the prior his-
tory. The clinician must make the diff fferential diag-
nosis with meniscal, capsular or cruciate ligament
lesions (5), and with the presence of corpora libera.
The patient frequently present with a hemarthro-
sis and a painful medial retinaculum and MPFL,
mostly at its femoral insertion (6). After a patel-
lar dislocation, the patient will frequently present
with a positive apprehension test in the subacute
and in the chronic phase.
The patellar dislocation occurs mainly from an
indirect trauma with the knee slightly flexed
fl and
externally rotated, with contraction of the quadri-
ceps muscle. The induced forces on the patella will
provoke a lateral dislocation of the patella. This Th
required force to dislocate the patella laterally is
decreased in case of patella alta, trochleodysplasia,
lateralization of the tibial tubercle or in case an
fficient/ruptured medial patellofemoral liga-
insuffi
ment (MPFL) is present. This latter is frequently
the case with a primary patellar dislocation. Th The
MPFL normally exerts 50–80% of the restraining
force of patellar lateralization. When no lateral
bony structural support is present in early fl flex-
534 The Traumatic Knee
ion arc, as in trochleodysplasia and in patella alta
(7), the incidence of an MPFL-lesion is markedly
increased (8).
When considering objective patellar instability, a
traumatic patellar dislocation can occur either in
the aligned or in the malaligned extensor mecha-
nism. Most patellar dislocations occur from a non-
contact force, typically a valgus/external rotation
force being applied to the involved knee. Most of
these dislocations reduce spontaneously and thus
few patients present with a permanent disloca-
tion. Often these knees present with one or more
anatomic risk factors that pre-dispose the patella
to a lateral dislocating event (9). In the dislocat-
ing patella the articular cartilage can be severely
damaged. Most of these non-contact dislocations
are lateral, and occur during sports. First time dis-
locations can be complicated by recurrent disloca-
tions. Female gender and young age at the time of
the first dislocation are risk factors for recurrent
instability (10). Medial PF dislocations are rare,
and are nearly always iatrogenic following previ-
ous surgery, in particular, a generous release of the
lateral soft tissues.
Patients with potential patellar instability are
those with a malaligned extensor mechanism as
evidenced by an anatomical abnormality. Patellar
malalignment can be considered as an abnormal
positioning of the patella in any plane which can
lead to patellar maltracking during the flexion-
fl
extension cycle.
Various forms include:
– Excessive lateral patellar tilt and/or translation,
best diagnosed on axial images.
– Excessive lateral patellar tendon offffset (Q-angle),
best diagnosed on physical exam and on overlap-
ping axial images.
– Dysplastic trochlear shape and length, best diag-
nosed on true lateral radiographs and on 3D
imaging reconstructions.
– Soft tissues imbalances, best diagnosed on physi-
cal examination.
– Combinations of the above.
The main issue of criticism with the terminology
“malalignment” is defi fining the limits of what is
normal and what is malalignment. Malalignment
can exist on imaging and physical examination
without symptoms. Therefore
Th careful patient his-
tory must be combined with clinical examination
and radiographic imaging.
In case of malalignment, the patella jumps from
lateral to medial into the trochlear groove during
flexion, which is called the “J-sign.”
The anatomic features that lead to “J-tracking” are
not well described, and may be multiple. J-track-
ing is sometimes called “dislocation in extension”.
J-tracking is a risk factor for lateral patellar dislo-
cations, but is often well tolerated by patients.
Physical examination
Excessive lateral translation is a necessary physi-
cal examination sign associated with lateral patel-
lar dislocations. Clinical examination will reveal
an increased lateral movement of the patella dur-
ing palpation. In a patient with PF instability,
the opposite un-injured knee can display exces-
sive lateral displacement as well, so this factor
alone is not diagnostic of a dislocation. This
Th could
be present in both knees, but with a unilateral
disorder there is a marked diff fference with the
pathological side. It can be diffi fficult to clinically
quantify excessive lateral displacement of the
patella. Often the attempt to dislocate the patella
is unpleasant for the patient, and to prevent this
manually induced dislocation the patient will
contract his quadriceps muscle (positive appre-
hension test).
A patient with recurrent PF instability usually
presents with pain around the knee cap as a result
of increased traction on the soft tissues secondary
to the dislocating events. The
Th patient often men-
tions a feeling of instability at the moment of sub-
luxation or repositioning of the patella.
Imaging
The radiological examination is both in anterior
knee pain and PF instability important in the diag-
nosis and in the selection of a (surgical) treatment.
When considering imaging, conventional radio-
logical examination including a true lateral and an
axial view are appropriate first steps. An MRI can
be performed if cartilage damage is suspected after
a traumatic dislocation. A CT scan could be consid-
ered in some patients for additional information.
Often this is done in preparation for surgical man-
agement.
Imaging of the knee joint is useful to diagnose
pre-disposing factors for patellar instability (9,
11) and in order to document cartilage, bone and
soft tissue lesions. In 1987, four principal factors
and four secondary factors were described for
patellar instability (12). In this study, a patient
group with patellar dislocation was compared
with a patient population only presenting pain
and with a control group. The Th principal factors
for the patellar instability were trochleodysplasia,
the distance between the anterior tibial tuberos-
ity and the trochlear groove (TT-TG), the height
of the patella and lateral patella tilt. Trochlear
dysplasia is characterized by flattening of the tro-
chlear groove to even a convexity. This dysplasia is
diagnosed on a conventional X-ray in a true lateral
position and shows the classical “crossing-sign”
of the trochlear groove and the anterior cortex of
 Anterior knee pain and patellar instability: diagnosis and treatment 535
the two anterior femoral condyles (Fig. 2) (9). This
Th
crossing sign was found in 96% of the patients
with patellar dislocations, in 12% in patients with
a painful knee and only in 3% of the patients in
the control group. Four diff fferent groups of tro-
chleodysplasia have been described (13). On the
lateral view a bony bump and a double contour
can be appreciated, respectively a prominence
of the trochlea and the bony prominence of the
medial part of the trochlea. ThThe strict lateral view
of the knee is often best obtained by radiofluoros-
fl
copy (6). The
Th distance between the anterior tibial
tuberosity and the middle of the trochlear groove
is measured by CT (Fig. 3) (14). Th The trochlear
groove is measured where the intercondylar notch
has the aspect of a roman arch, and a TT-TG above
20 mm is associated with a signifi ficantly higher
prevalence of patellar instability compared to the
control group.
The height of the patella is the only single factor
that correlates with objective patellar instabil-
ity. Several methods to measure the height of the
patella have been described (Fig. 4) (15–17). With
a high-riding patella, the patella is engaged in the
trochlea later in the flexion arc, with more time
spent in flexion outside the stability of the tro-
chlear walls. Th
This off
ffers an increased risk for patel-
lar dislocation. In 30% of patients with patellar
instability, the Caton-Deschamps index is above
1.2 compared with 0% in the control group. Th The
patellar height can also be measured on a lateral
view with the knee in 90° of flexion (18). When
the height of the patella is normal, the upper pole
of the patella will be on the same height as a line
drawn parallel to the anterior cortex of the dis-
Fig. 2 – A trochleodysplasia is diag-
nosed on a conventional X-ray in a true
lateral position (posterior condyles
on one line) and shows the classical
“crossing-sign”(black circle) of the tro-
chlear groove.
Fig. 3 – The distance (*)
between the anterior tibial
tuberosity and the middle
of the trochlear groove
(TT-TG) is measured by CT,
and a TT-TG above 20 mm is
abnormal resulting in a sig-
nificant higher prevalence of
patellar instability.
tal femur. If there is a patella alta present, this is
measured as the part of the patella being above
this line.
The basculating or tilting patella is the fourth prin-
cipal factor for defi
fining patellar instability and can
be seen on conventional radiographs on a profile fi
view in slight flexion of 20–30° (19). With the help
of CT with the knee in extension the tilting of the
patella is easily measured. The degree of tilting is
measured between the major axis of the patella
and the line of the posterior femoral condyles. This
Th
tilting of the patella is measured with a contracted
and a relaxed quadriceps muscle, making this a
dynamic evaluation. In a control population this
angle is between 10 and 20°, while in a dislocating
patella it measures more than 20° in 90% of the
cases (20). This basculating patella depends mainly
on a dysplastic quadriceps musculature with the
medial vastus muscle fibers inserting more vertical
and proximal to the patella (21) with retraction of
the vastus lateralis, depending on the presence of a
trochleodysplasia.
The secondary factors having an infl fluence on the
patellar instability are genu recurvatum, genu val-
gum, increased femoral anteversion and malrota-
tion of the knee These factors are, however, also
frequently observed in a control population as
well.
On the axial radiographic view of the knee,
taken in 30° of flexion (22), it is useful to rec-
ognize the degree of lateral patellar translation,
the presence of osteochondral fragments, and
measuring the sulcus angle (normal 138 ± 6°).
Osteochondral fragments are most frequently
originating from the medial patella or the lateral
trochlear edge.
MRI can visualize (osteo) chondral fragments and
cartilage defects in a more detailed way. About
only one third of the present cartilage lesions
detected during surgery are seen on conventional
radiographs (23), but MRI will be able to detect
more of these lesions. MRI is also very useful
to detect lesions of the MPFL and of the VMO
(Fig. 5) (8).
Fig. 4 – The height of the patella can be measured by the (1) Caton-Des-
champs, by the (2) Insall-Salvati or by the (Blackburne-Peel index. A patella
alta is considered if A/B in (1) is greater than 1.2, in (2) if greater than 1.2,
and in (3) if greater than 1.0.
536 The Traumatic Knee
Fig. 5 – MRI is also very useful
to detect lesions of the MPFL
and of the VMO. On this image
the bone bruise (gray arrow) on
the lateral femoral condyle and
the medial facet of the patella
as well the lesion (black arrow)
of the medial retinaculum and
the femoral insertion of the
MPFL is seen after a patellar
dislocation.
Treatment
The treatment of patellar instability and patel-
lar dislocation can be non-surgical and surgical.
Primary traumatic patellar dislocation should be
treated conservatively except if an osteochondral
fracture is present that needs refixation.
fi
After a primary traumatic patellar dislocation, the
knee can be immobilized for 4–6 weeks.
The only inconvenience with this treatment
option is that there will be quadriceps atrophy as
well as a reduced flexion after this immobiliza-
tion period (24), although isometric contractions
of the quadriceps could be initiated immediately
during the immobilization period (6). Keeping the
knee immobilized for this period has been shown
to reduce recurrent patellar dislocation, compared
with a shorter immobilization period or immedi-
ate bracing (25).
Several (retrospective) studies have been pub-
lished on the results of conservative treatment
after primary or recurrent patellar dislocation
(25–27). Mäenpää et al. presented the results of
100 patients treated either by a cast in extension
or bracing after a primary patellar dislocation,
with a follow-up of 13 years. Patients treated with
a cast immobilization showed a reduced exten-
sion/fl
flexion arc (range of motion) compared
with the bracing-group, though in the bracing
group the incidence of patellar dislocation was
signifi
ficantly higher. Thirty-seven per cent of the
included patients in this study showed a satisfac-
tory result after primary conservative treatment
although 44% showed a recurrent luxation of the
patella.
Primary repair is considered when an osteochon-
dral fracture, mostly originating from the patella
or the lateral trochlear wall, is present (3, 26, 28)
or when persistent patellar instability remains
after its dislocation (3, 26, 28).
Except for the above-mentioned indications for
primary repair after primary patellar dislocation, a
surgical stabilization of the patella should be con-
sidered only if repetitive patellar (sub) luxations
occur after failure of conservative measures.
References
1. Dye SF. Refl flections on patellofemoral disorders. In: RM
Biedert, editor. Patellofemoral disorders diagnosis and
treatment.
2. Atkin DM, Fithian DC, Marangi KS, et al. (2000) Char-
acteristics of patients with primary acute lateral patellar
dislocation and their recovery within the first fi 6 months of
injury. Am J Sports Med 28(4):472–479
3. Fithian DC, Paxton EW, Stone ML, et al. (2004) Epidemiol-
ogy and natural history of acute patellar dislocation. Am J
Sports Med 32(5):1114–1121
4. Nietosvaara Y, Aalto K, Kallio PE (1994) Acute patellar dis-
location in children: incidence and associated osteochon-
dral fractures. J Pediatr Orthop 14(4):513–515
5. Sarino J, Rantanen J, Heikkilä J, Orava S (2003) Acute
traumatic extension defi ficit of the knee. Epidemiology and
arthroscopic findings in 78 consecutive patients. Scand J
Med Sci Sports 13:155–158
6. Hinton RY, Sharma KM (2003) Acute and recurrent patel-
lar instability in the young athlete. Orthop Clin North Am
34(3):385–396
7. Senavongse W, Amis AA (2005) The Th effffects of articular,
retinacular or muscular defi ficiencies on patellofemoral
joint stability. A biomechanical study in vitro. J Bone Joint
Surgery 87(B):577–582
8. Elias DA, White LM (2004) Imaging of patellofemoral dis-
orders. Clin Radiol 59:543–557
9. Dejour H, Walsch G, Nové-Josserand L, Guier C (1994)
Factors of patellar instability: an anatomic radiographic
study. Knee Surg Sports Traumatol Arthrosc 2:19–26
10. Stefancin J, OParker R (2007) First-time traumatic patel-
lar dislocation: a systematic review. Clin Orthop Relat Res
455:93–101
11. Dejour D, Nové-Josserand L, Walsch G (1998) Patellofem-
oral disorders-classifification and an approach to operative
treatment for instability. Controversies in orthopedic
sports medicine, vol 22. pp 235–244
12. Dejour H, Walsch G, Neyret P, Adeleine P (1990) La dys-
plasie de la trochlée. Rev Chir Orthop 76:45–54
13. Dejour D, Reynaud P, Lecoultre B (1998) Douleurs et
instabilité rotulienne. Essai de classifi fication. Méd et Hyg
56:1466–1471
14. Goutallier D, Bernageau J, Lecudonnec B (1978) La mesure
de la distance entre tubérosité tibiale antérieur et gorge
de la trochlée. Technique et résultat. Rev Chir Orthop
64:423–428
15. Blackburne JS, Peel E (1977) A new method to measuring
patellar height. J Bone Joint Surg 59(B):241–242
16. Caton J, Deschamps G, Chambat P, et al. (1982) Les rotules
basses. A propos de 128 observations. Rev de Chir Orthop
68:217–325
17. Insall J, Goldberg V, Salvati E (1972) Recurrent disloca-
tion and the high-riding patella. Clin Orthop Relat Res
88:67–69
18. Laurin CA (1977) The investigation of the patellofemoral
joint. J Bone Joint Surg 59(B):107
19. Maldague B, Malghem J, Frot B (1988) Articulation
fémoropatellair. In: Imagerie en orthopédie et trauma-
tologie du genou. Cahiers d’enseignement de la SOF-
COT n 29. Expansion Scientifi fique Française, Paris, pp
242–259
20. Nové-Josserand L, Dejour D (1995) La dysplasie du quad-
riceps et bascule rotulienne dans l’instabilité rotulienne
objective. Rev Chir Orthop 81:497–504
21. Insall J, Bullogh PG, Burnstein AH (1979) Proximal “tube”
realignment of the patella for chondromalacia patellae.
Clin Orthop 144:63–69
22. Davies AP, Bayer J, Owen-Johnson S, et al. (2004) The Th
optimum knee flexion angle for skyline radiography is
thirty degrees. Clin Orthop Relat Res 423:166–171
 Anterior knee pain and patellar instability: diagnosis and treatment 537
23. Stanitski CL, Paletta GA Jr (1998) Articular cartilage
injury with acute patellar dislocation in adolescents.
Arthroscopic and radiographic correlation. Am J Sports
Med 26(1):52–55
24. Sallay PI, Poggi J, Speer KP, Garret WE (1996) Acute dis-
location of the patella. A correlative pathoanatomic study.
Am J Sports Med 24(1):52–60
25. Mäenpää H, Lehto MUK (1997) Patellar dislocation: the
long-term results of nonoperative management in 100
patients. Am J Sports Med 25(2):213–217
26. Cash JD, Hughston JC (1988) Treatment of acute patellar
dislocation. Am J Sports Med 16(3):244–249
27. Garth WP, Pomphrey M, Merrill K (1996) Functional treat-
ment of patellar dislocation in an athletic population. Am
J Sports Med 24(6):785–791
28. Ahmad CS, Stein BE, Matuz D, Henry JH (2000) Imme-
diate surgical repair of the medial patellar stabilizers for
acute patellar dislocation: a review of eight cases. Am J
Sports Med 28(6):804–810
29. Buchner M, Baudendistel B, Sabo D, Schmitt H (2005)
Acute traumatic primary patellar dislocation. Long term
results comparing conservative and surgical treatment.
Clin J Sports Med 15:62–66
30. Deie M, Ochi M, Sumen Y, et al. (2005) A long-term fol-
low-up study after medial patellofemoral ligament recon-
struction using the transferred semitendinosus tendon for
patellar dislocation. Knee Surg Sports Traumatol Arthrosc
13:522–528
31. Fulkerson JP (1983) Anteromedialization of the tibial
tuberosity for patellofemoral malalignment. Clin Orthop
Relat Res 177:176–181
32. Nikku R, Nietosvaara Y, Aalto K, Kallio PE (2005) Opera-
tive treatment of primary patellar dislocation does not
improve medium-term outcome. A 7-year follow-up report
and risk analysis of 127 randomized patients. Acta Orthop
76(5):699–704
33. Palme
l r SH, Servant CT, Maguire J, et al. (2004) Surgical
reconstruction of severe patellofemoral maltracking. Clin
Orthop Relat Res 419:144–148
34. Schöttle PB, Fucentese SF, Romero J (2005) Clinical and radio-
logical outcome of medial patellofemoral ligament reconstruc-
tion with a semitendinosus autograft for patella instability.
Knee Surg Sports Traumatol Arthrosc 13:516–521
35. Shelbourne KD, Porter DA, Rozzi W (1994) Use of a
modified Elmslie-Trillat procedure to improve abnor-
mal patellar congruence angle. Am J Sports Med
22(3):318–323
36. Verdonk R, Jansegers E, Stuyts B(2005) Trochleoplasty
in dysplastic knee trochlea. Knee Surg Sports Traumatol
Arthrosc 13:529–533

K. Raiszadeh, D. C. Fithian,
L. D. Latt
Patellar stabilization for episodic
patellar instability
Defifinition
I
n the overwhelming majority of cases, patellar
dislocation results in injury to the medial reti-
nacular ligaments, including the medial patel-
lofemoral ligament (MPFL), leading to increased
lateral patellar mobility. The MPFL is the primary
ligamentous restraint against lateral patellar dis-
placement. The competency of the MPFL is both
necessary and sufficient
ffi to restore lateral patellar
mobility to a normal range (1), and hence surgi-
cal treatment should be aimed at restoration of a
functional MPFL.
History
Repair has been described at the patellar insertion
of the MPFL or at its origin between the adduc-
tor tubercle (AT) and the medial epicondyle of
the femur. However, failure to identify any and
all locations of disruption may jeopardize the suc-
cess of the repair. Low rate of successful repair was
reported in the study by Nikku et al. in 1997.
Avikainen et al. in 1993 described a technique of
primary MPFL exploration and repair with the
addition of an adductor magnus tenodesis in acute
and chronic cases of patellar instability. In some
patients, particularly those with patella alta or
trochlear dysplasia, the MPFL may be structur-
ally incapable to restrain the patella. Even if it has
normal strength, some authors think that a lack
of bony constraint can put the ligament at risk
for repeated failure if additional measures are not
taken to augment or support the native medial
tether. Reconstruction of the MPFL in such cases
may be necessary if suffi
fficient collagen is not avail-
able to ensure a durable repair.
Chapter 47
Many difffferent graft materials have been used includ-
ing autograft, allograft, and synthetic polyesters.
Although the use of synthetic grafts for intra-artic-
ular ligament reconstruction has fallen out of favor
in the United States, several authors have reported
success using them for MPFL reconstruction.
Ellera Gomes was the first to report a true MPFL
reconstruction in 1992. He has recently published a
longer term follow-up study of the original patient
cohort, which showed good long-term durability of
the reconstruction.
Longstanding interest in patellar dislocation in
Japan has resulted in several series on MPFL recon-
struction. In the United States, Drez, Teitge, Burks,
and Steensen have also published techniques.
Erasmus of South Africa originally reported his
technique for MPFL reconstruction in 1998 and
has recently published good short-term clinical
results. Several Australian centers have recently
published techniques, and this year there are three
separate reports from Europe describing new tech-
niques for MPFL reconstruction.
This chapter presents a procedure that has been uti-
lized since May 2001 using a consistent technique
based on Muneta’s approach but using a semi-ten-
dinosus tendon autograft instead of a synthetic
graft.
Contraindications
– No objective signs of instability
– Primary complaint of pain with no objective
signs of instability
– Pre-existing arthritis (relative)
– Patient with collagen vascular disease
– Permanently dislocated patella
– Habitually dislocating patella
540 The Traumatic Knee

Pre-operative physical findings

fi
Table 1 – Methods for examining the unstable patella.
Examination Technique
Lateral–medial patellar Lateral and medial forces (about
translation 5 lb.) applied to patella
with the knee in 30° of flexion
Apprehension sign Lateral force applied to patella
with knee in 30° of flexion
Check-rein sign Lateral force is applied to patella
with knee fully extended, palpating
for the presence or absence
of an endpoint
Patellar facet palpation Medial force is applied to the patella
to expose the medial patellar facet,
which is then palpated
Medial retinacular palpation The patella is displaced medially
so that while fibers are being
palpated, they are also brought
away from underlying structures
in order to avoid confusion about
the site of tenderness
Effusion Milking maneuver, ballotable patella
Grading Significance
Increased laxity signified by: (1) >two quadrants
of translation; (2) 10 mm or more of lateral
translation; (3) No endpoint
Positive if elicits Inability to translate patella fully laterally
uneasiness in the because of patient guarding may be a sign
patient and feeling of patellar instability
of impending
dislocation. Usually
leads to involuntary
quadriceps contraction
The presence of a firm A positive test (no endpoint) signifies MPFL
endpoint indicates laxity (analogous to a Lachman's test)
a negative test.
The absence of a firm
endpoint indicates
a positive test
Tenderness may indicate an osteochondral
or avusion injury
Tenderness may indicate retinacular injury.
A palpable defect may be felt in the retinaculum
or even VMO
Mild, moderate, tense A tense effusion or hemarthrosis (on aspiration)
after an acute dislocation raises suspicion
for an osteochondral fracture. An MRI
or arthroscopy should be considered

Imaging and other diagnostic studies
Standing AP view, a true lateral view (posterior
condyles of femur superimposed) with the knee
flexed 30°, and a standard axial patellar view at 30
fl
or 45° flexion are mandatory.
On the true lateral X-ray, patellar height is mea-
sured according to the method of Caton and Des-
champs (ratio between the distance from the lower
edge of the patellar articular surface to the upper
edge of the tibial plateau and the length of the
patellar articular surface). A ratio of 1.2 or greater
indicates patella alta, which pre-disposes to patel-
lar instability due to late engagement of the patella
in the trochlea as the knee flexes. If present, a
tibial tubercle osteotomy and distalization may be
considered (Figs. 1 and 2).
Trochlear morphology can be assessed on the true
lateral X-ray. Trochlear dysplasia is evident when
the floor of the trochlea crosses the anterior border
of both femoral condyles (crossing sign) (2) (Figs. 3
and 4). Alternatively, positive trochlear prominence
(the sagittal distance between the trochlear groove
and the anterior femoral cortex) on the lateral view
has been shown to correlate well with trochlear
dysplasia (2, 3). A trochlear groove prominence of
3 mm indicates trochlear dysplasia (Fig. 5).
The axial patellar view may demontrate lateral patel-
lar subluxation or even frank dislocation. It may
demonstrate medial patellar avulsion fractures,
although these may be missed on plain radiographs.
Stress radiography has been advocated to demon-
strate abnormal patellar mobility. With the knee
flexed to 30°, an axial patellar view is taken with
a laterally directed force applied to the medial side
of the patella. Measurments are made on both the
symptomatic and asymptomatic knees. A side-to-
side increase of 3.7 mm of lateral translation on
the symptomatic side compared to the asymptom-
atic side is considered abnormal (4).
MRI identififies osteochondral injuries on the patella
and femur, as well as loose bodies, that may be missed
on plain radiographs. Presence of gross hemarthrosis
on joint aspiration is an indication for MRI to assess
 Patellar stabilization for episodic patellar instability 541

Fig. 1 – The height of

the patella is very diffi-
ffi
cult to measure, and the
reliability of the mea-
surement is still unsat-
isfactory. We used the
index of Caton and Des-
champs. This is the ratio
between the distance of
the lower edge of the
patellar joint surface to
the upper edge of the
tibial plateau and the
length of the patellar
articular surface. If the
index is superior to 1.2, Fig. 2 – Example of
the patella is high. patella alta.

Fig. 3 – Normal X-ray.

Fig. 4 – The crossing sign is a simple and characteristic image, a qualitative
criterion of trochlear dysplasia. At a given point, the line of the trochlear
floor crosses the anterior contour of the lateral femoral condyle and the tro-
chlea is considered flat at this level. This sign is of fundamental importance
in the diagnosis.
Fig. 5 – The Prominence (trochlear bump) is a quantitative characteristic
that is particularly significant in trochlear dysplasia. We measure the dis-
tance between anterior edge of the lateral condyle and the anterior cor-
tex. The more the trochlear bump, the more the dysplasia. Trochlear bump
greater than 3 mm is considered pathologic.
542 The Traumatic Knee
for osteochondral fracture and loose body. A tense
eff
ffusion should be aspirated. The TT-TG offffset is the
transverse distance between the anterior tibial tuber-
osity and the center of the trochlear groove (2). It can
be measured on the axial computed tomography (CT)
or magnetic resonance imaging (MRI) (Figs. 6 and 7).
Lateral off
ffsets of 20 mm or more should be cor-
rected with medialization of the tibial tubercle.
Fig. 7 – Various examples of measuring TTTG. Sometimes landmarks are diffi
MRI is also useful in identifying the location and
degree of medial soft tissue injury pre-opera-
tively. MPFL injuries occur commonly in the form
of tears near the femoral attachment or avulsions
off
ff the femur but may also occur as midsubstance
tears or avulsions off
ff the patella. Injuries to mul-
tiple sites in the medial ligamentous stabilizers
may occur (3). Table 2.
Fig. 6 – (a and b) The offset of the tibial tubercle is suspected clinically
but the analysis is qualitative. A CT scan (or MRI) allows a reliable and
reproducible measurement. Two slices, one through the anterior tibial
tubercle, the others through the femur at the level of the roman arch are
superimposed. The distance between these lines, parallel to the posterior
femoral condyles, is the TTTG (tibial tuberosity trochlear groove) offset.
fficult to define with certainty.

Table 2 – Imaging.
Type of imaging Significance
True lateral X-ray Patellar height measured
(Caton/Deschamps ratio)
Trochlear morphology assessed
Axial patellar X-ray Diagnose avulsion fractures
MRI TT-TG offset
Assess articular cartilage of patella
Surgical technique
Figures 8 and 9 demonstrate a medial and axial
schematic of the reconstruction. The semi-ten-
dinosis is harvested and secured to the femoral
attachment. The two limbs are passed through the
retinaculum and secured to the medial patella.
Fig. 8 – Medial schematic view of a right knee. The MPFL is shown, along
with the MCL and adductor magnus tendon attachments at the medial
femur. There is a ridge connecting the adductor tubercle and epicondyle,
from which MPFL originates. The MPFL fans out as it runs anteriorly and lat-
erally to insert on the proximal 2/3 of the medial patellar border. The MPFL
is reconstructed by making one blind tunnel at the femoral attachment, and
two tunnels on the patella which enter at the medial articular margin and
exit on the anterior (ventral) patellar surface.
Patellar stabilization for episodic patellar instability 543
Technical implications
If C/D ratio >1.2, consider tibial tubercle distalization
Crossing sign and prominence > 3 mm used to diagnose patients
with patellar instability, rarely addressed surgically
Large intra-articular fragments require ORIF
TT-TG greater than 20 mm correct with medialization of tibial tubercle
Consider appropriate tibial tubercle osteotomies. Distal chondral lesions
can be off loaded with distalization of tubercle to load patella more
proximally if cartilage intact. Lateral chondral lesions can be off loaded with
medialization of tubercle to load patella more medially if cartilage intact
Pre-operative planning
All appropriate imaging studies should be reviewed.
Plain radiographs should be reviewed for the pres-
ence of trochlear dysplasia (crossing sign and tro-
chlear prominence of 3 mm or more), patella alta,
and avulsion fractures and loose bodies.
If signs of trochlear dysplasia are present, then an
axial CT or MRI should be obtained to measure the
TT-TG offffset. Off
ffset of 20 mm or more should be
treated with medialization of the tibial tuberosity.
If patella alta is present (Caton-Deschamps ratio
of 1.2 or greater), then distalization of the tibial
tubercle should be considered. Associated osteo-
chondral fracture and loose body occurs in 3–4%
Fig. 9 – Axial schematic view of a right knee, from below. The MPFL graft
is shown, fixed in the blind femoral tunnel with an interference screw. The
graft passes outside the capsular layer (layer 3) so that it is extra-articular.
The two free arms of the graft are passed into the patellar tunnels from the
medial patellar border, exiting anteriorly, and the free ends are sewn back
onto themselves with two figure eight stitches of No. 2 non-absorbable
suture. All slack is removed from the graft before suturing, but the grafts
should be under no tension when the patella is centered in the groove.
Excess graft length is removed after tension and patellar mobility are con-
firmed to be satisfactory.
544 The Traumatic Knee
of first-time dislocators and is an indication for
acute surgical treatment. (In this case, primary
MPFL repair should be performed after fi fixation of
the osteochondral fracture. Pre-operative MRI can
help in localizing the site of MPFL injury.)
MRI should be reviewed for the presence of avulsion
fractures, osteochondral fractures, and loose bodies.
If MPFL repair is to be performed, MRI should be
reviewed to identify all locations of MPFL disrup-
tion. Failure to identify and treat each location of
MPFL disruption may jeopardize the repair.
Examination under anesthesia should confirm fi
excessive lateral patellar mobility. The Th patella
should displace more than 10 mm laterally from
the centered position with the knee flexed
fl 30°, and
there should be a soft end point or no end point
with the knee extended.
Positioning of patient
– Supine
– Thigh tourniquet
– If an osteochondral fracture and loose body ame-
nable to reduction and fixation are present, then
surgery may proceed with an open approach.
– A diagnostic arthroscopy is always performed
before MPFL reconstruction to stage cartilage
lesions and to confi
firm patellar instability if the
EUA was non-diagnostic. The
Th superolateral view-
ing portal is used for patellar visualization. Th
The
limb is then placed in an adjustable leg holder to
adjust knee flexion during the procedure.
Approach
For MPFL reconstruction three incisions are needed.
The first is located over the pes anserinus for the
Fig. 10 – Right knee, with incisions shown and with the two patellar tun-
nels exposed. Medial femoral epicondyle and adductor tubercle are marked.
The incision for the hamstring harvest is also shown.
harvest of the hamstring tendons. Th The second is
vertical incision over the medial third of the patella
for the patellar insertions. The third is just posterior
to the medial epicondyle for placement of the tibial
insertion (Fig. 10).
Step-by-Step description of technique
Diagnostic arthroscopy
Standard inferolateral and inferomedial portals
are used. A superolateral portal is used to facilitate
viewing of the patellar articular surface and pas-
sive patellar tracking and mobility. Articular car-
tilage lesions are addressed. Specifi
fically, the patel-
lofemoral compartment is assessed for the severity
of articular cartilage injury and the presence of
degenerative changes. Unstable cartilage flapsfl are
debrided and loose bodies are removed.
MPFL reconstruction
Step 1: Semi-tendinosus tendon graft harvest and preparation
The sartorial fascia is exposed through a 2–3 cm
length skin incision made 2 cm medial and distal to
the medial border of the tibial tuberosity (Fig. 10).
The sartorial fascia is incised in line with the palpable
gracilis tendon. Avoid making this incision too deep
to avoid injury to the underlying superficial
fi MCL.
Identify and isolate both the gracilis (proximal) and
semi-tendinosis (distal) tendons from their deep
aspect; that is, from within the bursal layer. Apply
tension to the semi-tendinosus while freeing it from
the crural fascia at the posteromedial corner with
tissue scissors. Place stay sutures of No. 1 absorbable
on a tapered needle, then divide the tendon from the
tibial insertion. Once all tendinous slips have been
freed, harvest the semi-tendinosus tendon using a
closed (preferred) or open tendon stripper.
Baseball stitches are placed on both free ends for
later graft passage throught the two patellar tun-
nels. The remaining free ends will then be discarded
after graft fi
fixation.
The graft is prepared on the back table. The mini-
mum graft length is 240 mm, leaving a doubled graft
length of 120 mm. Utilizing the maximum length
of the tendon and not removing any excess graft is
important because often times a length of up to 130
mm is required. A pullout suture of No. 5 polyester
is placed through the loop to be used for pulling the
doubled graft into the blind femoral tunnel.
A baseball stitch 20 mm in length is placed in the
looped end of the graft, similar to the technique that
is used for the docking of other tendon grafts into a
socket such as during ACL reconstruction. Th The looped
end will be anchored in the femoral socket, while the
two free ends will pass through the individual tunnels
in the medial patella. The
Th two free ends are baseball

stitched with absorbable suture in preparation for
their passage through the two patellar tunnels.
Step 2: Patellar tunnel placement
A longitudinal incision of the length of the patella
is made at the junction of the medial and middle
thirds of the patella (in line with the medial border
of the patellar tendon at the distal patellar pole).
The medial 8–10 mm of the patella is exposed by
subperiosteal dissection with a No. 15 scalpel. The
Th
dissection extends medially and dorsally around
the patella through layers 1 (longitudinal retinacu-
lum) and 2 (native MPFL), stopping after the trans-
verse fibers of the native MPFL have been cut. The
capsule (layer 3) is left intact.
A 4.5 mm drill hole is placed on the medial side of
the upper pole of the patella adjacent to the articu-
lar margin. A corresponding drill hole is placed on
the anterior surface of the patella approximately
8 mm from the medial border (this point corre-
sponds to the lateral edge of the original retinac-
ular dissection. The two drill holes are connected
with a curved curette.
A second 4.5 mm drill hole is placed on the medial
side of the patella at a point two thirds down the
length of the patella. Again, a corresponding drill
hole is placed on the anterior surface of the patella
about 8 mm from the medial border and the two
holes are connected with a curved curette. Avoid
placing this tunnel distal to the native insertion of
the MPFL to avoid constraining the distal pole of
the patella. If the semi-tendinosus graft is thicker
then 4.5 mm in diameter, enlarge the drill holes
slightly to facilitate graft passage.
Step 3: Femoral tunnel placement and measurement of isometry
Make a skin incision just anterior to the palpable
ridge connecting the medial femoral epicondyle and
the AT (Fig. 10). Flex the knee slightly to facilitate
palpation of this landmark (flexion
fl moves the ham-
strings posteriorly away from the medial epicondyle).
If the patient is obese and the landmarks are difficult
ffi
to palpate, make a small skin incision and use palpa-
tion through the wound to identifty the ridge.
The graft may be placed between layers 1 and 2 or
Th
between layers 2 and 3 (joint capsule); i.e., it may lie
ficial or deep to the native MPFL. Graft place-
superfi
ment between layers 2 and 3 is preferred because
blind dissection superfificial to the native MPFL may
disrupt the insertion of the VMO into the anterior
portion of the MPFL; in addition, by placing the graft
deep to the native MPFL, the latter may be repaired to
the graft during wound closure. The graft should not
be placed deep to the capsule (layer 3), because doing
so would lead to graft abrasion and slower healing.
Using a long curved clamp, develop the selected
interval (again, preferrably between layers 2 and 3)
from the patellar incision anteriorly to the medial
Patellar stabilization for episodic patellar instability 545
femoral epicondyle posteriorly. With the tip of the
clamp overlying the ridge between the medial epicon-
dyle and AT, incise layers 1 and 2 using a No. 15 blade.
Place the tip of a Bieth pin at a point 9 mm proximal
and 5 mm posterior to the medial epicondyle, then
pass the pin toward the lateral side of the femur.
Pass a loop of No. 5 braided polyethylene suture
through the Bieth pin, through the dissected retinac-
ular tunnel, then through one of the patellar tunnels.
Range the knee to evaluate isometry: If lengthening
occurs in flexion, place a second Bieth pin more
distally toward the medial epicondyle. Leave the
first pin in place to facilitate re-positioning while
drilling the second Bieth pin. Pass the loop of No.
5 suture through the second Bieth pin and range
the knee again. If isometry is acceptable, then
remove the first Bieth pin.
If lengthing occurs in extension, place a second
Bieth pin more proximally toward the AT. Again,
leave the first pin in place to facilitate re-position-
ing while drilling the second Bieth pin. Pass the
loop of No. 5 suture through the second Bieth pin
and range the knee. If isometry is acceptable, then
remove the first Bieth pin.
Once the femoral pin placement has been deter-
mined, then a femoral socket should be reamed
of a size appropriate for the doubled graft. For a
semi-tendinosus graft, this is usually 6–7 mm in
diameter by 20–25 mm in depth.
Step 4: Graft passage and fixation
Pass the No. 5 suture on the looped end of the graft
through the Bieth pin, then advance the pin out the
lateral femoral cortex to pass the graft into the fem-
oral socket. Fixation to the femur may be achieved
reliably with a 20-mm absorbable interference
screw (Fig. 11). The looped isometry suture, if left in
place in the retinacular tunnel, may be used to pass
the free ends of the graft through the retinacular
interval created previously (Fig. 12). Pass the free
graft arms individually through their respective
patellar tunnels using double No. 22 gauge stainless
steel wire or a curved suture passer. The graft arms
should enter the medial border of the patella and
exit anteriorly. The free graft arms are then doubled
back and sutured on themselves just medial to the
patella using two figure-of-eight mattress sutures of
No. 2 non-absorbable suture on a tapered needle.
Patellar mobility is checked after the first
fi suture is
placed. There should be a good endpoint, or check-
rein, with the knee in full extension and at 30° of
flexion, full knee range of motion, and 7–9 mm
of lateral patellar displacement from the centered
position at 30° of flexion.
fl The excess graft is then
removed sharply. Suture the native MPFL to the
graft, then close the retinaculum over the graft.
Close the wounds in standard fasion.
546 The Traumatic Knee

Fig. 11 – Graft fixed in femur, preparing to pass through retinaculum. Pass- Fig. 12 – Grafts passed in between layers 2 and 3 and ready to be passed
ing sutures are also shown. through patellar tunnels.

Pearls and pitfalls

Table 3 – Pearls and pitfalls.
Indications
Femoral tunnel placement
MPFL graft tensioning
Overtightened graft resulting
in excessive medial constraint
Breakage of patellar bone bridge
Perform EUA to confirm excessive lateral patellar mobility
Perform arthroscopy to stage articular cartilage lesions and rule out pre-existing arthritis, a contraindication
to MPFL reconstruction
This is one of the most critical steps in the operation.
Adjust the tunnel placement to ensure appropriate graft behavior during flexion and extension, recreating
isometry
Center the patella in the patellar groove and ensure that the MPFL graft is lax throughout a range of motion,
becoming tight only when the patella is displaced laterally from its centered position.
The patella should enter the trochlea from the lateral side as the knee is flexed
If the patella enters the trochlea from the medial side as the knee is flexed or if there is less than 5 mm of lateral
patellar glide with gentle manual force at 30° of knee flexion, then the graft is overtensioned. The sutures
should be removed and the graft retensioned
May occur during preparation of the two patellar tunnels or during passage of an oversized graftf through
a tight patellar tunnel.
If this occurs, then drill a second exit hole more laterally on the anterior patellar surface or drill the tunnel
transversely across the patella, exiting at the lateral patellar margin
The graft can be secured by tying the sutures over a button or suturing the end of the graft to the soft tissues
on the lateral patellar border

Post-operative care as soon as possible to restore range of motion and

Post-operative pain management is generally eas-
ier than for other knee reconstructive procedures,
as the synovium is not disturbed if the dissection
remains extra-atricular. Outpatient surgery is facil-
itated by the use of a femoral nerve block and oral
narcotics. Weight-bearing as tolerated is allowed
immediately post-operatively in a drop-lock or
knee extension brace. Bracing may be continued
for up to 6 weeks during ambulation to prevent
falls until quadriceps control is restored. After soft
tissue procedure, passive range of motion exer-
cises and resisted closed-chain exercises are begun
quadriceps control.
If a tibial tuberosity osteotomy is performed, pas-
sive range of motion using heel slides is begun
post-operatively. No active extension is allowed for
six post-operative weeks. Then full active range of
motion is begun, followed by closed-chain resis-
tance exercises at three post-operative months.
Patients are allowed to return to stressful activi-
ties including sports when they attain full range
of motion and regain at least 80% of their quad-
riceps strength compared to the non-injured
limb. If at least 90° of flexion is not achieved by
six postoperative weeks, then the intensity of the

therapy program must be increased; manipulation
under anesthesia (MUA) may be needed between 9
and 12 post-operative weeks if stiffness
ff does not
resolve with therapy alone.
Outcomes
In a series of 92 knees treated with MPFL recon-
struction, Fithian et al. (5) reported only seven
failures/re-operations (7.6%) and only one case of
frank patellar redislocation (1.1%). Most of the re-
operations were for stiff ffness and were treated suc-
cessfully with MUA.
Schottle et al. reported 86% good and excellent
results at 47 months after MPFL reconstruction
using semi-tendinosus autograft (6). In their series
of 15 MPFL reconstructions, there was one case
of bilateral recurrent instability. In Steiner et al.'s
series of 34 patients treated with MPFL reconstruc-
tion using a variety of graft sources, there were
91.1% good and excellent results at 66 months and
no recurrent dislocations (7). In both Schottle et
al. and Steiner et al.'s series (6, 7), the presence of
trochlear dysplasia did not affect
ff the outcome of
MPFL reconstruction. Nomura an Inoue reported
on 12 knees after hybrid MPFL reconstruction
using semi-tendinosus graft at a minimum of 3
year follow-up (8). There were 83% good and excel-
lent results, and no cases of recurrent patellar sub-
luxation or dislocation.
Complications
– Stiff
ffness – see discussion under post-operative
care.
– Redislocation.
– Arthrosis – Excessive medial patellar constraint
results in a painful overconstrained patella
(9–12). In the normal knee, the patella rests in a
central or slightly lateral position in the trochlear
groove, it can be displaced laterally with gentle
force, the MPFL then tightens preventing further
displacement. The goal of MPFL reconstruction
is to recreate this “checkrein.” Overtightening of
the graft will increse the contact forces on the
medial facet and can lead to painful arthrosis.
– Patellar fracture.
Conclusion
Th treatment of patellar instability requires a
The
step wise approach for optimal outcome. Appro-
priate diagnostic studies including X-rays, MRI,
Patellar stabilization for episodic patellar instability 547
or CT scan and an EUA which documents patellar
instability must be performed prior to proceeding
with MPFL reconstruction. Th
The outcomes of MPFL
reconstruction have been favorable in appropri-
ately indicated patients demonstrating patellar
instability.
References
1. Hautamaa PV, Fithian DC, Kaufman KR, et al. (1998)
Medial soft tissue restraints in lateral patellar instability
and repair. Clin Orthop 349:174–182
2. Dejour H, Walch G, Nove-Josserand L, Guier C (1994)
Factors of patellar instability: an anatomic radiographic
study. Knee Surg Sports Traumatol Arthrosc 2:19–26
3. Elias DA, White LM, Fithian DC (2002) Acute lateral patel-
lar dislocation at MR imaging: injury patterns of medial
patellar soft-tissue restraints and osteochondral injuiries
of the inferomedial patella. Radiology 225:736–743
4. Teitge RA, Faerber WW, Des Madryl P, Matelic TM (1996)
Stress radiographs of the patellofemoral joint. J Bone
Joint Surg Am 78:193–203
5. Fithian DC, Gupta N (2006) Patellar instability: princi-
pals of soft tissue repair and reconstruction. Tech Knee
Surg 5:19–26
6. Schottle PB, Fucentese SF, Romero J (2005) Clinical and
radiological outcome of medial patellofemoral ligament
reconstruciton with a semitendinosus autograft for
patella instability. Knee Surg Sports Traumatol Arthrosc
13:516–521
7. Steiner TM, Torga-Spak R, Teitge RA (2006) Medial patel-
lofemoral ligament reconstruction in patients with lateral
patellar instability and trochlear dysplasia. Am J Sports
Med 34:1254–1261
8. Nomura E, Inoue M (2006) Hybrid medial patellofemoral
ligament reconstruction using the semitendinosus ten-
don for recurrent patellar dislocation: minimum 3 years’
follow-up. Arthroscopy 22:787–793
9. Elias JJ, Cosgarea AJ (2006) Technical errors during
medial patellofemoral ligament reconstruction could over-
load medial patellofemoral cartilage. Am J Sports Med
34:1478–1485
10. Muneta T, Sekiya I, Tsuchiya M, et al. (1999) A technique
for reconstruction of the medial patellofemoral ligament.
Clin Orthop 359:151–155
11. Nomura E, Horiuchi Y, Kihara M (2000) Medial patell-
ofemoral ligament restraint in lateral patellar translation
and reconstruction. Knee 7:121–127
12. Nomura E, Horiuchi Y, Kihara M (2000) A mid-term fol-
low-up of medial patellofemoral ligament reconstruction
using an artifi
ficial ligament for recurrent patellar disloca-
tion. Knee 7:211–215
13. Andrade A, Thomas N (2002) Randomized comparison of
operative vs. nonoperative treatment following first
fi time
patellar dislocation. European Society for Sports, Knee
and Arthroscopy, Rome
14. Caton J, Deschamps G, Chambat P, et al. (1982) Patella
infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice
Appar Mot 68:317–325
15. Crosby EB, Insall J (1976) Recurrent dislocation of the
patella: relation of treatment of osteoarthritis. J Bone
Joint Surg Am 58:9–13
16. Fithian DC, Paxton WE, Stone ML, et al. (2004) Epidemi-
ology and natural history of acute patellar dislocation. Am
J Sports Med 32:1114–1121
17. Kessler I (1973) The grasping technique for tendon repair.
Hand 5:253–255
548 The Traumatic Knee
18. Maenpaa H, Lehto MU (1997) Patellofemoral osteoar-
thritis after patellar dislocation. Clin Orthop 339:156–
162
19. Nikku R, Nietosvaara Y, Aalto K, Kallio PE (2005) Opera-
tive treatment of primary patellar dislocation does not
improve medium-term outcome: a 7-year follow-up report
and risk analysis of 127 randomized patients. Acta Orthop
76:699–704
20. Nikku R, Nietosvaara Y, Kallio PE, et al. (1997) Opera-
tive versus closed treatment of primary dislocation of the
patella: similar 2-year results in 125 randomized patients.
Acta Orthop Scan 68:419–423
21. Nomura E, Horiuchi Y, Inoue M (2002) Correlation of MR
imaging findings and open exploration of medial patell-
ofemoral ligament injuries in acute patellar dislocations.
Knee 9:139–143
22. Nomura E, Inoue M, Osada N (2005) Anatomical analysis
of the medial patellofemoral ligament of the knee, espe-
cially at the femoral attachment. Knee Surg Sports Trau-
matol Arthrosc 13:510–515
23. Nomura E, Inoue M, Osada N (2005) Augmented repair of
avulsion-tear type medial patellofemoral ligament injury
in acute patellar dislocation. Knee Surg Sports Traumatol
Arthrosc 13:346–351
24. Remy F, Chantelot C, Fontaine C, et al. (1998) Inter- and
intraobserver reproducibility in radiographic diagnosis
and classifification of femoral trochlear dysplasia. Surg
Radiol Anat 20:285–289

D. Dejour, P. Byn Deepening trochleoplasty
for patellofemoral instability
Introduction
T
he patellofemoral joint has a low degree of
congruency by nature; therefore, it is more
susceptible to dislocation. Th There are active
and passive restraints that prevent to the patella
from being subluxed or dislocated. Th The passive sta-
bility depends on statical anatomical restraints,
the congruence between trochlea and patella which
is low as mentioned above. The active stability is
provided by dynamical restraints, the muscles, and
the balance between the ligaments; both bony and
soft tissues structures provide an active and pas-
sive stability which allows the patella to function
during knee movements.
Patellar dislocation has a low rate of recurrence
(1). Some pre-disposing factors, mostly congenital,
lead to chronic patellar instability; those factors
have a high genetic incidence.
Henri Dejour established in 1987 a classification
fi of
patellofemoral instability (2, 3) and described four
major factors for instability with a statistical thresh-
old. The four instability factors were trochlear dys-
plasia, patella alta, excessive distance between tib-
ial tubercle and trochlear groove (TT-TG > 20 mm)
and excessive patellar tilt (>20°).
Trochlear dysplasia is the main determinant, it is
present in 96% in the objective patellar instability
population. Sometimes it is obligatory to correct
the sulcus angle if there is a high grade trochlear
dysplasia (grades B and D) to achieve a normal
patellar tracking. The
Th trochlear shape can be modi-
fied by two types of trochleoplasties, either lifting
the lateral facet or deepening the trochlea creating
a new trochlear groove. It is the deepening tro-
chleoplasty that will be described in this chapter.
Indications
The indication of such surgery is a combination
between the clinical analysis and the radiological
analysis. On the clinical field the deepening tro-
chleoplasty is a very rare indication, it is recom-
mended only in high grade instability including
Chapter 48
patient with permanent or habitual dislocation or
dislocation in the daily activities and patient with
an abnormal patellar tracking as a J sign. Looking
to the radiographic analysis the trochleoplasty is
indicated in patients with severe trochlea dysplasia
(4). A trochlea is defi
fined dysplastic if it has little or
no congruence with the patella. These
Th trochleas are
flat or even convex.
In contrast to the lateral lifting trochleoplasty
the sulcus deepening trochleoplasty is correcting
the etiology of the deformation. It is indicated in
severe dysplasias, the types B and D, in which the
trochlea is prominent and convex and the patella
impinges on the trochlear bump during knee fl flex-
ion. An abnormal patellar tracking with a positive
J sign refl
flect these types.
The other instability factors are analysed to decide if
the procedure has to be combined or done isolated.
The distance between tibial tubercle and trochlear
groove is decreased by a deepening trochleoplasty
so this procedure creates a proximal realignment.
Therefore caution has to make to add a distal
realignment, this will often be unnecessary.
Often there are other anatomical abnormalities
associated in this patient population. Th The sur-
geon has to address the other instability factors
also. Consequently the trochleoplasty is seldom
performed isolated. It can be associated to a tib-
ial tubercle distalization to correct a high patella,
a medialization to correct an excessive TT-TG
(>20 mm). At present, a medial soft procedure is
always added. Previously this used to be a vastus
medialis plasty, the effifficacy of that procedure is
now doubted. At present the best combination is
a medial patellofemoral ligament (MPFL) recon-
struction using a gracilis tendon autograft with
two patellar tunnels and one blind tunnel at the
isometric point in the femoral insertion’s area
close to the medial epicondyle.
Contraindications
– High grade trochlear dysplasia with instability
associated with patellofemoral pre-arthritis or
arthritis.
550 The Traumatic Knee
– Anterior knee pain without instability.
– Absence of the trochlear bump (supratrochlear
spur).
Radiographic analysis
Although the diagnosis is made clinically a com-
plete radiographic assessment, including monopo-
dal weight-bearing AP and lateral views and axial
view at 30° of knee flexion, is mandatory. Before
any surgical decision is made, a CT scan (3 mm
slices acquisition) with the protocol of Lyon has to
be performed.
The AP weight-bearing view
These radiographs are taken to verify there is no
tibio-femoral arthritis. Also other abnormalities,
such as lateral condyle fracture or loose bodies
which are the signature of a previous dislocation,
can be noticed on this view.
The true lateral weight-bearing view
A true profi
file is taken in monopodal stance, align-
ing the posterior borders of the two femoral con-
dyles. This is mandatory for the analysis of the
trochlea. The radiologist has to use fluoroscopy to
perform a good sagittal view.
The dysplasia is defifined on the true lateral view by
the “crossing sign” (Fig. 1) described by Dejour in
Fig. 1 – The three trochlear dysplasia signs:
– Crossing sign: flat trochlea
– Supratrochlear spur: global prominence
– Double contour: radiographic line of the subchondral
bone of the hypoplasic medial facet
1987 (2, 3, 5). The line which represents the deep-
est part of the trochlear groove never crosses the
anterior border of the two condyles in a normal
knee. This line will join the anterior part of the
condyles in a dysplastic trochlea, this means that
the groove is flat
fl at this precise point. The cross-
ing sign is found in 96% of the population with a
history of true patellar dislocation and only in 3%
of the healthy controls. The trochlear dysplasia is a
primitive disease determine genetically (6, 7).
More recently two other signs of dysplasia have
been described by David Dejour (4, 8, 9).
– The supratrochlear spur Fig. 1, which is a global
prominence of the trochlea, resembles a ski jump.
The peak of this prominence corresponds to the
crossing sign.
– The double contour (Fig. 1) is a radiographic line
representing the subchondral line of the hyp-
oplasic medial facet on the lateral view. This
Th line
is pathological if its extent is going below the
crossing sign.
Dejour defined
fi a new classifi
fication with four types
of trochlea dysplasia (Fig. 2), using those three
elements. This new classifi fication system is more
reproducible (10, 11) than the former 3-type sys-
tem proposed by Henri Dejour in 1987.
Axial view at 30° flexion
The dysplasia will be defifined by a sulcus angle of
more than 145° (12). The quality of the X-ray is fun-
damental because this incidence shows perfectly
the upper part of the trochlea. If the axial view is
done at 45° or more the X ray beam will explore
only the lower part of the trochlea and the trochlear
dysplasia can be missed. Normally, on an axial view
at 30° of flexion, the lateral facet represent 2/3 of
the trochlea and the medial facet 1/3. The Th sulcus
angle normally should be under than 145°.
CT scan analysis
The trochlear exploration uses a 3 mm acquisition
cut going from the midfemoral shaft to the tibial
tubercle. The patient is lying supine on the CT scan
table with the knees is in full extension and the
feet joined. This is a reliable and reproducible (8)
manner of performing the CT scan. Th The first cut
with cartilage (cut with a slight densification
fi of the
subchondral bone on the lateral facet, or the cut
where the notch is well round like a roman arch)
is very important for the trochlear analysis. ThThis is
the reference cut for all the measurements.
On this reference cut, the morphology of the tro-
chlea is appreciated. It can be normal, flat,
fl convex,
or asymmetrical with a hypoplasia of the medial
 Deepening trochleoplasty for patellofemoral instability 551

Fig. 2 – Trochlear dysplasia classification (Dejour):

– Type A: crossing sign, trochlear morphology preserved
– Type B
– Crossing sign
– Supra-trochlear spur
– Flat or convex trochlea
– Type C
– Crossing sign
– Double contour
– Type D
– Crossing sign
– Supratrochlear spur
– Double contour
– Asymmetry of trochlear facets, vertical link between medial and lateral facet

facet and a convexity of the lateral facet. The

Th mea-
sure of the slope of the medial facet is interesting;
if inferior to 14° it is considered dysplastic. It is
also interesting to notice the presence or absence
of the patella on this reference image; if not pres-
ent it is a witness of a functional patella alta with a
failure in engagement.
The distance tibial tuberosity-trochlear groove
(TT-TG) (Fig. 3): the TT-TG in extension is mea-
sured by superposing two cuts, the trochlear
reference image and the cut through the tibial
tubercle.
The trochlear dysplasia has a high infl fluence on
the patellar tracking and the patellar tilt. Patel-
lar tilt is measured on the CT scan by superpos-
ing two slices, the first through the middle part of
the patella and the second through the reference
trochlear cut. Two lines are drawn, one line going
through the patellar axis and the second going
through the posterior bicondylar line. The angle
between those two lines reproduces the patellar
tilt (Fig. 4). Th
This tilt is measured with and with-
out quadriceps contraction. Eighty-three per cent
of the patients in the objective patellar instability
group has a patellar tilt superior to 20°. Patellar tilt
was previously considered as a direct consequence
of a vastus medialis dysplasia (13). More recently,
Dejour has demonstrated a high statistical corre-
lation between the type of trochlea dysplasia and
the patellar tilt; the greater the trochlea dysplasia,
the higher the patellar tilt with and without quad-
riceps contraction (4).
552 The Traumatic Knee
Fig. 3 – TT-TG measurement is the sur-imposition of two cuts:
– One the trochlear cut is the slice where the notch is round like a roman
arch (first cut with cartilage): the deepest trochlear point.
– One is the cut on the tibial tubercle tuberosity: the middle part of the TT.
The TT-TG is the length between these two points.
Fig. 5 – The deepening trochleoplasty remove the cancellous bone under the trochlea, then the two facets and push down and
fixed with two staples.
Technical procedure for deepening trochleoplasty
The principle of deepened the trochlea was first
described by Masse (14) in 1978; but Dejour in
1987 (2, 15) standardized the technique and pro-
posed a reliable procedure with selected indica-
tions (Fig. 5).
The main goal is to decrease the prominence of the
trochlear sulcus and to create a new groove with
a normal depth. This trochleoplasty is technically
more demanding than an elevating trochleoplasty
but it is more etiologic. It has the advantage of
treating the root cause of the dislocation by cor-
recting the abnormal patterns underlying the dif-
ferent grades of trochlear dysplasia.
This procedure typically requires 1 h of opera-
Th
tive time. A light general anesthetic is combined
with a femoral and sciatic nerve block, which
is also used for post-operative pain relief. Post-
Fig. 4 – The patellar tilt is the angle between the posterior condyle line
and the patellar axis.
operative pain control is critical otherwise early
full motion cannot be achieved and stiff ffness may
result.
A single dose of a third-generation cephalosporin
is administered intravenously at induction, for
example, 1.5 g cefuroxime. Chemical thrombopro-
phylaxis is routinely given. Cross-matching blood
for transfusion is not needed.
The patient is placed in the supine position and
an examination under anesthesia is performed to
include an assessment of patella tracking. A well-
padded, non-sterile tourniquet is applied to the
upper thigh, a padded post is placed adjacent to
the lateral thigh and a foot holder is fixed
fi on the
table to allow the leg to be held in a flexed
fl position
of 70° if desired.
A standard sterile prep and drape are completed
and a diagnostic arthroscopy through anterolat-
eral and anteromedial portals is performed for

assessing patellar tracking and confi firming that the
tibiofemoral joint is normal. Careful note is made
of any chondral injuries to the lateral condyle and
patella. Any identifified intra-articular pathology is
addressed at this time. Loose cartilage fragments
are excised while large osteochondral fragments
may be open reduced and internally fi fixed.
An open arthrotomy is then performed through a
midline longitudinal incision starting just medial
to the patellar tendon at the level of the tibio-fem-
oral joint line. The
Th proximal extent depends on the
thickness of the subcutaneous fat. A routine mid
vastus technique is usually performed. Th The inci-
sion is deepened through the subcutaneous and
pre-patellar fascial layers in the line of the incision
and should pass onto the medial part of the patella.
This will allow double-breasting medial reefi fing at
the end or a medial patellofemoral ligament recon-
struction if needed. Skin flaps are not developed.
Care should be taken to avoid incising the articu-
lar cartilage. Any medial ossicle is removed. Th The
patella and the trochlea are exposed and the carti-
lage damages are graded using the ICRS classifica- fi
tion. The patella is never everted (4). The patella is
retracted into the lateral gutter.
The new trochlea is mapped with a surgical pen (Fig.
6). Th
The trochlear sulcus is referenced off ff the inter-
condylar notch; the new groove has a 3–6° external
direction. The medial and lateral facets are mapped
using the trochleo-condylar junction as a landmark.
The superior part of the trochlea is exposed; the
peritrochlear periosteum and synovium are incised
from the medial to the lateral osteochondral junc-
tion. A strip of cortical bone is raised around the
proximal perimeter of the trochlea, to expose the
cancellous bone. The width of the bone strip corre-
sponds to the prominence of the trochlea (distance
between the anterior cortex of the femur and the
boundary of the trochlear cartilage).
Fig. 6 – The trochlear sulcus is referenced off the intercondylar notch; the
new groove has a 3–6° external direction. The medial and lateral facets are
mapped using the trochleo-condylar junction as a landmark.
Deepening trochleoplasty for patellofemoral instability 553
The under trochlear cancellous bone is removed
with a curette. Next, a reamer with a depth guide
is used to remove all the cancellous bone under
the trochlea (Fig. 7). Great care must be taken to
ensure that the cartilage is not violated and that
no thermal damage is caused to the cartilage or the
subchondral bone. More bone is taken away under
the central portion of the trochlea than on either
side. Cancellous bone removal is extended all the
way to the notch. TheTh trochlear bone shell created
must be suffifficiently compliant to prevent it frac-
turing during impaction. TheTh trochlear bone shell
is impacted into the trough created in the cancel-
lous bone. In order to achieve a correct pattern of
the sulcus, it may be necessary to split the cartilage
along the center of the groove.
Both facets are fixed with two small staples made
with a 1 mm K-wire astride the osteochondral junc-
tion, one on either side of the groove (Fig. 5). The
Th
new trochlea obtained is checked and measured. As
the knee is taken through its range of motion, there
must be no patellar impingement with the trochlea.
When patellar tracking is satisfactory, the peritro-
chlear periosteum and the synovium are closed with
transosseous stitches around the trochlea.
In many cases, ICRS Grade III patellar cartilage
damages will be found. Th The lesions are situated
in the mid-portion or close to the patella apex,
extending right across the cartilage surface. These
Th
lesions should be removed with a scalpel and
microfractures could be done when the subchon-
dral bone is exposed.
Fig. 7 – The cancellous bone is
removed with a bur linked to a
probe to prevent any cartilage
damage. The distance between the
bur and the probe is 5 mm (carti-
lage and subchondral bone).
554 The Traumatic Knee

An MPFL reconstruction is always associated with

the trochleoplasty.
The sequence is to correct first the anatomical
causes of the patellar dislocation (trochleoplasty,
tibial tubercle osteotomy if needed…) and then
correct the consequence of the patellar dislocation:
the MPFL rupture. The Th MPFL will be fixed as the
last stage.
The femoral origin of MPFL reconstruction is most
sensitive to reproduction of proper ligament isom-
etry. The MPFL is a static restraint or “checkrein”
to prevent lateral subluxation of the patella, there-
fore it should not be tightened too much.
A 3 cm incision is made directly over the pes anser-
ine (16). Where a distal realignment is performed, Fig. 8 – The MPFL is fixed while the trochleoplasty is done.
the same incision is used to harvest the gracilis.ten-
don. This tendon is harvested in a standard fash-
ion using an open tendon stripper. After removal
of residual muscle, whip stitches are placed in
each end of the harvested tendon using number
2 braided absorbable sutures. The total length of
the tendon should be at least 20 cm to allow ade-
quate length for the reconstruction. TheTh tendon is
then sized (for single and double strand, typically
5–6 mm and 7–8 mm, respectively). Th The medial
retinaculum is identifified through the same midline
longitudinal incision as the trochleoplasty. Blunt
dissection is performed over the retinaculum from
the lateral border of the patella to the medial epi-
condyle. The medial edge of the patella, the retinac-
ulum and periosteum are elevated off ff the medial
patella without violation of the synovial layer. At Fig. 9 – The MPFL is cycled and then fixed in a blind tunnel with an absorb-
the anterior aspect of the patella now two holes are able interference screw.
drilled with a 3.5 mm drill. Their position is at the
medial and superior quadrant of the patella. Th The the medial epicondyle, deep to the medial retinacu-
distance between these two holes is at least 15 mm. lum but superfi ficial to the synovium. The free ends
A tunnel is created by connecting these holes by of the graft are then pulled through the soft tissue
means of a right angle device. The gracilis graft is (in the second layer) tunnel and the whip sutures
looped through this tunnel. Palpation of the skin attached to the previously placed beath pin. The Th pin
proximally and medially allows identification
fi of the is then pulled through the anterolateral aspect of
MPFL origin in the region of the medial epicondyle. the thigh, so the two ends of the harvested tendon
A 3 cm longitudinal incision is made at this site to are pulled in the femoral tunnel (Fig. 9).
prevent subcutaneous dissection which is cause of The whip sutures are held under tension and the
post op pain (Fig. 8). A beath pin is placed medial to knee is ranged from flexion
fl to extension and back
lateral at the origin of the MPFL, slightly proximal to assess adequacy of position and be sure the graft
and posterior to the medial epicondyle and distal to is seated in the tunnels. Insuffi fficient tension will
the adductor tubercle. Care must be taken to avoid result in a lack of correction of the lateral instabil-
a proximal position relative to the native femo- ity, whereas excessive tension will cause increased
ral attachment site to avoid increasing the forces pressure in the patellofemoral joint and may
across the patellofemoral joint (16). The
Th pin should restrict knee range of motion. It is essential not to
exit the thigh on the anterolateral aspect. ThThe can- over tension (17). Tension should be sufficient
ffi to
nulated drill corresponding to the previously sized remove the slack in the graft but not translate the
doubled graft is then used to over-drill the beath patella medially. If tension is applied at 45–60° of
pin. The depth of the reamer should be suffi fficient flexion, the patella is engaged in the trochlea and
to allow seating of the two free ends of the graft, excessive tension is easier to avoid. If the knee is
typically a 40–50 mm femoral tunnel is created. then brought into 20° of fl flexion, there should be
Blunt dissection is carried out to create a soft tis- symmetric medial and lateral translation of the
sue tunnel from the medial aspect of the patella to patella. Once sufficient
ffi tension has been obtained,

the femoral attachment of the graft is secured with
a bio-absorbable interference screw with a size
1 mm larger as the drill used. The
Th decision whether
to perform a lateral retinacular release must be
critically assessed as this is only performed in
selected cases. A lateral release that is not indi-
cated may lead to over medialization of the patella.
However, if a lateral release is felt to be indicated,
it should be done after MPFL graft fixation
fi to help
minimize the risk of over tensioning the graft.
The whip sutures from the graft ends are then cut
under the skin. The wounds are irrigated and the
medial retinaculum repaired over the patella. The Th
tourniquet is then released and hemostasis is per-
formed. Then wound closure performed in layers
and the wounds are draped sterile.
Post-operative care
The post-operative care will need to take into account
the associated procedures, since the trochleoplasty
or another procedure is rarely carried out as an iso-
lated procedure. Therefore the following rehabili-
tation protocol is only a guide. The
Th rehabilation is
divided into three phases. There
Th are least three ses-
sions each week provided in each phase.
Phase 1 starts the day after the surgery and ends at
the 45th day. Immediate weight-bearing is allowed,
the patient has to walk with crutches and an exten-
sion brace for 6 weeks. Walking without a brace is
allowed after 1 month, only during the rehabilita-
tion sessions and if quadriceps locking is satisfac-
tory. Lateral and longitudinal quadriceps mobi-
lizations are performed, the posterior muscular
chain is stretched. Active ascension of the patella
is performed by isometric quadriceps contractions,
patient seated with the leg extended and the knee
unlocked. Range of motion is gradually regained
(avoiding passive, forced, or painfull postures)
until 100° of flexion and 0° of extension during the
first 6 weeks. Frequent knee movement is encour-
aged, to improve the nutrition of the cartilage and
to allow further moulding of the trochlea by patel-
lar tracking after trochleoplasty. Resting position
with the knee in 20° of flexion without a brace is
allowed and encouraged. Dynamical and isometric
quadriceps strengthening with weigths on the feet
or tibial tubercle is prohibited.
Phase 2 goes from the 46th day until the 90th day.
The extension brace is abandoned and full weight-
bearing is allowed. The articular running-in is con-
tinued, cycling is possible with a weak resistance
initially. Those resistances can gradually be intensi-
fied. Active ascension of the patella is performed by
isometric quadriceps contractions, patient seated
with the leg extended and the knee unlocked.
Range of motion is continued (avoiding passive,
Deepening trochleoplasty for patellofemoral instability 555
forced, or painful postures) from 90° of fl flexion
without limitation in flexion
fl to 0° of extension.
Active exercises are added: statical co-contractions
of the hamstrings and the quadriceps between 30
and 90°, statical and dynamical strengthening of
the hamstrings against resistance between 60 and
90°, in neutral position statical strenghtening of the
internal and external rotators with the knees 90°
flexed, strenghtening of the biceps and fascia lata
with the knee unlocked. Dynamical and isometric
quadriceps strengthening with weigths on the feet
or tibial tubercle is still forbidden. Th The anterior
and posterior muscular chains are stretched, and
the patient is encouraged to continue the rehabili-
tation on his own. Weight-bearing proprioception
exercises are started when the extension is com-
plete, first in bipodal stance and later in monop-
odal stance when there is no pain. Closed chain
muscular strengthening, weakly charged, between
0 and 60° can also be initiated.
If possible an isocinetic test of the hamstrings
(after a medical consultation) is performed after 3
months in order to restart running. This Th test pro-
vides objective data of the muscular balance and
recovery. With satisfactory values the patient can
restart running without risk. If there is an insuf-
ficient recovery or a muscular imbalance the reha-
bilitation is adjusted and running is delayed.
Phase 3 is passed from the 4th until the 6th month,
this is the sports phase. If the isocinetic values of
the hamstrings are satisfactory, running can be
initiated on a straight line, 5 min (chronowatch)
each day during the first week, 10 min (chrono-
watch) each day during the second week, 15 min
(chronowatch) each day during the third week.
Closed kinetic chain muscular reinforcement, leg
press and charged squatting between 0 and 60°
with minor loads but long series are allowed, so are
Kabat and mono- and bipodal proprioception exer-
cises. A global muscular work out is started, which
addresses the opposite leg, the spinal and abdomi-
nal muscles. Weight-bearing and monopodal pro-
prioception exercises are started when there is no
pain. If there is a contralateral hyperextension, ipsi-
lateral hyperextension is regained. Also strength-
ening training with the use specific fi machines are
implemented: leg behind (hamstring training),
vertical or horizontal press between 0 and 60°,
charged squatting between 0 and 60°, cycling and
elliptical cycling, rowing machine, steps, adductor
and abductor machines. Dynamical and isomet-
ric quadriceps strengthening with weigths on the
feet or tibial tubercle is still prohibited. Stretch-
ing of the anterior and posterior muscular chains
is continued. The patient is encouraged to proceed
through the rehabilitation on his own.
After 6 months sports on a recreative or competi-
tion level can be resumed.
556 The Traumatic Knee
Six weeks post-operatively control radiographs,
including AP and lateral views and an axial view in
30° of flexion, are taken. After 6 months, a control
CT scan is performed in order to document the
obtained correction.
Results
Two series were published in the “Journée lyon-
naise de chirurgie du genou” 2002
Group I
Th first group included 18 patients, who had
The
failed patellar surgery for instability. The mean age
at surgery was 24 years, there were no patients lost
to follow up. The mean follow up was 6 years (2–8
years). The new surgery was six times indicated
for pain, 12 times for recurrence of instability. The
Th
average number of surgeries before the trochleo-
plasty was 2 (medialization, arthroscopy, distaliza-
tion, lateral release, etc.).
The deepening trochleoplasty was eight times
Th
associated with a tibial tubercle medialization, six
times to a distalization, and 18 times to a medial
vastus plasty.
Pre-operatively there were grade B trochlear dys-
plasias, 4 grade C, and 6 grade D. The
Th mean TT-TG
was 18 mm (14–24), the mean Caton–Deschamps
Index was 1.1 (0.8–1.3). TheTh mean Patellar tilt was
35° (18–48).
Clinical results
All patients were revisited clinically and radio-
graphicaly with the IKDC form.
Sixty-five
fi per cent were satisfi
fied or very satisfi
fied,
the knee stability was rated 13 times type A and
five times type B. Twenty-eight per cent of the
fi
patients had residual pain, this was correlated to
the cartilage status at surgery. Two patients had
patellofemoral arthritis.
Radiological results
Th mean patellar index was 1 (0.8–1.1) and the
The
mean TG-TT was 12 (6–17). The mean patellar tilt
with the quadriceps relaxed was 21° (11–28°), the
mean patellar tilt with the quadriceps contracted
was 24° (16–32°).
Group II
In the second group there were 44 patients. They
all had no previous surgery or health problem. The
Th
mean age at surgery was 23 years, two patients
were lost to follow up. The mean follow up was
7 years (2–9 years).
Twenty-two tibial tubercle medializations, 26
distalizations, and 32 medial vastus plasties were
associated.
Pre-operatively there were 21 grade B trochlear
dysplasias, 12 grade C, and 11 grade D. TheTh mean
TT-TG was 24 mm (15–32), the mean Caton–
Deschamps Index was 1.3 (1–1.4). The mean patel-
lar tilt was 33° (24–52).
The patients were revisited clinically and radio-
graphicaly with the IKDC form.
Eighty-five
fi per cent were satisfi
fied or very satisfi
fied,
the knee stability was rated 31 times type A and 13
times type B. Five per cent had residual pain, this
was not correlated with the cartilage status at sur-
gery. No patellofemoral arthritis was noted.
Radiological results
The mean patellar index was 1 (1–1.1), the mean
TT-TG was 16 (14–21), and the mean patellar tilt
with the quadriceps relaxed was 18° (9–30°), the
mean patellar tilt with the quadriceps contracted
was 22° (14–34°).
Discussion
The conclusion of these two short series shows that
in the first group the risk of arthritis is high.
Other studies also reported this slightly higher
incidence of a degenerative changes (35% of
patients) in patients requiring late surgery for
recurrent instability than in patients treated non-
operatively (11–22% of patients at 6–26 years
after injury) (18). Some report that degenerative
changes are uncommon (19) and require more
than 5 years to develop (20), although it is pos-
sible that this may simply refl flect a greater sever-
ity of disease among patients receiving surgical
treatment (21). Other studies have also shown an
increased incidence of osteoarthritis in the sur-
gical group (22, 23), possibly because of overcor-
rection or failure to recognize and thus treat the
underlying abnormality. The longest published
results for trochleoplasty are a mean of 8.3 years
(24). All patients in this series said they would
undergo the surgery again, despite evidence of
greater than grade 2 radiographic patellofemoral
changes in 30% of patients.
The residual pain is still there in cases of previous
surgery; therefore, the indication should be care-
fully set in those patients. On the other hand, one
should have a guarded optimism about the ability
to treat isolated patellofemoral arthritis, especially
when it is associated with malalignment. Indeed,
trying to precisely correct the patellar alignment

in case of cartilage damage or pre-arthritis as advo-
cated by Arendt et al. (25) might be dangerous.
The trochleoplasty is indicated in case of recur-
rences of instability but not in case of residual
pain. In the second group of patients without sur-
gical antecedents, the deepening trochleoplasty is
a good option regarding stability and residual pain.
The anatomical abnormalities are very well cor-
rected especially the patellar tilt correction.
Outcomes for this patient population need to be
reviewed on the long term and on an ongoing
basis.
Conclusion
The classical lateral-facet elevating trochleoplasty
(Albee procedure) is still indicated in patients with
a flat or shallow trochlea, but without trochlear
prominence and without any other significant
fi fac-
tors of instability. Care must be taken to ensure
that this procedure does not result in greater
trochlear prominence, which might give rise to
impingement in flexion.
fl This procedure is eff
ffective
for stability but could lead to further patellofemo-
ral arthritis by increasing the compression forces.
Deepening trochleoplasty is much more etiologic
in correcting the prominence. Indication for deep-
ening trochleoplaty is rare because hight grade tro-
chlear dysplasia are uncommon. Th The best indica-
tion is when there is an abnormal patellar tracking
during knee flexion.
fl In case of abnormal patellar
tracking no other solution is possible.
Patellofemoral instability is a combination of sev-
eral anatomical abnormalities. TheTh first step is to
determine the pathologic population to which the
patient belongs. Only the objective patellar insta-
bility population requires surgery. Th
The second step
is to quantify the objective anatomical abnormali-
ties seen on the pre-operative true lateral view,
axial view at 30° flexion, and CT scan using the
patellar protocol. The last step is the pre-operative
surgical planning where the surgeon will system-
atically correct all anatomical abnormalities, as in
a “menu à la carte”(4).
References
1. Fithian DC, Paxton EW, Stone ML, et al. (2004) Epidemiol-
ogy and natural history of acute patellar dislocation. Am J
Sports Med 32(5):1114–1121
2. Dejour H, Walch G, Neyret P, Adeleine P (1990) Dyspla-
sia of the femoral trochlea. Rev Chir Orthop Reparatrice
Appar Mot 76(1):45–54
3. Dejour H, Walch G, Nove-Josserand L, Guier C (1994)
Factors of patellar instability: an anatomic radio-
Deepening trochleoplasty for patellofemoral instability 557
graphic study. Knee Surg Sports Traumatol Arthrosc
2(1):19–26
4. Dejour D, Le Coultre B (2007) Osteotomies in patello-fem-
oral instabilities. Sports Med Arthrosc 15(1):39–46
5. Walch G, Dejour H (1989) Radiology in femoro-patellar
pathology. Acta Orthop Belg 55(3):371–380
6. Glard Y, Jouve JL, Panuel M, et al. (2005) An anatomical
and biometrical study of the femoral trochlear groove in
the human fetus. J Anat 206(4):411–413
7. Jouve JL, Glard Y, Garron E, et al. (2005) Anatomical
study of the proximal femur in the fetus. J Pediatr Orthop
B 14(2):105–110
8. Tavernier T, Dejour D (2001) Knee imaging: what is the
best modality. J Radiol 82(3 Pt 2):387–405, 407–408
9. Tecklenburg K, Dejour D, Hoser C, Fink C (2006) Bony and
cartilaginous anatomy of the patellofemoral joint. Knee
Surg Sports Traumatol Arthrosc 14(3):235–240
10. Remy F, Besson A, Migaud H, et al. (1998) Reproducibil-
ity of the radiographic analysis of dysplasia of the femoral
trochlea. Intra- and interobserver analysis of 68 knees.
Rev Chir Orthop Reparatrice Appar Mot 84(8):728–733
11. Remy F, Chantelot C, Fontaine C (1998) Inter- and intrao-
bserver reproducibility in radiographic diagnosis and clas-
sifi
fication of femoral trochlear dysplasia. Surg Radiol Anat
20(4):285–289
12. Malghem J, Maldague B (1989) Depth insuffi fficiency of
the proximal trochlear groove on lateral radiographs
of the knee: relation to patellar dislocation. Radiology
170(2):507–510
13. Nove-Josserand L, Dejour D (1995) Quadriceps dysplasia
and patellar tilt in objective patellar instability. Rev Chir
Orthop Reparatrice Appar Mot 81(6):497–504
14. Masse Y (1978) Trochleoplasty. Restoration of the intercon-
dylar groove in subluxations and dislocations of the patella.
Rev Chir Orthop Reparatrice Appar Mot 64(1):3–17
15. Verdonk R, Jansegers E, Stuyts B (2005) Trochleoplasty
in dysplastic knee trochlea. Knee Surg Sports Traumatol
Arthrosc 13(7):529–533
16. Elias J, Cosgarea AJ (2006) Technical errors during medial
patellofemoral ligament reconstruction could overload
medial patellofemoral cartilage: a computational analysis.
Am J Sports Med (34):1478–1485
17. LeGrand A, Greis P, Dobbs R, Burks R (2007) MPFL recon-
struction. Sports Med Arthrosc 15(2):72–77
18. Maenpaa H, Lehto M (1997) Patellofemoral osteoarthritis
after patellar dislocation. Clin Orthop (339):156–162
19. Insall J (1976) Recurrent dislocation of the patella. Rela-
tion of treatment to osteoarthritis. J Bone Joint Surg Am
(58):9–13
20. Fithian D, Paxton E, Cohen A (2004) Indications in the
treatment of patellar instability. J Knee Surg (17):47–56
21. Mulford J, Eldridge J (2008) Technique of trochleoplasty
for the treatment of patella instability. Tech Knee Surg
7(1):13–18
22. Arnbjornsson A, Egund N, Rydling O (1992) Th The natural
history of recurrent dislocation of the patella. Long-term
results of conservative and operative treatment. J Bone
Joint Surg Br 74:140–142
23. Marcacci M, Zaffagnini
ff S, Iacono F (1995) Results in the treat-
ment of recurrent dislocation of the patella after 30 years’
follow-up. Knee Surg Sports Traumatol Arthrosc 3:163–166
24. von Knoch F, Bohm T, Burgi M (2006) Trochleaplasty for
recurrent patellar dislocation in association with trochlear
dysplasia: a 4- to 14-year follow-up study. J Bone Joint
Surg Br 88:1331–1335
25. Arendt E, Merchant AC, Leadbetter W (2005) Anatomy
and malalignment of the patellofemoral joint: its rela-
tion to patellofemoral arthrosis. Clin Orthop Relat Res
(436):71–75
II The Degenerative Knee
 Osteoarthritis
of the patello-femoral joint

J. Bellemans,
H. Vandenneucker,
Patellofemoral osteoarthritis :
K. Didden
pathophysiologie, treatment,
and results
Introduction
D
egeneration of the articular cartilage of the
patellofemoral joint is an extremely debili-
tating condition and is a relatively common
problem seen by knee surgeons. Isolated arthritic
disease in the patellofemoral compartment has
been described in 13.6–24% of women and in
11–15.4% of men in two radiographic studies of
subjects over 55 and 60 years of age, respectively.
However, not all of them were symptomatic. Con-
sidering only the symptomatic subjects, the preva-
lence of isolated patellofemoral cartilage degenera-
tion ranged from 5 to 8% (1, 2). Despite this high
incidence, and the various pre-disposing condi-
tions, little information is available in the literature
about the best conservative or surgical treatment
options. Older patients developing symptomatic
patellofemoral arthritis seem to be even more
refractory to conservative treatment than younger
patients with anterior knee pain. Nevertheless, a
conservative treatment protocol should be tried
out for at least 6 months before considering a sur-
gical procedure.
Pathofysiology
and Biomechanical Considerations
Understanding the biomechanics of the patell-
ofemoral joint and the etiology of patellofemoral
arthritis is essential to determinate the appropri-
ate and most successful conservative and operative
treatment strategy for each individual patient.
The patella increases the moment arm of the quad-
Th
riceps by acting as a lever arm, especially in late
extension, and acts as a fulcrum in the patellofem-
oral lever system (3). It has a number of specific fi
characteristics which allow, from a biomechanical
point of view, an optimal and durable function.
Unfortunately, this has some clinical implica-
tions.
During knee motion the contact zone on the patel-
lar cartilage shifts constantly, from distal to proxi-
mal, during flexion and back during extension.
Chapter 49
There is, however, also a difffferential torque in the
patellar and quadriceps tendon, with the patellar
tendon creating relatively higher forces at small
flexion angles and the quadriceps tendon at larger
flexion angles, while the patella acts as a balancing
beam. The patellofemoral compression force, being
the resultant of the quadriceps and the patellar
tendon force, increases with increasing knee flex- fl
ion, with a maximum contact pressure, however,
at a flexion angle of 80–90°. With further flexion
a signifi
ficant load sharing with the tendofemoral
contact zone occurs, resulting in a decreasing con-
tact pressure in deeper flexion. As the total patell-
ofemoral contact area also gradually increases with
flexion, up to a maximum at 90° of flexion, and as
the patellar cartilage has a maximum thickness
(5 mm) at the more central contact zone, reached
at 90° flexion, it seems that the normal knee is bio-
mechanically well designed to support this high
compressive load.
As a consequence, the smallest changes in this deli-
cate equilibrium may have important implications,
biomechanically as well as clinically. Th The cause of
this disturbance can be congenital, developmental,
or traumatic.
A dysplastic trochlea, whereby the trochlea is fl flat
or even convex, can lead to unusually high loads
and development of arthritis in younger patients.
A proximal–distal change in contact zones, like in
the case of patella alta or baja, results in high com-
pressive load on smaller contact area’s, which have
additionally a decreased cartilage thickness.
Similarly, mediolateral patellar malalignment and
tilting creates a maldistribution of force, in most
cases causing an overload on the lateral patellar
facet, with again a smaller contact area and higher
contact stress compared to the normal situation.
It is clear that higher contact stresses induce an
increased stress on the subchondral bone and the
release of cartilage breakdown products, resulting
in faster cartilage degeneration.
A fair amount of documentation in the literature
on patellar arthritis and treatment supports the
statement that patellofemoral malalignment is
probably the most important factor in the etiology
of patellofemoral arthritis (4, 5).
564 The Degenerative Knee
In the presence of normal patellofemoral anatomy
early degenerative changes are unlikely. However,
other less obvious and less expected situations can
also disturb the delicate patellofemoral balance.
Examples are anterior or posterior cruciate liga-
ment insuffifficiency, which cause increased patel-
lofemoral stress.
This easily disturbed patellofemoral mecha-
nism obviously has some therapeutical implica-
tions. Treatment strategies attempting to cre-
ate an appropriate and normal load distribution
and transmission, and a stable environment for
optimal mechanical performance, correcting the
observed biomechanical abnormalities, are logical
and often used. On the other hand, they are vul-
nerable to failure as the edge between improving
an imperfection and making it worse is very sharp
and not easy controllable. ThThose operative patel-
lofemoral procedures are not without risk. They
may not only lead to undercorrection or overcor-
rection of the problem, but they also risk to induce
new, unexpected, and undesirable changes in a
delicate biomechanical system. This
Th fact, in addi-
tion with a number of unpredictable healing vari-
ables, as there are muscular atrophy and scar tissue
formation, should be taken into account when one
is considering a patellofemoral surgical interven-
tion.
Conservative treatment options
and results
Before thinking about any surgery, one should con-
sider solutions that might avoid major aggressive
surgery, despite developed patellofemoral arthritis
(Table 1). A careful and pointed history and clinical
examination are imperative (6, 7).
First step is a trial of non-steroidal anti-inflamma-
fl
tory medication, heat and ice, rest, weight-control,
and activity modifi fication. Activity modifification
involves an avoidance of squats, wall-slides, and
large steps as well as the advice that, during exer-
Table 1 – Conservative treatment options for patients with isolated patel-
lofemoral arthritis.
NSAI/ice-heat/rest
Weight-control—activity modification
Intra-articular corticosteroid administration
Viscosupplementation
Stretching
Closed-chain strengthening exercises
Taping–bracing
cise, pain should be avoided and not be “worked-
through.”
Periodic intra-articular corticosteroid adminis-
tration and viscosupplementation may provide
enough relief for certain patients to avoid or delay
patellofemoral surgery.
Stretching of the lateral retinaculum, the iliotibial
band, the hamstrings, and quadriceps can dimin-
ish loading of the patellofemoral joint by softening
and elongating the peripatellar retinaculum, which
is often a source of pain.
A patellofemoral rehabilitation program focused
on closed-chain strengthening exercises, such
as bicycle riding, swimming, and leg-press, will
strengthen the quadriceps in a safe manner with-
out aggravating patellar problems. Given that bal-
anced activity in the medial and lateral quadriceps
is essential in maintaining patellofemoral joint
alignment, it is possible that alterations in either
the magnitude and/or timing of activity in these
muscles is more important in PFJ OA (patellofem-
oral joint osteoarthritis) than overall quadriceps
strength in se.
Taping (8, 9) and bracing (10, 11) the PFJ (patel-
lofemoral joint), using a device with an anterior
cut-out to minimize direct pressure, can provide
considerable support and reduction of focal pres-
sure in patients with PFJ OA associated with mal-
tracking. Although it is not clear how patella tap-
ing achieves its pain-relieving effects
ff in PFJ OA, it
is possible that subtle changes in patella position
alter the magnitude and distribution of PFJ stress,
but this has not been evaluated in a population
with PFJ OA.
The same conservative means of altering patella
position is by the use of a patella stabilizing knee
brace, working in the same manner as taping by
aiming to re-position the patella medially and
reduce joint stress. In younger patients with patel-
lofemoral pain syndrome, patella stabilizing braces
have been shown to reduce knee pain, as well as
PFJ stress, mostly through increasing PFJ contact
area, but they have not been evaluated in patients
with PFJ OA.
Given the fact that PFJ OA is frequently associated
with valgus knee joint alignment (larger Q angle),
knee braces that realign the joint in a varus direc-
tion might have a potential clinical application in
PFJ OA.
The same can be said of medially wedged orthotics
in the shoe, but it has not been evaluated in this
group of patients.
Although a lot of these treatment options would
not give patients a complete pain-free knee, in a
lot of cases surgical intervention can be avoided
or postponed. However, there is no standardized
method of treatment and there has been no valida-
tion of any particular technique (12). A conserva-
 Patellofemoral osteoarthritis : pathophysiologie, treatment, and results 565

tive treatment should be tried for at least 6 months to support this standpoint (14–19). Chondral deb-
before considering alternative treatment options. ridement, abrasion arthroplasty, and subchondral
drilling have been often used, but mostly in combi-
nation with realignment procedures. Success rates
vary from as low as 25% (16) to 78% in a study of
Operative management Goodfellow et al. (17) and 79% in a study of Ficat
of patellofemoral osteoarthritis et al. (19).
Superfi ficial debridement of fibrillated articular car-
Th goal of surgery should be to decrease disabling
The tilage without abrasion of subchondral bone might
pain enough to allow patients to return to most of produce limited benefi fit by diminishing inflflamma-
their daily life activities. Th
The expectations must be tion, but does not give satisfactory results, espe-
realistic and activity modification
fi will still be nec- cially not in the more severe degenerations (20).
essary after surgery. The value of debridement procedures is therefore
The outcomes after operations for isolated PFJ OA
Th questionable and not proven on the basis of pub-
are diffi
fficult to find, with exception of the results lished clinical reports.
of prosthesis surgery. Most papers dealing with
one of the treatment options include isolated PFJ
OA amongst a number of other diagnoses, which Realignment procedures
makes it impossible to evaluate the outcome for
isolated PFJ disease. Other papers focused on PFJ Soft-tissue realignment surgery to address carti-
degeneration review the result of a combination of lage disease in the patellofemoral joint has been
treatments, which makes it difficult
ffi to determine described in the literature on patellar instabil-
the eff
ffect of a single treatment procedure. ity. More than 150 variations of patellar realign-
The surgical options can be divided into six cat-
Th ments have been reported. They can be divided in
egories (13): (1) arthroscopic debridement proce- proximal procedures, such as lateral retinacular
dures; (2) realignment procedures; (3) unloading release, reattachment or reconstruction of the
procedures; (4) partial or total patellectomy; (5) patellofemoral ligament, and advancement of
autologous chondrocyte implantation, and (6) the vastus medialis obliquus, and in distal proce-
prosthetic resurfacing procedures. The Th final goal dures. Most distal procedures, involving osseous
is to improve joint mechanics or to improve the realignment, are based on transferring the tibial
articular surface(s), leading to a decrease of the tubercle.
secondary infl flammatory process. It is obvious and generally accepted that a realign-
ment procedure only has to be considered in the
case of objective evidence of patellar malalign-
Debridement procedures ment.
Several factors have an infl
fluence on patellar track-
Th purpose of debridement of cartilage lesions
The ing: the Q angle, the tightness of the lateral reti-
and subchondral bone is to fill fi the defect with naculum, the strength and function of the vastus
regenerated fibrocartilage. The rationale behind medialis muscle, the ratio vastus lateralis/VMO,
this treatment options is that fibrocartilage, femoral anteversion, position of the tibial tubercle,
although it has an inferior mechanical and biologi- and the shape of the trochlea. However, which is of
cal quality and although it is not able to withstand final importance is the position of the patella in rela-
long-term loading, is better than no cartilage at all. tion to the trochlea, especially in the early degrees
However, in literature there is not much evidence of flexion when the patella is entering the trochlear
groove. The use of computed tomography is the best
Table 2 – Operative treatment options for patients with isolated patell- diagnostic tool to measure the patellar position.
ofemoral arthritis. Based on this, malalignment can be divided into
Debridement procedures three groups (21): (1) patellar tilt, (2) patellar sub-
Realignment procedures luxation, and (3) tilt and subluxation (Fig. 1). TheTh
Lateral retinacular release Anteromedial transfer of the tibia
tubercle
Unloading procedures
Patellectomy
Facetectomy Total patellectomy
Autologous chondrocyte implantation (ACI)
Prosthetic resurfacing procedures
Fig. 1 – Types of patellofemoral malalignment (described by Schultzer et al.):
Patellofemoral arthroplasty Total knee arthroplasty Tilt (A), subluxation (B), tilt and subluxation (C).
566 The Degenerative Knee
type of malalignment determines the potentially
most successful surgical realignment procedure.
Lateral Retinacular Release
Lateral release is a procedure that historically has
been widely used for the treatment of anterior knee
pain. It should shift the patellofemoral contact
area medially and can therefore only be expected
to be successful in patients with an intact medial
articular cartilage. This procedure should only be
used when there is some tightness or a contracture
of the lateral retinaculum that tethers the lateral
border of the patella posterolaterally, resulting
in pain and overload in the lateral patellofemoral
compartment: in the case of a radiographic docu-
mented pathologic patellar tilt in the absence of
patellar instability or subluxation (1).
In these conditions it can lead to a significantfi
improvement in subjective outcome in patients
with mild to moderate cartilage degeneration (22,
23). The results are less satisfactory in the case of
more advanced cartilage damage (24–26). Ader-
into and Cobb (27) reviewed their results at an
average of 31 months post-operatively. Some of
the patients had also tibiofemoral arthritis. They
concluded that a release was worthwhile. How-
ever, four out of 53 knees underwent a total knee
replacement for ongoing symptoms and only half
of the 26 patients with isolated PFJ OA were sat-
isfi
fied. Unfortunately, the study does not diff ffer-
entiate between lateral and global patellofemoral
involvement.
An isolated lateral retinacular release is a consider-
able option in the treatment of PFJ OA when the
following conditions are present: (1) lateral patel-
lofemoral arthritis, (2) radiographic evidence of
tilt with no or little subluxation, and (3) no clinical
instability. This
Th procedure can be combined with
a partial lateral facetectomy when there is a large
osteophyte, or with a procedure that addresses
the damaged cartilage, to increase its utility, as
described in one of the next sections.
Anteromedial transfer of the tibia tubercle
A subluxation malalignment (2) of the patella can
be improved by an anteromedial transfer of the
tibial tubercle.
This procedure is carried out with an oblique osteot-
omy of the tibial tuberosity that is sloped in an
anteromedial-to-posterolateral direction. It does
not only provide relief of symptoms because of the
restoration of normal alignment and mechanical
function by a medial translation, but also because
it unloads a fragmented painful surface of the
patellofemoral joint by a combined anteriorization
(28, 29). In this way the lateral and distal aspect of
the patella is unloaded and the load is transferred
to the medial proximal part of the patella, result-
ing in higher contact stresses in this region earlier
in the flexion arc.
Fulkerson et al. (28, 30) reported that transfer-
ring the tubercle 8 mm anteriorly and medially
reduces contact pressures on the lateral facet by
30%. A transfer of 15 mm anteriorly and 8 mm
medially can reduce the pressures by 65%. Bel-
lemans et al. (31) showed an improvement of the
congruence angle of 16° with the use of this pro-
cedure in patients with only subluxation and an
improvement of 14° in patients with subluxation
plus tilt. This means a decrease of the tendency
toward lateral subluxation, resulting in decreased
contact pressures on the lateral facet. A subjective
improvement is described in 95% of patients with
mild cartilage degeneration (28, 31) and in 60–75%
of patients with more severe patellar disease (28,
32), although even in these cases Sakai et al. (33)
report a pain relief in 95% of patients (follow-up
5 year). This
Th is confi firmed in a study of Pidoriano
et al. (34). The grade of articular lesion seems to be
far less important than the location of the lesion in
determining the likelihood of success.
Historically, transfer of the tibial tubercle to re-
align the extensor mechanism with operations such
as the Elmslie-Trillat procedure and the Hauser
procedure has been reported with poor results (35,
36). The Elmslie-Trillat procedure does only cre-
ate a medialization without a general unloading
eff
ffect of the patella. The same can be applied to the
Hauser procedure, which was based on measure-
ments of the Q angle, without taking into account
the variation in normal values of the Q angle or the
potential increase in loading of the medial patellar
facet (Fig. 2).
An isolated anteromedial tibial tubercle transfer
has a role in the treatment of PFJ OA, considering
the following issues; (1) the candidate is a patient
with the typical malalignment (subluxation/sub-
luxation plus tilt) – related patellofemoral cartilage
breakdown, which means a chronic lateral patellar
tracking with a lateral and eventually distal articu-
lar lesion and (2) the cartilage in the medial proxi-
mal part of the patella and trochlea is reasonably
healthy. Th
The location of the lesion is much more
important than the grade of degeneration and the
obliquity of the osteotomy should be determined
by the site of degeneration that has to be unloaded.
Fig. 2 – Realignment procedures. Anteromedial translation of the tibial
tubercle (A), Elmslie-Trillat procedure (B), Hauser procedure (C).
 Patellofemoral osteoarthritis : pathophysiologie, treatment, and results 567
In other words, technical precision is of paramount
importance in achieving an optimal result.
A secured fixation of the osteotomy with corti-
cal lag screws is important to allow early range of
motion. Weight-bearing should be protected for at
least 6 weeks because of the risk of tibial fracture
(31, 37).
Anteromedial tibial transfer is also an important
adjunct to patellofemoral resurfacing procedures.
Unloading procedures
If patellofemoral pain is postulated to be the result
of loads applied to defi ficient cartilage, it stands
to reason that a diminution of those loads could
lead to pain relief. This has been the theory behind
operations that relocate the tibial tuberosity to a
more anterior position.
Maquet (38–40) was the first fi to develop a proce-
dure that moves the tibial tuberosity anteriorly,
suggesting an elevation of 2–2.5 cm (Fig. 3a and b).
On the basis of in vitro studies, Ferguson et al. (41)
later proposed a variation on Maquet’s operation,
whereby the tuberosity was elevated just 1.27 cm.
Subsequent investigators (42–44) have recom-
mended elevations as low as 1.25 cm and even
1 cm. Using in vitro measurements, both Naka-
mura et al. (43) and Ferrandez et al. (44) found an
elevation of >1 cm counterproductive with regard
to patellofemoral stresses.
The procedure has been reportedly associated with
an alarming number of serious complications, up
to 10–40% in some reports. These include nota-
bly skin necrosis, tibial fracture, tibial non-union,
loss of fixation, patellar tendonitis, the develop-
ment of a painful prominence at the level of the
tibial tuberositas and infection. These problems
Fig. 3 – Maquet procedure . (a) Advancement of the tibial tubercle by
elevation of the tibial crest and iliac bone graft interpositioning (described
by Maquet). (b) Postop X-ray.
might be addressed by lengthening the osteot-
omy fragment that is elevated, as this minimizes
the angulation required for a given elevation, and
by decreasing the amount of anteriorization.
Because Maquet’s procedure has been used for
a wide variety of patellofemoral conditions and
because the results have not always been corre-
lated with the etiology of the pain or the location
of the degeneration, the clinical results are difficult
ffi
to assess. The initially reported good results by
Maquet with improvement in as many as 90–95%
of patients have not been confirmed
fi in later litera-
ture (45–47).
Over the last 20 years, Maquet’s operation has
diminished in popularity in Europe, and the place
of the procedure in the treatment of PFJ OA
remains controversial.
Partial or total patellectomy
Partial patellectomy or facetectomy
Partial patellectomy (Fig. 4a and b) or facetectomy
can be considered in the treatment of moderate to
severe patellofemoral arthritis with predominant
involvement of the lateralmost portion of the com-
partment due to chronic lateral maltracking. In
this procedure, 1–1.5 cm from the lateral aspect of
the patella is removed without reattachment of the
lateral retinaculum.
Rationale is to achieve some correction of mal-
tracking and to remove the bone-to-bone articu-
lating part of the lateral patella.
Advantages are the simplicity of the procedure, the
relative short rehabilitation period and the quick
B
568 The Degenerative Knee
A B
Fig. 4 Lateral facetectomy. (a) Preop X-ray. (b) Postop X-ray.
recovery of function. Additionally, it does not jeop-
ardize the results of subsequent procedures if no
more than 1 cm–1.5 cm, depending on the size of
the patella, is resected, to preserve sufficient
ffi bone
stock.
The reported results (48–50) with this procedure
Th
are encouraging with satisfactory results in up to
90% of selected patients with grade 3 to 4 cartilag-
inous lesions classifified by the Outerbridge scale.
The success depends largely on the relief of pain; it
Th
does not provide any functional improvement.
Partial lateral facetectomy is an appropriate proce-
dure for patients with severe isolated lateral PFJ
OA. Ideal candidates are relative young and active
patients who have high physical demands.
Total patellectomy
A patellectomy is a resection arthroplasty of the
PFJ. The term encompasses a number of opera-
tions, the end result of which is the removal of the
patella. Various techniques have been described
with transverse, longitudinal, or oblique repair of
the peripatellar soft-tissues, but none seems to be
superior.
Adequate extensor realignment with avoiding
transaction of the tendinous portion of the exten-
sor mechanism is important (51). Th Therefore,
removal through a longitudinal split and care-
ful peeling out of the patella might be the best
approach.
Its attraction lies in its relative simplicity and
safety compared with other procedures. It can be
reasoned that removing half of a painful joint will
cause the pain to disappear.
However, the pain from an arthritic trochlea is
not gone by a patellectomy. Additionally, removal
of the patella has numerous disadvantages (52,
53), of which the most important is that it greatly
diminishes the lever arm of the extensor mecha-
nism of the knee. This can lead to extensor weak-
ness and/or extension lag. Patients take an unduly
long time to get even reasonable functional
strength for daily live activities. Other complica-
tions are decreased range of motion, unpredictable
pain relief, heterotopic bone formation, subjective
instability and displeasing cosmetic appearance.
An important remark is that the removal of the
patella may compromise the result of subsequent
total knee arthroplasty (54, 55).
The popularity of the procedure has gone through
cycles. The literature has been inconclusive regard-
ing results. Good results have been reported in
54–90% of cases (56, 57). A shortcoming of most of
the studies found in literature is a lack of descrip-
tion of the anatomic location of the arthritis. It is
not clear if the arthritis is limited to the patella or
present on both the patella and the trochlea.
In the treatment of PFJ OA patellectomy is a rea-
sonable alternative when (1) the patella itself is
severely damaged, (2) the trochlea is relatively
intact, and (3) the extensor mechanism is normally
aligned with an adequate advancement of the soft
tissues at the time of patellectomy to compensate
for the void left by the patellectomy. It is unclear
which patients should have patellectomy versus
patellofemoral arthroplasty, but an important cri-
terion is the maintenance of better strength after
patellofemoral prosthesis, which is an important
consideration especially in older patients. Th There-
fore, it might be better to consider it for the young
population.
Autologous Chondrocyte Implantation
Autologous chondrocyte implantation involves
harvest of articular cartilage from a portion of the
patient’s femoral condyle, culture of the chondro-
cytes to multiply their number, and reimplanta-
tion of the chondrocytes into the chondral defect
(Fig. 5a and b). Although the technique has been
used mainly for isolated defects of the femoral con-
dyle, attempts have been made to apply it to the
patellofemoral joint.
Although long-term follow-up is not yet available,
autologous resurfacing of the trochlea is a reason-
able alternative, but resurfacing of the patella is a
complete different
ff matter, due to the mechanics
 Patellofemoral osteoarthritis : pathophysiologie, treatment, and results 569

A B
Fig. 5 – ACI procedure. (a) Patellar chondral lesion preop ACI procedure.(b) Result at the end of the ACI procedure.

of patellofemoral contact. The unit load per square be considered. The procedure is expensive but may
centimeter of patellar articular cartilage when con- eventually be cost-eff
ffective if it provides a long-
sidered with time during fl flexion and extension is term pain relief.
greater than load to a corresponding part of the
trochlea. While during flexion there is a gradual
shift of loading from distal to proximal patellar Prosthetic resurfacing procedures
articular cartilage, the patella comes in contact
with a much broader surface of the trochlear car- Joint replacement for isolated patellofemoral
tilage. The new generated cartilage on the patella, arthritis has traditionally displaced the tibiofemo-
therefore, must be much more durable than that of ral joint as well. Recently, there is, however, again a
the trochlea. Additionally, the patellar subchondral growing interest in isolated patellofemoral replace-
bone is denser compared to that of the trochlea, ment.
which might make an ACI on the patella very dif-
ficult. These facts, combined with the vulnerability Patellofemoral arthroplasty
of the anterior knee, make an ACI of the patella In patellofemoral arthroplasty only the articular
uniquely complex. surface of the patella and trochlea are replaced,
The alternatives are, however, not very attractive, with the use of a cemented polyethylene patellar
and a failed ACI does not aff ffect the outcome of button and a cemented chrome cobalt or oxinium
subsequent procedures, should they be necessary. trochlear component (Fig. 6).
It is critical to a successful outcome that the History, technique, and results will be discussed
etiology and underlying cause of the defect is in the next chapter of this book. Th
The initial results
adequately identifi fied. Correction of underlying were disappointing, due to absence of strict indi-
abnormalities is necessary and it might be neces- cations, bad designs, not known technical pitfalls
sary to combine the procedure with, for example,
an anteromedialization of the tibial tuberosity or
another procedure to correct instability. The
Th carti-
lage loss also has to be contained and not diffuse.
ff
The more recent published results are promising.
Minas and Bryant (58) performed a 7-year, pro-
spective cohort study with a satisfying outcome
in 71% of patients. Minas and Peterson (33) are
reporting good results with ACI when used for tro-
chlear lesion, but had less success resurfacing the
patella.
ACI is a considerable option for disabling anterior
knee pain, resulting from large erosive chondral
defects, if they are contained, when on Merchant
or skyline radiographs the joint space remains
intact, and when combined with correction of the
underlying abnormality. With collapse of the joint
space, a prosthetic resurfacing procedure should Fig. 6 – Patellofemoral arthroplasty.
570 The Degenerative Knee
and no attention for realignment of the extensor
mechanism. Failures were associated with incom-
plete correction of malalignment, malposition of
components, and concomitant tibiofemoral arthri-
tis, but seldom with mechanical component failure.
In Europe this led to eff
fforts to redesign the implant
and improve the operative technique, while in the
United States most surgeons abandoned the pro-
cedure. The recent literature has been far more
encouraging.
At this moment, patellofemoral arthroplasty is a
valuable option in the treatment of severe PFJ OA
with important narrowing or obliteration of the
patellofemoral joint space and an intact tibiofemo-
ral joint.
Total knee arthroplasty
The excellent results with total knee arthroplasty
for general osteoarthritis of the knee have led to
the use of total knee arthroplasty to treat severe
isolated PFJ OA. This choice has recently in lit-
erature been confirmed
fi as an eff
ffective method of
dealing with this problem in the older age-group.
A traditional total knee arthroplasty removes all
present and future sources of arthritis and gives
reliable predictable results.
Although the technique of total knee arthro-
plasty for patellofemoral disease is, in essence,
the same as for tricompartimental arthrosis,
leaving aside the question whether the patella
should be routinely resurfaced, it is technically a
more challenging operation, because of the typi-
cal underlying abnormal mechanics and align-
ment. It is critical to avoid internal rotation and
medialization of both the femoral and tibial com-
ponent, to maintain the joint line, to position
the patellar button correctly, and to maintain
Table 3 – Algorithm for treatment of patellofemoral arthritis.
mild mild/
no underlying predominant lateral
malalignement malalignement
lateral
patellar tilt
debridement
procedure
lateral
release
patellar thickness, all in order to realize a perfect
patellar tracking. A higher rate of lateral release
can be expected.
Early failures are still described, but the longevity
of current designs is excellent and studies report
on good-to-excellent results in terms of pain relief
and function (59–61). In a study of Laskin and
Davis (59), the results for isolated PFJ OA were
even superior than the results achieved by compar-
ison groups that received a total knee arthroplasty
for tricompartimental arthrosis, as well concern-
ing range of motion, knee score, as satisfaction and
general health on SF-36 questionnaires. Neverthe-
less, three reports on this approach show a high
rate of residual post-operative patellar tilt, asym-
metrically resurfaced patellae, and residual sublux-
ation, refl
flecting the above-mentioned complexity
of this pathology.
Although one can question the resection of intact
cartilage, cruciate ligaments and menisci to treat
a unicompartimental disease, total knee arthro-
plasty currently remains a reasonable option, until
the same reliable results can be equalled by other
procedures.
Conclusions: algorithm for treatment
It is clear that there is a whole spectrum of patel-
lofemoral abnormalities and anomalies that can
finally lead to severe degeneration of the patel-
lofemoral joint. There is a correspondingly wide
array of treatment options (50, 62–64), depending
on the underlying reason for the development of
the lesions and on the location of the lesions. In
order to choose the appropriate treatment modal-
ity with the best predictable result, a determina-
conservative treatment
(min 6 months)
severe / severe / severe / diffuse
lateral facet localized
malalignement intact joint line
lateral patellar young old
subluxation
ACI
anteromedial tibial lateral total patellofemoral
tubercle transfer facetectomy patellectomy prosthesis
 Patellofemoral osteoarthritis : pathophysiologie, treatment, and results 571
tion of the precise etiology is mandatory. Despite
the progress in the treatment of patellofemoral
arthritis, it remains difficult
ffi to achieve absolute
unanimity on the best way to treat a given patient.
We need to learn more regarding which group of
patients with anterior knee pain or malalignment
will develop arthritis, in which this evolution
might be stopped by an early, not too invasive,
intervention. We need more prospective random-
ized long-term symptomatic and functional results
on current treatment options used to deal with
more severe isolated patellofemoral degeneration,
in stead of uncontrolled observational case series,
retrospectively reviewed, often with a mix of diag-
noses. In the meantime, the algorithm in Table 3,
based on current published results in literature,
can be helpful in the management of patients with
PFJ OA.
References
1. Davies AP, Vince AS, Shepstone L, Donell ST, Glasgow
MM (2002) The radiologic prevalence of patellofemoral
osteoarthritis. Clin Orthop 402:206–212
2. McAlindon TE, Snow S, Cooper C, et al. (1992) Radio-
graphic patterns of osteoarthritis of the knee joint in the
community: the importance of the patellofemoral jont.
Ann Rheum Dis 51:844–849
3. Bellemans J (2003) Biomechanics of anterior knee pain.
Knee 10:123–126
4. Fulkerson JP, Patellar tilt/compression and the excessive
lateral pressure syndrome (ELPS). In: Fulkerson JP (1997)
Disorders of the patellofemoral joint, 3rd edn. Williams
and Wilkins, pp 153–173
5. Cartier P, Sanouiller JL, Grelsamer RP (1990) Patellofemo-
ral arthroplasty. 2-12-year follow-up study. J Arthroplasty
5:49–55
6. Post W (1999) Clinical Evaluation of patients with patel-
lofemoral disorders. Arthroscopy 15:841–851
7. Post WR, Fulkerson JP (1994) Knee pain diagrams: corre-
lation with physical examination findings in patients with
anterior knee pain. Arthroscopy 10:618–623
8. Cushnaghan J, McCarthy C, Dieppe P (1994) Taping the
patella medially: a new treatment for osteoarthritis of the
knee joint? Br Med J 308:753–755
9. Hinman R, Crossley K, McConnell J, et al. (2003) Effi fficacy
of knee tape in the management of knee osteoarthritis: a
blinded randomised controlled trial. Br Med J 327:135–
138
10. Powers C, Ward S, Chan L, et al. (2004) The
Th eff ffect of brac-
ing on patella alignment and patellofemoral joint contact
area. Med Sci Sports Exerc 36:1226–1232
11. Powers C, Ward S, Chen Y, et al. (2004) The
Th eff ffect of brac-
ing on patellofemoral joint stress during free and fast
walking. Am J Sports Med 32:224–231
12. Wilk KE, Davies GJ, Mangine RE, et all (1998) Patellofemo-
ral disorders: a classifi
fication system and clinical guidelines
for nonoperative rehabilitation. J Orthop Sports Phys
Ther 28:307–322
13. Bellemans J (2000) Operative management of patellofem-
oral arthritis. Curr Opin Orthop 11:19–25
14. Federico D, Reider B (1997) Results of isolated patellar
debridement for patellofemoral pain in patients with nor-
mal patellar alignment. Am J Sports Med 25:663–669
15. Schonholtz G, Ling B (1985) Arthroscopic chondroplasy of
the patella. Arthroplasty 1:92–96
16. Bentley G (1978) The surgical treatment of chondromala-
cia patellae. J Bone Joint Surg Br 60B:74–81
17. Goodfellow J, Hungerord DS, Woods C (1976) Patellofem-
oral joint mechanics and pathology 2. Chondromalacia
patellae. J Bone Joint Surg Br 58B:291–299
18. Childers JC, Ellwood SC (1979) Partial chondrectomy
and subchondral bone drilling for chondromalacia. Clin
Orthop 144:114–120
19. Ficat RP, Ficat C, Gedeon P, et al. (1979) Spongializa-
tion: a new treatment for diseased patellae. Clin Orthop
144:74–83
20. Jackson R, The role of arthroscopy in patellofemoral
arthritis in the patellofemoral joint. In: Fox J, Del Pizzo W
(1993) The patellofemoral joint. McGaw-Hill
21. Schutzer SF, Ramsby GR, Fulkerson JP (1986) Th The evalua-
tion of patellofemoral pain using computerized tomogra-
phy. Clin Orthop 204:286–288
22. Fulkerson JP, Schutzer SF, Ramsby GR, et al. (1987) Com-
puterized tomography of the patellofemoral joint before and
after lateral release or realignment. Arthroscopy 3:19–24
23. Fabbriciani C, Panni A, Delcogliano A (1992) Role of
arthroscopic lateral release in the treatment of patell-
ofemoral disorders. Arthroscopy 8:531–536.
24. Osborne AH, Fulford PC (1982) Lateral release for chon-
dromalacia patellae. J Bone Joint Surg Br 64B:202–205
25. Christensen F, Soballe K (1988) Treatment of chondromal-
acia patellae by lateral retinacular release of the patella.
Clin Orthop 234:145–147
26. Jackson R, Kunkel S, Taylor G (1991) Lateral retinacu-
lar release for patellofemoral pain in the older patient.
Arthroscopy 7:283–286
27. Aderinto J, Cobb AG (2002) Lateral release for patellofem-
oral arthritis. Arthroscopy 18:399–403
28. Fulkerson JP, Becker GJ, Meany JA, Miranda M, Folcik
MA (1990) Anteromedial tibial tubercle transfer without
bone graft. Am J Sports Med 18:490–497
29. Fulkerson JP (1983) Anteromedialization of the tibial
tuberosity for patellofemoral malalignment. Clin Orthop
177:176–181
30. Fulkerson JP (1994) Patellofemoral pain disorders: evalua-
tion and management. J Am Acad Orthop Surg 2:124–132
31. Bellemans J, Cauwenberghs F, Witvrouw E, et al. (1997)
Anteromedial tibial tubercle transfer in patients with
chronic anterior knee pain and a subluxation-type patellar
malalignment. Am J Sports Med 25:375–381
32. Morshuis WJ, Pavlov PW, deRooy KP (1990) Anteromedi-
alization of the tibial tubercle in the treatment of patel-
lofemoral pain. Clin Orthop 255:242–250
33. Sakai N, Koshino T, Okamoto R (1996) Pain reduction
after anteromedial displacement of the tibial tuberosity:
5 year follow-up in 21 knees with patellofemoral malalign-
ment. Acta Orthop Scand 67:13–15
34. Pidoriano AJ, Weinstein RN, Buuck DA, Fulkerson JP
(1997) Correlation of patellar articular lesion
35. Hauser EW (1938) Total tendon transplant for slipping
patella. Surg Gynecol Obstet 66:199–214
36. Cox JS (1982) Evaluation of the Roux-Elmslie-Trillat pro-
cedure for knee extensor realignment. Am J Sports Med
10:303–310
37. Stetson WB, Friedman MJ, Fulkerson JP, Cheng M, Buuck
D (1997) Fracture of the proximal tibia in immediate
weight-bearing after a Fulkerson osteotomy. Am J Sports
Med 25:570–574
38. Maquet P (1976) Advancement of the tibial tuberosity.
Clin Orthop 115:225–230
39. Maquet P (1963) Un traitement biomecanique de
l’arthrose femoropatellaire: l’advancement du tendon
rotulien. Revue de rhumatologie et des maladies osteo-
articulaires 30:779–783
40. Maquet P (1979) Mechanics and osteoarthritis of the
patellofemoral joint. Clin Orthop 144:70–73
572 The Degenerative Knee
41. Ferguson AB Jr, Brown TD, Fu FH, et al. (1979) Relief of
patellofemoral contact stress by anterior displacement of
the tibia tubercle. J Bone Joint Surg Am 61:159–166
42. Schepsis AA, DeSimone AA, Leach RE (1994) Anterior
tibial tubercle transposition for patellofemoral arthrosis.
Am J Knee Surg 7:13–20
43. Nakamura N, Ellis M, Seedhom BB (1985) Advancement
of the tibial tuberosity. A biomechanical study. J Bone
Joint Surg Br 67:255–260
44. Ferrandez L, Usabiaga J, Yubero J, et al. (1989) An experi-
mental study of the redistribution of patellofemoral pres-
sures by the anterior displacement of the anterior tuber-
osity of the tibia. Clin Orthop Relat Res 238:183–189
45. Heatly FW, Allen PR, Patrick JH (1986) Tibial tubercle
advancement for anterior knee pain. A temporary or
permanent solution. Clin Orthop Relat Res 208:215–
224
46. Jenny JY, Sader Z, Henry A, et al. (1996) Elevation of the
tibial tubercle for patellofemoral pain syndrome. An 8- to
15-year follow-up. Knee Surg Sports Traumatol Arhrosc
4:92–96
47. Engelbretsen L, Svenningsen S, Benum P (1989) Advance-
ment of the tibial tuberosity for patellar pain. A 5-year
follow-up. Acta Orthop Scand 60:20–22
48. Martens M, De Rycke J (1990) Facetectomy of the
patella in patellofemoral osteoarthritis. Acta Orthop Belg
56:563–567
49. McCarroll JR, O’Donoghue DH, Grana WA (1983) The Th
surgical treatment of chondromalacia of the patella. Clin
Orthop 175:130–134
50. Yercan HS, Ait Si Selmi T, Neyret P (2005) The
Th treatment
of patellofemoral osteoarthritis with partial lateral facet-
ectomy. Clin Orthop Relat Res 436:14–19
51. Baker CL, Hughston JC (1988) Miyakawa patellectomy. J
Bone Joint Surg Am 70:1489–1494
52. Blatter G, Jackson R, Bayne O, et al. (1987) Patellectomy
as a salvage operation. Orthopedics 16:310–316
53. Sutton FS, Thompson CH, Lipke J, et al. (1976) The
Th effffect
of patellectomy on knee function. J Bone Joint Surg Am
58A:537–540
54. Lennox D, Hungerford D, Krackow K (1987) Total
knee arthroplasty following patellectomy. Clin Orthop
223:220–224
55. Joshi A, Lee C, Markowich L (1994) Total knee arthroplasty
after patellectomy. J Bone Joint Surg Br 76B:926–929
56. Lennox IA, Cobb AG, Knowles J, et al. (1994) Knee func-
tion after patellectomy. A 12-to 48 year follo-up. J Bone
Joint Surg Br 76:485–487
57. Compere CL, Hill JA, Lewinnek GE, et al. (1979) A new
method of patellectomy for patellofemoral arthritis. J
Bone Joint Surg Am 61:714–718
58. Minas T, Bryant T (2005) The role of autologous chondro-
cyte implantation in the patellofemoral joint. Clin Orthop
Relat Res 436:30–39
59. Laskin R, Davis J (1999) Total knee replacement in patients
with patellofemoral arthritis. Clin Orthop 367:89–95
60. Mont MA, Haas S, Mullick T, et al. (2002) Total knee
arthroplasty for patellofemoral arthritis. J Bone Joint
Surg Am 84:1977–1981
61. Parvizi J, Stuart MJ, Pagnano MW, et al. (2001) Total
knee arthroplasty in patients with isolated patellofemoral
arthritis. Clin Orthop 392:147–152
62. Grelsamer RP, Stein DA (2006) Patellofemoral arthritis. J
Bone Joint Surg Am 88:1849–1860
63. Donell ST, Glasgow MMS (2007) Isolated patellofemoral
osteoarthritis. Knee 14:169–176
64. Hinman RS, Crossley KM (2007) Patellofemoral joint
osteoarthritis: an important subgroup of knee osteoar-
thritis. Rheumatology 46:1057–1062
65. Minas T, Peterson L (2000) Aotologous cartilage trans-
plantation. Op Tech Sports Med 8:144–157
66. Saleh KJ, Arendt EA, Eldridge J, et al. Operative treat-
ment of patellofemoral arthritis. J Bone Joint Surg Am
87:659–671
 Chapter 50

J. H. Newman Patellofemoral replacement

Introduction cating a degree of dysplasia. It therefore seems

that patella instability is of paramount impor-

T
raditional knee replacement has been under- tance in the development of isolated PFOA. The Th
taken for tibio femoral disease with early association with patella dislocation has long been
designs usually ignoring the patellofemoral recognized but probably minor degrees of insta-
joint. However, in recent years it has become recog- bility, often associated with some pain can lead
nized that the patellofemoral joint is a frequent site to pre-mature isolated PFOA (6) with symptoms
for knee pain (1) and arthritic changes restricted
early in life persisting for many years before ulti-
to this joint are not at all uncommon (2).
mately the pathological and radiological changes
Multiple treatments have been tried both opera-
tively and non-operatively. None have been uni- develop (Fig. 2).
versally successful with the result that isolated
patellofemoral replacement (PFR) has increased
in popularity despite the relative lack of published
data. The procedure though remains infrequently
performed, representing just 1% of the knee
replacements undertaken in the UK and even less
in North America.

Pathogenesis of patellofemoral osteoarthritis

(PFOA)
Although PFOA can present as part of a general-
ized knee arthritis it is becoming obvious that
mechanical factors usually play an important part. Fig. 1 – A true lateral radiograph showing a crossing sign and mild anterior
boss.
The Bristol Knee database now contains patholog-
ical data on over 600 knees which have undergone
isolated PFR as well as others treated with re-align-
ment procedures. The most frequently recorded
pathological diagnosis is lateral facet osteoar-
thritis, which probably follows some instability
or mal-tracking. Until the last few years trochear
dysplasia was not recorded as a diagnosis though
previous dislocation was because for many years
this has been known to be associated with PFOA
whether or not treated by a re-alignment proce-
dure (3). Careful analysis of the Bristol cases has
shown trochlear dysplasia to be a frequent precur-
sor of PFOA. It has also been noted that patients
present with a variety of initial symptoms and
only two thirds have ever suff
ffered a dislocation (4)
even though Dejour et al. (5) have shown that 90% Fig. 2 – Operative picture of anterior femur in trochlear dysplasia. Note the
of knees with a dislocating patella have a positive complete absence of a groove. Patellectomy and multiple other operations
crossing sign on a true lateral X-ray (Fig. 1) indi- had previously been performed for the unrecognized trochlear dysplasia.
574 The Degenerative Knee
Patella fracture is also an important cause of iso-
lated PFOA though the number of cases seen is
small considering the frequency with which patella
fractures occur. This is probably because in youth
the patella is covered with a thicker layer of articu-
lar cartilage than any other joint which helps to
avoid the rapid development of arthritic changes.
Presentation
There is an amazing variation in the magnitude of
the symptoms caused by established PFOA. Just
as severe patellofemoral pain can be experienced
by youngsters who seem to have pristine joints so
many patients with gross radiological changes get
little in the way of pain though many have catch-
ing even if pain is not a symptom. More commonly
though patients present with anterior knee pain
which tends to be aggravated by activity; particu-
larly that which involves weight-bearing on a flexed
fl
knee. Stair climbing is usually painful and kneeling
or squatting impossible. Frequently the complaint
is of locking or giving way and night pain is more
common than in pure tibio femoral arthritis.
Non-operative treatment in the form of quadriceps
strengthening exercises can help since patients
frequently have gross weakness and wasting.
However, it is often impossible to build up wasted
quadriceps musculature since attempting to do so
aggravates the pain and prevents maximal effort.ff
Since the disease usually affects
ff the lateral facet
(Fig. 3), medializing the patella by taping or brac-
ing can help though it is usually not a satisfactory
long-term solution. Articular steroid injections can
help with exacerbations but do little for the long-
term and likewise hyaluronic acid injections seem
only to have a short-lived benefifit (7).
There are multiple non-arthroplasty surgical treat-
Th
ments for PFOA including arthroscopic debride-
Fig. 3 – A typical skyline of an elderly patient with advanced lateral com-
partment patellofemoral arthritis. The most common pattern.
ment, re-alignment procedures with or without
anteriorization, cartilage repair methods, lateral
facetectomy, and patellectomy. All have their advo-
cates but there are few long reports or control
studies which makes evaluation diffi fficult. However,
it has been known for many years that patellec-
tomy for isolated PFOA is unsatisfactory (8) and
that extensor mechanism re-alignment for insta-
bility can result in arthritic changes (3) so as yet no
conservative surgical treatment has proved univer-
sally satisfactory. It is against this background that
isolated PFR must be viewed.
Historical aspects of patellofemoral
replacement
Patella capping or hemi-arthroplasty
PFR was first reported in 1955 (9) by McKeever who
introduced a cap to re-surface the patella leaving the
trochlea untouched. Others adopted this approach
which was used both for cases of osteoarthritis and
chondromalacia patellae. Although some (10, 11)
noted good pain relief, movement and strength in
the short-term, others (12) found only half to be
satisfactory after a 12 year follow-up. In 1979, Wor-
rall (13) reported on the short-term outcome of 14
cases treated with a diff
fferent patella cap prosthesis
that could be reversed for use in either knee. Th
These
cases included both chondromalacia and osteoar-
thritis with most having good short-term improve-
ment at 2 years, though he concluded that the ideal
material still needed to be developed and shortly
afterwards interest in patella capping or hemi-ar-
throplasty of the patellofemoral joint seems to have
diminished in favor of total replacement.
Total patellofemoral joint replacement
(resurfacing type)
The earliest reports of PFR relate to the Richards
prosthesis introduced in 1974 (12) and the Lubinus
in 1975 (13). Both implants were of a re-surfacing
type and aimed to fit the trochlea and thereby pro-
vide a satisfactory surface for articulation of the
patella on which a polyethylene button could be
fixed. Interestingly in the early years these implants
were frequently used in association with other pro-
cedures, a practice that is possibly returning with
the recent interest in high level performance after
knee replacement and the concept of soft tissue
guided knee replacement (14). In one series (15) of
183 PFRs 103 had an associated uni-compartmen-

tal replacement and in another series of 87 had 36
associated uni-compartmental replacements, six
of which were on the lateral side (12). In addition,
multiple other soft tissue re-alignment procedures
were frequently performed and in one series the
age range extended from 19 to 81 (16) suggesting
that multiple pathologies were being addressed.
There were clearly no defi
Th finite indications for the
use of an isolated PFR.
Despite this most series reported a fairly high per-
centage of patients had been improved though the
majority of the early series had only short-term
follow-up. All the early reports noted a variety of
problems which included mal-position of the com-
ponents (16, 17), diffi
fficulty fitting the trochlea to
the shape of the femur (12), tibio femoral arthritis
(17), and extensor mechanism problems (16).
Three articles (18–20) have reported longer term
results with the Richards prosthesis and demon-
strated that most patients had continuing good
function after a decade. However, they report a
relatively high complication rate with a consider-
able number of surgical procedures being required
following the PFR, these included patellectomy,
extensor mechanism re-alignment, lateral release
for lateral pain and prosthetic revision, usually
to a total knee replacement. Most commonly this
was because of progression of arthritis in the tibio
femoral joint, especially the medial compartment.
Polyethylene wear and trochlea loosening were not
major problems despite the trochlear component
being deep with the object of constraining the V
shaped polyethylene patella button. Similar prob-
lems were reported after 7 years with the Lubinus
prosthesis which is also sculpted into the trochlea
(21). It therefore seems that although many good
short-term results were being achieved, the survi-
vorship at around 15 years was only in the region
of 75% which does not match that seen following
modern total knee replacement (22).
Contemporary designs
Whereas most of the older PFRs were designed
to be sculpted to fi
fit into a normal trochlea, in the
1990s prostheses were designed to follow total
knee technology and resect the anterior femur,
only removing a minimal extra amount of bone
to allow for seating of the trochlear groove. In
this way the problem of matching a component to
a worn or dysplastic trochlea is avoided. In addi-
tion, a flat resection of the anterior femur allows
for a broader groove and permits a degree of exter-
nal rotation of the prosthesis, both factors which
should help to maintain normal congruent patella
tracking. Several prostheses have followed this
principle (Hermes, Avon, Leicester). The geometry
of the articular surface can then replicate that of a
Patellofemoral replacement 575
Fig. 4 – The Avon prosthesis which resects the anterior femur and has a
broad shallow but symmetrical trochlear.
total knee replacement with the surgical technique
becomes more familiar. As a result, the popular-
ity of the procedure improved massively in the
last decade with larger numbers being performed,
particularly of the Avon implant (Fig. 4). ThThe suc-
cess rate with contemporary designs is said to be
80–90% at mid-term follow-up (23) though few
reports of results are available. The 5-year outcome
of the first 100 Avon cases from Bristol showed a
96% survivorship with high overall knee scores
(24). All had genuine patellofemoral arthritis and
the problem of recurrent or persistent instabil-
ity previously encountered with narrow trochlear
components was much diminished. However, this
did depend on adequate soft tissue releases and
re-alignment being performed at the time of the
surgery.
Unfortunately the problem of patient selection
was not fully solved although the prosthetic design
had improved. In Bristol over 400 cases of the
Avon PFR have been followed up over an 11-year
period and inevitably problems have been seen.
Initial Bristol experience with compartmental
knee replacement related to uni-compartmental
replacement of the tibio femoral joint. Studies had
shown there was a very low rate of progression of
arthritis in the other compartments (25) though
the problem was slightly greater after lateral uni-
compartmental replacement (26). This experience
resulted in cases with minor changes in the tibio
femoral joint being accepted for isolated PFR and
as a result some failures occurred. In addition,
progression of the arthritic process was noted in
either the medial (Fig. 5) or lateral compartments
(27), though interestingly progression of arthritis
was minimal amongst the younger cases where the
primary diagnosis was trochlear dysplasia as had
been previously noted (28).
Although progression of tibio femoral arthritis
is the major cause of failure following Avon PFR,
576 The Degenerative Knee
A B
Fig. 5 – Arthritic progression in the medial compartment 5 years after an Avon PFR.
Fig. 6 – The sided journey trochlear which resects the anterior femur but
has an S-shaped groove to aid patella capture and is made of Oxinium to
reduce wear in younger patients.
a recent review has highlighted other occasional
problems. Surgical error has defifinitely resulted in a
few failures and it has been particularly noted that
in some cases there has been a failure to achieve
correct external rotation of the trochlea component
which can result in lateral side pain, catching, and
wear (Fig. 7) (29). Such errors can probably be over-
come by improved instrumentation or navigation.
Modern designs
The Avon PFR has been much the most widely used
PFR in the last decade. However, it is a symmetri-
cal prosthesis based on the Kinemax + TKR. As all
modern knee arthroplasties are sided, it seems
logical the same should apply to PFR. Since 2000
several new designs have been created with a broad
sided trochlear component (FPV, Journey and Per-
formance). As yet these implants have only very
short-term results available. However, the design
concepts are probably superior. The Journey PFR
(Fig. 6) has an S-shaped trochlear groove based on
the Genesis TKR which helps to capture the patella
in extension. The trochlea itself is broad but deep
enough to resist patella displacement and in addi-
tion the implant is made of Oxinium which should
reduce the likelihood of polyethylene wear on the
patella button (Fig. 6) (30). This
Th is important since
many patients are young and will tend to wear
their patella button over a long time period.
Analysis of the rotation alignment with the Avon
trochlear component has highlighted a problem
(Fig. 7) and suggests that relying on instrumenta-
tion attached to the femoral jig is unreliable. Shake-
speare (31) has demonstrated that using the famil-
iar extra medullary tibial alignment systems can
give excellent rotational control, which is essential
for successful PFR. Use of such instrumentation
 Patellofemoral replacement 577

Fig 7 – Following bilateral replacement the right side was satisfactory but the left painful. CT scan shows undesirable internal rotation of the trochlear
component on the left.

Table I – Reported survivorship of patellofemoral replacements.

Prosthesis No FU (years) Survivorship (%) Author
Autocentric 66 5 85 Argenson
Avon 85 5 96 Ackroyd
LCS 15 4 100 Merchant
Lubinus 76 8 72 Tauro
Richards 24 11 80 de Winter
Richards 56 16 79 Kooijman
Richards 79 10 75 Cartier
Richards / CSF 25 5 72 Arciero
Richards 45 5 80 De Cloedt

has been incorporated into the Journey and FPV
systems and preliminary results suggest that bet-
ter rotational control can be achieved in this way,
which ought to improve outcomes.
Results
Th results of PFR are diffi
The fficult to give in any mean-
ingful way since different
ff series have treated dif-
ferent groups of patients and the implants have
undoubtedly evolved and improved over the years
(Table 1). In addition, it is frequently impossible to
be confi
fident of the survivorship from the figures
quoted in the article. However, table 1 gives an
indication of the revision rates reported in some
of the longer-term series. Th These figures do not
necessarily imply that the surviving cases were a
clinical success and it must of course be appreci-
ated that some compartmental replacements are
revised without any clear indication and doing so
does not guarantee improvement. It should also be
noted that in most cases the revision was not for
failure of the prosthesis itself as in general authors
report a very low rate of loosening or other pros-
thetic problems.
No published survivorship results are available
for a variety of patellofemoral prostheses includ-
ing the Leicester, FPV, Hermes, Journey, and Per-
formance.
An alternative approach
Customized PFR has been used in very small num-
bers since 1975 (32). The implant is designed to re-
establish the alignment and depth of the trochlear
groove and to re-position the patella anteriorly to
improve quadriceps function. All cases undergo a
pre-operative CT scan allowing a customized tro-
chlear component to be made which is designed
to replace the damaged articular cartilage. At sur-
gery the remaining cartilage is removed down to
subchondral bone and anchoring holes are drilled
prior to standard cemented implantation. Good
results are reported at 6 years for 25 cases, which
578 The Degenerative Knee

is interesting especially as there is no mention of
how to deal with the commonly seen lateral bone
loss. Presumably early cases were being treated
though the disease was said to be severe PFOA.
This variant of PFR will need to be watched with
interest especially with regard to patients who
merely have cartilage damage. However, the extra
work and expense of a pre-operative CT scan will
probably make the system unsuitable for general
use.
ticularly in the presence of dysplasia. Again the
available cutting jigs all rely on TKR technology
and achieving an oblique cut is all too easy, but
might be avoided by a diff fferent approach (33).
Further work is needed to improve the patella re-
surfacing, especially as these are young patients
in whom perfect alignment will probably help to
increase longevity.

Total Knee Replacement

The patella This is now a predictable and durable procedure
for end stage knee arthritis which can be used
Far less work seems to have been done in relation to treat isolated PFOA. Several authors (34–36)
to patella replacement in isolated PFOA than to have advocated this approach to the problem and
the trochlea. Some of the older systems used spe- Thompson et al. (37) report satisfactory short-
cially designed patella implants to fit the groove of term results in a small group of such patients
the trochlea and the well tried Richards Mod 2 and treated by knee replacement without patella re-
3 used a V-shaped patella button to help maintain surfacing, though one-third of their patients
stability. Contemporary systems rely on a total required a walking aid. However, all these series
knee type button since stability should be achieved were dealing with relatively low demand patients
by soft tissue balancing. While such buttons have with an average age of around 70 and the authors
largely proved satisfactory in TKR little is known
about their performance in isolated PFR where
two difffferent problems are posed. Firstly, patella
impingement on the femoral articular cartilage
can occur in deep flexion;
fl this occurred with the
Avon prosthesis and Kinnnex + button resulting in
modifification of the button by creation of an odd
facet. Such a modifification may help but no stud-
ies yet exist demonstrating the ideal shape for a
patella button in isolated PFR. Similarly, no report
exists for the use of a trochlear component with-
out patella re-surfacing; a principle which seems
to have worked fairly satisfactorily in total knee
replacement.
Secondly, the patella is frequently very worn
and sclerotic in patellofemoral arthritis par-
B

A
Fig. 8 – Instrumentation for obtaining optimal trochlear rotational align-
ment. Although the arm attached directly to the femur (a) can be used
greater accuracy and reliability is gained by using the extra medullary tibial
alignment guide (b and c).

felt the patients did as well as those having TKR
for bi- or tri-compartmental disease. By contrast,
Kolettis and Stern (38) found the results of TKR
for PFOA less good than for generalized knee
arthritis and Parvizi (39) noted 20% residual knee
pain and a high rate of asymmetric patella cuts
and balancing problems.
There is no doubt that TKR can provide a satis-
factory solution for the elderly group of patients
with PFOA but it is a much larger operation than
isolated PFR and is associated with a higher blood
loss and rate of pulmonary embolus (40). It is also
far harder to revise and sacrifi
fices a large number of
normal structures which contribute to the feeling
and function of the knee. It is certainly an inappro-
priate solution for the younger patients who make
up a substantial proportion of most series. How-
ever, it remains an option for the elderly though it
would be inappropriate for the significant
fi number
of patients under 55 with severely symptomatic
PFOA.
The Surgical Procedure
PFR can be performed through any standard knee
replacement incision so the majority of surgeons
utilize a medial parapatellar approach though
mid or subvastus approaches can be used if pre-
ferred. The incision should be based slightly proxi-
mal to that used for TKR and care must be taken
to avoid damaging the meniscus or tibio femoral
articular cartilage. The
Th patella does not need to
be everted and a minimally invasive approach can
be used. The entire joint is easily inspected and a
medial approach can be extended to allow TKR to
be undertaken if unexpected damage to the tibio
femoral joint is found.
Accurate alignment of the trochlear component
must be achieved, paying particular attention to
rotation (Fig. 8). No reports yet exist of leaving
the patella un-resurfaced so this should not be
done. The thickness of the patella should always
be measured since they are frequently misshapen
and extremely thin. Though it is desirable to leave
14 mm of bone this is not always possible. Care
must be taken to avoid an asymmetric cut and not
infrequently the button will need to be supported
on a peripheral rim with a central defect that can
be filled with bone graft or cement (Fig. 9). Virtu-
ally all patellae can be resurfaced in this way. The
Th
use of a patella augmentation button would be an
option in excessively thin patellae. In cases where
a previous patellectomy has been performed it is
unnecessary to attempt reconstruction44.
The ideal shape of the patella button is yet to be
determined. Most systems use an onlay button
Patellofemoral replacement 579
A B
C D
Fig. 9 – Resurfacing of a thin defective patella (a) can be achieved by creat-
ing a central defect and leaving a peripheral rim (b). Two good anchorage
holes can usually still be achieved (c) though a large size patella button may
be required to obtain an adequate peripheral support (d).
but inlay may prove to be at least as satisfactory
though many arthritic patellae are extremely
sclerotic and achieving optimal seating may be
hard.
The vital part of the operation is ensuring correct
tracking occurs. Many more cases than in TKR will
require a lateral release. Trochlear rotation is criti-
cal and in a small number tibial tubercle medial-
ization with or without VMO advancement will be
required. By whatever means, the necessary per-
fect tracking must be achieved or the patient will
suff
ffer with catching and lateral pain.
Since most cases present with lateral patellofemo-
ral disease, often associated with subluxation it is
perhaps logical to use a lateral approach. This gives
slightly less satisfactory access but seems sensible
as the capsular incision performs the lateral release
and can be left open if necessary. In addition, the
need for a medial incision is avoided thus preserv-
ing quadriceps function. The
Th skin incision can also
be placed more laterally thus preserving normal
sensation over the front of the knee. The disad-
vantages of a lateral incision are that it is a less
satisfactory approach should a TKR be required,
there is an increased risk of bleeding from the lat-
eral genicular vessels and a less well-defined
fi cap-
sular layer makes closure, when required, more
diffi
fficult.
Indications for PFR
There is a poor relationship between pathology
and symptoms which can make decision-making
diffi
fficult but naturally the procedure should only
be carried out on severely symptomatic knees
(Table 2).
580 The Degenerative Knee

Table II – Indications for isolated patellofemoral replacement.

1 Isolated patellofemoral arthritis in the elderly
2 Patellofemoral arthritis in middle age especially when associated with extensor mechanism instability and dysplasia
3 PFOA following patella fracture
4 Persistent patella instability with chondral damage
5 Severely symptomatic chondral damage to the PFJ
6 Persistent subluxation of the extensor mechanism after patellectomy
7 Post patellectomy pain when done for PFOA
Note: The procedure is not indicated for adolescent anterior knee pain or “chondromalacia patellae.”

A C

D E

Fig. 10 – Pre-operative radiographs (a and b) showing a normal tibiofemoral joint in association with patella dislocation, trochlear dysplasia, and PFOA.
Post-operative films show a satisfactory PFR with a well-tracking patella. (c–e).

Although PFR has grown in popularity its precise
indications have yet to be clearly defined.
fi It seems
probable that PFOA may occur as the primary dis-
ease in the elderly when PFR would be appropriate.
Traditionally this has been the primary indication;
however, care must be taken to ensure that the
PFOA is not just the first
fi part of tri-compartmen-
tal arthritis since in such circumstances failure
from progression of arthritis in the tibio femoral
joint will occur within a few years. The
Th tibiofemoral
joint therefore has to be near perfect at the time
of surgery.
Undoubtedly PFOA occurs as a secondary problem
following extensor mechanism instability and dys-
plasia. In these circumstances, the patient tends to
present with severe symptoms between the ages of
30 and 60 when most surgeons would be reluctant
to undertake a total knee replacement. It is this
group which forms the prime indication for PFR
since their tibio femoral joints are likely to remain
intact for many years and excellent results from a
fairly minor procedure can be expected. Similarly,
those with PFOA following a patella fracture can
usually be helped.
Persistent subluxation or dislocation of the exten-
sor mechanism normally implies a dysplastic tro-
chlear groove with an anterior bump displacing the
patella or quadriceps tendon. Such cases require a
groove in order to obtain stability. In the young
with intact cartilage this can be achieved by a tro-
chleoplasty but once eburnated bone is exposed
trochlear replacement is preferable and can give
excellent results whether or not a previous patel-
lectomy has been performed (41). (Fig. 10).
All series of PFR note a high number of previ-
ous surgical procedures, usually unsuccessfully
attempting to stabilize the extensor mechanism
or to repair the damaged articular cartilage. A few
though will have post-patellectomy pain where the
patellectomy has been performed for PFOA or ado-
lescent anterior knee pain. The former can usually
be helped, though probably not the latter.
Most early series of PFR included some cases of
adolescent anterior knee pain or chondromalacia
patellae. Th
These did not do well and this condition is
now defifinitely not an indication for PFR.
Conclusion
Patellofemoral pain has proved difficult
ffi to treat over
a number of years. It is now recognized as being a
common problem that does not always respond to
conservative treatment. Isolated PFR has been tried
for over 50 years with major design improvements
being made in the last decade. Excellent results can
now be expected at least in the mid-term though
Patellofemoral replacement 581
careful patient selection is still needed. The proce-
dure is here to stay but in small numbers. Improve-
ments in prosthetic design and instrumentation
will no doubt occur and further improvement in the
results should then be achieved.
References
1. MacAlindon TE, Snow S, Cooper C, Dieppe PA (1992)
Radiographic pattern of osteoarthritis of the knee joint
in the community: the importance of the patellofemoral
joint. Ann Rheum Dis 53:612–613
2. Davies AP, Vince AS, Shepstone L, et al. (2002) TheTh radio-
logic prevalence of patellofemoral osteoarthritis. Clin
Orthop 402:206–212
3. Crosby BE, Insall JH (1976) Recurrent dislocation of the
patella: relation of treatment to osteoarthritis. J Bone
Joint Surg 58-A:9–13
4. Newman JH (2005) Patello-femoral replacement. A per-
sonal view. SA Orthop J: 48–54
5. Dejour M, Walch G, Neyret P et al. (1990) Dysplasia of the
femoral trochlear. Rev Clin Orthop 76:45–54
6. Utting MR, Davies G, Newman JH (2005) Is anterior knee
pain a predisposing factor to patellofemoral osteoarthri-
tis? Knee 12:362–365
7. Clark S, Lock V, Duddy J, et al. (2005) Intra-articular hylan
in the management of patellofemoral osteoarthritis of the
knee. Knee 12:57–62
8. Ackroyd CE, Polyzoides AJ (1970) Patellectomy for
osteoarthritis. J Bone Joint Surg 60-B:353–357
9. McKeever DC (1955) Patellar prosthesis. J Bone Joint
Surg 37-A:1074
10. Aglietti P, Insall JN, Walker PS, Trent P (1975) A new
patella prosthesis: design and application. Clin Orthop
107:175–187
11. De Palmer AF, Sawyer B, Hoff ffman JD (1960) Reconsid-
eration of lesions aff
ffecting the patellofemoral joint. Clin
Orthop 18:63–85
12. Cartier P, Sanouiller J-L, Grelsamer R (1990)Patellofemo-
ral arthroplasty. A 2–12 year follow-up study. J Arthro-
plasty 5:49–55
13. Lubinus HH (1979) Patella glide bearing total replace-
ment. Orthopaedics 2:119–127
14. Engh G (2007) Tissue guided knee replacement. Presiden-
tial address American Knee Society, San Diego
15. Agenson J-N A, Guillaume J-M, Aubaniac J-M (1995) Is
there a place for patellofemoral arthroplasty? Clin Orthop
Relat Res 321:162–167
16. Blazina ME, Fox JM, Del Pizzo W, et al. (1979) Patellofem-
oral replacement. Clin Orthop Relat Res 144:98–102
17. Arcerio RA, Toomey HE (1988)Patellofemoral arthroplasty:
a 3 to 9 year follow-up study. Clin Orthop 236:60–71
18. Cartier P, Sanouiller JL, Khefacha A (2005) Long-term
results with the first patellofemoral replacement. Clin
Orthop Relat Res 436:47–54
19. De Winter WE, Feith R, Van Loon CJ (2001) The Th Richards
type II patellofemoral arthroplasty: 26 cases followed for
1–20 years. Acta Orthop Scand 72:487–490
20. Kooijman HJ, Driessen AP, Van Horn JR (2003) Long-
term results of patellofemoral arthroplasty. A report of 56
arthroplasties with 17 years follow-up. J Bone Joint Surg
85-B:836–840
21. Tauro B, Ackroyd CE, Newman JH, Shah NA (2001) Th The
Lubinus patellofemoral arthroplasty—a five to ten year
prospective study. J Bone Joint Surg 83-B:696–701
22. Merchant AC (2004) Early results with a total patellofem-
oral joint replacement arthroplasty prosthesis. J Arthro-
plasty 19:829–836
582 The Degenerative Knee
23. Lonner JH, Jasko JG, Booth RE Jr (2006) Revision of a
failed patellofemoral arthroplasty to a total knee arthro-
plasty. J Bone Joint Surg 88-A:2337–2342
24. Ackroyd CE, Newman JH, Evans R, et al. (2007) TheTh Avon
patellofemoral arthroplasty: five year survivorship and
functional results. J Bone Joint Surg 89-B:310–315
25. Weale AE, Murray DW, Baines J, Newman JH (2000)
Radiological changes five years after unicompartmental
knee replacement. J Bone Joint Surg 82-B:996–1000
26. Walton MJ, Weale AE, Newman JH (2006) The progres-
sion of arthritis following lateral unicompartmental knee
replacement. Knee 13(5):374–377
27. Nicol SG, Loveridge JM, Weale AE, et al. (2006) Arthritis
progression after patellofemoral joint replacement. Knee
13:290–295
28. De Cloedt P, Lagaye J, Lokietek W (1999) Femoro-patella
prosthesis. Acta Orthop Belg 65:170–175
29. Mulford JS, Elridge JDJ, Porteous AJ et al (2009) Revi-
sion of isolated patellofemoral arthroplasty to total knee
replacement. Current orthopaedic Practice 20:437–41
30. Reis MD, Sahehi A, Widding K, Hunter GB (2001) Poly-
ethylene wear performance of oxidised zirconium and
chrome cobalt knee components under abraided condi-
tions. J Bone Joint Surg 83-A:129
31. Shakespeare D, Dikko B (2005)A simple precise technique
for making the anterior cut in patellofemoral resurfacing.
Knee 12:454–455
32. Sisto DJ, Sarin VK (2006) Custom patellofemoral arthro-
plasty of the knee. J Bone Joint Surg 88-A:1475–1480
33. Ammari T, Zniber B, Boisrenoult P, et al. (2005) Patellar
position and lateral approach for total knee arthroplasty
in degenerative knees with femoro patellar arthrosis. Rev
Chir Orthop Reparatrice Appar Mot 91:215–221
34. Laskin RS, Van Steijn M (1999) Total knee replacement
for patients with patello-femoral arthritis. Clin Orthop
367:89–95
35. Mont MA, Haas S, Mullick T, Hungerford DS (2002) Total
knee arthroplasty for patello-femoral arthritis. J Bone
Joint Surg 84-A:1977–1981
36. Dalury DF (2005) Total knee replacement for patellofemo-
ral disease. J Knee Surg 18:274–277
37. Thompson NW, Ruiz AL, Breslin E, Beverland DE (2001)
Total knee arthroplasty without patellar resurfacing in
isolated patello-femoral osteo-arthritis. J Arthroplasty
16:607–612
38. Kolettis GT, Stern SH (1992) Patellar resurfacing for
patellofemoral arthritis. Orthop Clin North Am 23:665–
673
39. Parvizi J, Stuart MJ, Pagnano MW, Hanssen AD (2001)
Total knee arthroplasty in patients with isolated patel-
lofemoral arthritis. Clin Orthop Relat Res 392:147–
152
40. Henderson MS, Newman JH, Hand GCR (1999)Blood loss
following knee replacement surgery; use it don’t lose it.
Knee 6:125–129
41. Ackroyd CE, Smith EJ, Newman JH (2004) Trochlear
resurfacing for extensor mechanism instability following
patellectomy. Knee 11:109–111
Indications in osteoarthritis
of the femoro-tibial joint

P. Djian, G. Bellier, B. Moyen,
X. Ayral, J. P. Bonvarlet
Is there a place for arthroscopy
in the degenerative knee?
Introduction
O
steoarthritis is the most prevalent chronic
joint disorder. Traditional surgical proce-
dures that address the arthritic knee involve
bone re-alignment such as high tibial osteotomy or
resurfacing by total knee arthroplasty and unicom-
partmental arthroplasty. Arthroscopic treatment
could be an option in the management of osteoar-
thritis of the knee. Arthroscopic management of
the osteoarthritic knee has become popular; this is
due at least in part to the fact that the more com-
plex surgical alternatives require longer recovery
periods, are more costly, and are associated with
greater morbidity. Although the primary goal of
arthroscopic surgery is to provide pain relief, one
of the benefifits of this minimally invasive approach
is that it enables patients to continue their regular
activities and to delay.
The first report for arthroscopic treatment was
made by Burman et al. (1) in 1934. Despite this
paper, the role of arthroscopy in the management
of osteoarthritis, however, has been more contro-
versial. The aim of the paper is to know if there is
some evidence-based medicine in the literature
indicates that arthroscopic procedures can predict-
ably serve as long-term treatment options in the
management of the arthritic knee.
Background
The first reported series in which arthroscopy
was successfully used to treat degenerative knee
arthrosis was published by Burman et al. (1) in
1934. These authors attributed their results to
mechanical washout of the knee alone. The
Th litera-
ture in following years emphasized the use of open
procedures. In 1940, Haggart (2) reported the suc-
cessful treatment of degenerative knee arthritis
with resection of osteophytes, loose bodies, hyper-
trophic synovium, and diseased cartilage through
an open arthrotomy. In 1941, Magnuson (3) intro-
duced the term joint debridement to describe this
technique and reported complete recovery in 60
Chapter 51
of 62 procedures. Procedural methods varied little
until 1959, when Pridie (4) introduced the concept
of drilling through eburnated bone to stimulate
the regeneration of articular cartilage. He did the
drilling with a Kwire. Subsequent research has
shown that this regenerated cartilage lacks the
wear characteristics and proteoglycan concentra-
tion found in native hyaline cartilage (5, 6). It was
only fibrocartilage.
The literature of the 1970s refl
flected a resurgence
of interest in arthroscopic management of the
osteoarthritic knee. In 1972, Jackson and Abe
(7) noted clinical improvement after diagnostic
arthroscopy in 200 consecutive painful knees. In
1973, O’Connor (8) reported marked improve-
ment after arthroscopic lavage in a significantfi
number of patients with crystal-induced synovitis
of the knee. Jackson (9) attempted to definefi the
role of arthroscopy in the assessment of disor-
ders and injuries of the knee. In addition to rein-
forcing the role of the arthroscope as a detector
of pathology, Jackson suggested expanding the
function of the arthroscope to include removal
of loose bodies and meniscal fragments. In 1981,
Sprague (10) reported the results of a large series
of patients who had undergone arthroscopic deb-
ridement as a treatment for degenerative arthritis
of the knee. Sixty-nine knees underwent removal
of meniscal tears and osteophytes, partial syn-
ovectomy, and chondral shaving. At a mean of
14 months, 74% of knees had good results, 10%
had fair results, and 16% were rated as failures.
No clinical or radiographic correlation was found
between extent of the arthritis and outcome.
Much of the ensuing literature on the effective-
ff
ness of arthroscopically delivered procedures in
the treatment of arthritic knees has done more
to confuse than to clarify. This
Th is because it is dif-
ficult to standardize the many variables present
in the cohorts of patients that are potential can-
didates for such procedures. Compounding this
problem are the diff ffering techniques of various
investigators and the varying inclusion criteria.
Due to these obstacles, the predictors for a suc-
cessful outcome are just now being defined
fi more
clearly.
586 The Degenerative Knee
Overview of the literature
Despite considerable documentation about surgi-
cal and non-surgical results, there is a few study
which is a Level I investigation of the treatment of
osteo-arthritis (OA) with arthroscopy.
The first study was done by Moseley et al. (11) in
Th
2002. Patients were enrolled from October 1995 to
September 1998.
The criteria for inclusion in the study included:
Th
(i) an age less than 75 years; (ii) osteoarthritis as
defi
fined by the American College of Rheumatol-
ogy; (iii) at least moderate knee pain on average,
despite maximal medical treatment for at least 6
months; and (iiii) no arthroscopy performed on
the knee in the previous 2 years. The severity of
OA was assessed radiographically and graded on
a scale of 1–4. The scores from all three compart-
ments were added for a total of 0–12. Patients were
excluded for severity greater than 9 on this scale,
severe deformity, or serious medical problems. Of
the 324 consecutive patients, 144 declined partic-
ipation. Patients provided informed consent, and
were made aware they may only receive placebo
surgery. The participants were stratifified into three
groups based on severity of OA, then randomized
into three treatment groups: arthroscopic lavage,
arthroscopic debridement, or placebo procedure.
The surgical procedure was performed by one sur-
Th
geon.
The primary end point of the study was pain in
Th
the knee 24 months after intervention, assessed
by a 12-item self-reported knee-specificfi pain scale.
Several secondary end points were used to assess
pain and function at all time points. ThereTh was
good reliability of these measurement scales, with
a Cronbach’s  exceeding 0.80.
The investigation, by Moseley et al. concluded out-
Th
comes after arthroscopic lavage or arthroscopic
débridement were no better than those after pla-
cebo procedure.
There are many details about this study which
Th
require critical evaluation because they are relevant
to the conclusion arthroscopy is no more effective
ff
than placebo in the treatment of OA. Forty-four
per cent (144/324) of the eligible participants
declined to participate in the study, creating an
immediate and substantial potential for selection
bias. The patients who agreed to participate were
younger, had more severe arthritis.
There was no stratifi
Th fication of results by grade of
OA. The method of grading OA is also troublesome
because it combined results for three compart-
ments on a 1–4 scale, meaning a patient with very
severe changes in one compartment would ulti-
mately be graded the same as a patient with only
mild changes in all three compartments.
Despite these criticisms, Moseley has provided
the best investigation of this topic and it would be
unwise to completely discount the conclusions.
The second randomized trial study was done by Kirk-
ley et al. (12) in 2008. The patients were randomly
assigned to receive optimized physical and medical
therapyalone (control group) or to receive both opti-
mized physicaland medical therapy and arthroscopic
treatment. The randomization was stratifi fied accord-
ing to surgeon and disease severity (defined
fi according
to the Kellgren–Lawrence grade). The Th arthroscopic
treatment was done 6 weeks after the randomiza-
tion. The surgeon evaluated the medial, lateral, and
patellofemoral joint compartments, graded articular
lesions according to the Outerbridge classification,
fi
irrigated the compartment with at least 1 L of saline,
and performed one or more of the following treat-
ments: synovectomy; débridement; or excision of
degenerative tears of themenisci, fragments of artic-
ular cartilage, or chondral flaps and osteophytes that
prevented full extension. Abrasion or microfracture
of chondral defects was not performed. The primary
outcome was the WOMAC score at 2 years after the
initiation of treatment. No signifi ficant difffferences
were observed between the treatment groups for
any of the secondary outcome measures. Specifi- fi
cally, patients assigned to arthroscopic surgery were
no more likely to improve with respect to physical
function, pain, or health-related quality of life than
were those assigned to the control group. After
2 years, the SF-36 Physical Component Summary
scores were 37.0 ± 11.4 and 37.2 ± 10.6, respectively
(absolute diff
fference, −0.2 ± 11.1; 95%CI, −3.6 to 3.2;
P = 0.93).
Other studies, however, reported substantial long-
term pain relief for patients with knee OA after
arthroscopic intervention.
Considering the details of these investigations may
provide some insight into which patients are expected
to gain relief from arthroscopy and which will not.
Patients with symptomatic OA of the knee are
known to have an incidence of meniscal tears up to
91% on magnetic resonance imaging.
McBride et al. (13) compared the results of par-
tial arthroscopic meniscectomies on patients with
an average age of 56-years-old. Two groups were
compared: the fi first included traumatic lesions
such buckle handle without any cartilage lesion.
The second included degenerative meniscal lesions
with cartilage lesions. Ninety-six per cent of good
results were found in the first group. Only 65% of
good results in the second group. Furthermore,
cartilage lesions were progressive in the second
group with varus malalignment.
In Dervin’s (14) article attempting to elicit factors
that would predict a successful arthroscopy of the
osteoarthritic knee, the three significant
fi factors all
pointed to the presence of meniscus abnormalities.

These included an “unstable” tear, medial joint-line
tenderness and, most accurately according to their
study, a positive Steinmann test.
Jackson and Rouse (15) reported 95% good to
excellent results obtained with arthroscopic par-
tial meniscectomy for otherwise healthy knees
with meniscus tears deteriorated only to 80% in
the presence of substantial osteoarthritis.
Chang et al. (16) concluded patients with knee OA
did not consistently gain relief after arthroscopic
débridement, the subgroup of patients with tears
of the anterior two-thirds of the medial meniscus
or any lateral meniscus tear did greatly improve.
Lotke et al. (17) reported a series of 101 patients
of age higher than 45 years. ThThe patients with nor-
mal X-rays initially have 90% of chance to obtain
a good result. Patients with degenerative X-rays
have 21% of chance to obtain a good result.
Bonamo (18) reported 118 patients with degenera-
tive articular cartilage lesions and meniscus tears,
83% were “satisfi fied” after partial meniscectomy
and limited débridement of fibrillary cartilage
degeneration at a mean of 3.3 years follow-up.
Matsusue (19) stratified
fi the results for meniscus
tear débridement by grade of co-existing degenera-
tive change and observed worse results with advanc-
ing grade of OA. While patients with degenerative
changes rated as grade I or II had 87% excellent
results, only 7% of those with grade III or IV changes
were documented as excellent. Whether or not they
were greatly improved in this study is uncertain.
Each of these studies reporting the outcome of
patients with knee osteoarthritis who underwent
meniscal and articular cartilage débridement has
major limitations. All these studies are retrospec-
tive study design, and none had a control group for
comparison of the natural history of the condition
or the results of other treatment modalities.
Loose bodies within the knee joint have been sug-
gested by expert opinion as another factor predict-
ing pain relief from arthroscopy in patients with
OA (20). Good datas on this topic are practically
non-existent. Aaron et al. attributed their inabil-
ity to find a correlation to lack of power, due to
only nine of 122 patients in their study having an
identifi
fied loose body. While Merchan et al. (21)
removed seven loose bodies in 35 knees, they did
not stratify results for these patients. One may
suggest their good results of 75% substantial
improvement were related to the high incidence
of meniscal tears (31/35) and loose bodies in their
patient population, but these subgroups were not
analyzed separately so no specificfi conclusions can
be drawn about appropriate indications.
During the past decade, several methods have
been developed for the penetration of subchondral
bone to stimulate cartilage repair. Some of them
are abrasion of the articular surface arthroplasty,
Is there a place for arthroscopy in the degenerative knee? 587
drilling through the bone, and microfracture tech-
nique. In regions with full-thickness loss of carti-
lage, penetration of the subchondral bone disrupts
the blood vessels and leads to formation of a fibrin
clot. Then a fibrocartilage tissue often forms over
the surface (22, 23). Experimental work has shown
that undifffferentiated mesenchymal cells from the
marrow enter the fibrin clot and then diff fferenti-
ate into chondroblasts and chondrocytes (22). This
Th
fibrocartilage repair tissue is composed of types I
and III collagen. In some patients, this tissue has
persisted for years, but it does not have the same
mechanical properties as the hyaline cartilage (24).
Abrasion arthroplasty
This very aggressive technic was defended since
1979 by Johnson (23, 24). The motorized cutting
device must accomplish parallel grooves in the bone
approximatively 1–3 mm thick. Interosseous ves-
sels are exposed and bleeding forms a fibrin
fi clot,
allowing fibrous
fi tissue repair over the eburnated
bone. Than this tissue needs to be protected from
weight-bearing for 6–8 weeks. Johnson reported in
a retrospective study not controlled on 423 cases,
16% of re-operation at 5 years follow-up.
In their trial, Bert and Maschka (25) used debride-
ment in 67 patients and debridement with abrasion
in 59 patients. At 5 years follow-up, the abrasion
arthroplasty group reported 51% good to excellent
results, 16% fair results, and 33% poor results. The
Th
other group with debridement alone reported 66%
good to excellent results, 13% fair results, and 21%
poor results. The authors did not observe any corre-
lation between outcome and age, degree of arthritis,
weight, previous surgery, or limb malalignment.
Rand (26) published a series of 73 patients with
1 year follow-up. They observed 77% improvement
in the debridement group compared with 39%
improvement in the abrasion group. At 3 years of
follow-up, 32% of the abrasion group were worse
and 50% needed a joint replacement.
The results of abrasion arthroplasty, even in suit-
able candidates, are unpredictable. It is not indi-
cated for patients with infl flammatory arthritis,
knee stiff
ffness, deformity, and instability, or for
patients who do not accept the post-operative regi-
men of no weight-bearing for 2 months.
Subchondral drilling: Pridie
The concept of drilling was introduced in 1959 by
Pridie (4), in a retrospective study that reported the
results in 60 patients (62 knees) with an average
588 The Degenerative Knee
age of 53 years. Good results were obtained in 74%
of the patients.
Richards and Lonergen (27), in a retrospective
study, evaluated 22 patients who had been treated
with drilling and debridement. Of those, 80% had
improvement at 25 months follow-up. In another
group of 21 patients who had only debridement, 81%
reported improvement at 40 months follow-up.
Microfractures
The microfracture technique for full-thickness
chondral defects has been described by Steadman
et al. (28, 29, 30). Their technique is based on a
theory of healing similar to that of abrasion and
drilling. An awl is used to create multiple holes in
the exposed subchondral bone. The perforations
are 3–4 mm deep and 3–4 mm apart. The post-
operative rehabilitation program includes the use
of continuous passing motion (CPM) for 6–8 h per
day and restriction for weight-bearing for 8 weeks
(28). The awl generates less heat and thermal dam-
age than a drill. The authors (29) reported ,in a
prospective study with 298 patients with an aver-
age follow-up of 7 years, 75% patients with good
results, 20% of unchanged patients, and 5% with
poor results. In 77 cases with second look arthros-
copy, biopsies have shown hylain cartilage with
viable chondrocytes.
Drilling and microfractures should be considered
for full thickness chondral defects in the femoral
surface for patients with mild arthritis and normal
alignment (29).
Conclusion
The role of arthroscopy for the treatment of the
osteoarthritic knee is controversial. There are few
evidence-based data on which to determine indi-
cations—or lack of indications—for arthroscopic
débridement or lavage of the osteoarthritic knee.
Although the article by Moseley et al. (11) nicely
demonstrated the presence of OA is not an indica-
tion for a predictably successful arthroscopy, other
investigations have suggested certain subgroups
may benefit.
fi
References
1. Burman MS, Finkelstein H, Mayer L (1934) Arthroscopy
of the knee joint. J Bone Joint Surg Am 16:255–268
2. Haggart GE (1940) Surgical treatment of degenerative
arthritis of the knee joint. J Bone Joint Surg Br 22:717–
729
3. Magnuson PB (1941) Joint debridement: surgical treat-
ment of degenerative arthritis. Surg Gynecol Obstet
73:1–9
4. Pridie KH (1959) A method of resurfacing osteoarthritic
knee joints. J Bone Joint Surg Br 41:618–619
5. Mankin HJ (1982) The response of articular cartilage to
mechanical injury. J Bone Joint Surg Am 64:460–466
6. Mitchell N, Shepard N (1976) Resurfacing of adult rabbit
articular cartilage by multiple perforations through the
subchondral bone. J Bone Joint Surg Am 58:230–233
7. Jackson RW, Abe I (1972) The role of arthroscopy in the man-
agement of disorders of the knee. An analysis of 200 conser-
vative examinations. J Bone Joint Surg Br 54:310–327
8. O’Connor RL (1973) The arthroscope in the management
of crystal-induced synovitis of the knee. J Bone Joint Surg
Am 55:1443–1449
9. Jackson RW (1974) The role of arthroscopy in the man-
agement of the arthritic knee. Clin Orthop 101:28–35
10. Sprague NF (1981) 3d: arthroscopic debridement for
degenerative knee joint disease. Clin Orthop 160:118–123
11. Moseley JB, O’Malley K, Petersen N, et al. (2002) A con-
trolled trial of arthroscopic surgery for osteoarthritis of
the knee. N Engl J Med 347:81–88
12. Kirkley A, Birmingham TB, Litchfield fi RB, et al. (2008) A
randomized trial of arthroscopic surgery for osteoarthri-
tis of the knee. N Engl J Med 359:1097–1107
13. Mc Bride GG, Constine RM, Hofmann AA, et al. (1984)
Arthroscopic partial meniscectomy in the older patients.
J Bone and Joint Surg 66A:547–551
14. Dervin G, Stiell I, Rody K, et al. (2003) Eff
ffect of arthroscopic
debridement for osteoarthritis of the knee on health-re-
lated quality of life. J Bone Joint Surg 85:10–19
15. Jackson RW, Rouse DW (1982) The results of partial
arthroscopic meniscectomy in patients over 40 years of
age. J Bone and Joint Surg 64B:481–485
16. Chang RW, Falconer J, Stulberg SD, et al. (1993) A ran-
domized, controlled trial of arthroscopic surgery versus
closed-needle joint lavage for patients with osteoarthritis
of the knee. Arthritis Rheum 36:289–296
17. Lotke PA, Lefkoe RT, Ecker ML (1981) Late results folled-
ingue médial meniscectomy in older population. J Bone
and Joint Surg 63A:115–119
18. Bonamo JJ, Kessler KJ, Noah J (1992) Arthroscopic
meniscectomy in patients over the age of 40. Am J Sports
Med 20:422–429
19. Matsusue Y, Thomson NL (1996) Arthroscopic partial
medial meniscectomy in patients over 40 years old: a 5- to
11-year follow-up study. Arthroscopy 12:39–44.
20. Stuart MJ, Lubowitz JH (2006) What, if any, are the indi-
cations for arthroscopic debridement of the osteoarthritic
knee? Arthroscopy 22:238–239
21. Merchan EC, Galindo E (1993) Arthroscope-guided sur-
gery versus nonoperative treatment for limited degen-
erative osteoarthritis of the femorotibial joint in patients
over 50 years of age: a prospective comparative study.
Arthroscopy 9:663–667
22. Buckwalter JA, Rosenberg LC, Hunziker EB (1990) Articu-
lar cartilage: composition, structure, response to injury,
and methods of facilitating repair. In: Ewing JW (ed.)
Articular Cartilage and Knee Joint Function: Basic science
and arthroscopy. Raven Press, New York, pp 19–56
23. Johnson LL (1986) Arthroscopic abrasion arthroplasty
historical and pathologic perspective: present status.
Arthroscopy 2:54–56
24. Johnson LL (1986) Arthroscopic abrasion arthroplasty. J
Arthroplasty 2:54–63
25. Bert JM, Maschka K (1989) The arthroscopic treatment
of unicompartmental gonarthrosis: a five-year follow-up
study of abrasion arthroplastie plus arthroscopic debride-
ment and arthroscopic debridement alone. J Arthroscopy
5:25–32

26. Rand JA (1991) Role of arthroscopy in osteoarthritis of
the knee. J Arthroscopy 7:358–363
27. Richard RN, Lonergan RP (1984) Arthroscopy surgery
for relief of pain in the osteoarthritis knee. Orthopedics
7:1705–1707
28. Steadman JR, Rodkey WG, Singleton SB, et al. (1997)
Microfracture technique for full-thickness chondral
defects: technique and clinical results. Oper Tech Orthop
7:300-304
Is there a place for arthroscopy in the degenerative knee? 589
29. Steadman JR, Briggs KK, Rodrigo JJ, et al. (2003) Out-
comes of microfracture for traumatic chondral defects of
the knee: average 11-year follow-up. Arthroscopy 19:477-
484
30. Rodrigo JJ, Steadman JR, Silliman JF, et al. (1994)
Improvement of full-thickness chondral defect healing
in the human knee after debridement and microfracture
using continuous passive motion. Am J Knee Surg 7:109-
116

F. Lavoie, S. Lustig,
E. Servien, S.R. Piedade,
Surgical indications in medial knee
P. Neyret
osteoarthritis
Introduction
I
solated degeneration of the medial femoro-
tibial compartment is a common pathologic
process, being the source of important social
costs due to disease-related disability and treat-
ment expenses (1–3). Simultaneously aff ffecting
the cartilage, the menisci and, in later stages, the
ligaments, it is currently viewed as an irreversible
process. In that, it is distinguished from isolated
well-circumscribed cartilaginous lesions for which
articular surface restoration techniques are avail-
able. Although such lesions may over time evolve
into frank degenerative arthritis (4, 5), their treat-
ment will be addressed in other sections of this
book. The goal of this chapter is to present the
reader with a global view of medial knee osteoar-
thritis (OA), focusing on the rationale of the vari-
ous surgical indications.
Etiologies, demographics, and modifying factors
Amongst the various aetiologies of medial OA,
the most frequent is the idiopathic form for which
the physiopathology has not been fully elucidated
up to this date. While this form mainly affectsff
older age groups (usually over 60 years old), other
aetiologies can induce an earlier onset of medial
degenerative changes, for example post-traumatic
arthritis or following a total or subtotal medial
menisectomy, especially in the context of an unsta-
ble knee. Other causes are sometimes encoun-
tered, like spontaneous osteonecrosis of the knee
which typically affffects individuals over 55 years
old (6, 7). The clinician has to be aware that many
infl
flammatory diseases like rheumatoid arthritis or
micro-crystalline arthropathies can initially induce
articular changes that mimic isolated medial OA:
therefore, such pathologies need to be ruled out in
every patient as they will compromise the results
of many therapeutic options used in isolated
medial OA (8).
Although they cannot be viewed as a cause of
medial OA, mechanical factors like obesity, the reg-
Chapter 52
ular practice of high-impact physical activities, or
varus lower limb alignment can hasten the devel-
opment of clinical symptoms of OA and, to some
extent, accelerate its progression; therefore, those
factors need to be taken into consideration in the
management of medial OA of the knee (3, 9).
Clinical assessment of the knee
As with any field of clinical medicine, a thorough
assessment of the patient as a whole is the key to
a successful outcome because many factors, some-
times apparently unrelated to the knee, can change
the way a knee problem is addressed. Therefore,
Th
before focusing on the knee, history and physical
should be patient-oriented. Knowledge of the age,
height, body weight, and activity level will give the
clinician a good idea of the functional status of the
patient and of the loads being transmitted by the
knee on a daily basis. Similarly, as stated in the
previous section, systemic infl flammatory diseases
need to be ruled out: multiple joint involvement,
especially of the wrist and finger joints, and pso-
riatic lesions of the skin or nails must be sought
and, when found, warrant a rheumatology consult
for investigation and proper medical treatment.
Rheumatoid arthritis also needs to be diagnosed
because of the high prevalence of upper cervical
instability amongst rheumatoid patients and its
potentially disastrous consequences if present but
overlooked. In the same train of thought, any med-
ical condition that the patient may suffer
ff from and
the treatments currently undertaken need to be
recorded as they may increase his or her anesthe-
siology risk. A pre-operative anesthesiology con-
sult will be routinely ordered to determine if the
patient is medically fit to undergo surgery and to
optimize peri-operative management of any medi-
cal co-morbidity.
Assessment of the knee begins by clarifying the
symptoms presented by the patient. The Th most
consistent one is pain, which is usually located on
the medial aspect of the knee and exacerbated by
physical activity. Pain irradiating distal to the knee
592 The Degenerative Knee
and relieved by sitting suggests a lumbar origin:
this must be ruled out prior to any invasive pro-
cedure to the knee. Similarly, knee pain can origi-
nate from the hip through irritation of the obtura-
tor nerve: decreased hip range of motion with or
without pain mandates ordering a radiograph of
the pelvis and hip. Pain mostly felt when climb-
ing stairs must alert the clinician of the likelihood
of signifi
ficant patellofemoral disease. Other symp-
toms like knee eff ffusion, giving way, and catching
are noted. The patients’ ability to climb stairs,
walk a long distance, and perform their usual
physical activities gives a good idea of how much
their knee affffects their lifestyle and will often jus-
tify a surgical intervention. Finally, knowledge of
which treatment modalities have been tried so far
is helpful to build a realistic treatment plan with
the patient.
Examination of the knee begins by looking at
the alignment of the lower limb with the patient
standing, then by observing the patient walk, look-
ing for a limp, or a fl
flexion contracture of the knee,
but mostly for the presence of a varus thrust which
needs to be considered in the choice of treatment.
The presence of scars, muscular atrophy of the
thigh, and knee eff ffusion is noted and the range of
motion of the knee is recorded and compared to
the contralateral knee. Knee structures are system-
atically palpated and painful areas are noted, pay-
ing particular attention to the lateral tibiofemoral
compartment and to the patellofemoral articula-
tion in which pain may be a sign of multi-com-
partmental knee disease. The integrity of knee
ligaments is assessed by specific fi stress tests, espe-
cially the anterior cruciate ligament (ACL) which
will aff
ffect the therapeutic options when disrupted.
Finally, the reducibility of the varus angulation of
the knee, when present, is assessed.
Imaging studies
Good imaging studies of the affected
ff knee are
mandatory as they provide the clinician with an
objective evaluation its articular status. Standard
weight-bearing anteroposterior (AP) and lateral
views of the knee are examined, looking for nar-
rowing of the tibiofemoral spaces, condensation of
the subchondral bone, osteophytes, and tibiofemo-
ral subluxation. A postero-anterior weight-bearing
incidence, sometimes referred to as the Rosenberg
view or the Schuss view, is more sensitive to the
earliest degenerative radiographic changes and
should be ordered routinely (10). An axial view of
the patella performed at 30° of knee fl
flexion evalu-
ates the patellofemoral articulation and also should
be routinely ordered.
A classifi
fication of the degenerative changes of the
knee can be made based on the radiographic fi find-
ings. Keeping in mind that any classifi fication sys-
tem is prone to interobserver variability issues,
classifying the stage of OA allows treatment algo-
rithms to be drawn and evaluated. A modified fi ver-
sion of the Ahlback classification
fi is used in our
institution (11). In this classifi
fication, stage 1 OA,
or pre-arthrosis, presents with partial tibiofemoral
narrowing on the Schuss view. Partial narrowing
on the AP standing view or complete narrowing
on the Schuss view is considered stage 2, or early
arthrosis. Complete femorotibial narrowing on the
AP standing view corresponds to advanced arthro-
sis. In stage 3, the cup of tibial erosion has a depth
of 5 mm or less. In stage 4, the cup is deeper than
5 mm; tibial subluxation is often seen at this stage
where the ACL is almost always disrupted.
Long-leg standing radiographs allow objective
measurement of the frontal plane alignment of the
lower limb and provide valuable information when
considering high tibial osteotomy or unicompart-
mental knee replacement. Similarly, AP varus and
valgus stress radiographs objectively assess the
reducibility of the knee deformation but their rou-
tine use is controversial.
Additional imaging modalities are ordered if other
pathologies are suspected because of an atypical
clinical presentation. For example, nuclear medi-
cine or magnetic resonance imaging will help con-
firm a suspicion of avascular necrosis in an elderly
woman with rapidly developing medial pain on a
previously asymptomatic knee.
Therapeutic principles
Treatment of isolated medial knee OA needs to
be individualized based on the various elements
gathered during the clinical assessment. Satisfy-
ing results have been reported for most widely
used procedures but the benefi fits of many are still
under investigation. While ideal conditions can be
described for each therapeutic alternative, many
patients obviously do not represent the “perfect
indication” for any of them. In that situation, it
is the responsibility of the surgeon to carefully
weight the potential benefit
fi of a procedure with its
respective complication risk, being mindful of the
expectations of the patient.
Conservative treatment
With the exception of patients initially presenting
with end-stage OA or with mechanical symptoms

suggestive of intra-articular derangement, most
patient will benefifit from a trial of non-operative
treatment. Over-the-counter medication like par-
acetamol and non-prescription non-steroidal anti-
flammatory drugs (NSAIDs) are used as first-line
infl
agents (12–15). Physical therapy, weight loss, and
non-impact exercise have all shown some effi fficacy
in relieving symptoms attributed to knee OA (9,
16–19). Unloading braces and foot orthoses can
also be helpful in some individuals but compliance
issues are often encountered (20–24). Patients
unresponsive to this regimen should be prescribed
oral NSAIDs, being mindful of potential their
gastro-intestinal adverse eff ffects (25–28). Topical
NSAIDs should be used in patients with known
digestive problems as it appears to be as effec- ff
tive as oral NSAIDs while being better tolerated
(29, 30). Oral intake of the interleukin-1 inhibi-
tor diacerein has shown to be as effectiveff as oral
prescription NSAIDs and can also be tried (31–33).
Chondroitin sulfate and glucosamine sulfate have
been shown to have a mild to moderate effect ff on
knee OA symptoms when compared to placebo
and constitute an additional therapeutic alterna-
tive (34–36). Disease-modifying properties have
been attributed to these supplements but this
issue remains to be proven (36). Intra-articular
injection of corticosteroids seems to be effective
ff in
relieving symptoms for a short period in the con-
text of acute flares of OA symptoms but no long-
term benefifit has been demonstrated (37–39). Vis-
cosupplementation in the form of intra-articular
injections of hyaluronan and hylan derivatives has
demonstrated modest but longer-lived beneficial fi
eff
ffects on pain and function than corticosteroids
injections (35, 40–42). The
Th reader should note that
the mechanism of action of these products is not
well understood, knowing that viscosupplementa-
tion products are cleared from the joints within
hours to days after their injection (35). Also, vari-
ous commercial preparations vary regarding the
molecular weight of their hyaluronic acid deriva-
tive with potential but still unproven effect ff on
their effi
fficacy and side effffects profifile (35, 43). The
total amount of synovial fluid in the joint may
play a role in the effi
fficacy of viscosupplementation
products (44). Finally, offi
ffice intra-articular lavage
of the knee in an attempt to clear the joint from
infl
flammatory mediators and degradative enzymes
has failed to demonstrate significant
fi benefifits and
should probably be avoided (45–47).
Arthroscopic debridement
Arthroscopic lavage and debridement of tissue
debris from the osteoarthritic knee has been pro-
Surgical indications in medial knee osteoarthritis 593
posed for many years as a relatively benign proce-
dure able to suffi
fficiently decrease pain so that more
radical interventions could be postponed. Contro-
versy has always surrounded this technique, espe-
cially since the publication of a randomized double-
blind study by Moseley et al. (48) which showed no
diff
fference between the results of an arthroscopic
procedure and a sham procedure. Although this
study was criticized due to methodological fl flaws, it
remains that arthroscopic lavage and debridement
should not be part of the treatment algorithm for
all knee OA patients. While most patients may ben-
fit from short-term improvement in knee symp-
efi
toms, this does not justify the invasiveness and the
cost of the procedure. However, greater symptom-
atic relief and more persistent pain relief can be
achieved in patients who have acute onset of pain,
mechanical disturbances from cartilage or menis-
cal fragments, normal lower extremity alignment,
and minimal radiographic evidence of degenerative
disease (47, 49, 50). In that context, arthroscopic
lavage and debridement limited to loose fragments
and floating meniscal and articular flaps may be a
reasonable option (49). Even then, the patient has
to be clearly informed that the natural history of
the pathologic process is unlikely to be altered and
that symptoms may persist or recur shortly after
surgery.
Osteotomies
The basic principle of osteotomies is to unload a
diseased tibiofemoral compartment by altering the
shape of a bone, usually the tibia, in the coronal
plane so that the mechanical axis of the lower limb
is shifted away from the affected
ff compartment.
The main advantage of osteotomy techniques over
arthroplasty techniques is that the articular sur-
faces are preserved, potentially allowing the prac-
tice of any physical activity once the osteotomy
has healed. However, this type of surgery does not
apply to all degenerative knees as results can vary
greatly depending on the indication. Rates of sur-
vival at 10 years ranging from 50 to 80% have been
reported, survival being defined
fi as no revision to
total knee arthroplasty (TKA) (51–54). However,
diff
fferences of patient characteristics and surgical
technique make the literature difficult
ffi to interpret
as to the results of knee osteotomies. For example,
better results are associated with patients aged less
than 50 years old at surgery and avoidance of over
or undercorrection of the diff fformity (52, 55–59).
Other aspects like the type of osteotomy are likely
to have an impact on the long-term results but
still need to be demonstrated (60). Like any sur-
gical technique, osteotomies share their load of
594 The Degenerative Knee
complications: knowledge of the numerous factors
involved appears essential for their proper use by
the surgeon.
Indications
Valgus-inducing osteotomies are classically consid-
ered in the young and active patient with isolated
medial tibiofemoral OA and varus alignment of the
knee. Contra-indications are infl flammatory arthri-
tis, signifi
ficant pathology in the other compart-
ments of the knee, lateral subluxation of the tibia,
limited range of motion of the knee (i.e., flexum
fl of
10° or more, flexion of 90° or less), and inability to
comply to the non-weight-bearing post-operative
regimen on the operated knee (8, 61, 62). Th The pres-
ence of a varus thrust during gait evaluation does
not contra-indicate an osteotomy but has to be
taken into account when planning the amount of
correction to avoid overcorrection (55, 63). Medical
conditions potentially compromising the healing
of the osteotomy, like diabetes mellitus or heavy
tobacco use, are relative contra-indications. Obese
patients are more likely to have a poor outcome
following osteotomy and should undergo a weight-
loss program before osteotomy is performed (51,
61). Associated knee pathologies like meniscal
lesions, cartilage defects, and ligament deficiencies
fi
have to be considered before choosing this option
as they may have to be addressed simultaneously
or in a staged manner (64).
Ideal patient characteristics
Ideal patient characteristics for an osteotomy are:
• Isolated medial or lateral joint line pain
• Age 40–60
• BMI < 30
• High demand activity but no running or jumping
• Alignment < 15°
• Metaphyseal varus
• Full range of motion
• Normal contralateral and patellofemoral com-
partments
• No cupula on radiographs
• Normal ligament balance
• Non-smoker
Technical considerations
Various types of valgus osteotomies are described
around the knee. First, the surgeon has to choose
between performing the osteotomy on the tibia, the
femur, or both. Because of the varus orientation of
the tibiofemoral articulation in the frontal plane,
valgus-inducing osteotomies are usually performed
at the proximal tibia, resulting in an articular sur-
face neutrally aligned or in slight valgus. Another
reason is that the varus originates from the proxi-
mal tibia in 88% of cases (65). In the opposite, a
valgus osteotomy performed at the distal femur
would increase the valgus orientation of the distal
femoral articular surface and result in greater varus
of the tibiofemoral articulation, which will induce
shearing forces across the knee (65, 66). Addition-
ally, a valgus osteotomy of the distal femur will be
eff
ffective in lateralizing the loads only in extension
as the correction is in the frontal plane. Indeed,
the tibial articular surface is perpendicular to the
frontal plane of the femur in full extension, grad-
ually converging towards it as the flexion angle
increases, being completely in the transverse plane
of the femur in 90° of flexion. Therefore, a femo-
ral osteotomy has a decreasing effect ff on the loads
crossing the joint as fl flexion increases. However,
a valgus femoral osteotomy can be considered in
combination with a tibial osteotomy in large angu-
lar deviations, i.e., when more than 10° of joint line
obliquity would result if a single large tibial osteot-
omy was performed, potentially inducing shearing
forces across the knee (67). The surgeon should
then weight the deleterious effects ff of the oblique
joint line with those of performing osteotomies on
both sides of the knee.
Bone axis modifi fication can be achieved in many
diff
fferent fashions. The first method was described
by Jackson (68) and popularized by Coventry (51,
61, 69): it consists of removing a wedge of bone
on the lateral side of the tibia and closing the gap
created, hence the name closing-wedge osteotomy.
The osteotomy is usually performed above the tib-
ial tuberosity to improve healing rates (70). Disad-
vantages of closing-wedge osteotomies include the
necessity to free the tibia from the fi fibula, either
through osteotomy of the fibula, fi resection of the
fibular head, or by disrupting the proximal tibiofi fib-
ular joint, with a potential of injury to the peroneal
nerve (54, 70). Closing-wedge osteotomy may be
ill-advised in the context of a shorter limb on the
operated side (70). Another considerable disad-
vantage is the lateral translation of the proximal
tibial epiphysis that is an inherent consequence of
this technique and that makes a subsequent knee
arthroplasty considerably more diffi fficult (71–73).
Indeed, the lateral shift of the epiphysis may create
a conflflict of the tibial prosthetic keel with the lateral
cortex of the tibia and result in valgus positioning
of the tibial component if overlooked (71–73). Off- ff
set stems or keels help avoid this complication but
make the procedure less straightforward. Another
surgical diffifficulty is created by the loss of bone
stock, which does not leave much room to perform
the tibial prosthetic cut, especially if a large angu-

lar correction was done. Indeed, the surgeon has
to balance the need to resect enough tibia (at least
down to subchondral bone) with the consequences
of overcutting the tibia, which tends to reduce the
size of the component that can be implanted due
to the trapezoidal shape of the proximal tibia in
the frontal plane. Knowing that the objective of
this technique is to delay TKA, not to avoid it (74),
performing a surgery that makes it more difficult ffi
therefore appears counter-productive to many sur-
geons. It is one of the reasons why opening-wedge
osteotomy techniques were developed and are
increasingly used.
In opening-wedge osteotomies, a transverse cut is
made in the proximal tibial metaphysis from the
medial side, maintaining a hinge of intact bone
and periosteum on the lateral aspect of the cut. The Th
osteotomy is gradually opened using stacked osteot-
omes or dedicated spreaders until the targeted axis
correction is reached. Fixation of the osteotomy
is performed with either staples or one of many
systems of plate and screws. Filling of the void cre-
ated by the osteotomy is done with autologous iliac
bone grafting, cancellous allografting, bone substi-
tutes, or nothing at all. One of the advantages of
opening-wedge osteotomies is their ease of adjust-
ment of angular correction, compared to closing-
wedge osteotomies in which the angular correction
is determined by the size of the bone wedge that is
removed. The fact that bone is added rather than
removed constitutes another advantage in light of
future arthroplasty procedures (75); it also makes
this type of osteotomy more appropriate if the
operated leg is shorter than the other one (70).
Finally, preservation of the proximal tibiofibular
fi
joint and protection of the peroneal nerve are addi-
tional positive aspects, especially in patients with
lateral-side laxity in which disruption of the lateral
structures is counter-productive. Disadvantages
include potential non-union of the osteotomy and
risk of patella baja. Technical pitfalls are loss of cor-
rection due to insuffifficient fixation and increase of
the tibial posterior slope due to failure to open the
posterior aspect of the osteotomy adequately (76).
This last point takes a special importance when
performing this procedure on an ACL-deficient fi
patient, especially if no concomitant ACL recon-
struction is performed, knowing that an increase
of the posterior tibial slope causes an anterior shift
of the tibia (77).
Other osteotomy techniques were described. A
technique combining a lateral closed wedge with a
medial opening wedge was recently described with
good long-term results (78). Another technique is
the dome osteotomy in which a dome-shaped cut
of the proximal tibia is performed, allowing axis
correction without bone loss or important transla-
tion of the epiphysis in comparison with closing-
Surgical indications in medial knee osteoarthritis 595
wedge osteotomies, and maintaining bone contact
after correction, decreasing non-union concerns
(79–81). The main drawbacks of this technique are
its technical diffi
fficulty, the need for an osteotomy of
the fibula, as well as the extended use of an exter-
nal fixator as a fixation device, with the potential
for pin-tract infections (54, 82, 83).
Another osteotomy technique is the hemicallota-
sis opening wedge osteotomy, in which an open-
ing-wedge osteotomy is performed in a minimally
invasive fashion and progressively opened in the
following weeks with the use of a hybrid external
fixator, following the hemicallotasis principles
described by Ilizarov (54, 84, 85). The advantages
of this technique are the possibility to precisely
adjust the axis correction over the time of distrac-
tion and the theoretical decreased risks of non-
union. Its main inconveniences are pin-tract infec-
tions, the bulkiness of the external fixator, and the
dedication it necessitates from the patient. This Th
technique may be more suited for the correction of
complex bone deformations than for limb realign-
ment in the context of medial OA.
To this date, no conclusion can be drawn regard-
ing the relative effectiveness
ff of specifi
fic osteotomy
techniques (60). In the end, the choice of technique
is left to the surgeon in light of the numerous con-
siderations that were exposed and that have to be
applied to each individual patient, keeping in mind
the objective of this procedure.
Tibial surface hemiarthroplasty and UniSpacer
The McKeever tibial hemiarthroplasty (MTH) was
introduced in the late 1950s (86). It consists of a
keeled metallic component designed to approxi-
mate the shape of the tibial plateau, which can be
implanted either on the medial or lateral plateaus,
cemented or uncemented, in patients with isolated
tibiofemoral OA. This device may be considered in
patients that are too heavy, too young, or too active
for total or unicompartmental knee arthroplasty
(UKA) and for which an osteotomy is not an option
(87). A cited example would be a 40-year-old physi-
cally active male with isolated medial tibiofemoral
OA and knee flexion below 90° and a flexum of 15°,
which are relative contra-indications to osteot-
omy. Contra-indications to this procedure are a lot
like those of an UKA: a defi ficient ACL, signifi
ficant
degenerative changes in the other compartments
of the knee, collateral ligament defificiency, as well
as important difffformities in the frontal and sagit-
tal planes. Pre-operatively, the patient should not
expect a normal knee after surgery but be aware that
this procedure is performed to alleviate the painful
symptoms, to increase the level of activity, and to
596 The Degenerative Knee
delay more radical arthroplasty options. To some
extent, the MTH implantation technique makes it
possible to regain some range of motion (87).
The McKeever hemiarthroplasty is implanted
Th
through a para-patellar longitudinal approach and
necessitates a wide enough exposure to allow the
surgeon to remove peripheral and intercondylar
osteophytes as well as the meniscal remnants. After
visual confi
firmation of the integrity of the ACL, an
oscillating saw is used to shape the tibial plateau to
fit the undersurface of the tibial component, also
to resect 3 mm of the posterior femoral condyle to
create room for the tibia in flexion.
fl The surgeon
makes sure that the transition between the poste-
rior femoral cut and the distal aspect of the femur
is smooth, using the oscillating saw. A T-shaped
slot is performed in the tibia to fifit the keel of the
tibial component using either a high-speed burr or
a small oscillating saw. The
Th size and thickness of
the McKeever implant are chosen with the use of
templates, taking care that no mediolateral over-
hang is present, and ensuring that stress-testing
of the knee in the frontal plane in extension opens
the joint by 1 mm approximately. As previously
said, the MTH can be implanted with or without
cement.
The MTH never gained widespread acceptance
in the orthopedic community, mainly because of
its limited indications combined with the steep
learning curve of this technique. Because of this,
few long-term reports of the results of this pro-
cedure are available, as well as no comparative
studies. Published results include those of Scott
et al. (88) who reported on 44 knees at an aver-
age follow-up of 8 years, showing a rate of 70%
good or excellent results as well as six revisions
to a unicompartmental or TKA. In the same year,
Emerson and Potter published the results of 61
MTH at an average 5-year follow-up and reported
72% knees being rated as good or excellent (89).
More recently, Springer et al. (87) published the
results of a minimum 12 year follow-up series of
26 consecutive MTH in 24 patients aged less than
60 years old at the time of surgery. At an average of
16.8 years after surgery, nine patients (10 knees)
had a surviving implant (38.4%), all of them sub-
jectively reporting being extremely satisfied,
fi while
13 implants in 12 patients had to be revised at an
average of 8 years after implantation. Based on
their results, the authors advocate that the McK-
eever hemiarthroplasty remains a good option for
the young patients for which an osteotomy is not
an alternative, highlighting that subsequent revi-
sion to a unicompartmental or TKA can be per-
formed without diffifficulty (87). However, they state
that the indications for this implant are limited to
1% of patients, giving it small chances of ever gain-
ing popularity (87).
A variation on the principles of the McKeever
hemiarthroplasty was recently developed in the
form of a mobile spacing implant inserted through
a minimally invasive approach (UniSpacer®; Cen-
terpulse, Austin, Texas). Its indications are simi-
lar to those of the MTH, although it can only be
implanted in the medial compartment due to its
mobility which would make dislocation more likely
if implanted in the lateral compartment. Again,
published results for this implant are few but, in
this case, show a high rate of complications with
up to 16% of implant dislocation, 24% of arthrofi- fi
brosis requiring manipulation, and 32% poor clini-
cal results leading to revision TKA (90–93). In the
light of these results and the limited indications of
this implant, it appears that the UniSpacer® should
be used with extreme caution, if at all.
Unicompartmental knee arthroplasty
UKAs were first introduced in the late sixties by
Marmor (94) and a few years later in France by
Cartier et al. (95). Many series were published to
report the early results of these UKAs (96, 97).
When compared to TKAs, UKAs were first fi believed
to lead to less favorable and less reproducible out-
comes. However, the initially high failure rates were
probably attributable to poor patient selection,
unfavorable prosthetic design, or technical errors.
UKA currently benefitsfi from a renewed interest,
partly because of the publication of results from
the Swedish registry (98) which put the causes of
failure into perspective. Compared to TKA, UKAs
have the advantage of a less invasive approach to
the knee, a decreased surgical morbidity, an accel-
erated post-operative recovery, and a higher rate of
optimal functional results (sometimes referred to
as “forgotten knees”) (99, 100).
Indications
Osteoarthritic stage: The first therapeutic criterion
is the extent of the degenerative process. An iso-
lated medial femorotibial compartment OA with
complete or almost complete femorotibial narrow-
ing on weight-bearing radiographs (stages 2 and 3)
represents the most common indication. It is of
note that knees presenting a cupula of 5 mm or
more on the radiographs (stage 4) are not consid-
ered for UKA. In the opposite, medial femoral con-
dyle osteonecrosis represents a good indication.
Tibiofemoral morphotype: The final goal of a UKA is
to undercorrect the pre-operative articular defor-
mity. UKA should be viewed as a weight-bearing
spacer designed to replace the osteoarticular wear,

not as a way to restore a normal tibiofemoral align-
ment. However, this concept has limits in cases of
severe varus deformity: indeed, the post-operative
tibiofemoral alignment should be less than 5° to
avoid overloading the implant (101, 102). Soft tis-
sue releases should not be undertaken to realign
the limb as only reducible deformities should be
considered for UKA: the reducibility of the defor-
mity can be appreciated clinically by manual test-
ing or radiologically with the use of valgus stress
radiographs. Furthermore, overstuffi ffing of the
operated compartment by increasing the thickness
of the implant as a way to realign the knee should
be avoided as some residual laxity has been shown
to be necessary to a good functional result (101).
Therefore, UKA is generally not indicated in knees
with a varus of more than 10° on long leg films.
fi
Pre-operative range of motion: Knee motion should
be normal or close to normal, with less than 10° of
flexum and more than 100° of flexion.
Body weight: As the fixation area of UKAs is rather
small and because of concerns about implant fail-
ure, the impact of body weight on the results has
been examined. On one hand, good results have
been reported in obese patients (103), with some
authors performing UKAs on patients weighting
up to 125 kg (104). On the other hand, obesity
combines with the undercorrection of the defor-
mity inherent to the surgical technique, increasing
contact pressures to levels that might exceed the
tolerance of the implant. For that reason, we pre-
fer not to proceed with UKA on patients weighting
more than 80 kg, although obesity is not an abso-
lute contra-indication in itself.
Activity level: Post-operative results with UKA may
be so good that the patients feel they could resume
any physical activity: the “forgotten knee.” How-
ever, patients must be advised not to practice any
impact activity for the sake of implant longevity.
Tibial osteotomy may be better advised for high-
demand patients as we previously noted.
Age: Like Swienckowski et al. (105), we think that
young age should not be considered an absolute
contra-indication to UKA. Indeed, in some cir-
cumstances like post-traumatic OA, UKA can be
performed in patients younger than 60 years old.
However, long-term results can vary because of
the increased risk of peri-articular pain and sub-
sequent implant loosening. Therefore,
Th UKA should
mostly be proposed to patients older than 65 years
old.
Contra-indications
There are only a few absolute contra-indications
to UKA, as opposed to relative contra-indications
which are more numerous.
Surgical indications in medial knee osteoarthritis 597
All infl
flammatory forms of arthritis are the first
absolute contra-indications, the most common
form being rheumatoid arthritis. These systemic
conditions must be ruled out by a thorough clinical
evaluation of the patients.
The second absolute contra-indication is related to
the first one: arthritis involving the other compart-
ments of the knee must be ruled out by carefully
analyzing the pre-operative knee radiographs.
Associated ligamentous laxity, in particular ante-
rior laxity and laxity of the medial collateral liga-
ment, must be looked for. Especially, a functional
ACL is mandatory to a successful UKA (106, 107).
It is evaluated clinically and on weight-bearing AP
and lateral radiographs: an anterior tibial transla-
tion of more than 10 mm, a posterior cupula on
the tibial articular surface, and a spiked aspect of
the tibial spines are elements in favor of ACL dys-
function and should contra-indicate a UKA.
Finally, limited range of motion contra-indicates
UKA as was stated earlier: flexion should be supe-
rior to 100° and knee flexum, if present, must be
less than 10°.
Ideal patient characteristics
Based on UKA indications and contra-indications
that were just exposed, ideal patient characteris-
tics for UKA are:
– Pain localized to the site of the radiographic
arthritis
– Normal range of motion
– Normal ligament balance
– Passively correctable deformity
– Age >65
– BMI <30
– Weight <80 kg.
– No cupula on radiographs
– Isolated, single compartment arthritis with nor-
mal contralateral and patellofemoral compart-
ments
– Deformity <10º with osseous part <5º
– Activity should exclude running and jumping
Total knee arthroplasty
Total knee replacement represents the “extreme
solution” in the treatment of medial knee OA. It
should be considered when the other therapeutic
options are not indicated for the various reasons
that were exposed in this chapter. Patient age has
to be considered, especially when it is less than
50 years old, but it should not be an absolute con-
tra-indication to TKA as long as more conservative
options were excluded.
598 The Degenerative Knee
Implant design and surgical technique are beyond
the scope of this text and will be discussed in other
chapters. Nonetheless, the surgeon must be aware
that the choices he makes through the multiple
possibilities of implants and techniques are likely
to have significant
fi consequences on the results,
with some options being more adapted to some
specific
fi situations.
While in most cases the post-operative results are
good enough to allow patients to lead a normal life,
including low impact physical activities like golfi
fing
and cross-country skiing, réf high impact activi-
ties involving pivoting or violent loading must
be avoided to limit the risk of premature implant
loosening or of periprosthetic fractures. Good
pre-operative patient counseling is the key in that
aspect.
Conclusion
Surgical indications in cases of medial knee OA
necessitate a complete evaluation of the clini-
cal situation, with a thorough revision of patient
complaints, a careful physical examination, and a
meticulous analysis of imaging data. A broad range
of therapeutic alternatives are currently available,
ranging from various forms of conservative treat-
ment to TKA. Therefore, the clinician should focus
on finding the treatment best adapted to each indi-
vidual patient and particularly patient expectation.
Total knee replacement should be the option once
other treatments either are not a good indication
or contraindicated.
References
1. Bijlsma JW, Knahr K (2007) Strategies for the prevention
and management of osteoarthritis of the hip and knee.
Best Pract Res Clin Rheumatol 21:59–76
2. Gupta S, Hawker GA, Laporte A, et al. (2005) The
Th economic
burden of disabling hip and knee osteoarthritis (OA) from
the perspective of individuals living with this condition.
Rheumatology (Oxford) 44:1531–1537
3. Iorio R, Healy WL (2003) Unicompartmental arthritis of
the knee. J Bone Joint Surg Am 85-A:1351–1364
4. Minas T, Nehrer S (1997) Current concepts in the treat-
ment of articular cartilage defects. Orthopedics 20:525–
538
5. Scopp JM, Mandelbaum BR (2005) A treatment algorithm
for the management of articular cartilage defects. Orthop
Clin North Am 36:419–426
6. Mont MA, Baumgarten KM, Rifai A, et al. (2000) Atrau-
matic osteonecrosis of the knee. J Bone Joint Surg Am
82:1279–1290
7. Patel DV, Breazeale NM, Behr CT, et al. (1998) Osteonecro-
sis of the knee: current clinical concepts. Knee Surg Sports
Traumatol Arthrosc 6:2–11
8. Stuchin SA, Johanson NA, Lachiewicz PF, Mont MA
(1999) Surgical management of infl flammatory arthritis of
the adult hip and knee. Instr Course Lect 48:93–109
9. Powell A, Teichtahl AJ, Wluka AE, Cicuttini FM (2005)
Obesity: a preventable risk factor for large joint osteoar-
thritis which may act through biomechanical factors. Br J
Sports Med 39:4–5
10. Piperno M, Hellio Le Graverand MP, Conrozier T, et al.
(1998) Quantitative evaluation of joint space width in
femorotibial osteoarthritis: comparison of three radio-
graphic views. Osteoarthr Cartil 6:252–259
11. Dejour H (1991) Histoire Naturelle de l’Arthrose Fémoro-
Tibiale: Données Anatomiques, Biomécaniques, Classifica-fi
tion Anatomo-clinique. In: Dejour H, Neyret Ph (eds) 7e
Journées Lyonnaises de Chirurgie du Genou: les Gonar-
throses. Lyon, France, pp 97–114
12. Pavelka K (2004) Symptomatic treatment of osteoar-
thritis: paracetamol or NSAIDs? Int J Clin Pract Suppl
Oct;(144):5-1
13. Towheed TE, Maxwell L, Judd MG, et al. (2006) Acet-
aminophen for osteoarthritis. Cochrane Database Syst
Jan 25;(1):CD004257
14. Wegman A, van der Windt D, van Tulder M, et al. (2004)
Nonsteroidal antiinflflammatory drugs or acetaminophen
for osteoarthritis of the hip or knee? A systematic review
of evidence and guidelines. J Rheumatol 31:344–354
15. Zhang W, Jones A, Doherty M (2004) Does paracetamol
(acetaminophen) reduce the pain of osteoarthritis? A
meta-analysis of randomised controlled trials. Ann Rheum
Dis 63:901–907
16. Bennell K, Hinman R (2005) Exercise as a treatment for
osteoarthritis. Curr Opin Rheumatol 17:634–640
17. Brosseau L, MacLeay L, Robinson V, et al. (2003) Intensity
of exercise for the treatment of osteoarthritis. Cochrane
Database Syst Rev (2):CD004259
18. Lisinski P, Zapalski W, Stryla W (2005) Physical agents for
pain management in patients with gonarthrosis. Ortop
Traumatol Rehabil 7:317–321
19. Roddy E, Doherty M (2006) Changing life-styles and
osteoarthritis: what is the evidence? Best Pract Res Clin
Rheumatol 20:81–97
20. Brouwer RW, Jakma TS, Verhagen AP, et al. (2005) Braces
and orthoses for treating osteoarthritis of the knee.
Cochrane Database Syst Rev Jan 25;(1):CD004020
21. Brouwer RW, van Raaij TM, Verhaar JA, et al. (2006)
Brace treatment for osteoarthritis of the knee: a prospec-
tive randomized multi-centre trial. Osteoarthr Cartil
14:777–783
22. Krohn K (2005) Footwear alterations and bracing as treat-
ments for knee osteoarthritis. Curr Opin Rheumatol
17:653–656
23. Reilly KA, Barker KL, Shamley D (2006) A systematic
review of lateral wedge orthotics – how useful are they in
the management of medial compartment osteoarthritis?
Knee 13:177–183
24. Richards JD, Sanchez-Ballester J, Jones RK, et al. (2005)
A comparison of knee braces during walking for the treat-
ment of osteoarthritis of the medial compartment of the
knee. J Bone Joint Surg Br 87:937–939
25. Berenbaum F, Grifka J, Brown JP, et al. (2005) Effi
fficacy of
lumiracoxib in osteoarthritis: a review of nine studies. J
Int Med Res 33:21–41
26. Bjordal JM, Ljunggren AE, Klovning A, Slordal L (2004)
Non-steroidal anti-inflflammatory drugs, including cyclo-
oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-
analysis of randomised placebo controlled trials. BMJ
329:1317
27. Fenton C, Keating GM, Wagstaff ff AJ (2004) Valdecoxib:
a review of its use in the management of osteoarthritis,
rheumatoid arthritis, dysmenorrhoea and acute pain.
Drugs 64:1231–1261
28. Garner SE, Fidan DD, Frankish R, Maxwell L (2005) Rofe-
coxib for osteoarthritis. Cochrane Database Syst Rev Jan
25;(1):CD005115

29. Banning M (2006) The Th use of topical diclofenac for pain
in osteoarthritis of the knee: a review. Br J Community
Nurs 11:487–492
30. Towheed TE (2006) Pennsaid therapy for osteoarthritis
of the knee: a systematic review and metaanalysis of ran-
domized controlled trials. J Rheumatol 33:567–573
31. Fidelix TS, Soares BG, Trevisani VF (2006) Diacerein
for osteoarthritis. Cochrane Database Syst Rev Jan
25;(1):CD005117
32. Hunter DJ, Wise B (2007) Review: diacerein is more effec- ff
tive than placebo and is as effective
ff as NSAIDs for knee
and hip osteoarthritis. Evid Based Med 12:74
33. Rintelen B, Neumann K, Leeb BF (2006) A meta-analysis
of controlled clinical studies with diacerein in the treat-
ment of osteoarthritis. Arch Intern Med 166:1899–1906
34. Bruyere O, Reginster JY (2007) Glucosamine and chon-
droitin sulfate as therapeutic agents for knee and hip
osteoarthritis. Drugs Aging 24:573–580
35. Hanypsiak BT, Shaff ffer BS (2005) Nonoperative treatment
of unicompartmental arthritis of the knee. Orthop Clin
North Am 36:401–411
36. Poolsup N, Suthisisang C, Channark P, Kittikulsuth W
(2005) Glucosamine long-term treatment and the progres-
sion of knee osteoarthritis: systematic review of random-
ized controlled trials. Ann Pharmacother 39:1080–1087
37. Bellamy N, Campbell J, Robinson V, et al. (2006) Intraar-
ticular corticosteroid for treatment of osteoarthritis of the
knee. Cochrane Database Syst Rev Apr 19;(2):CD005328
38. Godwin M, Dawes M (2004) Intra-articular steroid injec-
tions for painful knees. Systematic review with meta-anal-
ysis. Can Fam Physician 50:241–248
39. Schumacher HR, Chen LX (2005) Injectable corticos-
teroids in treatment of arthritis of the knee. Am J Med
118:1208–1214
40. Bellamy N, Campbell J, Robinson V, et al. (2006) Viscosup-
plementation for the treatment of osteoarthritis of the
knee. Cochrane Database Syst Rev Apr 19;(2):CD005321
41. Divine JG, Zazulak BT, Hewett TE (2007) Viscosupple-
mentation for knee osteoarthritis: a systematic review.
Clin Orthop Relat Res 455:113–122
42. Waddell DD, Bricker DC (2007) Total knee replacement
delayed with Hylan G-F 20 use in patients with grade IV
osteoarthritis. J Manag Care Pharm 13:113–121
43. Vitanzo PC Jr, Sennett BJ (2006) Hyaluronans: is clini-
cal eff
ffectiveness dependent on molecular weight? Am J
Orthop 35:421–428
44. Waddell DD, Marino AA (2007) Chronic knee effusions ff
in patients with advanced osteoarthritis: implications for
functional outcome of viscosupplementation. J Knee Surg
20:181–184
45. Ayral X (2005) Arthroscopy and joint lavage. Best Pract
Res Clin Rheumatol 19:401-415
46. Chang RW, Falconer J, Stulberg SD, et al. (1993) A ran-
domized, controlled trial of arthroscopic surgery versus
closed-needle joint lavage for patients with osteoarthritis
of the knee. Arthritis Rheum 36:289–296
47. Siparsky P, Ryzewicz M, Peterson B, Bartz R (2007) Arthroscopic
treatment of osteoarthritis of the knee: are there any evidence-
based indications? Clin Orthop Relat Res 455:107–112
48. Moseley JB, O’Malley K, Petersen NJ, et al. (2002) A con-
trolled trial of arthroscopic surgery for osteoarthritis of
the knee. N Engl J Med 347:81–88
49. Hunt SA, Jazrawi LM, Sherman OH (2002) Arthroscopic
management of osteoarthritis of the knee. J Am Acad
Orthop Surg 10:356–363
50. Stuart MJ, Lubowitz JH (2006) What, if any, are the indi-
cations for arthroscopic debridement of the osteoarthritic
knee? Arthroscopy 22:238–239
51. Coventry MB, Ilstrup DM, Wallrichs SL (1993) Proximal
tibial osteotomy. A critical long-term study of eighty-
seven cases. J Bone Joint Surg Am 75:196–201
Surgical indications in medial knee osteoarthritis 599
52. Naudie D, Bourne RB, Rorabeck CH, Bourne TJ (1999)
The Install Award. Survivorship of the high tibial valgus
osteotomy. A 10- to 22-year followup study. Clin Orthop
Relat Res 367:18–27
53. Ritter MA, Fechtman RA (1988) Proximal tibial osteot-
omy. A survivorship analysis. J Arthroplasty 3:309–311
54. Weale AE, Lee AS, MacEachern AG (2001) High tibial
osteotomy using a dynamic axial external fixator.
fi Clin
Orthop Relat Res 382:154–167
55. Dugdale TW, Noyes FR, Styer D (1992) Preoperative
planning for high tibial osteotomy. TheTh effffect of lateral
tibiofemoral separation and tibiofemoral length. Clin
Orthop Relat Res 274:248–264
56. Hernigou P, Medevielle D, Debeyre J, Goutallier D (1987)
Proximal tibial osteotomy for osteoarthritis with varus
deformity. A ten to thirteen-year follow-up study. J Bone
Joint Surg Am 69:332–354
57. Holden DL, James SL, Larson RL, Slocum DB (1988) Prox-
imal tibial osteotomy in patients who are fifty years old or
less. A long-term follow-up study. J Bone Joint Surg Am
70:977–982
58. Matthews LS, Goldstein SA, Malvitz TA, et al. (1988)
Proximal tibial osteotomy. Factors that influencefl the
duration of satisfactory function. Clin Orthop Relat Res
229:193–200
59. Odenbring S, Tjornstrand B, Egund N, et al. (1989) Func-
tion after tibial osteotomy for medial gonarthrosis below
aged 50 years. Acta Orthop Scand 60:527–531
60. Brouwer R, Raaij van T, Bierma-Zeinstra S, et al. (2007)
Osteotomy for treating knee osteoarthritis. Cochrane
Database Syst Rev Jul 18;(3):CD004019
61. Coventry MB (1973) Osteotomy about the knee for degen-
erative and rheumatoid arthritis. J Bone Joint Surg Am
55:23–48
62. Insall JN, Joseph DM, Msika C (1984) High tibial osteot-
omy for varus gonarthrosis. A long-term follow-up study.
J Bone Joint Surg Am 66:1040–1048
63. Naudie DD, Amendola A, Fowler PJ (2004) Opening wedge
high tibial osteotomy for symptomatic hyperextension-
varus thrust. Am J Sports Med 32:60–70
64. Noyes FR, Barber SD, Simon R (1993) High tibial osteot-
omy and ligament reconstruction in varus angulated,
anterior cruciate ligament-deficient
fi knees. A two- to sev-
en-year follow-up study. Am J Sports Med 21:2–12
65. Cooke TD, Pichora D, Siu D, et al. (1989) Surgical implica-
tions of varus deformity of the knee with obliquity of joint
surfaces. J Bone Joint Surg Br 71:560–565
66. Kettelkamp DB, Leach RE, Nasca R (1975) Pitfalls of proxi-
mal tibial osteotomy. Clin Orthop Relat Res 106:232–241
67. Babis GC, An KN, Chao EY, et al. (2002) Double level osteot-
omy of the knee: a method to retain joint-line obliquity.
Clinical results. J Bone Joint Surg Am 84-A:1380–1388
68. Jackson JP, Waugh W (1961) Tibial osteotomy for osteoar-
thritis of the knee. J Bone Joint Surg Br 43-B:746-751
69. Coventry MB (1965) Osteotomy of the upper portion of
the tibia for degenerative arthritis of the knee. A prelimi-
nary report. J Bone Joint Surg Am 47:984–990
70. Preston CF, Fulkerson EW, Meislin R, Di Cesare PE (2005)
Osteotomy about the knee: applications, techniques, and
results. J Knee Surg 18:258–272
71. Mont MA, Antonaides S, Krackow KA, et al. (1994) Total
knee arthroplasty after failed high tibial osteotomy. A
comparison with a matched group. Clin Orthop Relat Res
299:125–130
72. Neyret P, Deroche P, Deschamps G, Dejour H (1992) Total
knee replacement after valgus tibial osteotomy. Techni-
cal problems. Rev Chir Orthop Reparatrice Appar Mot
78:438–448
73. Windsor RE, Insall JN, Vince KG (1988) Technical consid-
erations of total knee arthroplasty after proximal tibial
osteotomy. J Bone Joint Surg Am 70:547–555
600 The Degenerative Knee
74. Mont MA, Stuchin SA, Paley D, et al. (2004) Different
ff sur-
gical options for monocompartmental osteoarthritis of
the knee: high tibial osteotomy versus unicompartmental
knee arthroplasty versus total knee arthroplasty: indica-
tions, techniques, results, and controversies. Instr Course
Lect 53:265–283
75. Kitson J, Weale AE, Lee AS, MacEachern AG (2001) Patel-
lar tendon length following opening wedge high tibial
osteotomy using an external fixator
fi with particular ref-
erence to later total knee replacement. Injury 32(Suppl
4):SD140–143
76. Parker RD (2005) Valgus-producing opening wedge proxi-
mal tibial osteotomy: what, when, and how. Orthopedics
28:977–979
77. Giffi
ffin JR, Vogrin TM, Zantop T, et al. (2004) Effects
ff of
increasing tibial slope on the biomechanics of the knee.
Am J Sports Med 32:376–382
78. Nagi ON, Kumar S, Aggarwal S (2007) Combined lateral
closing and medial opening-wedge high tibial osteotomy.
J Bone Joint Surg Am 89:542–549
79. Maquet P (1976) Valgus osteotomy for osteoarthritis of
the knee. Clin Orthop Relat Res 120:143–148
80. Paley D, Maar DC, Herzenberg JE (1994) New concepts in
high tibial osteotomy for medial compartment osteoar-
thritis. Orthop Clin North Am 25:483–498
81. Sundaram NA, Hallett JP, Sullivan MF (1986) Dome
osteotomy of the tibia for osteoarthritis of the knee. J
Bone Joint Surg Br 68:782–786
82. Geiger F, Schneider U, Lukoschek M, Ewerbeck V (1999)
External fixation in proximal tibial osteotomy: a compari-
son of three methods. Int Orthop 23:160–163
83. Magyar G, Toksvig-Larsen S, Lindstrand A (1999) Hemi-
callotasis open-wedge osteotomy for osteoarthritis of the
knee. Complications in 308 operations. J Bone Joint Surg
Br 81:449–451
84. Magyar G, Ahl TL, Vibe P, et al. (1999) Open-wedge
osteotomy by hemicallotasis or the closed-wedge tech-
nique for osteoarthritis of the knee. A randomised study
of 50 operations. J Bone Joint Surg Br 81:444–448
85. Nakamura E, Mizuta H, Kudo S, et al. (2001) Open-wedge
osteotomy of the proximal tibia hemicallotasis. J Bone
Joint Surg Br 83:1111–1115
86. McKeever DC (2005) The classic: tibial plateau prosthe-
sis.1960. Clin Orthop Relat Res 440:4–8 (discussion 3)
87. Springer BD, Scott RD, Sah AP, Carrington R (2006) McK-
eever hemiarthroplasty of the knee in patients less than
sixty years old. J Bone Joint Surg Am 88:366–371
88. Scott RD, Joyce MJ, Ewald FC, Thomas
Th WH (1985) McK-
eever metallic hemiarthroplasty of the knee in unicom-
partmental degenerative arthritis. Long-term clinical
follow-up and current indications. J Bone Joint Surg Am
67:203–207
89. Potter TA (1969) Arthroplasty of the knee with tibial
metallic implants of the McKeever and MacIntosh design.
Surg Clin North Am 49:903–915
90. Hallock RH (2003) The UniSpacer Knee System: have we
been there before? Orthopedics 26:953–954
91. Hallock RH, Fell BM (2003) Unicompartmental tibial
hemiarthroplasty: early results of the UniSpacer knee.
Clin Orthop Relat Res 416:154–163
92. Scott RD (2003) UniSpacer: insuffi fficient data to support
its widespread use. Clin Orthop Relat Res 416:164–166
93. Sisto DJ, Mitchell IL (2005) UniSpacer arthroplasty of the
knee. J Bone Joint Surg Am 87:1706–1711
94. Marmor L (1988) Unicompartmental arthroplasty of the
knee with a minimum ten-year follow-up period. Clin
Orthop Relat Res 228:171–177
95. Cartier P, Cheaib S, Vanvooren P (1987) Unicompartmen-
tal prosthetic replacement of the knee. Apropos of 159
cases – a maximum follow-up of 10 years. Rev Chir Orthop
Reparatrice Appar Mot 73(Suppl 2):130–133
96. Insall J, Aglietti P (1980) A five to seven-year follow-up of
unicondylar arthroplasty. J Bone Joint Surg Am 62:1329–
1337
97. Laskin RS (1978) Unicompartmental tibiofemoral resur-
facing arthroplasty. J Bone Joint Surg Am 60:182–185
98. Robertsson O, Borgquist L, Knutson K, et al. (1999) Use of
unicompartmental instead of tricompartmental prostheses
for unicompartmental arthrosis in the knee is a cost-effective
ff
alternative. 15,437 primary tricompartmental prostheses
were compared with 10,624 primary medial or lateral uni-
compartmental prostheses. Acta Orthop Scand 70:170–175
99. Griffi
ffin T, Rowden N, Morgan D, et al. (2007) Unicompart-
mental knee arthroplasty for the treatment of unicom-
partmental osteoarthritis: a systematic study. ANZ J Surg
77:214–221
100. Wood JE (2006) Unicompartmental knee arthroplasty.
Curr Opin Orthop 17:139–144
101. Cartier P, Deschamps G (1997) Surgical principles of UKR.
In: Cartier Ph, Deschamps G, Hernigou P (eds) Unicompar-
timental Knee Arthroplasty, cahier d’enseignement de la sof-
cot N° 61, Expansion Scientififique Française, Paris, 137-143
102. Dejour D, Chatain F, Dejour H (1997) Clinical results of
the HLS UKR. In: Cartier P, Deschamps G, Hernigou P
(eds) Unicompartimental Knee Arthroplasty, cahier
d’enseignement de la sofcot N° 61, Expansion Scientifique fi
Française, Paris, 214-219
103. Tabor OB Jr, Tabor OB, Bernard M, Wan JY (2005) Unicom-
partmental knee arthroplasty: long-term success in middle-
age and obese patients. J Surg Orthop Adv 14:59–63
104. Berger RA, Meneghini RM, Jacobs JJ, et al. (2005) Results
of unicompartmental knee arthroplasty at a minimum of
ten years of follow-up. J Bone Joint Surg Am 87:999–1006
105. Swienckowski JJ, Pennington DW (2004) Unicompart-
mental knee arthroplasty in patients sixty years of age or
younger. J Bone Joint Surg Am 86-A(Suppl 1):131–142
106. Deschamps G (1997) Unicompartimental Knee Replace-
ment and ligaments. In: Cartier EJP, Deschamps G,
Hernigou P (eds) Unicompartimental Knee Replacement,
cahier d’enseignement de la sofcot N° 61, Expansion Scien-
tifi
fique Française, Paris, 144-146
107. Goodfellow J, O’Connor J (1992) The anterior cruciate liga-
ment in knee arthroplasty. A risk-factor with unconstrained
meniscal prostheses. Clin Orthop Relat Res 276:245–252
Osteotomy around the knee

P. Hernigou, S. Zilber,
A. Poignard, R. Jalil,
Biomechanics, basis, and indications
P. Filippini,
M. Mukisi Mukasa of osteotomies around the knee
Introduction
O
steoarthritis of the knee is often associ-
ated with varus or valgus malalignment of
the aff
ffected extremity. Such malalignment
may pre-dispose patients to accelerate the degen-
erative joint disease. Osteotomy has long been
recognized as the treatment of knee osteoarthri-
tis in young patients. The effffect of the procedure
is to redistribute body weight away from the dis-
eased tibiofemoral compartment and onto the
adjacent compartment. While osteotomy was for
many years the surgical treatment of choice for
unicompartmental tibiofemoral arthritis, it is
increasingly giving way to unicompartmental and
total knee arthroplasty as such techniques have
become more widespread and surgeons more
confifident in their results following arthroplasty.
Nevertheless, osteotomy is still appropriate in
young, active patients for its potential to allow
improved activity. In some cases, osteotomy may
be considered as a bridge to eventual arthroplasty.
This article discusses both the mechanical con-
Th
siderations and the various forms of osteotomy
that can be performed to treat unicompartmental
tibiofemoral arthritis.
Osteotomies for the varus nee
with osteoarthritis
Medial opening wedge osteotomy
Although opening wedge osteotomy (OWO) has
been described since many years, its advantages
compared with a closing wedge osteotomy (CWO)
have only been recently discussed particularly
in the English language literature. Up until now,
opening wedge tibial osteotomy has been criticized
because of the risks or inconvenience related to the
use of cortico-cancellous grafts used to fill the gap
for one technique and the complications of infec-
tion that can follow osteotomies stabilized by an
external fixator for the technique using hemical-
lotasis.
Chapter 53
Technique
A longitudinal incision is made from the medial
border of the patellar ligament distally along the
medial aspect of the tibia for 10 cm. TheTh insertions
of the Sartorius, Gracilis, and Semitendinosus
muscles are divided, and the tendons are separated
from bone. The Pes Anserinus is incised longitudi-
nally 0.5 cm medial to its attachment to the tibia;
if only moderate correction is required the incision
may be incomplete. Th The distal portion of the super-
ficial medial collateral ligament (MCL) is exposed
and is separated from bone proximally as far as the
level of the osteotomy, which should be started
at least 3.5 cm distal to the medial joint-line and
directed laterally and proximally toward the tip of
the fibula. The posterior compartment is opened at
the level of the osteotomy following the posterior
surface with a periosteal elevator, being directed
toward the upper end of the fi fibula.
A pin is inserted by a drill at this point and is
directed toward the lateral border of the tibia just
above the head of the fibula. Its position is checked
radiologically.
The osteotomy is made with an osteotome. The line
of the osteotomy is made with a chisel on the dis-
tal side of the pin. It is slightly oblique from below
to upwards. If the line of the osteotomy passes
through the tibial tubercle, the upper part of the
tuberosity is separated from the upper tibia by a
horizontal cut.
With a 2.6 mm drill, the posterior tibial cortex is
perforated by multiple holes by putting the drill
through the fine of the osteotomy to avoid splin-
tering the cortex when the osteotome is inserted.
The posterior cortex is first divided with a nar-
row osteotome; the remainder is divided with a
wide osteotome whose posterior part is placed in
the fine of bone division already made. The fibula
and tibiofi
fibular joint must be respected. The cut is
made with osteotomes, leaving the lateral part of
the cortex of the lateral tibal intact. The bone at
the site of the osteotomy is forced open. The leg
below the osteotomy is then pushed into valgus,
while the large osteotome maintains the upper
end of the tibia in place. The surgeon puts his hand
under the Achilles tendon to avoid flexion at the
604 The Degenerative Knee

site of the osteotomy. The opening must be greater

at the posterior part than at the anterior part of
the osteotomy.
At operation, the wedge must have a base that is
exactly the height that is needed; it is inserted in the
opened osteotomy site posteriorly. This Th is done to
avoid relative shortening of the patellar ligament as
well as an increase of the posterior slope of the tibia.
The wedge (Duowedge implant) is held in place by
Th
the compressive force in the osteotomy site. Based
on ultra-innovative reconstructive tridimensional
ceramic stereo-lithography technology, Duowedge
is a unique tibial osteotomy wedge featuring two
portions with diff fferent porosities: a solid highly
resistant portion, (+80 MPa), which fits fi into the
cortical area, i.e., the maximum load-bearing zone; a
porous portion to be incorporated in the cancellous Fig. 1 – Opening wedge osteotomy with fixation with a Duowedge.
area. Osseointegration of this porous section serves
to anchor Duowedge in the tibia. usually more than 90° of fl flexion of the knee. Fill-
A buttress plate is then applied to the anterior part ing of the osteotomy line progresses from laterally
of the medial aspect of the tibia to hold the upper to medially. Full weight-bearing was allowed at 45
end of the tibia and the shaft. days at a time when bone filling did not occur com-
The desired correction is the diff
Th fference in degrees plete. Th
The bone filling occured to be complete after
between the anteroposterior alignment on pre-op- a mean of 3 months following the osteotomy.
erative radiographs made on a long XR (Hip Knee
Ankle angle) and the desired post-operative result.
This correction can be checked during surgery by cal- Hemicallotasis techniques with an external fixator
fi
culating the angle between the anatomical axis of the
tibia and a line perpendicular to the tibial plateau. It may be used when performing an OWO. Pro-
The same measure can be done on the lateral radio-
Th posed advantages include a controlled correction
graph to be sure that flexion
fl has not been introduced and no obstruction to an eventual arthroplasty.
in the osteotomy site (Fig. 1 and Table 1). The short-term results of this technique are compa-
Cancellous bone taken from the upper and lower rable to those of the conventional CWO. For a large
surfaces of the osteotomy is packed into the poste- correction or if tightening of the MCL is desired, a
rior part of the opening. combined medial opening and lateral CWO can be
The wound is closed by repairing the divided ten- performed. The combined osteotomy will maintain
dons and superfi ficial MCL and then approximating the leg length and increase the amount of angular
the subcutaneous tissue and skin. correction for a given wedge thickness.
The knee is not immobilized post-operatively. A
suction drain is used for 3 days after operation.
Prophylactic antibiotics are given orally for 5 days, Lateral Closing Wedge Osteotomy
starting just after surgery, and anticoagulant are
administered for 2 months. Quadriceps-setting The lateral CWO can be performed above or below
and straight-leg-raising exercises are begun the the tibial tubercle. Formerly, the level of the
day after operation. Passive flexion
fl of the knee was osteotomy was below the level of the tibial tuber-
also begun immediately. By 15 days, patients have cle, but more recent studies advocate an osteotomy

Table 1 – Table of correction: the angle β is the angle of correction. M is the width of the tibia at the site of the osteotomy. From Ref. (13, 16, 17).
M 4 5 6 7 8 9 10 11 12 13 14 15 16* 17 18 19
50 3 4 5 6 7 8 9 10 10 11 12 13 14 15 16 16
55 4 5 6 7 8 9 10 10 11 12 13 14 15 16 17 18
60 4 5 6 7 8 9 10 11 12 14 15 16 17 18 19 20
65* 5 6 7 8 9 10 11 12 14 15 16 17 18* 19 20 21
70 5 6 7 8 10 11 12 13 15 16 17 18 20 21 22 23
75 5 6 8 9 10 12 13 14 16 17 18 20 21 22 24 25
80 6 7 8 10 11 13 14 15 17 18 19 21 22 24 25 26
 Biomechanics, basis, and indications of osteotomies around the knee 605
above the level of the tubercle. The advantage of an
osteotomy below the level of the tubercle is that it
allows a greater degree of correction and preserva-
tion of the Q-angle; however, the disadvantage is
that the osteotomy is through cortical bone with
associated lower healing rates. Advantages of the
more proximal osteotomy include a larger surface
area of cancellous bone, the compressive pull of
the quadriceps muscle to aid in healing, and the
ability to correct the deformity closer to the joint
line; disadvantages include the possibility of proxi-
mal fragment avascular necrosis, iatrogenic pla-
teau fracture, and elevation of the tibial tubercle,
which may compromise exposure for future TKA.
Osteotomy behind the level of the tibial tubercle
promotes a greater range of correction with high
healing rates. This procedure also avoids raising
the tubercle and scarring of the infrapatellar fat
pad, which may aid in revision to TKA.
The preferred surgical approach uses an L-shaped
incision, starting laterally at the joint line and
extending distally to the midline. The Th L-shaped
incision can be extended distally along the anterior
tibia as needed for exposure, and the midline por-
tion can be extended superiorly for later TKA sur-
gery if needed. Some authors advocate an anterior
longitudinal incision, which can be easily extended
for the same reason. The level of the osteotomy
should be ≥10 mm below the joint line; most
studies advocate a level of 15 mm. A more distal
osteotomy decreases the risk of iatrogenic plateau
fracture and avascular necrosis of the proximal
fragment.
The osteotomy should be performed using an
oscillating saw or multiple 3-mm drill holes and
an osteotome. The oscillating saw is more accurate
and results in a smoother surface for bone heal-
ing, but it can also result in thermal necrosis of
the bone edges. The osteotomy should be directed
medial and distal to stay parallel with the joint
line and avoid compromising the medial plateau.
The medial cortex and periosteum should also be
preserved to use as a hinge when closing the two
fragments.
The advantages of a lateral CWO are its high heal-
ing rate and ability to achieve desired correction.
Its primary disadvantages are (1) the lateral expo-
sure in the area of the peroneal nerve, (2) the neces-
sity to do a fibular osteotomy or a proximal tibio-
fibular release, and (3) the loss of bone stock, which
may not be suitable for patients with a pre-operative
leg-length discrepancy or an arthroplasty later.
Dome Osteotomy
The dome osteotomy is typically convex superiorly
and located either proximal or distal to the tibial
tubercle. This osteotomy also allows anteropos-
terior translation without any risk of torsional
modifification. The technique involves marking a
curved line on the tibia with the apex of the dome
just proximal to the tuberosity. Th
Three-millimeter
drill holes are placed anterior to posterior, with
care being taken to protect the posterior neurovas-
cular bundle. The osteotomy is completed using a
15-mm osteotome, and the desired correction is
made using Steinmann pins placed proximally and
distally as a guide.
Discussion on osteotomies for the varus knee
with arthritis
The OWO has some immediate advantages: dur-
ing the osteotomy no fibula osteotomy; no nerve
palsy; no instability with the lateral ligament. Th
The
technique of rigid internal fixation
fi with a plate
and screws has the advantage of avoiding pin-track
infection that occurs frequently in open-wedge
osteotomy by hemicallotasis. However, probably
the most important advantages of the opening
wedge technique are the preservation of bone
stock and an easier operative procedure when it is
necessary later to do a total knee replacement or to
repeat osteotomy if the patient is young.
After an OWO performed with a medial longitu-
dinal incision, the same incision can be used and
extended to perform the prosthesis; the plate and
screws that were used to fix the osteotomy can be
removed during the arthroplasty with the same
incision. At the contrary after a CWO, the incision
is usually lateral and if the surgeon want to use a
medial longitudinal incision, the blade plates or
other fixation devices used to fix the osteotomy
must be removed often before the arthroplasty.
Since after closed osteotomy the wedge of bone
removed in the previous osteotomy reduces the
amount of bone stock above the tibial tuberosity,
eversion of the patellar mechanism at operation is
diffi
fficult in these knees and it is usually necessary
to perform a lateral retinacular release early in the
operation to facilitate the eversion of the patella.
After OWO, eversion of the patellar mechanism
is easier and the lateral retinacular release is not
required as often.
One of the criticisms of high tibial osteotomy is
that there is a high risk of patella baja resulting
in a diffi
fficult conversion to a total knee arthro-
plasty. With a CWO this phenomenon is prob-
ably linked to the fact that removing a wedge of
bone, the distance between the tubercle and the
joint line is decreased creating redundancy of the
patellar ligament and secondary scarring in the
retropatellar fat in absence of early motion. With
an OWO, it can be due to an excessive anterior
606 The Degenerative Knee
opening. Therefore, it is important to insert the
block at the posterior site of the gap to avoid any
increase of the distance between the tubercle and
the joint line. Patella baja did not develop in any
patient of our study most likely because attention
to this point and also because continuous passive
and active motion was used immediately after the
procedure.
After a CWO, the use of prostheses that have a
tibial component with a central peg may result in
impingement of the tip of the peg on the lateral
part of the tibial cortex, even though the com-
ponent appears to be centered on the tibial pla-
teau. This diffi
fficulty is due to the abrupt change in
the flare of the tibial cortex that is caused by the
osteotomy, which also alters the relative position
of the medullary canal. Consequently, it may be
necessary to shift the tibial component slightly
medially so that this impingement will not occur.
Sometimes a custom made component will be
needed to accommodate the altered anatomy of
the tibia. With an OWO, the same phenomenon
does not occur because the tibial cut is more prox-
imal.
Another difffference between the two techniques is
the possibility to know the level of the native tibial
joint after an OWO. After a CWO, there is no pos-
sibility to know the exact level of the joint space,
because the lateral tibial plateau has been pushed
down and the medial compartment has bone loss.
After an OWO, the lateral compartment is kept
with the same level, which may help the surgeon to
choose the level of the joint space.
A correct rotational alignment in our experience
between the upper part of the osteotomy and the
diaphysis is more frequent after the OWO. This Th
may be explained by the fact that with the OWO
there is no cut of the fibula and that the osteot-
omy keeps an hinge to act as a turning point when
opening. This hinge and the absence of section of
the fibula avoid rotational malalignment during
the osteotomy. This
Th malrotation of the upper part
of the osteotomy is more frequent in our experi-
ence after CWO.
Osteotomies for the valgus knee
Valgus deformity of the knee is much less common
than varus deformity and is caused most often by
primary arthrosis. A varus-producing osteotomy
can be performed on either the proximal tibia or
the distal femur. Contraindications are similar to
those for a valgus osteotomy, including an exten-
sion defi
ficit >15° and a flexion arc <90°. The type
of osteotomy performed depends on the degree of
the deformity.
Proximal tibial closing wedge osteotomy
For tibiofemoral deformities <10°, a proximal tib-
ial closing wedge varus-producing osteotomy can
be performed. Any greater deformity will be diffi-
ffi
cult to correct because of the anatomical valgus of
the femur. A larger correction will necessitate an
excessive wedge size and result in obliquity of the
joint line. The
Th consequence in such cases is medio-
lateral instability and sheer stresses across the
joint. In performing a proximal tibial osteotomy, a
correction angle of zero has been recommended to
unload the lateral compartment and prevent recur-
rence.
Lateral opening wedge tibial osteotomy
Among the advantages of the lateral opening
wedge tibial osteotomy for the valgus knee are a
familiar exposure, tightening of secondary lateral
ligamentous laxity, and preserving the pes anseri-
nus on the medial side. An oblique fibular diaphy-
seal osteotomy is also performed, and the wedge is
filled with tricortical iliac crest bone graft or a bone
substitute. Disadvantages to this approach are (1)
the distal displacement of the patella, (2) the risk
of non-union, and (3) the risk of peroneal nerve
palsy.
Distal femoral osteotomy by medial approach
Valgus deformities >12° should be approached
with a varus-producing distal femoral osteotomy.
The femoral osteotomy is also useful in case of
oblique joint line, which is often the case in valgus
deformities.
Technique
The distal femur is approached medially through a
longitudinal incision, with the patient supine. The
Th
femoral vessels must be protected if the medial
approach is selected. An anterior skin incision can
be used; however, most authors prefer to approach
the operated side directly. ThThe vastus medialis is
refl
flected anteriorly with the femoral cortex and
medial condyle exposed. An arthrotomy may be
performed to provide a better view of the joint
line and guide wire placement. Under fluoroscopic
fl
guidance, drill a guide pin for the blade plate chisel
across the femur 2.5 cm proximal to the condyles.
Direct the pin at a gentle angle from anterior to
posterior to keep it centered within the condyles.
Place a second, proximal Steinmann pin perpen-
dicular to the femoral shaft proximal to the osteot-
omy site. Use a third pin to reproduce the desired
angle of correction in relation to the perpendicu-
 Biomechanics, basis, and indications of osteotomies around the knee 607
lar, proximal pin. Place this pin between the fi first
two pins. The pre-fabricated angle template can
help with proper placement of this pin. It is impor-
tant to prepare for easy blade plate placement by
seating the chisel fully into the condyles before the
actual osteotomies are performed.
Most studies advocate the use of a supracondylar
blade plate for fixation after osteotomy. The goal
of correction is to be within ±2° of varus–valgus
alignment. In this procedure, the chisel is placed
first in the anterior half of the medial femoral con-
dyle 2–3 cm above the joint line. The osteotomy is
performed above the adductor tubercle; K-wires or
Steinmann pins can be used to guide the osteot-
omy. The advantage of this technique is that proxi-
mal femoral cortex can be impacted into the can-
cellous distal femur allowing for a greater healing
potential of the osteotomy site. The rigid internal
fixation with the blade plate allows for early range
of motion and full weight-bearing. Use 3–4 bicorti-
cal screws to fix the plate to the proximal segment;
place one cancellous screw through the plate into
the distal segment.
Distal femoral osteotomy by lateral approach
The lateral approach follows a similar sequence.
Make an anterior or direct lateral incision. Use the
pre-fabricated angle template to direct the tip of
the blade into the distal femur. Make the osteot-
omy perpendicular to the shaft, above the adduc-
tor tubercle. Seat the blade. As the plate contacts
the cortex of the lateral shaft, the proximal seg-
ment is impacted onto the distal segment and the
correction is obtained.
Patient selection and evaluation
The ideal indication
Osteotomy around the tibiofemoral joint as a
treatment for osteoarthritis typically is reserved
for young, active patients who expect to con-
tinue moderately demanding physical activity. Th The
osteotomy may also be used in patients presenting
with varus malalignment and ligamentous insta-
bility or focal chondral defi
ficiency. Patient selection
generally is considered essential to successful out-
comes.
Medical comorbidities should be addressed as well
as functional expectations to determine whether
a patient would be better treated by osteotomy or
by arthroplasty. An osteotomy is ideal for those
patients in whom repetitive loading of the tibiofem-
oral joint would be so great that arthroplasty would
carry a high risk of pre-mature implant loosening
or accelerated polyethylene wear. While there is no
specific
fi cutoffff age, it has been suggested osteoto-
mies for unicompartmental arthritis be limited to
patients <65 years.
Ideally, patients should be of normal body weight.
Obesity can lead to poor wound healing and dif-
ficulties in post-operative rehabilitation. Patients
more than 1.32 times normal body weight have a
poorer outcome after osteotomy. Obese patients
whose lifestyle makes them a better candidate for
osteotomy should undergo a nutritional weight
loss program prior to surgery.
Patients considered for osteotomy should have
unicompartmental arthritis verifi fied by radio-
graphs and physical examination. More favorable
outcomes have been reported in patients with
early radiographic staging of their disease. Physi-
cal examination should reveal localized joint-line
tenderness; meniscal pathology should be ruled
out if an isolated osteotomy is planned. The Th patel-
lofemoral joint should be painless. A ligamentous
examination should be performed, and any history
of instability should be elicited. Patients with an
anterior cruciate ligament (ACL) tear may benefit fi
from a staged or simultaneous ACL reconstruction
with osteotomy. Patients with diagnosed inflam- fl
matory arthritis are more appropriately treated
with TKA; tibiofemoral joint realignment is con-
traindicated in this population.
Knee range of motion is another important factor
when considering knee realignment osteotomy;
a knee arc of motion >100° with <10–15° of flex- fl
ion contracture should be present. Varus or valgus
stressing of the joint may reveal laxity of the ipsilat-
eral ligament on the aff ffected side. Moderate laxity
often is correctable by osteotomy, and refractory
laxity can be addressed with ligament advance-
ment. The patient's gait should be observed, with
special attention paid to varus thrust. A large varus
thrust may be a sign of lateral insuffi fficiency that
should be addressed. A high adduction moment
is a predictor for a poor outcome after osteotomy.
A varus recurvatum of the knee should be noted
and may be a sign of injury to the posterolateral
corner of the knee. A foot and ankle examination
should reveal no varus deformity that will further
load the medial compartment in medial tibiofemo-
ral arthritis. Finally, any leg-length discrepancy
should be noted; a short extremity on the affectedff
side is best managed with an OWO that is also
ffective in retensioning the MCL.
eff
Radiographic knee evaluation should include rou-
tine AP, lateral, and patellofemoral views, all of
which should be evaluated to rule out multi-com-
partmental arthritis. The Rosenberg view – a poste-
ro-anterior radiograph with the patient standing in
608 The Degenerative Knee
45° of flexion – may be helpful in the evaluation of
the articular involvement of the medial and lateral
compartments. Supine varus–valgus stress views
may be helpful in the assessment of patients who
exhibit substantial laxity on physical examination.
Magnetic resonance imaging (MRI) may be per-
formed on patients with symptoms of instability or
suspected ligamentous or chondral pathology.
Operative planning should be based on a stand-
ing, three-joint radiograph with the patient 10 feet
from the X-ray tube. To ensure reproducibility of
follow-up examinations, the patella should be fac-
ing forward toward the beam. From this view, the
various mechanical alignments can be obtained,
and the appropriate angle of correction may be
determined.
Other indications
– Relative contra indication to an arthroplasty:
diabetes, arteritis, severe anticoagulation, previ-
ous infection in the joint.
– Degenerative changes in the medial compart-
ment after patellofemoral arthroplasty.
– Osteoarthritis in the ACL defi ficient knee as an
alternative to UKA.
– In association with UKA or TKA.
References
1. Berman AT, Bosacco SJ, Kirshner S, Avolio A Jr (1991) Fac-
tors infl
fluencing long-term results of high tibial osteotomy.
Clin Orthop 272:194
2. Burr DB (1998) The importance of subchondral bone in
osteoarthrosis. Curr Opin Rheumatol 10:256
3. Coventry MB (1973) Osteotomy about the knee for degen-
erative and rheumatoid arthritis: indications, operative
technique, and results. J Bone Joint Surg [Am] 55:23
4. Coventry MB (1987) Proximal tibial varus osteotomy for
osteoarthritis of the lateral compartment of the knee. J
Bone Joint Surg [Am] 69:32
5. Coventry MB, Ilstrup DM, Wallrichs SL (1993) Proximal
tibial osteotomy: a critical long-term study of eighty-
seven cases. J Bone Joint Surg [Am] 75:196
6. Phillips MJ, Krackow KA (1999) Distal femoral varus
osteotomy: indications and surgical technique. Instr
Course Lect 48:125
7. Fowler JL, Gie GA, MacEachhern AG (1991) Upper tibial
valgus osteotomy using a dynamic external fi fixator. J Bone
Joint Surg [Br] 73:690
8. Fujisawa Y, Masuhara K, Shiomi S (1979) Th The eff
ffect of
high tibial osteotomy on osteoarthritis of the knee. An
arthroscopic study of 54 knee joints. Orthop Clin North
Am 210:585
9. Grelsamer RP (1995) Unicompartemtnal osteoarthritis of
the knee. J Bone Joint Surg [Am] 77:278
10. Hernigou P, Medevielle D, Debeyre J, Goutallier D (1987)
Proximal tibial osteotomy for osteoarthritis with varus
deformity. J Bone Joint Surg [Am] 69:332
11. Hernigou P, Goutallier D (1989) Usure osseuse et sublux-
ation des gonarthroses fémoro-tibiales. Revue du Rhuma-
tisme 56:269
12. Hernigou P, Duparc F, de Ladoucette A, Goutallier D (1992)
Le récurvatum du genu valgum arthrosique (conséquences
cliniques, anatomiques et chirurgicales dans les ostéoto-
mies et les prothèses unicompartimentales). Revue de
Chirurgie Orthopédique 78:292-299
13. Hernigou P, Ovadia H, Goutallier D (1992) Modélisation
mathématique de l'ostéotomie tibiale d'ouverture et table
de correction. Revue de Chirurgie Orthopédique 78:258–
263
14. Hernigou P, Ovadia H, Goutallier D (1992) Mathematical
model of opening wedge upper tibial osteotomy and tables
of correction. J Orthop Surg 6(3):274–279
15. Hernigou P, Bassaine M (1999) Total knee arthroplasty
after opening wedge osteotomy. J Bone Joint Surg
81-B(supp. II):158
16. Hernigou P, Ma W (2001) Openwedge tibial osteotomy with
acrylic bone cement as bone substitute. Knee 8:103–110
17. Hernigou P (2002) Open wedge tibial osteotomy: com-
bined coronal and sagittal correction. Knee 9:15–20
18. Hernigou P, Garabedian JM (2002) Intercondylar notch
width and the risk for anterior cruciate ligament rupture
in the osteoarthritic knee; evaluation by plain radiography
and CT scan. Knee 9:313–316
19. Hernigou P (2002) Recul à plus de 20 ans de la gonar-
throse fémoro-tibiale interne après ostéotomie tibiale de
valgisation: ostéotomie unique versus, ostéotomie itéra-
tive. Revue de Chirurgie Orthopédique 88:68–73
20. Hernigou P, Jaafar A, Hamadou A (2002) Modification fi
de la longueur du membre inférieur après ostéotomie du
genou. Revue de Chirurgie Orthopédique 88:68–73
21. Hernigou P, Manicom O, de Abreu L. (2004) le cas par-
ticulier des ostéotomies fémorales inférieures. Revue de
Chirurgie Orthopédique 90(4):380–381
22. Hernigou P, Deschamps G (2004) Posterior slope of the
tibial implant and the outcome of unicompartmental knee
arthroplasty. J Bone Joint Surg 86-A:506–511
23. Hofmann AA, Wyatt RWB, Beck SW (1989) High tibial
osteotomy: use of an osteotomy jig, rigid fixation,
fi and
early motion versus conventional surgical technique and
cast immobilization. Clin Orthop 271:212
24. Insall JN, Joseph DM, Misika C (1984) High tibial osteot-
omy of varus gonarthrosis: a long-term follow-up study. J
Bone Joint Surg [Am] 66:1040
25. Jackson JP, Waugh W. Tibial osteotomy for osteoarthritis
of the knee. J Bone Joint Surg [Br] 43:746
26. Korn MW (19969) A new approach to dome high tibial
osteotomy. Am J Knee Surg 9:12
27. McDermott AG, Finklestein JA, Farine I, et al. (1988) Dis-
tal femoral varus osteotomy for valgus deformity of the
knee. J Bone Joint Surg [Am] 70:110
28. McKellop HA, Sigholm G, Redfern FC, et al. (1991) The Th
eff
ffect of simulated fracture-angulation of the tibia on car-
tilage pressures in the knee joint. J Bone Joint Surg [Am]
73:1382
29. Miniaci A, Ballmer FT, Ballmer PM, Jakob RP (1989) Prox-
imal tibial osteotomy: a new fi fixation device. Clin Orthop
246:253
30. Mont MA, Alexander N, Krackow KA, Hungerford DS (1994)
Total knee arthroplasty after failed proximal tibial osteotomy
for osteoarthritis. Orthop Clin North Am 25:515
31. Morrey BF, Edgerton BC (1992) Distal femoral osteotomy
for lateral gonarthrosis. Instr Course Lect 42:77
32. Murphy SB (1994) Tibial osteotomy for genu valgum: indi-
cations, preoperative planning, and technique. Orthop
Clin North Am 25:477
33. Nizard RS, Cardinne L, Bizot P, Witovet J (1998) Total
knee replacement after failed tibial osteotomy: results of a
matched-pair study. J Arthroplasty 13:857
34. Paley D, Maar DC, Herzenberg JE (1994) New concepts in
high tibial osteotomy for medial compartment osteoar-
thritis. Orthop Clin North Am 25:483
 Biomechanics, basis, and indications of osteotomies around the knee 609

35. Paley D, Tetsworth K (1992) Mechanical axis deviation of
the lower limbs. Preoperative planning of uniapical angu-
lar deformities of the tibia or femur. Clin Orthop 280:48
36. Sundaram NA, Hallett JP, Sullivan MF (1986) Dome
osteotomy of the tibia for osteoarthritis of the knee. J
Bone Joint Surg [Br] 68:782
37. Westrich GH, Peters LE, Haas SB, et all (1998) Patella
height after high tibial osteotomy with internal fixation
fi
and early motion. Clin Orthop 354:169
38. Windsor RE, Insall JN, Vince KG (1988) Technical consid-
erations of total knee arthroplasty after proximal tibial
osteotomy. J Bone Joint Surg [Am] 70:547

D. Kohn, D. Pape Technique of closing wedge HTO
History
O
steotomies have been initially introduced
in the nineteenth century for the treat-
ment of post-traumatic deformities, rick-
ets, and other bowing disorders of the femur.
During the 1960s, high tibial osteotomies (HTO)
have been used as a treatment option for uni-
compartmental osteoarthritis of the knee.
In 1961, Jackson and Waugh (1) introduced
an osteotomy just distal to the tibial tuberos-
ity to correct varus or valgus deformities in
patients with osteoarthritis. In 1965, Coven-
try (2) described a closing wedge technique
made just proximal to the tibial tuberosity. He
was an early and most influential supporter of
an internal fixation with stepped staples. In a
follow-up examination, Coventry found a per-
sisting pain relief and a restoration of function
in 60% of patients 10 years after surgery. The
major complication was recurrence of deformity
which coincided with the recurrence of pain. In
a 1993 report of 87 patients with HTOs, Coven-
try found that the risk of failure was increased
if the alignment was not overcorrected to at
least 8° of valgus and if the patient was substan-
tially overweight (>30% over ideal body weight).
Most reports have shown satisfactory results in
about 80% at 5 years and 60% at 10 years after
high tibial osteotomy in the closing wedge tech-
nique (3–6).
In the 30 years since its advent, this procedure
has undergone many modifications. It has been
combined with other procedures such as ACL
reconstruction, ACT, OATS, or arthroscopic
microfracturing. Internal fixation with staples,
buttress plates, blade plates, and tension band
devices have been explored. Finally, internal
plate fixators with angle stable screws have
gained some popularity. In spite of these devel-
opments, this osteotomy technique has retained
its fundamental principles from earlier days:
an osteotomy directed through cancellous bone
with rapid healing; a correction near the defor-
mity to shift the force to the healthy lateral com-
partment.
Chapter 54
Technical principles
Correction of genu varus deformity in cases of
symptomatic early medial femorotibial osteoar-
thritis in knees with intact lateral femorotibial
joint. Slight overcorrection with lateralization
of the long leg axis is the goal. It is achieved by
removal of a wedge shaped piece of bone from the
tibial head. The wedge is created by two osteoto-
mies situated between the proximal tibiofibular
fi
joint and the insertion of the patella ligament.
Closed wedge HTO is particularly suited for
patients with a constitutional varus angle (7).
When closing the osteotomy gap the height of the
patella above the joint line will be increased.
Pre-conditions
Age below 60 years in males or 50 years in females.
Intact soft tissues around the knee. No obesity
(BMI not above 40).
Informed consent
The patient has to know about the risks of the
operation.
General risks: Thromboembolic complications
Infection
Specifi
fic risks: Injury to the peroneal nerve (8)
Loss of correction (9)
Non-union of tibia
Injury to the popliteal vessels (10)
Fracture of the tibial head (11)
Pre-operative planning
Valgus-producing osteotomy of the proximal tibia is
a well-established treatment for medial femorotibial
osteoarthritis in the varus knee. The reproducibility
of postoperative outcome with regard to a predict-
able anatomic alignment and functional recovery
must have a high priority to avoid undercorrection
or overcorrection, two factors held responsible for
early failure of the procedure (12–14).
612 The Degenerative Knee

Coventry (15) recommended to overcorrect the resents the path of transmission of forces relative
varus alignment to at least 8° of anatomic valgus to the lower extremity. If this load-bearing axis
based on regression analysis of the longevity of passes medial or lateral to the center of the knee,
HTOs. Hernigou (16) used the mechanical limb axis it creates a moment arm acting to increase force
and found good clinical results in patients with a transmitted across either the medial or lateral
mechanical valgus angle between 3 and 6°. Smaller tibiofemoral compartment, respectively.
(<3°) or bigger (>6°) correction angles were associ- Although physiologic alignment is often depicted
ated with poorer clinical results. Recently, Dugdale with the WBL passing through the center of the
and Noyes (17) showed that correcting an angular knee, radiographic studies have shown that the
deformity based on the weight-bearing line (WBL) WBL passes immediately medial to the center of
accounts for tibial and femoral length and is more the knee (20). WBL and mechanical axis of the
accurate than relying on the tibiofemoral angle as limb are congruent if the WBL passes through the
determined from radiographs limited to the knee center of the knee or if the mechanical axis (angle
region. They recommended to use the WBL through between the femoral and tibial mechanical axis)
a point 62–66% of the tibia width. This line will pass is 0°–1.2 ± 2.3° on average (21). The
Th deviation of
through the lateral compartment. This Th corresponds the WBL can be quantified
fi in millimeters form the
to a mechanical femorotibial angle of 3–5° of val- center of the knee or as a percentage of the medial
gus. The preference to use the WBL for planning an plateau width (22). The medial edge of the medial
osteotomy is based on the study by Fujisawa (18) compartment is indicated by 0% and the lateral
who demonstrated that cartilage ulceration did not edge of the lateral compartment by 100% (Fig. 2,
further deteriorate after HTO in cases where the
WBL passed through the 30–40% width lateral to the
center of the knee. Miniaci (19) recommended a tar-
get zone between 60 and 70% width of the tibial pla-
teau. Noyes finally suggested to use the 62.5% width
of the plateau which is usually identical to the point
of the downslope of the lateral tibial eminence.
There are difffferent pre-operative planning meth-
ods varying between simple estimates of correc-
tion angles and specifi fic radiographic planning
tools. These methods can be based on the anatomi-
cal axis, the mechanical axis or the WBL.
However, the most accurate planning result is
achieved if the WBL is used. The following anatomi-
cal defi
finitions on plain radiographs are mandatory
for accurate pre-operative planning. Th These defifini-
tions are applicable if the tibia and femur are shaped
within physiologic range in the absence of angular
deformity due to fracture, pseudarthrosis, or oste-
malacia.

Joint centers
The center of the hip is the center of the femoral head
indicated by a concentric hip template. TheTh center of
the knee is the midpoint of a line connecting the tib-
ial spines. In severe osteoarthritis with a subluxated
knee joint, two separate midpoints of the tibia and
femur need to be established. A perpendicular line to
the subchondral joint of both proximal tibia and dis-
tal femur is drawn with the midpoint being halfway
from medial to lateral end of the line. The center of
the tibiotalar joint is the midpoint of the talar width
and the midpoint of the talar height (Fig. 1).

Weight-bearing line
The WBL of the lower limb connects the center of Fig. 1 – Standing right anteroposterior radiograph showing the center of
the hip with the center of the ankle (Fig. 2). It rep- the hip, knee, and tibiotalar joints.

small picture). Th
The WBL can be <0% or >100% if it
passes outside the joint.
Planning method according to Miniaci (19)
Miniaci et al. recommend using the WBL do deter-
mine the frontal/coronal plane correction (Fig. 3).
Line 1 represents the planned WBL for the post-
operative correction extending from the center of
the hip through a coordinate 60–70% of the tibial
plateau width past the ankle. Line 2 connects the
osteotomy hinge point (H) H with the center of the
ankle. With the osteotomy hinge point as the center
and the length of line 2 as the radius, an angular arc
is drawn from the center of the ankle to the intersec-
tion of line 1. Line 3 connects the osteotomy hinge
point with the arc intersection of line 1. The angle
formed by lines 2 and 3 is the planned correction
angle (x
(x). In closing wedge osteotomies, the hinge
point is situated in the medial proximal tibial meta-
physis approximately 2.5 cm below the joint line.
Planning method according to Dugdale and Noyes (17)
Noyes et al. uses the WBL for pre-operative planning
and has described two planning methods. In the
first method, Line 1 is drawn from the center of the
femoral head to the 62.5% of the tibial width. Line
Fig. 2 – Standing right anteroposteerior radio-
graphs with a weight-bearing line (W WBL) medial
to the medial tibial spine. WBL and mechanical
m
limb axis can be colinear in cases with a mechani-
cal axis of 0°–1.2° ± 2.3 of valgus or a WBL
W passing
through the knee center. Small picture:: the devia-
tion of the WBL from the center of the kknee can be
reported as a percentage of the tibial width.
w according to the method by Miniaci [23].
Technique of closing wedge HTO 613
2 is drawn from the center of the tibiotalar joint to
the 62.5% coordinate. The angle formed by these
two lines is the correction angle ((xx) (Fig. 4). In the
second planning method, a line is drawn from the
center of the hip to the 62.5% coordinate (Fig. 5a),
the radiograph is cut in line with the osteotomy side
and the distal tibia is rotated until the WBL passes
through the 62% coordinate (Fig. 5b). The Th correc-
tion angle (x(x) corresponds to the lateral overlap
for lateral closing wedge osteotomies or the medial
opening for medial opening wedge osteotomies.
Instruments
Hohmann and Langenbeck retractors of different
ff
sizes
Oscillating saw with a long saw plate
Osteotomy guides (Firma)
L-compression plate and compression instrument
(Firma)
Operative technique
With the buttock on the operated side slightly ele-
vated a tourniquet is placed on the proximal thigh
Fig. 3 – Weight-bearing anteroposterior whole
lower limb radiograph in full extension for
planning a closing wedge high tibial osteotomy
614 The Degenerative Knee
and infl
flated for the tibial osteotomy. Prophylactic
antibiotics are administered. General anesthe-
sia is preferred because four osteotomies have to
be done. The leg is prepped and draped from the
midthigh region to the foot. Two gloves are put
over the foot and are secured to the distal shank
with adhesive tape.
Fibular segment resection
The fibular shaft is exposed via a separate longi-
tudinal incision that is placed above the bone and
started 5 cm distal to the knee joint line. The length
of this incision is 5 cm. The fascia is incised just
anterior to the septum intermusculare cruris pos-
terius and the fibularis muscles are freed from the
septum and held anteriorly with two Langenbeck
retractors. The fibular shaft is reached by blunt
dissection. The periosteum is incised and a careful
subperiostal dissection around the fibula is per-
Fig. 4 – Weight-bearing anteroposterior whole lower limb radiograph in full
extension for planning a high tibial osteotomy according to the method by
Dugdale and Noyes [12].
formed. The save zone of the bone (8) is exposed
subperiostally. A 1 cm segment is resected with an
oscillating saw protecting the soft tissues with two
blunt Hohmann retractors.
Tibial head osteotomy
An L-shaped lateral approach is established with
the short part of the L running parallel to the lat-
eral joint line and the long leg directed 7 cm parallel
and lateral to the anterior crest of the tibia and the
tibial tubercle. The tibial head is freed subperios-
tally exposing its lateral surface back to the tibio-
fibular joint. The infrapatellar bursa is entered and
the patella ligament is protected by a Langenbeck
retractor at all times. The posteriolateral edge of
the tibia is approached immediately beneath the
tibiofi
fibular joint and for a length of 2 cm the perios-
teum is elevated from the edge and from the poste-
rior surface of the tibia by careful dissection with a
Fig. 5 – (a and b) In this method by Dugdale and Noyes [12], the template
is cut through the osteotomy site and the tibia is rotated until the weight-
bearing line passes through the 62% coordinate.

curved rasp. The knee is bent to 90° during this part
of the dissection. The base of the wedge should now
be free of soft tissues from anterior to posterior.
Two small diameter K-wires are used to identify
the joint-line on the medial and on the lateral side.
A 2.2 mm drill point is drilled parallel to the joint-
line and 1 cm beneath it. The position of this wire is
controlled fluoroscopically because it will guide all
following steps. A second wire is drilled parallel and
more posteriorly according to the first osteotomy
guide. The transverse osteotomy jig is shifted over
the wires and fixed to the tibial head (Fig. 6). A third
hole is drilled all the way trough the tibia guided by
the jig. Th
This hole perforates the medial cortex. The
length of the tibia at this level is measured including
the width of the lateral sawguide (11, 23).
The first drillguide is removed and a slotted cali-
brated osteotomy jig with 2° increments is inserted
over the two drillbits and stabilized in the first fi
osteotomy additionally by means of its blade
(Fig. 7). The oblique portion of the osteotomy is
performed according to the planned angle (Fig. 8).
Again the patella ligament and the posterior soft
tissues are protected by retractors.
The horizontal osteotomy is performed with the
oscillating saw protecting the patella ligament with
a small Langenbeck retractor and the popliteal
Fig. 6 – See text.
Fig. 8 – See text.
Technique of closing wedge HTO 615
fossa with the blunt Hohmann retractor. The depth
of the osteotomy is controlled by the laser mark-
ings on the saw-blade and is kept 5 mm less com-
pared to the width of the tibial head as measured
in the step before.
The pins and the drillguide are removed. An L-but-
tress plate (Fig. 9) is applied to the proximal part
of the tibia with two fully threaded unicortical
cancellous bone screws of 50 mm length each. A
3.2 mm hole is drilled distal to and in line with the
plate. The compression device is inserted into this
monocortical hole with one and into a hole of the
plate with the other limb (Fig. 10). It is gradually
compressed to close the osteotomy wedge over
5–10 min (Figs. 11 and 12). It is hypothesized that
plastic deformation of the remaining medial bone
bridge is better achieved with slow compression
compared to acute and rapid closure.
A bicortical 4.5 mm cortical screw is placed in the
most distal hole of the plate and the compression
device is removed. Fluoroscopic control is performed
to ensure an intact medial bone bridge and a closed
osteotomy. If the medial bone bridge is broken it
is critical neither to tighten the fi
first cortical screw
too much nor to insert the two other screws now.
The step-off ff between the proximal and the distal
segment of the tibia must be compensated for fi first
Fig. 7 – See text.
Fig. 9 – See text.
616 The Degenerative Knee
by insertion of a spacer. High viscosity acrylic bone
cement loaded with antibiotics (Refobacin® PALA-
COS®, Heraeus Medical, Wehrheim, Germany) can
be used as a spacer (9) (Figs. 13 and 14). After the
cement has cured two more distal screws can be
inserted and all distal screws can be tightened. If
Fig. 10 – See text.
Fig. 11 – See text.
Fig. 12 – See text.
this step is omitted the distal fragment will be dis-
placed laterally against the inferior part of the plate
and the cortical contact on the medial side will be
lost (Figs. 15 and 16). This inevitably will lead to a
loss of correction during the post-operative phase
or even to non-union of bone.
Fig. 13 – In this case, the medial cortex broke. If the distal screws
are tightened they will pull the tibia against the plate and dislocate
the osteotomy.
Fig. 14 – A cement spacer (white arrow) was placed between the
plate and the bone. The distal screws can now be tightened safely.

Fig. 15 – See text.
Wounds are closed in layers with resorbable mate-
rial. Two overfl
flow drains are placed in the proximal
tibial and the fibular approach. A light compres-
sion bandage from toes to groin is applied. Active
knee motion is started on the first post-operative
day as tolerated. The
Th patient is mobilized with two
crutches and touchdown weight-bearing on the
operated leg for 8 weeks. After this time X-rays in
two planes are obtained and evaluated. If the posi-
tion of bone and hardware is unchanged begin-
ning bony union can be assumed and increasing
weight-bearing might be allowed. If the medial
bone bridge was broken a removable long-leg cast
should be used for 8 weeks.
Integrity of the opposite cortex
Primary stability of bone-implant constructs can
be infl
fluenced by diff
fferent intra-operative factors,
such as (1) the plate design used (locking versus
non-locking plates); (2) the technique of osteot-
omy (uniplanar versus biplanar (24)); or (3) the
integrity of the opposite cortex.
In biomechanical studies, the infl fluence of plate
design and osteotomy technique on construct
stability have been clearly demonstrated: If plates
with non-locking screws were used, the integrity of
the opposite cortex seemed to be vital to maintain
the desired correction (25). A fracture of the oppo-
site cortex can lead to a loss of correction even in
the presence of lockings screws if shorter spacer
plates were used (26). In addition, the combina-
Technique of closing wedge HTO 617
Fig. 16 – See text.
tion of plate design (spacer plate versus plate fix-
fi
ator) and osteotomy technique (uniplanar versus
biplanar) seems to infl fluence the primary stability
of implant-bone constructs (24). However, clinical
randomized studies are missing that clearly proof
the clinical significance
fi of these biomechanical
data gathered in the absence of muscular power
and support. Unlike the latter two factors (plate
design and osteotomy technique), there are numer-
ous biomechanical and clinical studies that demon-
strate the impact of a fracture of the opposite cor-
tex on revarization and impaired clinical outcome
(9, 25, 27, 28).
Previous studies using radio stereometric analysis
(RSA) to quantify intersegmental micromotion in
HTO patients showed considerable early instabil-
ity after fixation with COVENTRY staples although
the opposite cortex was left intact (29). Our own
RSA data indicated that a fracture of the opposite
cortex in the presence of a rigid L-plate fixation
fi led
to a fivefold increase in lateral displacement of the
distal tibial segment early after surgery with sub-
sequent revarization and a poorer clinical outcome
compared to patients with an intact opposite cor-
tex (9, 30).
We identifi fied two diff
fferent failure modes to injure
the opposite cortex. The cortex fractured predomi-
nantly during the gradual approximation of the tib-
ial segments indicating that the capacity for plas-
tic deformation has been exceeded. The opposite
cortex fractured less frequently while tightening
the distal cortical screws due to a level arm force
pulling the distal tibial segment laterally (Fig. 17).
Although epidemiological data and risk factors
618 The Degenerative Knee
Fig. 17 – See text.
for HTO failure were comparable in all patients
of our study, the degree of malalignment prior to
surgery was signifi ficantly higher in patients with a
subsequent intra-operative fracture of the oppo-
site cortex. Consequently, the average wedge size
resected was signifi ficantly higher in patients with a
fracture (average wedge size of 10.7°) compared to
patients with the opposite cortex left intact (aver-
age wedge size 7.1°). Stratifying these clinical data
by wedge size would suggest that approximately
70% of patients with a wedge size of 10° or greater
sustained a fracture as compared to only 30% of
patients with a wedge size of 8° or less. ThThese data
indicate that the capacity of the opposite cortex for
plastic deformation might have been exceeded in
osteotomies with larger wedge sizes (>8°) leading
to a non-displaced fracture of the medial cortex of
the proximal tibia in later stages of the operation
(Fig. 13).
Reviewing the literature, it used to be disputed
whether the opposite cortex should be left intact or
should be broken in a greenstick manner by exert-
ing a valgus force after completion of the osteotomy
(2). Engel et al. (12) advised to make drill holes into
the medial cortex after the removal of the wedge to
produce a greenstick fracture. Coventry (31) and
Miniaci (19) recommended to maintain the cortex
to provide suffi
fficient stability and to avoid a situa-
tion similar to a proximal tibial fracture. Bohler et
al. (27) performed a biomechanical study on human
cadavers showing a decreasing cortical contact area
of tibial segments after a complete osteotomy with
detachment of the opposite cortex. In his specimen,
the distal tibial segment displaced laterally and the
cancellous bone of the medial tibial plateau did not
sustain the compressive stress of weight-bearing
leading to caving-in on the medial side and to subse-
quent loss of valgus correction.
Our in vivo RSA data support the in vitro findings
by Bohler emphasizing the importance of an intact
opposite cortex to support fi fixation of an HTO
until bony healing occurs. We conclude that the
propensity for a lateral displacement of the distal
tibia increases with a fractured opposite cortex.
This is especially true if the distal cortical screws
were tightened without having earlier placed a
mechanical cement bar underneath the distal plate
to compensate for the tibial step-off ff (Fig. 14). This
cement bar neutralizes the laterally directed lever
arm by approximately 75% when the distal corti-
cal screws were tightened (32). In rare cases with
a displacement following an opposite cortex frac-
ture, prophylactic additional medial fi fixation rather
than lateral L-plate fixation
fi alone is advisable to
minimize the propensity for a lateral displacement
of the distal tibia and to avoid subsequent poten-
tial loss of valgus correction.
References
1. Jackson JP, Waugh W, Green JP (1969) High tibial osteot-
omy for osteoarthritis of the knee. J Bone Joint Surg Br
51 (1):88
2. Coventry MB (1989) Osteotomy of the upper portion of
the tibia for degenerative arthritis of the knee. A prelimi-
nary report 1965. Clin Orthop (248):4
3. Aglietti P, Buzzi R, Vena LM, et al. (2003) High tibial val-
gus osteotomy for medial gonarthrosis: a 10- to 21-year
study. J Knee Surg 16(1):21
4. Berman AT, Bosacco SJ, Kirshner S, Avolio A Jr (1991) Fac-
tors infl
fluencing long-term results in high tibial osteotomy.
Clin Orthop Relat Res (272):192
5. Insall JN, Joseph DM, Msika C (1984) High tibial osteot-
omy for varus gonarthrosis. A long-term follow-up study.
J Bone Joint Surg Am 66(7):1040
6. Ivarsson I, Myrnerts R, Gillquist J (1990) High tibial
osteotomy for medial osteoarthritis of the knee. A 5 to 7
and 11 year follow-up. J Bone Joint Surg Br 72(2):238
7. Bonnin M, Chambat P (2004) Der Stellenwert der valgi-
sierenden Tibiakopfosteotomie bei der medialen Gonar-
throse. Der Orthopäde 33:135
8. Kirgis A, Albrecht S (1992) Palsy of the deep peroneal
nerve after proximal tibial osteotomy. An anatomical
study. J Bone Joint Surg Am 74(8):1180
9. Pape D, Adam F, Seil R, et al. (2005) Fixation stability fol-
lowing high tibial osteotomy: a radiostereometric analy-
sis. J Knee Surg 18(2):108
10. Smith PN, Gelinas J, Kennedy K, et al. (1999) Popliteal
vessels in knee surgery. A magnetic resonance imaging
study. Clin Orthop Relat Res(367):158
11. Blauth M, Stünitz B, Hassenpfl flug J (1993) Die interliga-
mentäre valgisierende Tibiakopfosteotomie bei Varusgo-
narthrose. Operat Orthop und Traumatol 1:1
12. Engel GM, Lippert FG (1981) Valgus tibial osteotomy:
avoiding the pitfalls. Clin Orthop (160):137

13. Kettelcamp D, Wenger D, Chao E, Thompson C (1976)
Results of proximal tibial osteotomy: the effects ff of
tibiofemoral angle, stancephase fl flexion-extension and
medial plateau force. J Bone Joint Surg Am 58:952
14. Tjornstrand B, Selvik G, Egund N, Lindstrand A (1981)
Roentgen stereophotogrammetry in high tibial osteotomy
forgonarthrosis. Arch Orthop Trauma Surg 99(2):73
15. Coventry MB (1985) Upper tibial osteotomy for osteoar-
thritis. J Bone Joint Surg Am 67(7):1136
16. Hernigou P, Medeville D, Debeyre J (1987) Proximal tibial
osteotomy for osteoarthritis with varus deformity: a ten to
thirteen year follow-up study. J Bone Joint Surg Am 69:332
17. Dugdale TW, Noyes FR, Styer D (1992) Preoperative
planning for high tibial osteotomy. The Th eff
ffect of lateral
tibiofemoral separation and tibiofemoral length. Clin
Orthop (274):248
18. Fujisawa Y, Masuhara K, Shiomi S (1979) Th The eff ffect of
high tibial osteotomy on osteoarthritis of the knee. An
arthroscopic study of 54 knee joints. Orthop Clin North
Am 10(3):585
19. Miniaci A, Ballmer FT, Ballmer PM, Jakob RP (1989) Prox-
imal tibial osteotomy. A new fi fixation device. Clin Orthop
(246):250
20. Hsu RW, Himeno S, Coventry MB, Chao EY (1990) Normal
axial alignment of the lower extremity and load-bearing dis-
tribution at the knee. Clin Orthop Relat Res (255):215
21. Chao EY, Neluheni EV, Hsu RW, Paley D (1994) Biomechan-
ics of malalignment. Orthop Clin North Am 25(3):379
22. Tetsworth K, Paley D (1994) Malalignment and degenera-
tive arthropathy. Orthop Clin North Am 25(3):367
23. Billings A, Scott DF, Camargo MP, Hofmann AA (2000)
High tibial osteotomy with a calibrated osteotomy guide,
rigid internal fixation, and early motion. Long-term fol-
low-up. J Bone Joint Surg Am 82(1):70
24. Pape D, Lorbach O, Schmitz C, et al. (2009) Effect ff of a
biplanar osteotomy on primary stability following high
Technique of closing wedge HTO 619
tibial osteotomy – a biomechanical cadaver study. Knee
Surg Sports Traumatol Arthrosc (submitted)
25. Stoff
ffel K, Stachowiak G, Kuster M (2004) Open wedge
high tibial osteotomy: biomechanical investigation of the
modifified Arthrex Osteotomy Plate (Puddu Plate) and the
TomoFix Plate. Clin Biomech (Bristol, Avon) 19(9):944
26. Agneskirchner JD, Freiling D, Hurschler C, Lobenhoffer ff
P (2006) Primary stability of four different
ff implants for
opening wedge high tibial osteotomy. Knee Surg Sports
Traumatol Arthrosc 14(3):291
27. Bohler M, Fuss FK, Schachinger W, et al. (1999) Loss of
correction after lateral closing wedge high tibial osteot-
omy – a human cadaver study. Arch Orthop Trauma Surg
119(3–4):232
28. Tjornstrand BA, Egund N, Hagstedt BV (1981) High
tibial osteotomy: a seven-year clinical and radiographic
follow-up. Clin Orthop Relat Res (160):124
29. Magyar G, Toksvig-Larsen S, Lindstrand A (1999) Changes
in osseous correction after proximal tibial osteotomy:
radiostereometry of closed- and open-wedge osteotomy in
33 patients. Acta Orthop Scand 70(5):473
30. Pape D, Adam F, Rupp S, et al. (2004) Stability, bone heal-
ing and loss of correction after valgus realignment of the
tibial head. A roentgen stereometry analysis. Orthopade
33(2):208
31. Coventry MB, Ilstrup DM, Wallrichs SL (1993) Proximal
tibial osteotomy. A critical long-term study of eighty-
seven cases. J Bone Joint Surg Am 75(2):196
32. Schmitz C (2007) Stabilität und Korrekturverlust
nach valgisierender, lateral schließender Umstellung-
sosteotomie des Tibiakopfes mit winkelstabilen und
nicht-winkelstabilen Implantaten: Eine biomechanisch/
radiostereometrische Studie an nicht fixierten humanen
Präparaten. Thesis/Dissertation, Universitätskliniken
des Saarlandes, Orthopädie, Kirrbergerstrasse 1, 66421
Homburg/Saar

P. Lobenhoffer,
J. D. Agneskirchner
Technique of open wedge HTO
Introduction
H
igh tibial osteotomy (HTO) has become a
widely accepted technique in the treatment
of varus malalignment and medial osteoar-
thritis of the knee since the work of Maquet (1) and
Coventry (2). Middle-term and long-term results
are good if the indications are respected and an
adequate correction is achieved (3–9). Corrective
osteotomy of the proximal tibia may be performed
by a subtractive technique (closed wedge), by a bar-
rel-vault (dome) osteotomy, or by an additive tech-
nique (open wedge). The closed-wedge technique
of Coventry with the removal of a bone wedge
from a lateral approach and fixation with staples,
a plate or a tension-band system, has gained most
popularity. Disadvantages of this technique are the
risk for peroneal nerve injuries (10, 26), the need
of fibula osteotomy or separation of the proxi-
mal tibiofifibular joint, and the detachment of the
extensor muscles. Large corrections cause marked
shortening of the leg and an offset
ff of the proximal
tibia, which may compromise later placement of
the tibial component of a total knee replacement.
Open-wedge osteotomy from the medial side can
be performed without any muscle detachment, the
correction can be “fi fine-tuned” during the proce-
dure, and no leg shortening occurs. Whereas this
technique has been described long ago, only few
surgeons used this method. The Th harvest of bicor-
tical bone grafts from the pelvic crest to fill
fi the
osteotomy caused signifi ficant morbidity and fixa-
tion with conventional implants was unsafe. Open-
wedge osteotomy has regained interest with the
development of new stable implants that enable
the surgeon to fix the correction safely as well as to
avoid bone grafting in most cases.
Indications
The technique described is mainly suited for
monocompartmental medial osteoarthritis of the
knee in patients with a varus malalignment of
the tibia. Patients with straight tibiae and varus
Chapter 55
deformity by medial osteoarthritis and wear may
be also treated by HTO but the success rate will
be limited (3); patients with femoral varus defor-
mity should be treated by a femur osteotomy. The Th
patient should not be older than 65–70 years; how-
ever, this is not a definite
fi criterion. The patient
should not be severely overweight and the range of
motion should be at least 10–120°. A mild flexion
fl
contracture may be accepted if a sagittal correction
of the tibial slope is included in the surgical plan.
Open-wedge osteotomy should not be used if leg
lengthening is contraindicated and if the medial
soft tissue coverage is compromised. Patella pain is
not a contraindication; however, in cases of patella
infera, a special type of osteotomy described later
should be used (25). An intact lateral compart-
ment of the knee is an obligatory pre-requisite for
this technique. The
Th patient should not have lateral
joint line pain and no radiographic signs of lateral
osteoarthritis should be present. Nicotine use is
a relative contraindication, because bone healing
and bone formation may be compromised. Pri-
mary cancellous bone grafting may be discussed in
this situation.
Clinical examination
Clinical examination should focus on the range
of motion of the knee, ligamentous stability, and
leg length. Joint-line pain is regularly found on
the medial side. Patella tracking is registered and
patella pain should be carefully evaluated. Any
pain on the lateral side of the knee is a warning
sign and may indicate degeneration of the lateral
compartment of the knee. Th The indication for val-
gus HTO should be carefully re-evaluated in these
cases and the status of the lateral compartment
must be reconfi firmed by arthroscopy during the
procedure. The status of the ligaments is carefully
evaluated. Defi
ficiency of the anterior or posterior
cruciate ligament is no contraindication against
this type of osteotomy, because joint stability can
be improved by adjustment of the tibial slope.
The medial collateral ligament is usually intact or
622 The Degenerative Knee
contracted in varus malalignment. Our routine
technique involves release of the inferior part of
the superfificial medial collateral ligament from the
tibia. Th
This maneuver does not interfere with medial
joint stability, because the deep portion of the liga-
ment adjacent to the joint remains intact. If the
long fibers of the ligament would not be detached
during the procedure, the tension would increase
signifi
ficantly because of the increased distance of
the insertion points. ThisTh eff ffect could increase
medial joint pressure and would be contraproduc-
tive in the treatment of medial osteoarthritis (23).
In the case of medial instability (usually after com-
plex knee trauma), an open-wedge osteotomy can
also be performed without detachment of the long
fibers of the medial collateral ligament. A longi-
tudinal deep incision behind the medial collateral
ligament is used in this situation to control the
posterior opening of the osteotomy and to insert
a bone spreader.
Imaging
Imaging should include radiographs of the knee
in three planes and a flexed-knee postero-anterior
weight-bearing radiograph. A long-leg weight-
bearing radiograph of the involved leg is necessary
for pre-operative planning. In cases of ligament
instability, stress radiographs should be performed
to study the medial and lateral joint line opening,
because signifi ficant ligament instability must be
considered in the pre-operative planning. Magnetic
resonance tomography may be used to study the
joint status but is not obligatory, because the joint
is examined arthroscopically in all cases of open-
wedge osteotomy. In questionable indications, a
technetium scintigraphy may be helpful to identify
the area of maximum pathology (hot spot) of the
knee, usually indicating the source of pain.
Planning
Exact pre-operative planning is mandatory for this
procedure. We recommend determining the exact
amount of separation of the two planes of the
osteotomy in millimeters by planning on a long-leg
radiograph either digitally or manually on trans-
parent paper (11).
First step: The center of the femoral head and the
center of the ankle joint are marked on the radio-
graph. A template with circles of varying diameter
is used to find the center of the femoral head. The
bisector of the transverse width of the talus under
the joint line is used as center of the ankle joint.
Second step: The knee baseline is drawn parallel to
the subchondral sclerosis of the two tibial plateaus.
The weight-bearing line through the knee joint
is now drawn connecting the center of the femo-
ral head and the center of the ankle. The line will
cut the knee baseline in the medial compartment
of the knee, depending on the degree of varus the
patient has.
Third step: The projected post-operative intersec-
tion of the weight-bearing line with the knee base-
line is marked. Because the osteotomy aims for
a shift of the weight-bearing line into the lateral
compartment, this intersection should be located
at a point 62% of the total width of the proximal
tibia from medial to lateral. Fujisawa found that
optimum results were obtained with HTO when
this amount of correction was obtained (24).
Fourth step: The projected post-operative weight-
bearing line is now drawn by connecting the center
of the femoral head with the new intersection point
mentioned previously. Th This line is continued to the
area of the ankle joint. The
Th planned new ankle cen-
ter is marked using the same length of the line as
for the previous weight-bearing line.
Fifth step: The hinge point of the open-wedge
osteotomy is marked on the radiograph. We use a
hinge point on the lateral cortex at the upper bor-
der of the proximal tibiofi
fibular joint. Two lines are
drawn from this hinge point to the old and the new
ankle joint center. The angle between these lines
is the correction angle of the open-wedge osteot-
omy. The osteotomy planes can now be marked on
the radiograph. We perform an oblique ascend-
ing osteotomy and start the cut at the transition
between the convex upper and the concave lower
part of the proximal tibia, which usually represents
the upper border of the Pes anserinus tendons.
When the two planes with the correction angle
between are marked, the opening of the osteotomy
in millimeters can be read at the medial cortex.
Conventional long-leg radiograph has no relevant
magnifification factor and the measurements can be
directly used during surgery. In digital planning,
the radiograph should be calibrated and a correc-
tion factor is used to compensate for magnification
fi
of the picture. Caution should be used when signifi-fi
cant discongruency of the medial and lateral open-
ing is encountered in the weight-bearing long-leg
radiograph. In this situation, a correction formula
must be used to avoid overcorrection in HTO.
Technique
This procedure can be performed with lumbar or
general anesthesia. We routinely do not use a tour-
niquet and drape the entire leg and hemipelvis

Fig. 1 – The anatomical landmarks are marked on the skin. An oblique skin
incision of 5–7 cm length is used, directed from the posteromedial edge of
the tibial plateau to the most anterior and superior edge of the Pes anseri-
nus insertion.
free. This allows the surgeon to control the entire
extremity visually during the procedure or to har-
vest a bone graft from the pelvis, if necessary. A
small buttress is mounted to the operating table
to support the heel in 90° flexion
fl of the knee. A
side post is placed against the thigh to stabilize the
leg laterally in knee fl
flexion. If this setup is used,
only one surgical assistant is required. Intravenous
antibiotic prophylaxis is used (2 g of cefazolin). A
fluoroscope is mandatory for this procedure and is
placed on the contralateral side. The surgeon should
check that correct visualization of the knee is pos-
sible in the ap. plane before the leg is draped.
After the leg is prepared and draped, the anatomic
landmarks are marked with a surgical marker.
Points of interest are the superior border of the
Pes anserinus, the tibial tuberosity, and the medial
joint line. An oblique skin incision of 5–7 cm
length is used, directed from the posteromedial
edge of the tibial plateau to the most anterior
and superior edge of the Pes anserinus insertion
(Fig. 1). Th
The interval behind the patellar tendon is
now freed and the insertion area of the tendon is
visualized. The long fibers of the medial collateral
ligament are mobilized from the tibia and a release
is performed by inserting a scalpel under the distal
part of the ligament and detaching the fibers grad-
ually. As many fifibers are detached as to allow the
insertion of a blunt retractor behind the postero-
medial cortex of the tibia (Fig. 2). The leg is now
extended and the fluoroscope is placed over the
knee. Slight adjustments of the flexion angle are
made until the fluoroscope shows an exact antero-
posterior projection of the tibial plateaus (no dou-
ble-projection of the joint lines). The rotatory posi-
tion of the tibia is now modified
fi until exact neutral
rotation is achieved (patella anterior, fi fibula one-
Technique of open wedge HTO 623
B
Fig. 2 – (a) With gentle and selective retraction, this skin incision exposes
the proximal tibia, the medial border of the patellar tendon, the Pes anseri-
nus and the anterior fibers of the medial collateral ligament. (b) The long
distal fibers of the MCL are detached from the tibia under the Pes anserinus
tendons, thus exposing the posteromedial aspect of the proximal tibia.
third superimposed by tibia). In this position, two
Kirschner wires (K-wires; 2.3–2.5 mm) are drilled
from medial to lateral to mark to osteotomy plane.
These K-wires are controlled fluoroscopically until
they end exactly at the level of the lateral cortex of
the tibia. The two wires should be absolutely par-
allel in the anteroposterior plane, i.e., completely
superimposed on the anteroposterior fluoroscopy
image (Fig. 3). Th
The width of the proximal tibia at the
level of the osteotomy is now measured. Th The easi-
est method is to use a third K-wire with the exact
length of the two wires inserted into the tibia. The
Th
third wire is held parallel to the wire inserted into
the bone with the tip in contact with the tibial cor-
tex. The diff
fference in free length between the two
K-wires equals the total width of the tibia at the
level of the osteotomy. Usually the posterior width
of the tibia is 5–10 mm more than the anterior
width. The
Th measurements are marked on a ster-
ile paper with a surgical marker. ThThe depth of the
osteotomy is 10 mm less than the total width of
the tibia. The insertion depth of the oscillating saw
and the chisels should be marked on the instru-
ments with a surgical marker.
624 The Degenerative Knee

Fig. 4 – The posterior two-third of the tibia are cut with an oscillating saw.
Fig. 3 – The tibial plateau is visualized under the fluoroscope in ap.-projec- The saw is inserted under the two K-wires and a Hohmann retractor is used
tion. The lateral plateau should be in an exact ap.-projection (only one joint to protect the posterior soft tissues. The osteotomy is performed at a slow
line is visible). The patella is oriented in the center of the knee and the fibula pace and heat is avoided by continuous irrigation with cold fluid.
should be covered one-third by the tibia. A first K-wire is inserted as far pos-
terior on the tibia as possible. The starting point is the upper border of the
Pes anserinus. This reflects the transition between the convex and the concave
part of the tibial cortex. The endpoint of the K-wire is the upper border of the
proximal tibio-fibular joint. The wire should end in the lateral cortex. A sec-
ond wire is inserted under fluoroscopic control exactly parallel to the first one
1.5 cm more anterior (the distance reflects the width of the sawblade). The
saw will then be guided by the two wires giving an osteotomy plane exactly
parallel to the individual tibial slope of the patient. The width of the proximal
tibia is measured with a third K-wire and the depth of the osteotomy (10 mm
less than the distance measured) is marked on the sawblade.

The osteotomy usually starts at the upper border of

the Pes anserinus and ends at the upper border of
the proximal tibiafi
fibular joint. The osteotomy level
is oblique because with a transverse osteotomy
there would be a significant
fi off
ffset of the medial
cortex after opening of the osteotomy planes and
the area of bone healing would be smaller. Th The
saw cut is planned distal of the K-wires to rule
out any possibility of deviation of the saw into the
joint (Fig. 4). Obviously, by starting the osteot-
omy relatively low, the tibial tuberosity would be
cut in many patients. However, we use a biplanar
L-shaped osteotomy with a 100° angulated ante-
rior cut behind the tuberosity. With this modifica-
fi
tion, the position of the tuberosity does not inter-
fere with the osteotomy, and the anterior second
osteotomy plane induces a higher rotational stabil-
ity and an anterior restraint against extension. The
Th
angulation point of the osteotomy is at approxi-
mately 70% of the posterior–anterior diameter of
the medial tibia and the anterior cut should exit
the tibia above the insertion of the patellar ten-
don. The anterior cut can be marked with an elec-
trocautery on the bone (Figs. 5 and 6).
The osteotomy is created with an oscillating saw.
We prefer battery-driven motors and saw blades of
90 mm length. It is important to remember that
in contrast to total joint replacement, the success
Fig. 5 – The biplanar osteotomy technique greatly improves stability
against sagittal angulation and rotation. Healing of this bone area behind
the tuberosity was observed as early as 3 weeks after surgery.
of the procedure depends mainly on the biologic
healing of the osteotomy planes. All efforts
ff must
be undertaken to avoid damages to the local bone
stock and the periosteum. We use the saw at a slow
pace and continuously irrigate the blade with cold
fluid. The saw is withdrawn periodically to allow for
better irrigation, and all debris is flushed
fl out of the
osteotomy plane. It usually takes several minutes
to create the osteotomy and the depth is carefully
controlled to leave 10 mm of bone on the lateral
side. It is important to cut the posteromedial crest
of the tibia completely, whereas the thin posterior
cortex must not to be completely divided, because
this thin bone will crack with the insertion of the
chisels in the next step. We do not use a retractor
in the back of the knee; however, this is technically
possible with our approach. When the saw is care-
 Technique of open wedge HTO 625

A B

Fig. 6 – (a and b) The second osteotomy is angulated 100° against the first cut and is performed with a thinner blade. In contrast to the first
osteotomy, this cut goes through the opposite cortex.

fully pressed against the posterior bone with a low

power setting, the loss of resistance can be easily
felt when the bone is divided. The saw can then be
stopped without soft tissue damage.
For the anterior cut, we use a smaller and thinner
saw blade. The tibia is divided completely behind
the tuberosity, taking care to orient the cut exactly
in the frontal plane of the tibia.
The saw is now withdrawn and a broad chisel is
inserted in the transverse part of the osteotomy.
This chisel glides into the saw slot under the
Th
K-wires and is inserted as deep as the saw has
protruded. A second broad chisel is now inserted
between the first
fi chisel and the K-wires. This chisel
is now tapped into the osteotomy with light blows
of a hammer, slightly less deep than the fifirst chisel Fig. 7 – Flat chisels are now introduced sequentially into the posterior part
(Fig. 7). The surgeon should take some time for of the osteotomy. The first chisel is driven in as deep as the osteotomy was
this step to allow the bone to adapt to the grad- cut with the saw. The next chisels are each inserted 1 cm less deep. The
second chisel and the next chisels thereafter are tapped in with light ham-
ual opening of the osteotomy. The opening of the mer blows, with constant monitoring of the osteotomy site. The osteotomy
transverse and anterior oblique osteotomy planes should open gradually in the transverse and in the ascending parts. The
should be monitored carefully. Th There should be angle of 100° between the transverse and the ascending parts of the bone
a continuous and smooth separation of the two cut is seen in the anterior part of the wound.
planes. A third chisel can now be inserted between
the first two chisels. Again, this chisel is tapped
into the osteotomy with light blows of a hammer spreader (Synthes) can now be inserted in the pos-
over the course of 1–2 min. If necessary, this elas- terior part of the osteotomy plane (Fig. 8). The leg
tic deformation maneuver can be repeated until is extended and the correction is checked visually
the desired opening is achieved. Alternatively, a and fluoroscopically. A long metal alignment rod
large spreader can be placed between the two fi first (Synthes) can be used to connect the center of
chisels. Gradual opening of the spreader has the the femoral head with the center of the ankle, and
same effffect. The opening of the osteotomy is now the intersection with the knee baseline as well as
measured with graded wedges (Synthes). If the the orientation of the new knee line in the frontal
correction is achieved, the wedge is inserted ante- plane is observed. If no alignment rod is available,
rior to the chisels and the chisels are now removed. the cable of the electrocautery device can be used
The wedge holds the osteotomy open and a bone for this purpose. Modification
fi of the correction
626 The Degenerative Knee
Fig. 8 – When the planned opening has been achieved, the chisels are
exchanged by a bone spreader inserted exactly on the posteromedial crest
of the proximal tibia. Observe the excentric opening of the osteotomy gap
indicating an unchanged tibial slope.
is easy by opening or closing the spreader gradu-
ally. Besides the correction in the anteroposterior
plane, the change in the sagittal plane must be
closely monitored. TheTh tibial slope is an impor-
tant parameter for knee extension. In patients
with pre-operative full knee extension, the tibial
slope usually should not be altered. Because of the
anatomy of the proximal tibia, this means that the
osteotomy planes should have opened asymmetri-
cally when looked at from the medial side (more in
the back than in the front) and the surgeon should
be able to extend the patient’s knee completely
at this step of the procedure. The opening of the
osteotomy can be modifi fied at this time by reposi-
tioning of the spreader, use of an additional wedge
in the anterior part of the osteotomy, or by shift-
ing the wedge more anterior or posterior. If the
patient had an extension defi ficit pre-operatively,
reduction of the tibial slope can be used to improve
extension. The osteotomy then should be opened
markedly more in the back and less in the front,
and the effffect on knee extension should be care-
fully monitored intra-operatively. Often significant
fi
manual force must be applied to femur and tibia
at this time to achieve complete extension. A hard
bolster under the heel is very helpful. An exten-
sion osteotomy may also be used in patients with a
high natural tibial slope and anterior knee instabil-
ity. Slope reduction will shift the tibia backwards
under weight and will reduce the anterior transla-
tion (12–14), If the patient has a symptomatic pos-
terior knee instability and hyperextension of the
knee, the opposite eff ffect can be helpful to reduce
the posterior drawer and hyperextension (15). The
tibial slope can be increased by lifting the anterior
part of the osteotomy more than that of the pos-
terior part until the knee has no hyperextension
during the procedure. Th The increased tibial slope
also induces an anterior shift of the tibia in stance
and gait, thus counteracting the posterior drawer
of these patients (16).
When the correction fulfi fills all criteria, the osteot-
omy can be fi fixed. We use a special internal plate
fixator with locked bolts, the Tomofi fix implant
(4, 12, 17–21). This plate is pre-contoured for
the proximal medial tibia and carries four locked
screws for the proximal fragment and four screws
for the distal fragment (Figs. 9–12). The Th directions
of the screws are adapted to the anatomy of the tib-
ial head and the plate is designed for anteromedial
placement on the tibia, thus giving proximal screw
lengths of 50–85 mm. The proximal long screws
are self-tapping and in the interest of precise place-
ment, pre-drilling is required with a special plate-
mounted drill sleeve. The lengths of the proximal
screws can be measured by the drill bit or with the
AO/ASIF measuring device after the drill sleeve is
removed. The three most distal screws are 26 mm
long, self-drilling, and self-tapping. Because they
are placed in the hard bone of the tibial shaft, only
monocortical fixation is needed here.
The plate is mounted with three drill sleeves in
the upper three holes. An insertion tool eases
the mounting of the drill sleeves. It is important
to understand that this implant is placed subcu-
taneously above the MCL and the Pes anserinus.
Two 3-mm distance bolts are used to keep the
plate in due distance from the soft tissues during
application, thus avoiding compression of the Pes
anserinus or the medial collateral ligament by the
plate (Fig. 12b). A subcutaneous tunnel is created
distally to enable the plate to glide under the skin
on the periosteum of the tibia. Th The subcutaneous
layer is also dissected proximally as much as it is
necessary to push the plate upwards to the desired
height near the joint line (Fig. 9).
The leg is now extended and the fluoroscope is
placed over the knee. An exact anteroposterior
Fig. 9 – The Tomofix implant is now inserted into a subcutaneous pouch. It
usually centers itself automatically on the proximal tibia.
 Technique of open wedge HTO 627

A B

Fig. 10 – (a and b) The Tomofix plate is specifically configured

for use in this osteotomy technique. Four locked bolts are
placed in the proximal fragment and their position is pre-de-
termined to achieve maximum length. Four locked bolts used
in the distal fragment. The bolts in the shaft are inserted by a
stab skin incision.

B
Fig. 11 – The plate has combination holes in the middle and distal sec-
tion, which allow to insert alternatively a conventional lag screw as well as
a locked bolt in the same hole.

projection is obtained using the guidelines men-

tioned. The longitudinal part of the plate is pushed
under the skin distally and the transverse part is
now pushed upwards toward the joint line. Usu-
ally, the plate ends 10 mm under the joint line and
firm contact with the tibia should be obtained. A
fi Fig. 12 – The mechanics of a plate fixator differ fundamentally from a
2-mm inner drill sleeve is inserted into the middle conventional plate. (a) This implant type requires pressure of the plate on
drill sleeve mounted on the plate and a K-wire is the bone to block the screw and avoid motion. The soft tissues under the
drilled into the proximal tibia under fluoroscopic plate are compressed. (b) Plate fixators do not need plate/bone contact for
stability, since the screw is locked in the plate. In the Tomofix technique,
control while pressure is applied to the plate. This
Th two 3-mm distance bolts are initially mounted into the plate. They avoid
K-wire should be placed in the proximal tibia with compression of the plate against the Pes anserinus and the medial collateral
suffi
fficient clearance to the joint but still allowing ligament and allow a minimal-invasive insertion in a subcutaneous pouch.
the placement of the fourth ascending bolt into This offset of 3 mm. avoids pressure necrosis of the MCL and the Pes and
the proximal fragment of the osteotomy. Th The sur- reduces implant-related pain significantly.
628 The Degenerative Knee
geon should keep in mind that the direction of this
K-wire indicates the future position of the three
proximal bolts. These bolts should be parallel to the
joint line for optimum fit
fi of the plate. The longitu-
dinal part of the plate should be oriented parallel
to the tibia and well centered over the tibial shaft.
The surgical assistant must control the position of
the plate end by palpation until the two first
fi proxi-
mal bolts are inserted (Fig. 10). If the placement of
the plate is suboptimal, the K-wire is removed and
replaced after correction. Th
Then, the first bolt is pre-
drilled, the drill sleeve is removed, and a measur-
ing device is used to determine the length of the
bolt. Bicortical fixation should be obtained in the
proximal tibia in patients with questionable bone
quality. Th
The bolt is inserted with the power drill
and then tightened with the special screwdriver to
guarantee the correct insertional torque. Th The two
other proximal bolts are inserted in the same man-
ner. Fluoroscopic control of the bolt positions is
recommended.
The next step is the insertion of a lag screw dis-
Th
tal to the osteotomy. This conventional lag screw
will pretension the plate and cause compression
on the lateral side of the osteotomy. Th The screw is
pre-drilled with the special drill sleeve. ThThe lower
part of the combined plate hole is used to avoid
damage to the treads in the proximal part. The Th
direction of the screw is distal and lateral. After
Fig. 13 – A conventional lag screw is now inserted distal to the osteotomy,
aiming in a posterolateral direction. This lag screw allows compression of
the lateral cortical bridge of the osteotomy and elastic pretension of the
plate. If any diastasis in the lateral cortex was identified after spreading of
the osteotomy, it can be eliminated at this point by careful tightening of
the lag screw. The pretensioning must be performed cautiously to avoid
reduction of the opening of the osteotomy. The lag screw is exchanged by a
bicortical locked bolt at the end of the procedure after the other steps have
been performed.
drilling, a self-tapping AO/ASIF cortical screw is
inserted (Fig. 13). If any distraction has occurred
laterally during the opening of the osteotomy, this
can be reversed by insertion of the lag screw. The Th
screw is tightened gradually and the osteotomy
is carefully monitored to avoid loss of correction.
Fluoroscopic control is advocated at this time. Now
the three distal monocortical bolts are inserted. A
stab incision is made over the middle of the three
most distal holes and the skin is pulled distally
and proximally to expose the holes. Th The near cor-
tex is first pre-drilled with a special drill and then
the self-drilling/self-tapping bolt is inserted with
the power drill. The
Th final tightening is performed
with the torque-limited screwdriver. Th The distance
bolt is removed and replaced with a monocortical
bolt. Now the proximal distance bolt is removed
and replaced with the drill sleeve. A self-tapping
screw is inserted after pre-drilling and length mea-
surement. The lag screw is removed and the drill
sleeve is mounted to the proximal part of this hole.
Both cortical surfaces are drilled and a screw with
adequate length for bicortical fixation
fi is inserted
in this hole (Fig. 13). The
Th spreader is now removed
and a final fluoroscopic control of the osteotomy is
achieved in anteroposterior and lateral projection.
The clearance of the Pes anserinus and the medial
collateral ligament are checked. These
Th structures
should move freely under the plate. No formal
repair of the medial collateral ligament fibersfi is
required, but the distal ligament fi fibers should be
repositioned over the osteotomy gap. A small col-
lagen sponge is placed over the anterior osteotomy
cleft to seal the gap and to avoid post-operative
hematoma formation. An overfl flow drain is inserted.
The osteotomy site should be filled with blood clots
at this moment and these clots must not be aspi-
rated, nor should the osteotomy be flushed empty.
The subcutaneous layer is closed with interrupted
thin resorbable sutures and the skin is closed with
interrupted sutures. A padded elastic compression
drape is applied over the entire leg and a cryocom-
pression unit is placed over the knee.
Complications
Intraarticular fractures
Fractures into the joint have been described dur-
ing open wedge procedures. When the osteotomy
is not opened gradually with chisels but forces are
applied directly on the medial cortex, cracks may
occur into the lateral tibial plateau with frank sepa-
ration of the fragments. The spreading tool should
be removed from the osteotomy in this situation.
 Technique of open wedge HTO 629

A B C

D E F

Fig. 14 – (a and b) Radiographs of a 50-year-old

man with varus osteoarthritis of the left knee after
medial meniscectomy. A 10 mm correction was
performed and full weight-bearing and unre-
stricted ADL were achieved after 6 weeks. (c and
d) Anteroposterior and lateral radiographs after
6 weeks. The patient was able to bear full weight
at this time without pain. (e and f) Anteroposte-
rior and lateral radiographs after 24 months. The
patient is completely pain-free and is not restricted
in his activities. Note the solid bone formation in
the central and posterior parts of the osteotomy. (g
and h) Cosmetic and functional result. No removal
G H of the implant was planned.
630 The Degenerative Knee
When the osteotomy is closed, the fracture should
reduce and a clamp can be used to fix fi the reduc-
tion. Two or three percutaneous small fragment
cortical screws are now inserted from the lateral
side under fluoroscopic control parallel to the joint
line, close to the subchondral sclerosis zone. ThThe
osteotomy is now carefully checked to assure that
the bone cut is deep enough, leaving not more than
5–10 mm lateral bone in all areas. Chisels are now
introduced and the osteotomy plane is opened
again as described. The
Th Tomofifix plate can then be
applied in the way described.
Fracture of the lateral hinge
Fractures of the lateral cortical hinge with sepa-
ration of the two fragments may occur especially
in young patients with hard bone. If this scenario
occurs, the plate is first
fi fixed to the proximal tibia
and then the lag screw is applied in a posterolateral
direction in the first hole of the distal fragment.
By tightening this lag screw carefully under flfluoro-
scopic control, the distal fragment moves medially
and due to the oblique osteotomy plane the lateral
hinge will come under compression and the planes
will approximate again. Care must be taken not to
tighten this screw too much; otherwise, the correc-
tion might be partially lost. Th
The implant is so stable
that when all bolts are applied correctly, no change
in the rehabilitation program is necessary.
Hematoma formation
Because of the exposed cancellous bone, signifi-fi
cant hematoma may develop in the lower leg after
surgery, especially when the patient starts walk-
ing. The calf will be warm and redness may appear
over the shin. Significant
fi edema is also present.
Treatment should include rest, ice, manual lymph
drainage, and the use of a pneumatic calf pump.
Since we seal the osteotomy site with a collagen
sponge and restrict mobilization in the first
fi 48 h,
the incidence of hematomas has decreased signifi-
fi
cantly.
Inadvertent change of the tibial slope
Whereas the correction in the frontal plane may
be controlled clinically and fluoroscopically dur-
ing the procedure, it is more difficult
ffi to monitor
the position of the proximal fragment in the sag-
ittal plane. The medial osteotomy gap should be
carefully inspected during the procedure. The
Th two
planes should be oriented according to the surgical
plan. The anterior opening (positive slope) can be
increased by using a second osteotomy spreader or
a wedge in the anterior part of the osteotomy. Th The
posterior opening (negative slope) can be increased
by extending the leg and placing the spreader in the
very posterior part of the osteotomy. Active change
of the tibial slope may be considered in three situ-
ations. In cases of extension defi ficit, decreasing
the slope will improve knee extension. In cases
of hyperextension of the knee, an increase of the
tibial slope may limit hyperextension and thus sta-
bilize the knee. In cases of chronic posterior knee
instability, increasing the slope will improve sta-
bility of the knee in extension, because the femur
slides back and the tibia slides forth (16, 27).
Rehabilitation
The patient is allowed to walk on the operated leg
with 15 kg partial weight-bearing the day after
surgery using two crutches. Flexion of the knee is
trained actively. If signifi
ficant swelling of the lower
leg develops, manual lymph drainage is performed
and an intermittent pneumatic compression unit
is used for the first days. The patient leaves the
hospital as soon as the wounds are dry and when
walking with crutches is safe. He is allowed to load
the leg adapted to the pain level and no formal
weight-restriction protocol is used any more. Many
patients are able to walk without crutches on flat fl
ground after 3–4 weeks. Six weeks after surgery,
the patient is examined in our outpatient depart-
ment and radiographs of the knee in two planes
are obtained. Range of motion should be normal
at this time, the patient should be painfree, and
the radiographs should demonstrate partial heal-
ing of the osteotomy and no lysis zones or instabil-
ity signs. The patient is allowed to progress to all
activities of daily living, which usually takes 1–4
more weeks. Occasionally, pain may develop in the
hip or the ankle joint because of changes in the
weight-bearing line. TheTh patient is counseled that
the full eff
ffect of the osteotomy will be experienced
not before 3–5 months after surgery. No further
routine radiographic controls are scheduled and
the patient returns to the care of the referring phy-
sician. The plate may not be removed before heal-
ing of the osteotomy gap, usually not earlier than
12–18 months after surgery, but can also be left
in place if the patient does not demand implant
removal.
Bone healing
Spontaneous healing of this type of osteotomy
may be questioned. Th
The authors have observed

more than 1000 cases and found that spontaneous
filling of the gap by callus formation occurs regu-
larly and that bone substitutes do not enhance this
process (Fig. 14). In our experience, healing is safe
when the major biologic principles are respected.
The oscillating saw must be used with great care
Th
to avoid heat damage of the local osteoblasts and
the correction should be achieved by deformation
of the tibia and not by fracture, thus maintaining
a vital hinge of lateral bone and periosteum. No
suction drainage should be used near the osteot-
omy site, because the blood clot formation in the
osteotomy cleft is essential for bony healing. A
stable implant is absolutely mandatory for this
procedure and the forces on the osteotomy planes
are generally underestimated. TheTh Tomofi fix plate
fixator should always be used exactly in the way
presented here and the technique should not be
modifified. No bolt should be omitted and the proxi-
mal bolts should be as long as possible for optimum
stability. There is consensus in the group of medi-
cal developers that bone grafting or implantation
of bone substitutes is not necessary in this proce-
dure up to 20 mm opening when the technique is
carefully followed and the biologic environment
regarding bone healing is normal (22). In doubt-
ful cases (revision surgery, older patients, osteo-
porosis, nicotine use), cancellous bone graft may
be harvested from the iliac crest. The bone graft is
placed in the osteotomy gap without pressure. It is
not advisable to use tricortical bone wedges when
the Tomofi fix implant is used.
With this type of fixation, delayed healing of an
open-wedge osteotomy will not lead to implant fail-
ure but to minor radiologic symptoms. However,
the patient will not be able to tolerate full weight-
bearing 6–8 weeks after surgery and chronic soft
tissue infl
flammation near the osteotomy site may
be found. We would recommend a minimal-inva-
sive cancellous bone graft in this situation which
usually leads to rapid healing of the osteotomy.
Results
From October 2000 to February 2006, the authors
performed high tibial valgization osteotomy
according to the described technique in a total
of 707 patients. The average patient age was 40
years. The mean width of the osteotomy gap was
10.6 mm. All patients attended follow-up until
they were capable of full weight-bearing and had
returned to normal activities of daily live. Second-
ary loss of correction did not occur in any of our
cases. Hematoma was evacuated during hospital
stay in 12 cases. Revision surgery was needed for
two patients in the first post-operative days due to
Technique of open wedge HTO 631
intra-operative over-correction. In these cases the
distal locking screws were removed from the plate
fixator, the mechanical axis was corrected and the
plate was re-stabilized by insertion of new bicorti-
cal locking screws in the distal part of the longi-
tudinal arm. The further course for these patients
was uneventful.
Eleven patients received secondary cancellous
bone grafts to treat delayed bone healing. No
implant failure was observed and no manifest
instability of the fixation
fi was observed. However,
the patients developed chronic pain when weight-
bearing and mostly a lysis zone in the region of
the lateral hinge. A limited incision to the osteot-
omy site was performed, the gap was curetted and
cancellous bone graft was inserted. Full weight-
bearing was possible after 4–6 weeks in all these
patients.
In three other cases, late infection with irritation
of the soft tissues over the implant became mani-
fest 4–5 months post-operatively. After removal of
the plate fi
fixator and insertion of antibiotic carri-
ers, there were no further healing disturbances in
these patients. No losses of corrections occurred
after early plate removal.
References
1. Maquet P (1976) Valgus osteotomy for osteoarthritis of
the knee. Clin Orthop (120):143–148
2.Coventry MB (1979) Upper tibial osteotomy for gonarthro-
sis. The evolution of the operation in the last 18 years and
long-term results. Orthop Clin North Am 10(1):191–210
3. Bonnin M, Chambat P (2004) [Current status of val-
gus angle, tibial head closing wedge osteotomy in media
gonarthrosis] Der Stellenwert der valgisierenden, zuklap-
penden Tibiakopfosteotomie bei der medialen Gonar-
throse. Orthopade 33:135–142
4. Brinkman JM, Lobenhoff ffer P, Agneskirchner JD, et al.
(2008) Osteotomies around the knee. J Bone Joint Surg
[Br] 90-B:1548–1557
5. Hassenpfl flug J, von Haugwitz A, Hahne HJ (1998) Long-
term results of tibial head osteotomy. Z Orthop Ihre Gren-
zgeb 136(2):154–61
6. Insall JN, Joseph DM, Msika C (1984) High tibial osteot-
omy for varus gonarthrosis. A long-term follow-up study.
J Bone Joint Surg [Am] 66(7):1040–1048
7. Insall JN, Joseph DM, Msika C (1984) High tibial osteot-
omy for varus gonarthrosis. A long-term follow-up study.
J Bone Joint Surg [Am] 66(7):1040–1048
8. Naudie D, Bourne RB, Rorabeck CH, Bourne TJ (1999)
The Install Award. Survivorship of the high tibial valgus
osteotomy. A 10- to -22-year follow-up study. Clin Orthop
Relat Res 367:18–27
9. Yasuda K, Majima T, Tsuchida T, et al. (1992) A 10-to
15-year follow-up observation of high tibial osteotomy
in medial compartment osteoarthrosis. Clin Orthop Med
Res (282):186–195
10. Aydogdu S, Cullu E, Arac N, et al. (2000) Prolonged per-
oneal nerve dysfunction after high tibial osteotomy: pre-
and postoperative electrophysiological study. Knee Surg
Sports Traumatol Arthrosc 8:305–308
11. Pape D (2008) Detailed planning algorithm for high tibial
osteotomy. In: Lobenhofferff P, van Heerwaarden RJ, Stau-
632 The Degenerative Knee
bli AE, Jakob RP, Galla M, Agneskirchner JD (eds) Osteot-
omies around the knee. AO Publishing Thieme Verlag
Stuttgart, New York: 39-48
12. Lobenhoff ffer P, De Simoni C, Staubli AE (2002) Open-
wedge high-tibial osteotomy with rigid plate fi fixation. Tech
Knee Surg 1:93–105
13. Jakob RP (1990) Instabilitätsbedingte Arthrose: spezielle
Indikationen für Osteotomien bei der Behandlung des
instabilen Kniegelenks. In: Jakob R, Stäubli H-U (eds)
Kniegelenk und Kreuzbänder. Anatomie, Biomechanik,
Klinik, Rekon struktion, Komplikationen, Rehabilitation.
Springer Verlag, Heidelberg, pp 555–578
14. Lobenhoff ffer P (1999) Chronic instability after posterior
cruciate ligament injury. Tactics, techniques and results.
Unfallchirurg 102(11):824–839
15. Noyes F, Barber SD, Simon R (1993) High tibial osteotomy
and ligament reconstruction in varus angulated, anterior
cruciate ligament-defi ficient knees. A two- to seven-year
follow-up study. Am J Sports Med 21:2–12
16. Agneskirchner JD, Hurschler C, Stukenborg-Colsman
C, et al. (2004) Eff ffect of high tibial flexion osteotomy
on cartilage pressure and joint kinematics: a biome-
chanical study in human cadaveric knees. Winner of the
AGA-DonJoy Award 2004. Arch Orthop Trauma Surg
124:575–584
17. Agneskirchner JD, Freiling D, Hurschler C, Lobenhoffer ff
P (2006) Primary stability of four different
ff implants for
opening wedge high tibial osteotomy. Knee Surg Sports
Traumatol Arthrosc 14:291–300
18. De Simoni C, Staubli AE (2000) Neue Fixationstechnik für
mediale open-wedge Osteotomien der proximalen Tibia.
Schweiz Med Wochenschrift 119:130.
19. Lobenhoff ffer P, Agneskirchner JD (2003) Improvements in
surgical technique of valgus high tibial osteotomy. Knee
Surg Sports Traumatol Arthrosc 11:132–138
20. Staubli AE, De Simoni C, Babst R, Lobenhoff ffer P (2003)
TomoFix: a new LCP-concept for open wedge osteotomy of
the medial proximal tibia—early results in 92 cases. Injury
34(Suppl 2):B55–B62
21. Takeuchi R, Aratake M, Bito H, et al. (2008) Simultaneous
bilateral opening-wedge high tibial osteotomy with early
full weight-bearing exercise. Knee Surg Sports Traumatol
Arthrosc 16:1030–1037
22. Staubli AE (2008) Radiological examination of bone heal-
ing after open-wedge tibial osteotomy. In: Lobenhoffer ff
P, van Heerwaarden RJ, Staubli AE, Jakob RP, Galla M,
Agneskirchner JD (eds) Osteotomies around the knee. AO
Publishing Thieme Verlag Stuttgart, New York: 131-146
23. Agneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer
P (2007) The effects of valgus medial opening wedge
high tibial osteotomy on articular cartilage pressure of
the knee: a biomechanical study. Arthroscopy 23:852–
861
24. Fujisawa Y, Masuhara K, Shiomi S (1979) Th The eff
ffect of
high tibial osteotomy on osteoarthritis of the knee. An
arthroscopic study of 54 knee joints. Orthop Clin North
Am 10(3):585–608
25. Gaasbeek RD, Sonneveld H, van Heerwaarden RJ, et al.
(2004) Distal tuberosity osteotomy in open wedge high
tibial osteotomy can prevent patella infera: a new tech-
nique. Knee 11:457–461
26. Pape D, Adam F, Rupp S, et al. (2004) Stability, bone heal-
ing and loss of correction after valgus realignment of the
tibial head. A roentgen stereometry analysisStabilitat,
Knochenheilung und Korrrekturverlust nach valgisieren-
der Tibiakopfumstellung. Eine Rontgenstereometrieanal-
yse. Orthopade 33:208–217
27. Slocum B, Devigne T (1983) Crucial tibial thrust: a pri-
mary force in the canine stifle.
fl J Am Vet Med Assoc
183(4):456–459

A. Amendola,
D. E. Bonasia
Results of HTO in medial OA
of the knee
Introduction
H
igh tibial osteotomy (HTO) is a widely
accepted and performed procedure in medial
osteoarthritis of the knee. Many techniques
have been described (i.e., closing, opening, dome,
and “en chevron” osteotomies), but the most com-
monly preferred are the opening (medial) or clos-
ing (lateral) wedge osteotomies (1).
Although the goal of the treatment is to unload
the aff
ffected knee compartment, the real mecha-
nism of pain relief after an HTO is not completely
understood. In fact Shaw and Multon (2), in their
biomechanical cadaver study, show that to obtain
a complete medial compartment unload the valgus
correction should be at least 25°. Th This is contrast
with the daily practice of HTO, in which the goal is
considered a slight valgus overcorrection (6–10°).
Nevertheless most authors report good results
with a correct patient selection (3). Th
The ideal can-
didate for an HTO is a young, active patient (<60
years of age), with isolated medial osteoarthritis,
with good range of motion and without ligamen-
tous instability. Although overall HTO results seem
to show the effffectiveness of the procedure, there
are still some debated issues about osteotomies.
These include the choice between opening or clos-
ing tibial osteotomy, the graft selection in opening
osteotomies, the type of fixation, the necessity of
associate procedures, the eff ffect on patellofemoral
joint and if HTO affects
ff a subsequent total knee
arthroplasty (TKA) implant.
Overall results
Many short and long-term outcomes and survival
analysis have been reported in the literature. Sur-
vivorship analysis are a good methods of under-
standing quality and durability of the results,
because they do not exclude inadequate follow-up,
loss to follow-up, and patients’death (4).
Aglietti et al. (5) performed 139 osteotomies with
three diff
fferent methods and thus patients were
divided into three groups. Group A underwent a
Chapter 56
lateral wedge osteotomy, without internal fixation,
fi
and had a long leg cast for average 94 days (aver-
age non-weight-bearing 2 months). Group B had a
lateral wedge or an “en chevron” osteotomy synthe-
sized with two screws and long leg cast, followed by
removal splint (average total 50 days and average
non-weight-bearing 2 months). Group C underwent
a close wedge osteotomy according to Insall (6), no
internal fixation, and cylinder cast (average 52 days
with weight-bearing from the second post-oper-
ative day). Patients were evaluated with Hospital
for Special Surgery (HSS) knee rating system, with
femorotibial angle for the alignment and with a
modifified Ahlbach classifi
fication for the osteoarthri-
tis degree. The outcomes were satisfactory in 87%
(from 2–5 years of follow-up), in 70% (from 6–10
years of follow-up), and in 64% (more then 10 years
of follow-up). The authors concluded that group C
had better results and better correction, that severe
articular destruction had poorer outcomes, and that
undercorrected knees tended to relapse.
Matthews et al. (7) treated 40 patients with Coven-
try (8) or Coventry–Bowman (9) techniques with
minor modifi fications. A cast was used in all cases,
internal fixation with staples was performed in
25 cases and external fixation in three cases. They
evaluated patients’pain level (with a 0–5 scale), the
activity level (with a 0–5 scale), the number of sub-
sequent joint replacements, if the patients would
have undergone again the osteotomy and made a
survival analysis of the data. Th
Their results were sat-
isfactorily in 86% at 1 year from surgery, in 64% at
3 years, in 50% at 5 years, and in 28% at 9 years.
They concluded that obesity, advanced age, over or
under-correction had the worst outcomes.
Rudan et al. (10) treated 79 knees with valgus clos-
ing wedge HTO. They evaluated the patients for an
average follow-up period of 5.8 years (range 3–9
years) with a modifi fied HSS scoring system and
with radiographs. They reported 80% of good or
excellent results at last follow-up. They stated that
undercorrection was associated with a higher fail-
ure rate (62.5%), that patellofemoral arthrosis was
related with a poorer prognosis, and that the risk of
overcorrection is increased in knees with femoral
shaft-transcondilar (FS-TC) angle greater than 10°.
634 The Degenerative Knee
Ivarsson et al. (11) performed 99 lateral closing
wedge HTO, synthesized with staples and immo-
bilized in a cast for 6 weeks. They re-evaluated the
patients with a five-point scale questionnaire, with
radiographs and with a modifi fied Lysholm knee
scale. They report 75% of good and acceptable out-
comes at 5.7 years and 60% at 11.9 years. They also
considered that best results were seen in patients
with Ahlback Grade I or II osteoarthritis and in
post-operative corrections of 3–7° of valgus.
Naudie et al. (12) performed 106 HTO (94 closing
wedge and 12 dome osteotomies), synthesized with
staples (except one case with external fi fixator). A
bone graft was used in 35 patients and a stove-pipe
cast in 75 patients. In their Kaplan–Meier survivor-
ship analysis 75% of patients did not require a TKA
at 5 years, 51% at 10 years, 39% at 15 years, and
30% at 20 years. However, in patients less than age
50, ROM greater than 120°, the longevity increased
to 80% at 10 years. They thus underlined the impor-
tance of correct patient selection. They noted that
earlier failure was associated with age older than
50 years, previous arthroscopic debridments, lat-
eral tibial thrust, pre-operative knee flflexion <120°,
undercorrection and delayed union or non-union.
Sprenger et al. (13) treated 76 knees with closing
wedge HTO, synthesized medially with two screws
connected with a figure-of-eight wire and laterally
with a plate. No cast was used, toe-touch was allowed
at 6 weeks and full weight-bearing at 12 weeks.
Survival rates at 10 years follow-up were 65–74%
(end points were conversion to TKA, HSS score <70
points and patient’s dissatisfaction). Survival at 10
years was 90%, when the femorotibial angle was
between 8 and 16° at 1 year from surgery.
Koshino et al. (14) performed 75 closing wedge
HTO, synthesized with Charnley external fi fix-
ator clamps (20 cases), Koshino’s blade plate plus
a medial plate (39 cases), and long leg cast (the
remaining 16 cases). Patients were evaluated with
the American Society Knee Score and Function
Score, with radiographs and with patient’s satisfac-
tion degree. ThThe survivorship reported was 97.3%
at 7 years, 95.1% at 10 years, and 86.9% at 15 years
from surgery.
Tang et al. (15) treated 67 knees with lateral closing
HTO, synthesized with staples or plate or immobi-
lized in a long leg cast. Post-operative protocol was
toe-touch weight-bearing for 3 weeks and then a
brace with full weight-bearing until union, in case
of synthesis, or non-weight-bearing for 2 weeks
and partial weight-bearing for further 4 weeks, in
case of cast immobilization. Tegner and Lysholm
scoring system, level of performance (0–10 scale),
level of activity, pain, and level of satisfaction were
recorded during follow-up. Survival rates reported
were 89.5% at 5 years, 74.7% at 10 years, and
66.9% for 15 and 20 years.
Asik et al. (16) performed 65 open wedge osteoto-
mies with the Puddu plate. Post-operative rehabili-
tation included hinged brace, early motion, sudden
partial weight-bearing, and full weight-bearing at
3 months. HSS, American Knee Society, Oxford
knee scores, and radiological assessments were
used for re-evaluation. They reported signifi ficant
improvement of pain and knee function at average
34 months follow-up (range 18–60).
Chiang et al. (17) used dome-shaped HTO and
external fixation in 25 cases. Early joint motion
and partial weight-bearing were suddenly allowed.
All patients were evaluated with HSS score, which
was excellent or good in 18 knees at 5 years and in
13 knees at average 15 years.
Papachristou et al. (18) followed up 44 closing wedge
HTO, synthesized with one or two staples. Sudden
partial weight-bearing and early muscle strength-
ening were permitted. HSS score was used for re-
evaluations. Survivorship analysis showed a success
rate of 80 and 66% at 10 and 15 years respectively,
and over 52.8% at 17 years of follow-up.
Flecher et al. (19) followed up 301 closing wedge
HTO, synthesized with a Blount staple plus an AO
half tube plate. Immediate partial weight-bearing
and early full motion were permitted. Patient sat-
isfaction, radiograph, and survivorship were ana-
lyzed. Survival was 85% at 20 years with revision
as the endpoint. They also concluded that the most
important risk factors predicting revision were age
older than 50 years and pre-operative Ahlback 3 or
more arthrosis.
Gstöttner et al. (20) treated 134 knees with lateral
closing HTO, synthesized with staples. Post-opera-
tively, a knee brace was used and a partial weight-
bearing permitted. Survival rates and the influ- fl
ence of age, gender, and the mechanical axis were
investigated. ThThe survival rates were 94% after 5
years, 79.9% after10 years, 65.5% after 15 years,
and 54.1% after 18 years. Between the factors con-
sidered in the study only the age of patients had a
significant
fi infl
fluence on the survivorship.
Akizuki et al. (21) followed up 118 closing wedge
HTO, synthesized with a plate. Post-operative pro-
tocol included immediate active motion and par-
tial weight-bearing for 6 weeks. ThThe HSS score was
used for the re-evaluation. Survival was 97.6% at
10 years and 90.4% at 15 years from surgery.
Summary of literature review
In the review of the literature (Table 1), HTO
reports good or excellent short and midterm results
in treating isolated medial compartment arthrosis.
Furthermore, it is evident that the outcomes grad-
ually deteriorate to a success rate between 60 and
70% at 10 years from surgery (4).
 Results of HTO in medial OA of the knee 635

Table 1 – Review of the results for HTO.

Authors Year Follow-up Results
Aglietti et al. (5) 1983 >10 years Satisfactory outcomes in 87% (at 2–5 years), in 70% (at 6–10 years), and in
64% (>10 years)
Matthews et al. (7) 1988 Mean of 7 years Satisfactorily results in 86% at 1 year, in 64% at 3 years, in 50% at 5 years, and
(1.4–14.4 years) in 28% at 9 years
Rudan et al. (10) 1990 Mean of 5.8 years 80% of good or excellent results at last follow-up
(3–9 years)
Ivarsson et al. (11) 1990 5–13 years 75% of good and acceptable outcomes at 5.7 years and 60% at 11.9 years
Naudie et al. (12) 1999 10–22 years 75% of patients at 5 years, 51% at 10 years, 39% at 15 years, and 30% at 20
years did not require a TKA
Sprenger et al. (13) 2003 10 years Survival rates at 10 years follow-up were 65–74%
Koshino et al. (14) 2004 15–20 years Survivorship of 97.3% at 7 years, 95.1% at 10 years, and 86.9% at 15 years from
surgery
Tang et al. (15) 2005 20 years Survival rates of 89.5% at 5 years, 74.7% at 10 years, and 66.9% for 15 and 20
years
Asik et al.(16) 2006 Mean 34 months Significant improvement of pain and knee function
(18–60)
Chiang et al. (17) 2006 Mean 15 years Excellent or good HSS scores in 18 knees at 5 years and in 13 knees at average
(13–16) 15 years
Papachristou et al. (18) 2006 Mean 10 years Survival rate of 80% at 10 years, 66% at 15 years, and over 52.8% at 17 years
(5–17) of follow-up
Flecher et al. (19) 2006 Mean 18 years Survival was 85% at 20 years
(12–28)
Gstöttner et al. (20) 2008 Mean 12.4 years Survival rates were 94% after 5 years, 79.9% after10 years, 65.5% after 15
(1–25) years, and 54.1% after 18 years
Akizuki et al. (21) 2008 Mean 16.4 years Survival was 97.6% at 10 years and 90.4% at 15 years
(16–20)

Other considerations may be inferred reviewing of re-intervention (23). Furthermore Brouwer

the literature: severe articular destruction (three
or more according to Ahlback classifi fication) (5, 11,
19), undercorrected (5, 7, 11–13), or overcorrected
(7) knees, advanced age (12, 19, 20), patellofemo-
ral arthrosis (10), noticeably decreased range of
motion (12), previous arthroscopic debridments
(12), joint instability (4), loss of correction (4), and
lateral tibial thrust (12) have poorer outcomes,
while a slight valgus correction is associated with
better results (4, 11, 12).
Body mass index is a controversial factor; a few
studies report higher failure rates in lighter
patients (21, 12), while other papers (7, 22) affirm
ffi
the opposite. Given the lower success rates of
unicompartmental (UKA) and total knee (TKA)
arthroplasties in heavier patients, these seem to
be more amenable to HTO, in order to delay the
joint replacement.
These considerations underline the crucial role
Th
of correct patient’s selection in high tibial osteo-
tomies.
Although a good number of studies are available
on HTO outcomes, a close comparison and pooling
of the results are challenging because of the differ-
ff
ent evaluation systems used: these include scoring
systems, pain relief, patient satisfaction, and rates
(23) in his systematic review analysis states that
there is “silver” level evidence (www.cochranemsk.
org) that valgus HTO improves knee function and
reduces pain, but that there is no evidence whether
an osteotomy is more eff ffective than conservative
treatment and that a conclusion about effectiveness
ff
of specifi
fic surgical techniques cannot be drawn.
Complications
Fractures
Medial hinge and lateral hinge fractures in lateral
and medial HTO respectively are described compli-
cations that may impair osteotomy stability and
healing process (24). If this circumstance occurs,
a stable fixation should be achieved to reduce loss
of correction and non-union risks (24). When
the fracture is intrarticular the risk of incongru-
ity should be considered as well. Th
The incidence of
intrarticular fractures is 11% in medial opening
HTO (25) and between 10 and 20% in lateral clos-
ing HTO (7).
636 The Degenerative Knee
Non-union
The non-union is more common in opening wedge,
than in closing wedge osteotomies. The
Th risk rate is
0.7–4.4% (26–29). Bone autograft and allograft,
bone substitutes and growth factors have been
used to fill the void in opening HTO and to decrease
non-union, but the most reliable technique is still
controversial (see below).
Infection
The deep and superfi ficial infections rates range
from 2.3 to 54.4% (28). The higher risk is associ-
ated with external fixator synthesis, but in these
cases the infection is usually superficial,
fi limited to
the pin tract and positively responding to oral anti-
biotics (24). In osteotomies synthesized with inter-
nal fixation the risk can only reach the 4% (30).
Patella baja or patella alta
Before the introduction of the internal fixation
and early motion in HTO, when the cast immobi-
lization was part of the post-operative treatment,
authors recorded a risk between 7.6 and 8.8% of
having a patella baja following a lateral closing
wedge osteotomy (31, 32). ThisTh complication was
probably due to the contracture of the patellar ten-
don during the cast immobilization (24). A more
recent study (33) shows that closing wedge osteot-
omy increases patellar height, whereas opening
wedge osteotomy lowers patellar height. The
Th clini-
cal implications of patellar height changes on the
outcomes and on the following total joint replace-
ment are still controversial.
Compartment syndrome
Although the complication has been described,
the exact incidence of compartment syndrome
in HTO is not available (24, 28) and no data are
available about the methods to reduce this risk.
Some authors suggest using a drain to reduce the
anterior compartment pressure (24, 34), other
authors reported the increased risk with associated
arthroscopic ligament reconstruction (24, 35).
Peroneal nerve palsy
The palsy of the peroneal nerve, due to direct injury,
is a complication described for closing wedge HTO
(28) and its incidence ranges from 2 to 16% (36, 37).
If the osteotomy of the fibula
fi is performed more
than 15 cm distally to the head, the risk is reduced
(38). Nonetheless, neurological complications after
medial opening osteotomy have been reported (36).
Thromboembolism
The incidence of deep vein thrombosis ranges
between 1.3 and 9.8% (39, 40) and also fatal pul-
monary embolism has been reported (41).
Other complications
Other complications described include pseudoar-
throsis of the fibula (only in closing wedge HTO),
vessel injuries, necrosis of the tibial head, Sudek
syndrome, and failure of the osteosynthesis with or
without loss of correction (28). For most of these
circumstances, the exact incidence is not available
and they are mainly described in case reports (28).
Closing versus opening high tibial osteotomy
Lateral closing wedge HTO has been considered for
long time the gold standard in treating medial knee
osteoarthritis. However, this technique implies
peroneal osteotomy or proximal tibiofibular
fi joint
disruption, lateral muscle detachment, peroneal
nerve dissection, more demanding subsequent
total joint replacement, and bone stock loss. For
all these reasons, the opening wedge HTO rose in
popularity and became a widely performed alter-
native option. This technique, however, is not free
from complications and these include possibility of
collapse and loss of correction and the necessity of
bone graft with possible donor site morbidity (in
case of autograft) or disease transmission (in case
of allograft).
Currently, in the literature only one randomized
controlled trial has been reported comparing
opening and closing wedge HTO (42). At 1-year
follow-up the authors concluded that both groups
had knee function and pain improvements with no
statistically significant
fi diff
fferences. Nevertheless
opening wedge osteotomy showed higher compli-
cations rate and lower correction accuracy (42).
However, no conclusion can be drawn on which
technique should be preferred and the choice
remains a matter of preference of the surgeon,
until further studies will be available.
Augmentation in opening wedge HTO
The way to fill the void created with an opening
wedge HTO has always been a matter of interest

and many techniques have been developed. Th The
research is moving in two different
ff directions to
solve this issue. The first is to find a reliable fixa-
tion device that can rule out the necessity of aug-
mentation; the second is to determine the best
augmentation technique.
Many methods have been used to fill fi the osseous
gap and these include bone grafts (auto or
allograft), synthetic bone substitutes (hydroxy-
apatite, -tricalcium phosphate, a combination of
both, bone cement) with or without platelet rich
plasma (PRP), growth factors, and bone marrow
stromal cells.
Autograft bone is generally considered to be the
most successful bone filling material because of its
osteoconductive, osteoinductive, and osteogenic
properties (43–47). Drawbacks of the autograft
include the increased operative time and the
donor site morbidity, while the allograft has lower
osteoinductive properties and entails disease
transmission risk. The bone substitutes attempt to
reduce the risks of bone grafting and have a good
biological degradability, but their major problem
is due to low resistance of macroporous ceramics
to compressive loads (48). The
Th use of bone cement
as a spacer has been described (49), but in order
to achieve a more biological regeneration it is not
recommendable (48).
Encouraging results and improvement in osteot-
omy union have been reported with the use of PRP,
bone marrow stromal cells, and growth factors
(48, 50, 51), associated with both bone grafting
and bone substitutes augmentation. Nevertheless,
if synthetic augmentation combined with PRP
is equal or even superior to autologous iliac crest
graft has not been demonstrated yet (48) and the
use of plasma products still remains experimental.
Type of fixation
fi
When closing wedge osteotomies were fi first intro-
duced for medial compartment knee arthrosis, no
fixation was performed and the limb was immobi-
lized in a long leg cast. With this method the risk
of loss of correction, joint stiffness,
ff and patellar
tendon contracture was high and staples were then
used to improve the fixation stability and to accel-
erate the rehabilitation programs.
With the diffffusion of opening wedge HTO a more
stable synthesis was required and new devices were
introduced. They include eternal fixators (both
axial and circular) and plates (conventional, lock-
ing, long or short plates, with or without a spacer).
A few papers comparing the different ff fixation
devices have been published, but the most reliable
fixation system is still controversial.
Results of HTO in medial OA of the knee 637
Stoff
ffel et al. (52) compared the biomechanical
properties of the modifi fied Puddu plate (Arthrex,
Naples, Fla), and the TomoFix plate (Synthes,
Solothurn, Switzerland). The Th authors concluded
that both the Puddu and the TomoFix plates create
immediate stability. However, if the lateral cortical
shows signs of fracture, an additional lateral fixa-
fi
tion is recommended for the Puddu plate, while
TomoFix has enough axial and torsional residual
stability.
Agneskirchner et al. (53) compared four different
ff
plates: a short spacer plate, a short spacer plate
with multi-directional locking screws, a long spacer
plate with multi-directional locking screws, and a
long medial tibia plate fixator with locking screws.
They stated that a rigid long plate fixator with angle
stable locking screws yields the best results.
Zhim et al. (54) compared the biomechanical sta-
bility of the Puddu plate (Arthrex, Naples, Fla)
and the Hoff ffman II external fixator (Stryker
Howmedica, Osteonics, Rutherford, NJ, USA)
and concluded that plate fixation was superior
in maintaining correction, although progressive
adjustment of the distraction with the external
fixator allowed precise “fi fine-tuning” during the
healing process.
Dorsey et al. (55) in their biomechanical study
tested three fixation devices: VS Osteotomy plate
(EBI, Parsippany, NJ), Arthrex Osteotomy plate
(Arthrex, Naples, Fla), and OsteoTrac plate (DJ
Orthopedics Inc, Vista, Calif). They found that
there were no statistical significant
fi diff
fferences
between the devices.
Spahn et al. (56) made a biomechanical investiga-
tion of diff
fferent internal fixation techniques (con-
ventional plate, angle stable plate with or without
spacer) and concluded that spacer implants have
superior biomechanical properties and that angle
stable plates may prevent fractures of the lateral
cortex.
We can conclude that the results are still inconclu-
sive and there are not randomized clinical trials
that signifificantly show the most reliable fixation
device. Furthermore, despite the long locking plate
showed stronger biomechanical properties, it is
corpulent, its removal is necessary in almost every
case and has higher costs (48).
Associated procedures
The need for associate surgical procedures in the
young and middle aged patients is a matter of
interest (57). Abrasion arthroplasty, microfrac-
tures, autologous chondrocytes implantation, and
meniscal transplant together with HTO have been
described, but the results are still inconclusive.
638 The Degenerative Knee
Matsunaga et al. (58) divided patients with medial
knee arthrosis into a group undergoing HTO alone,
a group undergoing HTO plus microfractures, and
a group undergoing HTO plus abrasion arthro-
plasty. The extent of cartilage repair was compared
at 1 year after surgery by arthroscopy, while the
clinical outcome was evaluated at 1, 3, and 5 years
post-operatively. They concluded that the repair
of articular cartilage at 1 year was accelerated in
abrasion arthroplasty group, but not in microfrac-
ture group, but there were no differences
ff of the
clinical outcome between the three groups. One of
the drawbacks of this well-conducted study is the
advanced age of the patients.
Akizuki et al. (59) in their randomized study stated
that HTO combined with abrasion arthroplasty
achieved better cartilage repair than HTO alone,
but again there was no difference
ff in the clinical
outcome at 2–9 years post-operatively between the
two groups.
Sterett and Steadman (60) in a case series study
concluded that combining a medial opening wedge
HTO with the microfracture chondral resurfacing
procedure is an eff ffective method of decreasing
pain and increasing function at a minimum of 2
years follow-up.
Franceschi et al. (61) stated that the association
of arthroscopic implantation of autologous chon-
drocytes with a medial opening wedge HTO is a
reliable option for the management of chondral
defects in varus knees.
Brouwer (23) in his meta-analysis showed that
there is silver level evidence for no diff fferences of
Japanese Orthopaedic Association (JOA) knee
score after HTO without and HTO with abrasion
arthroplasty.
However, no randomized controlled trials about
the eff
ffectiveness of these associate procedures are
available (61).
Meniscal transplant associated with HTO has been
described for low grade arthritic and meniscecto-
mized knees and HTO seems both to protect the
implant and to unload the aff ffected compartment
(32, 62, 63). However, no randomized trials com-
paring HTO alone to HTO combined with menis-
cus have not been performed to demonstrate what
component of the surgery is most beneficial. fi
Comparison between unicompartmental knee
arthroplasty and HTO
With the increasing popularity of unicompartmen-
tal knee arthroplasty (UKA) and with the improve-
ment of its results at mid and long-term follow-up,
the interest to compare the outcomes of HTO and
UKA is growing.
Most comparison studies available in literature
compare UKA versus lateral closing wedge HTO
(64).
Brughton et al. (65) retrospectively reviewed at
5–10 years follow-up 49 lateral closing wedge HTO
and 42 UKA. The type of surgery was decided by
the surgeon, but the two groups were considered
similar and comparable. A modified fi HSS score
showed results signifi ficantly better for the UKA
than for the HTO (76% versus 43% good results).
Ivarsson and Gillquist (66) matched 10 patients
with UKA and 10 with HTO during their reha-
bilitation program. All patients regained motion
without problems, with no difference
ff between the
groups. The results of muscle torque in UKA group
at 6 months from surgery were better than those
of HTO group at 12 months. In the UKA group
there was an increase in the maximal gait velocity
and the duration of single support. Th The authors
concluded that arthroplasty is advised for older
patients.
Stukenborg-Colsman et al. (67) prospectively com-
pared the outcome of 32 HTO and 28 UKA, at
7–10 years follow-up. More intra- and post-oper-
ative complications were observed after HTO. The Th
Kaplan–Meier survival analysis 7–10 years post-
operatively showed a survivorship of 77% for UKA
and 60% for HTO. The Th authors concluded that UKA
off
ffers better long-term success.
Maistrelli et al. (64) compared 56 consecutive UKA
and 54 opening wedge HTO. They found that there
were no clinical or radiological differences
ff between
the two groups at average 4.2 years follow-up for
HTO and average 2.73 years for UKA. This Th is the
first study comparing the opening wedge HTO
with UKA.
Although these data seem to support the use of
UKA rather than an HTO, Brouwer (23) in his
meta-analysis stated that there is no significant
fi
diff
fference in pain, function, and gait analysis
between HTO and UKA. However, he also affirmedffi
that HTO causes more complications compared
with UKA.
Total Knee Replacement after HTO
Another concern (that currently seems to be
solved) is whether the HTO can impair the results
of a subsequent total knee replacement (TKR). All
data published do not demonstrate statistically
signifi
ficant diff
fferences in outcomes of patients
treated with a primary TKR or with a TKR follow-
ing an HTO.
Amendola et al. (68) in their retrospective study
compared primary TKR with TKR following HTO.
They concluded that osteotomy does not seem to

aff
ffect the outcome of TKR, but range of motion
following TKR appears to be less in HTO group. In
addition, an HTO may alter the inclination of the
tibial plateau.
Karabatsos et al. (69) in their retrospective cohort
study stated that TKR after HTO is a technically
more challenging procedure than primary TKR,
but there are not statistically significant
fi diff
ffer-
ences in the outcomes at 5 years from TKR.
Van Rajii et al. (70) performed a matched case
control study to assess the effect
ff of prior HTO on
results and complications of TKR and concluded
that TKR after HTO seems to be technically more
demanding, but clinical outcome was almost iden-
tical between the two groups.
Kazakos et al. (71) in their cohort study showed
that HTO does not have a signifi ficant negative
eff
ffect on a subsequent TKA.
Reviewing the literature, we can then infer that
TKR after HTO has outcomes similar to primary
TKR. In all the studies cited above, a closing wedge
tibial osteotomy was performed prior to TKR and
most of the authors conclude that, besides the
similar outcomes, the revision of HTO to TKR is
more technically demanding. Although no data are
available yet, we believe that the joint replacement
after the opening medial osteotomy is easier. The Th
reasons are that, with this technique, there is no
risk of patella alta, the bone stock is maintained
and there is lower risk of impingement between
the tibial component stem and the anterior cortex
of the tibia.
Conclusions
We can conclude that HTO for medial arthrosis
of the knee is a reliable procedure with a correct
patient selection and a precise surgical technique,
even if the outcomes deteriorate with time. Good
to excellent results have been reported for both
opening and closing wedge HTO.
In open wedge osteotomy, the most reliable fi fixa-
tion and augmentation techniques are still con-
troversial. Gold standards seem to be the locked
plates and the autologous bone graft.
Although UKA achieves slightly better results com-
pared to HTO, the osteotomy is still the treatment
of choice for the younger, heavier, and more active
patient with medial knee arthrosis.
Although a revision of lateral closing HTO to TKR
is technically more demanding than a primary
implant, there is no difffference in the long-term
outcomes.
In the younger patient, an associate procedure
of chondral resurfacing or a meniscal transplant
should be considered to improve the function and
Results of HTO in medial OA of the knee 639
biomechanics of the damaged compartment. How-
ever, the results of these associated procedures are
still controversial, but in our opinion any attempt
should be tried to protect the cartilage.
References
1. Amendola A (2003) Unicompartmental osteoarthritis
in the active patient: the role of high tibial osteotomy.
Arthroscopy 19(10):109–116
2. Shaw JA, Moulton MJ (1996) High tibial osteotomy: an
operation based on a spurious mechanical concept. Am J
Orthop 25:429–436
3. Amendola A, Panarella L (2005) High tibial osteotomy for
the treatment of unicompartmental arthritis of the knee.
Orthop Clin North Am 36(4):497–504.
4. Segal NA, Buckwalter JA, Amendola A (2006) Other surgi-
cal techniques for osteoarthritis. Best Pract Res Clin Rheu-
matol 20(1):155–176
5. Aglietti P, Rinonapoli E, Stringa G, Taviani A (1983) Tibial
osteotomy for the varus osteoarthritic knee. Clin Orthop
176:239–251
6. Insall J, Shoji H, Mayer V (1974) High tibial osteotomy. A
five year evaluation. J Bone Joint Surg 56A:1397
7. Matthews LS, Goldstein SA, Malvitz TA, et al. (1988) Prox-
imal tibial osteotomy. Factors that influence
fl the duration
of satisfactory function. Clin Orthop 229:193–200
8. Coventry MB (1973) Osteotomy about the knee for degen-
erative and rheumatoid arthritis: Indications, operative
techniques and results. J Bone Joint Surg 55A:23
9. Coventry MB, Bowman PW (1982) Long term results of
upper tibial osteotomy for degenerative arthritis of the
knee. Acta Orthop Belg 48:139
10. Rudan JF, Simurda MA (1990) High tibial osteotomy. A
prospective clinical and roentgenographic review. Clin
Orthop 255:251–256
11. Ivarsson I, Myrnerts R, Gillqvist J (1990) High tibial
osteotomy for medial osteoarthritis of the knee. J Bone
Joint Surg Br 72:238–244
12. Naudie D, Bourne RB, Rorabeck CH, Bourne TJ (1999)
The Install Award. Survivorship of the high tibial valgus
osteotomy. A 10- to 22-year followup study. Clin Orthop
367:18–27
13. Sprenger TR, Doerzbacher JF (2003) Tibial osteotomy
for the treatment of varus gonarthrosis: survival and fail-
ure analysis to twenty-two years. J Bone Joint Surg Am
85:469–474
14. Koshino T, Yoshida T, Ara Y, et al. (2004) Fifteen to
twenty-eight years’follow-up results of high tibial valgus
osteotomy for osteoarthritic knee. Knee 11:439–444
15. Tang WC, Henderson IJP (2005) High tibial osteotomy:
long term survival analysis and patients’perspective. Knee
12:410–413
16. Asik M, Sen C, Kilic B, et al. (2006) High tibial osteotomy
with Puddu plate for the treatment of varus gonarthrosis.
Knee Surg Sports Traumatol Arthrosc 14:948–954
17. Chiang H, Hsu H, Jiangl C (2006) Dome-shaped high tib-
ial osteotomy: a long-term follow-up study. J Formos Med
Assoc 105(3):214–219
18. Papachristou G, Plessas S, Sourlas J, et al. (2006) Deterio-
ration of long-term results following high tibial osteotomy
in patients under 60 years of age. Int Orthop 30:403–408
19. Flecher X, Parratte S, Aubaniac JM, Argenson JN (2006)
A 12-28-year followup study of closing wedge high tibial
osteotomy. Clin Orthop 452:91–96
20. Gstöttner M, Pedross F, Liebensteiner M, Bach C (2008)
Long-term outcome after high tibial osteotomy. Arch
Orthop Trauma Surg 128(1):111–115.
640 The Degenerative Knee
21. Akizuki S, Shibakawa A, Takizawa T, et al. (2008) The long-
term outcome of high tibial osteotomy: a ten- to 20-year
follow-up. J Bone Joint Surg Br 90(5):592–596
22. Coventry MB, Ilstrup DM, Wallrichs SL (1993) Proximal
tibial osteotomy. A critical long-term study of eighty-
seven cases. J Bone Joint Surg Am 75(2):196–201
23. Brouwer RW, van Raaij TM, Bierma-Zeinstra SM, et
al. (2007) Osteotomy for treating knee osteoarthritis.
Cochrane Database Syst Rev 18(3):CD004019
24. Wright JM, Crockett HC, Slawski DP, et al. (2005) High
tibial osteotomy. J Am Acad Orthop Surg 13(4):279–289
25. Hernigou P, Medevielle D, Debeyre J, Goutallier D (1987)
Proximal tibial osteotomy for osteoarthritis with varus
deformity. J Bone Joint Surg Am 69:332–354
26. Aydogdu S, Sur H (1997) High tibial osteotomy for varus
deformity superior to 20 degrees. Rev Chir Orthop
83:439–446
27. Bettin D, Karbowski A, Schwering L, Matthias HH (1998)
Time-dependent clinical and roentgenographical results of
Coventry high tibial valgisation osteotomy. Arch Orthop
Trauma Surg 117:53–57
28. Spahn G (2004) Complications in high tibial (medial
opening wedge) osteotomy. Arch Orthop Trauma Surg
124(10):649–653
29. Tjornstrand B, Hagstedt B, Persson BM (1978) Results of
surgical treatment for non-union after high tibial osteot-
omy in osteoarthritis of the knee. J Bone Joint Surg Am
60:973–979
30. Billings A, Scott DF, Camargo MP, Hofmann AA (2000)
High tibial osteotomy with a calibrated osteotomy guide,
rigid internal fixation, and early motion: longterm fol-
low-up. J Bone Joint Surg Am 82:70–79
31. Scuderi GR, Windsor RE, Insall JN (1989) Observations
on patellar height after proximal tibial osteotomy. J Bone
Joint Surg Am 71:245–248
32. Verdonk R, Almqvist KF, Huysse W, Verdonk PC (2007)
Meniscal allografts: indications and outcomes. Sports
Med Arthrosc 15(3):121–125
33. Wright JM, Heavrin B, Begg M, et al. (2001) Observations
on patellar height following opening wedge proximal tibial
osteotomy. Am J Knee Surg 14:163–173
34. Gibson MJ, Barnes MR, Allen MJ, Chan RN (1986) Weak-
ness of foot dorsiflflexion and changes in compartment
pressures after tibial osteotomy. J Bone Joint Surg Br
68:471–475
35. Marti CB, Jakob RP (1999) Accumulation of irrigation fluid
fl
in the calf as a complication during high tibial osteotomy
combined with simultaneous arthroscopic anterior cruci-
ate ligament reconstruction. Arthroscopy 15:864–866
36. Flierl S, Sabo D, Horning K, Perlick L (1996) Open wedge
high tibial osteotomy using fractioned drill osteostomy: a
surgical modification
fi that lowers the complication rate.
Knee Surg Sports Traumatol Arthrosc 4:149–153
37. Georgoulis AD, Makris CA, Papageorgiou CD, et al. (1999)
Nerve and vessel injuries during high tibial osteotomy
combined with distal fibular osteotomy: a clinically rel-
evant anatomic study. Knee Surg Sports Traumatol
Arthrosc 7:15–19
38. Wootton JR, Ashworth MJ, MacLaren CA (1995) Neuro-
logical complications of high tibial osteotomy: the fi
fibular
osteotomy as a causative factor. A clinical and anatomical
study. Ann R Coll Surg Engl 77:31–34
39. Kleinert B, Scheier HJG, Munzinger U, Steiger U (1985)
Ergebnisse der Tibikopfosteotomie. Orthopäde 14:154–
160
40. Rinonapoli E, Mancini GB, Corvaglia A, Musiello S (1998)
Tibial osteotomy for varus gonarthrosis. A 10- to 21-year
follow- up study. Clin Orthop 353:185–193
41. Insall JN, Joseph DM, Msika C (1984) High tibial osteot-
omy for varus gonarthrosis: a long-term follow-up study.
J Bone Joint Surg Am 66:1040–1048
42. Brouwer RW, Bierma-Zeinstra SMA, Raaij TM, et al
(2006) Osteotomy for medial compartment arthritis
of the knee using a closing wedge or an opening wedge
controlled by a Puddu Plate. J Bone Joint Surg Br
88-B(11):1454–1459
43. Buser D, Hoff ffmann B, Bernard JP, et al. (1998) Evaluation
of filling materials in membrane-protected bone defects. A
comparative histomorphometric study in the mandible of
miniature pigs. Clin Oral Implants Res 9(3):137–150
44. Eid K, Zelicof S, Perona BP, et al. (2001) Tissue reactions
to particles of bone-substitute materials in intraosseous
and heterotopic sites in rats: discrimination of osteoin-
duction, osteocompatibility, and inflammation.
fl J Orthop
Res 19(5):962–969
45. Gaasbeek RD, Toonen HG, van Heerwaarden RJ, Buma
P (2005) Mechanism of bone incorporation of beta-
TCP bone substitute in open wedge tibial osteotomy in
patients. Biomaterials 26(33):6713–6719
46. LeGeros RZ (2002) Properties of osteoconductive bioma-
terials: calcium phosphates. Clin Orthop 395:81–98
47. Stoll T, MOMTBS (2004) New aspects in osteoinduction.
Mat-wiss u Werkstoff fftech 35(4):198–202
48. Aryee S, Imhoff ff AB, Rose T, Tischer T (2008) Do we need
synthetic osteotomy augmentation materials for opening-
wedge high tibial osteotomy. Biomaterials 29(26):3497–
3502
49. Hernigou P, Ma W (2001) Open wedge tibial osteot-
omy with acrylic bone cement as bone substitute. Knee
8(2):103–110
50. Dallari D, Savarino L, Stagni C, et al. (2007) Enhanced
tibial osteotomy healing with use of bone grafts supple-
mented with platelet gel or platelet gel and bone mar-
row stromal cells. J Bone Joint Surg Am 89(11):2413–
2420
51. Kawaguchi H, Jingushi S, Izumi T, et al. (2007) Local appli-
cation of recombinant human fibroblast growth factor-2
on bone repair: a dose-escalation prospective trial on
patients with osteotomy. J Orthop Res 25(4):480–487
52. Stoff
ffel K, Stachowiak G, Kuster M (2004) Open wedge
high tibial osteotomy: biomechanical investigation of the
modifi fied Arthrex Osteotomy Plate (Puddu Plate) and the
TomoFix Plate. Clin Biomech 19(9):944–950
53. Agneskirchner JD, Freiling D, Hurschler C, Lobenhoffer ff
P (2006) Primary stability of four different
ff implants for
opening wedge high tibial osteotomy. Knee Surg Sports
Traumatol Arthrosc 14(3):291-300
54. Zhim F, Lafl flamme GY, Viens H, et al. (2005) Biomechani-
cal stability of high tibial opening wedge osteotomy:
internal fixation versus external fixation. Clin Biomech
20(8):871–876
55. Dorsey WO, Miller BS, Tadje JP, Bryant CR (2006) Th The
stability of three commercially available implants used in
medial opening wedge high tibial osteotomy. J Knee Surg
19(2):95–98
56. Spahn G, Mückley T, Kahl E, Hofmann GO (2006) Bio-
mechanical investigation of different
ff internal fixations
in medial opening-wedge high tibial osteotomy. Clin Bio-
mech 21(3):272–278
57. Pagnano MW, Clarke HD, Jacofsky DJ, et al. (2005) Sur-
gical treatment of the middle-aged patient with arthritic
knees. Instr Course Lect 54:251–259
58. Matsunaga D, Akizuki S, Takizawa T, et al. (2007) Repair
of articular cartilage and clinical outcome after osteotomy
with microfracture or abrasion arthroplasty for medial
gonarthrosis. Knee 14(6):465–471
59. Akizuki S, Yasukawa Y, Takizawa T (1997) Does
arthroscopic abrasion arthroplasty promote cartilage
regeneration in osteoarthritic knees with eburnation? A
prospective study of high tibial osteotomy with abrasion
arthroplasty versus high tibial osteotomy alone. Arthros-
copy 13:9–17

60. Sterett WI, Steadman JR (2004) Chondral resurfacing and
high tibial osteotomy in the varus knee. Am J Sports Med
32(5):1243–1249
61. Franceschi F, Longo UG, Ruzzini L, et al. (2008) Simulta-
neous arthroscopic implantation of autologous chondro-
cytes and high tibial osteotomy for tibial chondral defects
in the varus knee. Knee 15(4):309–313
62. Amendola A (2007) Knee osteotomy and meniscal trans-
plantation: indications, technical considerations and
results. Sports Med Arthrosc Rev 15:32–38
63. Cameron JC, Saha S (1997) Meniscal allograft transplan-
tation for unicompartmental arthritis of the knee. Clin
Orthop 337:164–171
64. Dettoni F, Maistrelli GL, Rossi P, et al. (2008) UKA versus
HTO: clinical results at short term follow up. 75th AAOS
Annual Meeting, San Francisco, CA
65. Broughton NS, Newman JH, Baily RA (1986) Unicompart-
mental replacement and high tibial osteotomy for osteoar-
thritis of the knee. A comparative study after 5-10 years’
follow-up. J Bone Joint Surg Br 68(3):447–452
66. Ivarsson I, Gillquist J (1991) Rehabilitation after high
tibial osteotomy and unicompartmental arthroplasty. A
comparative study. Clin Orthop 266:139–144
Results of HTO in medial OA of the knee 641
67. Stukenborg-Colsman C, Wirth CJ, Lazovic D, Wefer A
(2001) High tibial osteotomy versus unicompartmental
joint replacement in unicompartmental knee joint osteoar-
thritis: 7-10-year follow-up prospective randomised study.
Knee 8(3):187–194
68. Amendola A, Rorabeck CH, Bourne RB, Apyan PM (1989)
Total knee arthroplasty following high tibial osteotomy
for osteoarthritis. J Arthroplasty 4(Suppl):S11–S17
69. Karabatsos B, Mahomed NN, Maistrelli GL (2002) Func-
tional outcome of total knee arthroplasty after high tibial
osteotomy. Can J Surg 45(2):116–119
70. van Raaij TM, Bakker W, Reijman M, Verhaar JAN (2007)
The eff
ffect of high tibial osteotomy on the results of total
knee arthroplasty: a matched case control study. BMC
Musculoskelet Disord 8:74
71. Kazakos KJ, Chatzipapas C, Verettas D, et al. (2008)
Mid-term results of total knee arthroplasty after high
tibial osteotomy. Arch Orthop Trauma Surg 128:167–
173
72. Westrich GH, Peters LE, Haas SB, et al. (1998) Patella
height after high tibial osteotomy with internal fixation
fi
and early motion. Clin Orthop 354:169–174
 Chapter 57

G. Puddu, L. Panarella Osteotomies in the valgus knee

Introduction Radiographic assessment and pre-operative

A
valgus painful knee is a disabling condition
planning
that can affffect patients of all ages. In many The standard evaluation begins with an assess-
patients, anti-valgus osteotomies are the ment of the alignment of the lower limbs with
treatment of choice to correct the valgus deformity four short films: bilateral weigth-bearing antero-
and eliminate pain and other functional problems. posterior views in full extension, bilateral weigth-
In particular, patients with an early arthritis of the bearing postero-anterior views at 45° of fl flexion as
lateral femorotibial compartment or damage of described by Rosenberg (2) and both lateral and
the cartilage of the lateral femoral condyle are can- skyline films
fi of both knees. The Rosenberg view
didates for anti-valgus osteotomies. Both the lat- has a strong predictive value when the chondral
wear is prevalent in the posterior part of the lateral
eral femoral condyle and the lateral tibial plateau
tibial plateau (Fig. 1). Magnetic resonance imaging
have convex surfaces, the congruence of which is (MRI) can be very useful in studying a candidate for
maintained in relation to the integrity of the lat- knee osteotomy, since it shows not only an initial
eral meniscus. The absence of the meniscus can damage to the cartilage but also the stress reaction
lead to a progressive deterioration of the opposing of the subchondral bone as well. If an anti-valgus
cartilage surface, due to the increased concentra- osteotomy is indicated, one should obtain a bilat-
tion of stress. Middle aged patients with previous eral full length standing alignment film (Fig. 2).
involvement in sports activities can develop lateral Careful pre-operative planning for an anti-valgus
femorotibial arthritis early, which may lead to a lat- osteotomy is essential if the desired correction of
eral meniscectomy in early age (1). Damage to the alignment with long-term satisfactory outcome is
cartilage of the lateral femoral condyle associated
with an anterior cruciate (ACL) and or posterior
cruciate (PCL) acute tear or chronic laxity can also
lead to lateral meniscectomy. A congenital valgus
deformity often associated with overweight can
also cause early lateral arthritis due to the rapid
degeneration of the meniscus and then of the car-
tilage. A lateral meniscus cysts or a lateral discoid
meniscus represent a relatively frequent indication
for a “subtotal” meniscectomy even in young ath-
letes. All of the above may be considered candidates
for anti-valgus osteotomy. There are many relative
contraindications for these osteotomies. Patients
over than 60 may be better treated with a uni or
total knee replacement (TKR). Similarly patients
with osteonecrosis of the lateral femoral condyle
or severe patellofemoral osteoarthritis may be con-
traindicated. High body mass index (BMD), while
controversial, is not an absolute contraindication.
Extreme valgus deformity associated with a sub-
luxation of the tibia is an absolute contraindica-
tion to anti-valgus osteotomy. Fig. 1 – The Rosenberg’s view of a valgus knee.
644 The Degenerative Knee
Fig. 2 – A bilateral full length standing alignment film.
to be achieved. Normal lower extremities align-
ment parameters have been reported by many
authors (3, 4). However, both the definitions
fi of
alignment parameters and methods used to obtain
them are inconsistent and can be confusing (5).
The center of the hip (H) is the center of the femo-
ral head. The center of the knee (K) is the midpoint
of a line connecting the medial to the lateral pla-
teau. The center of the ankle (A) is the midpoint of
the talar width (Fig. 3a). The weight-bearing line
(WBL) is the mechanical axis of the lower extrem-
ity and can be measured as distance from the cen-
ter of the knee or as percentage of the tibial width
(Fig. 3b). The medial edge of the medial compart-
ment is indicated by 0% and the lateral edge of the
lateral compartment by 100%. The Th WBL can be
<0% or if it passes outside the joint >100%. Align-
ment of the knee on the sagittal plane is not com-
monly used in pre-operative planning but recently
the amount of the tibial slope has been found very
important when the osteotomy is associated with
a chronic ligaments laxity.
According to Marty (6) and Gross (7) the desired
correction should shift the mechanical axis (WBL)
at 50% of the tibial width. To calculate the desired
correction angle we use the pre-operative planning
suggested by Noyes (8) using the WBL to deter-
mine the frontal correction. A line is drawn from
the center of the femoral head (H) to the point of
Fig. 3 – (a) Definition of alignment parameters. (b) The weight-bearing
line or mechanical axis.
the desired correction at 50% of the tibial width.
A second line is drawn from the center of the tibi-
otalar joint to the 50% coordinate, The
Th correction
angle is formed by line 1 from the center of the
femoral head to 50% of the TW and line 2 from the
center of the talus to the 50% coordinate (Fig. 4a).
By measuring the width of the femur at the level of
the proposed osteotomy, the surgeon can convert
the angular correction to the wedge size (Fig. 4b).
Extensive clinical experience has shown that over-
correction in varus is absolutely contraindicated if
an optimal long-term result is to be gained.
Surgical options
To perform an anti-valgus osteotomy surgeon can
choose among three main surgical options: distal
femoral medial closing wedge osteotomy, distal
femoral lateral opening wedge osteotomy, and
proximal tibial medial closing wedge osteotomy.
Distal femoral medial closing wedge osteotomy
Distal femoral medial closing wedge osteotomy
is performed from the medial side, just proximal
to the adductor tubercle and the anterior margin
 Osteotomies in the valgus knee 645

Fig. 5 – (a) The titanium femoral plate. (b) The tooth enters into the osteot-
omy holding the position and preventing a later collapse of the bone with
the recurrence of the deformity.

rection, calculated in advance in the pre-operative

Fig. 4 – (a) To calculate the correction angle, a line is drawn from the
center of the femoral head to the point of the desired correction at 50%
of the tibial width. A second line is drawn from the center of the tibiota-
lar joint to the 50% coordinate. The angle between the two lines is the
correction angle. (b) By measuring the width of the femur at the level
of the osteotomy the surgeon can convert the angular correction to the
wedge size.
of the femoral articular surface. A medially based
wedge of bone is then removed from the proximal
femoral fragment. The osteotomy is generally fixed
with a 90° offffset dynamic compression blade plate
(6, 7). This type of osteotomy requires a medial, and
therefore a more precarious approach, the removal
of a bone wedge can also be difficult
ffi and imprecise.
planning. Th
The three holes of the horizontal lower
arm of the femoral “T” steel plate allow the intro-
duction of the AO 6.5 mm full threaded cancellous
screws, while the holes in the vertical arm of the
femoral plate are cut for the AO 4.5 mm cortical
screws. The second generation titanium femoral
osteotomy plate enable the surgeon to lock 6.5 mm
cancellous or 4.5 mm cortical screws within the
plate itself. This creates an extremely strong con-
struct with the plate and bone without sacrifi ficing
the plate’s low profifile design. It allows the surgeon
to angle each screws for optimum screw placement
within the bone. Since it is very important to make
the femoral osteotomy at 90° with the diaphyseal
axis, we advocate the use of a small and easy guide.
To prevent a possible fracture of the medial femo-
ral hinge we use a new tool, the “osteotomy Jack”
(Fig. 6a and b). It facilitates a gradual and progres-

Open wedge distal femoral osteotomy

To accomplish reproducible results with fewer tech-
nical diffi
fficulties, the senior author (9–12) devel-
oped a complete yet simple system of dedicated
plates and instruments (Arthrex, Naples, Florida).
The plates specially designed for this osteotomy are
“T” shaped with seven holes (Fig. 5a) and are made
in steel or titanium. Their peculiarity is a spacer
(Fig. 5b), a tooth as it were, available in eight differ-
ff
ent sizes from 5 to 17.5 mm in thickness. The tooth
enters into the osteotomy holding the position and
preventing a later collapse of the bone with the
recurrence of the deformity. Th The thickness of the
spacer must coincide with the desired angle of cor- Fig. 6 – (a and b) The osteotomy Jack.
646 The Degenerative Knee

Fig. 7 – The wedge opener has two graduates, wedge shaped tines to facil-
itate the measure of the opening and the positioning of the plate between
the tines.

sive opening of the osteotomy, specially in the

younger patients in which the bone is more hard.
Fig. 8 – The skin incision.
A “wedge opener” is then inserted into the osteot-
omy. This tool (Fig. 7) has two graduated, wedge
shaped tines to facilitate the measure of the open-
ing and the positioning of the plate.

Surgical technique
Surgery is performed under tourniquet control
with the patient supine on the operating table.
A radiolucent table must be used to allow fl fluoro-
scopic visualization of hip, knee, and ankle joint for
the intra-operative assessment of the correction.
The patient is draped as is usual in knee surgery, if
iliac crest bone autograft is to be used, the ipsilat-
eral crest is also prepared and draped. TheTh tourni-
quet is infl
flated and in all the cases an arthroscopy
is carried out before the osteotomy. The Th arthros-
copy serves two purposes: to assess the “relative”
integrity of both the medial compartment and the
patellofemoral joint and to treat any intra-artic-
ular pathology such as the removal of a meniscal
flap, or anterior tibial osteophyte which can pre-
vent knee extension. A longitudinal straight skin
incision 15 cm long is made on the lateral aspect of
the distal third of the femur, starting two fingers
breadth distal to the lateral epicondyle (Fig. 8). The
Th
dissection is carried down to the vastus lateralis,
which is retracted from the posterolateral inter-
muscular septum by a special dedicated retractor
(Fig. 9). Perforating vessels are to be expected and
should be controlled with ligature or electrocau-
tery. The joint capsule is left intact. The lateral
cortex is exposed and the procedure is facilitated
by flexing
fl of the knee. A Homan retractor is placed
under the posterior aspect of the femoral metaph-
ysis to protect the vessels and to expose the pos-
terolateral aspect of the femur in order to permit
the correct placement of the plate (Fig. 9). With
the knee in extension and under fluoroscopic con-
trol, a guide wire is drilled, by “free hand,” through
the distal femur from lateral to medial. The sur-
geon should maintain a slightly oblique direction
Fig. 9 – The vastus lateralis is retracted with a dedicated instrument. A
Homan retractor is placed posteriorly to protect the vessels and to expose
the posterolateral aspect of the femur.
(about 20°) from a proximal point on the lateral
cortex, three finger breadth above the lateral epi-
condyle, above the trochlear groove, to a distal
point few mm proximal to the medial epicondyle.
(Fig. 10a and b). It is important not to make the
medial hinge in the cortical bone, since it can eas-
ily fracture creating an instability. Th
The instruments
system provides also a simple osteotomy cutting
guide to facilitate the use of the oscillating saw
and to keep the osteotomy perpendicular to the
long axis of the femur in order to have later the
T plate well oriented with the femoral shaft. The Th
osteotomy is then performed keeping the oscillat-
ing saw blade proximal and parallel to the cutting
guide, in order to prevent a possible migration of
the osteotomy into the joint. Th
The saw is used to cut
only 1 cm in depth of the lateral cortex. A sharp
osteotome always proximal to the osteotomy in
order to prevent a possible intrarticular fracture
is used to finish the osteotomy (Fig. 11). The sur-
geon should be certain that the anterior and poste-
rior cortices, and all of the cancellous metaphysis
are completely interrupted but should preserve a
medial hinge of intact bone (about 1 cm). While
 Osteotomies in the valgus knee 647

Fig. 10 – (a and b) A Steinmann pin is drilled under fluoroscopy.

Fig. 11 – The osteotome must always be proxi-

mal to the osteotomy line in order to prevent a
possible intrarticular fracture.

Fig. 12 – The osteotomy is opened using the osteotomy Jack.

performing the osteotomy, it is important to regu-
larly check progress with the fl
fluoroscope to ensure
the appropriate depth and direction of the cut. The
Th
osteotomy is easily opened to the desired degree
of correction with the assistance of the jack (Fig.
12a and b). The wedge opener is then introduced
and slowly advanced into the osteotomy. TheTh sur-
geon measures the dimension of bone gap directly
on the graduated tines of the wedges (Fig. 13a)
and selects the proper plate in accordance with
the pre-operative measurement. By removing the
handle and, if necessary, one of the wedges, with
the other one still into the osteotomy, the plate can
be readily positioned on the lateral femoral cortex.
Before fixing the plate, the new mechanical axis is
checked fluoroscopically using a long rod extend-
ing from the center of the femoral head through
the knee to the center of the talus (Fig. 13b). ThThe
correction and the plate can be changed at this
time, if necessary. The plate is then fixed distally
648 The Degenerative Knee

Fig. 13 – (a and b) The surgeon measure the bone gap using the wedge
opener, and with a long metal rod can check the mechanical axis intra-
operatively.

Fig. 14 – The osteotomy is fixed and the gap filled with iliac crest bone.

Fig. 15 – (a and b) Post-operative X-ray control.


with two cancellous screws and proximally with
four cortical screws. The authors prefer to fill the
osteotomy defect with two or three wedge-shaped
tricortico cancellous grafts from the ipsilateral
iliac crest (Fig. 14). Final flfluoroscopic assessment
ensures adequate position of the hardware and of
the bone graft and the final radiograph are made
(Fig. 15a and b). The wound is irrigated and a suc-
tion drain placed against the bone posterolaterally.
After surgery the knee is immobilized in a range-
of-motion brace in full extension or at slight flex-
fl
ion of about 10° that allows a full range of motion
when unlocked. Passive flexion
fl and extension in a
continuous passive motion device are started the
day after surgery. TheTh drains are removed 48 h
later. Patients are allowed to walk with no weight-
bearing by the limb from the second post-opera-
tive day. They are discharged from the hospital
in 4–5 days. When post-operative knee pain and
eff
ffusion are minimal, range of motion flexibil-
ity and strengthening exercises commence. Th The
exercise program must also integrates the trunk,
hip, and ankle muscles to provide dynamic knee
stabilization while addressing isolated quadriceps
femoris defificiencies. Rehabilitation after a femoral
osteotomy requires continual attention to the bal-
ance between protection and function. Although
progressive weight-bearing and ROM exercises
are vital to recovery, excessive and to early weight-
bearing can compromise the integrity of the sur-
gical realignment. Patients are usually able to
completely flex
fl the knee within the first 4 weeks
following surgery. After 6 weeks according to the
X-rays control partial weight-bearing is allowed.
Full weight-bearing is normally possible after 8 or
9 weeks provided there is a radiographic evidence
that the bone has suffi fficiently healed. Restoring
proprioception must also be emphasized.
Complications
The risk of intrarticular fracture is always present.
This is more often due to a mistake in positioning the
Th
guide pin too close to the joint, leaving little meta-
physical bone stock between the osteotomy and
the articular surface, it also may result from failure
to completely interrupt the posterior or more often
anterior cortex. This may cause an articular fracture
to occur when the correction is attempted. Th The osteot-
omy Jack reduces this risk, but does not eradicate it
completely. Another possible intra-operative compli-
cation is subluxation of the osteotomy. It can happen
when the surgeon does not leave a suffi fficient hinge
of intact bone or if the medial hinge is too proximal
in the cortical bone. Failure of the hardware, espe-
cially the plates, is very rare. It can happen however.
Osteotomies in the valgus knee 649
A screw might break when weight-bearing is allowed
to early in the post-operative period (which is against
the rehab protocol), or if the spacer tooth has no con-
tact with one or both cortices. In this case the screws
have to support the weight to prevent collapse of the
osteotomy until the bone heals, but they can develop
fatigue fracture of the metal and break before a com-
plete recovery is achieved. The osteotomy must be
perfectly oriented in the sagittal plane, perpendicular
to the longitudinal axis of the femur to have the long
arm of the plate completely in contact with bone, in
the center of the diaphysis. Th
The spacer tooth forms a
right angle with the plate, hence the osteotomy cut in
the sagittal plane cannot be oblique or the plate will
not conform to the femoral shaft. Variations from
this technique may allow for impaired fixation
fi with
screw or plate fracture, collapse of the osteotomy and
mal-or non-union. Similar problems of union can
occur from lack of compliance with the rehabilitation
program. Vascular injuries are very rare provided the
surgeon protects the vessels through correct use of
a posterior Homan retractor and the knee remains
flexed during surgery. Thrombophlebitis and infec-
tions are generic complications common to all the
other surgical procedures performed on the lower
limb. Non-union although a possibility, did not occur
in our series of 26 femoral osteotomies.
Tibial medial closing wedge osteotomy
When a small correction is required, tibial medial
closing wedge osteotomy may be a suitable surgi-
cal choice (Fig. 16a). In our experience, supported
by Coventry (13), Chambat (14), and Marti (15), a
joint surface tilt of 10° in the coronal plane is well
tolerated. If the correction is greater than 10° the
tibia gradually subluxates laterally (16) and on an
anteroposterior radiograph, the femur appears to
fall of the medial tibial plateau. A medial proximal
tibial approach is used (the same as in opening
wedge osteotomy). No graft is required and healing
generally occurs in 4 weeks from surgery.
After arthroscopy, an anteromedial longitudinal
skin incision is performed, pes anserinus is par-
tially detached. Th
The superfificial layer of the medial
collateral ligament is divided and the medial tibial
metaphysis is exposed. The Th distal insertion of the
patellar tendon is exposed and the osteotomy site
confifirmed with fluoroscopy using a Steinmann
pin. The pin is driven from medial to lateral and
from distal to proximal above the tibial tuberosity,
pointing towards the fi fibular head. The osteotomy
is begun with the oscillating saw then completed
by the appropriate osteotome running underneath
the guide wire to prevent entering the epiphisis
or the joint space. It is necessary to leave at least
5 mm of intact lateral tibial cortex (“hinge”) intact
650 The Degenerative Knee
Fig. 16 – (a) The pre-operative X-ray before a medial tibial closing wedge osteotomy shows a moderate valgus. (b) At 6 weeks
from surgery the high tibial osteotomy is completely healed.
to ensure good stability of the osteotomy. Resec-
tion must be minimal and can be performed under
fluoroscopy and commensurate with the pre-
fl
operative planning. As in the distal femoral open
wedge osteotomy, the final correction has to bring
the mechanical axis to 50% of the tibial plateau.
It is important that resection be minimal and by
forcing the knee into varus, fracture of the lateral
hinge permits medial bone impaction and good
bone contact. Final correction can be checked intra-
operatively with the guide rod. The osteotomy can
be fixated with a 4-holes plate with two proximal
cancellous and two distal cortical screws or with a
couple of staples. Post-operatively, the lower limb
is immobilized in a functional brace with unlimited
range of motion and full weight-bearing at 30 days.
One can expect complete healing of the osteotomy
by 6 weeks from surgery (Fig. 16b).
Results
The results of supracondylar osteotomy reported
in the literature are generally good. Healy (17)
reported a series of 23 distal femoral osteotomies
with a follow-up of 4 years. ThThe Hospital for Spe-
cial Surgery (HSS) Knee Score improved from an
average of 65 points to 86 points post-operatively.
McDermott (18) reported about 24 patients for
whom the greatest improvement were found in the
“pain” category with an average increase of of 16.5
points. Miniaci (19) reported 86% good or excellent
results in a series of 40 supracondylar femoral clos-
ing wedge varus osteotomies, with a mean follow
up of 5.5 years. Finkelstein in a study of 21 knees
(20) demonstrated that the probability of survival
at 10 years was 64%. Marti (6) analyzing 15 closed
wedge varus femoral osteotomies, obtained 75%
good results without any complication. Gross (7)
over 70 patients operated for osteoarthrosis of the
lateral compartment found good or excellent func-
tional results in 92% of patients in the short term
(average 4 years). Survivorship at this time was
83%. At 10 years, this deteriorated to 64%.
The author experience includes a series of 21
patients with an average age of 54 years (7 males
and 14 females) operated on between 1992 and
2004 with a follow-up of 4–14 years (Fig. 17). Every
patient improved according to both the Interna-
tional Knee Committe Documentation Committee
(IKDC) rating scale and the HSS system.
In a series of 47 patients operated with a medial
tibial closing wedge osteotomy followed for a mini-
mum 10 years, Chambat (14) found that 72% of
patients had “good” and “very good” results, with
an improvement in pain in 91. In our six cases
operated on between 1996 and 2002, there was
excellent improvement of pain and functional
capabilities with the HSS score improving from an
average of 60 points to 87 points.
Conclusions
We conclude that with proper patient selection and
without technical problems, anti-valgus osteoto-
mies represent an effffective surgical treatment for
the lateral compartment gonarthrosis associated
with valgus deformity. Unicompartmental pros-
thesis arthroplasty is indicated in older patients
and particularly in those cases with osteonecro-
sis or severe lateral arthrosis. Patients with a
depressed lateral compartment and extreme valgus
deformity are more suitable treated with TKR. The
Th
literature (6, 20, 21) suggests that supracondylar
osteotomy does not preclude TKR. A varus distal
femoral osteotomy can make a future TKR techni-
cally easier (22).

Fig. 17 – A long-term follow-up (10 years) X-ray result.
Opening wedge lateral femoral anti-valgus osteot-
omy represents a precise and easy technique that
allows one to obtain an accurate correction of the
alignment moving the weight-bearing axis from
the lateral tibial plateau towards the center of the
knee joint. Moreover, its peculiar method of fixa-
fi
tion by special plates with spacers helps prevent
secondary loss of correction and shortening of the
limb. The medial tibial closing wedge osteotomy
is a valid alternative for minor corrections (10°
or less). The procedure is easy, safe, and does not
compromise range of motion.
References
1. Puddu G, et al. (2000) Femoral antivalgus opening wedge
osteotomy. Oper Tech Sports Med 8:56–60
Osteotomies in the valgus knee 651
2. Rosenberg TD, Paulos LE, Parker RD, et al. (1988) The Th
forty-fi
five degree posteroanterior flexion weight-bearing
radiograph of the knee. J Bone Joint Surg Am 70:1479–
1483
3. Chao EYS, Neluheni EVD, Hsu RWW, et al. (1994) Biome-
chanics of malalignment. Orthop Clin North Am 25:239–
386
4. Hsu RWW, Himeno S, Coventry MB, et all (1990) Normal
axial alignment of the lower extremity and load bearing
distribution of the knee. Clin Orthop 255:215–217
5. Brown GA, Amendola A (2000) Radiographic evaluation
and preoperative planning for high tibial osteotomies.
Oper Tech Sports Med 8:2–14
6. Marti RK, Schroder J, Witteveen A (2000) Th The closed
wedge varus supracondilar osteotomy. Oper Tech Sports
Med 8:48–55
7. Gross AE, Hutchison CR (2000) Realignment Osteotomy
of the knee. Distal femoral varus osteotomy for osteoar-
thritis of the valgus knee. Orthop Clin North Am 8:122–
126
8. Dugdale TW, Noyes FR, Styer D (1992) Preoperative plan-
ning for high tibial osteotomy. Clin Orthop 274:248–264
9. Puddu G, Cerullo G, Cipolla M, et al. (2003) Osteotomies
about the knee. Management of osteoarthritis of the
Kknee: an International Consensus. American Academy of
Orthopaedic Surgeons, pp 17–30
10. Puddu G, Franco V, Cipolla M, et al. (2003) Opening wedge
osteotomy. Proximal tibia and distal femur. Reconstruc-
tive knee surgery. Master techniques in orthopaedic sur-
gery. Lippincott Williams and Wilkins, pp 375–390
11. Puddu G, Cipolla M, Cerullo G, et al. (2005) Opening wedge
asteotomy: femoral. Surgical techniques of the knee. ThThi-
eme Med. Publish. Inc., New York, pp 241–249
12. Franco V, CerulloG, Cipolla M, et al. (2005) Osteotomy for
osteoarthritis of the knee. Curr Orthop 19:415–427
13. Coventry MB (1987) Proximal tibial varus osteotomy for
osteoarthritis of the lateral compartment of the knee. J
Bone Joint Surg Am 69:32–38
14. Chambat P, Selmi Tarik Aik S, Dejour D (2000) Varus tibial
osteotomy. Oper Tech Sports Med 8:44–47
15. Marti RK, Verhagen RAW (2000) Upper tibial osteotomy
for osteoarthritis of the knee. Surg Tech Orthop Trauma-
tol 55:530–536
16. Shoji H, Insall J (1973) High tibial osteotomy for osteoar-
thritis of the knee with valgus deformity. J Bone Joint
Surg Am 55:963–973
17. Healy WL, Anglen JO, Wasilewsky SA, et al. (1988) Distal
femoral varus osteotomy. J Bone Joint Surg Am 70:102–
109
18. McDermott PA, Finkelstein JA, Farine I, et al. (1988) Dis-
tal femoral varus osteotomy for valgus deformity of the
knee. J Bone Joint Surg Am 70:110–116
19. Miniaci A, Grossman SP, Jacob RP (1990) Supracondylar
femoral varus osteotomy in the treatment of valgus knee
deformity. Am J Knee Surg 3:65–73
20. Finkelstein JA, Gross AE, Davis A (1996) Varus osteotomy
of the distal part of the femur: A survivorship analysis. J
Bone Joint Surg Am 78:1348–1352
21. Cameron HU, Park YS (1997) Total knee replacement
after supracondylar femoral osteotomy. Am J Knee Surg
10:70–71
22. Wachtl SW, Gautier E, Jacob RP (2003) Supracondylar
femoral osteotomy for osteoarthritis of the knee. Surg
Tech Orthop Traumatol 55–520

R. J. van Heerwaarden Medial closing wedge varus
osteotomy of the distal femur
Introduction
T
he aim of varus osteotomy of the distal femur
is to relieve lateral single-compartment degen-
eration at the knee by shifting the mechanical
axis medially. Degeneration of the lateral knee with
valgus deformity is known to be the natural history
after subtotal or total lateral meniscectomy. Valgus
deformities that are post-traumatic or subsequent
to growth disorders or partial epiphyseodesis also
require surgical correction.
Varus osteotomy of the distal femur can be per-
formed with a medial closing-wedge or lateral
opening-wedge technique. Less frequently used
dome osteotomies also take place in the supra-
condylar region of the femur. Supracondylar
varus osteotomy of the femur today is generally
performed as a medial closing-wedge osteotomy.
Stabilization of the osteotomy is achieved by appli-
cation of conventional blade plates, angle stable
plates, or insertion of a distal femoral nail (1).
Stable osteosynthesis is of great importance in a
supracondylar osteotomy of the femur as it permits
undisturbed bone healing and functional rehabili-
tation. In addition to the angled blade plate (2–10),
the curved semitubular plate (11, 12) and a more
recently developed plate fixator (13) can be consid-
ered for osteotomy stabilization. In biomechanical
investigations substantial differences
ff have been
found in the primary stability of different
ff fixation
methods and these diff fferences must be respected
when planning post-operative rehabilitation (14).
Apart from the fixation technique, the type of
osteotomy, its orientation and localization also
play an important role in primary stability. An
incomplete, medial, closing-wedge osteotomy with
an intact lateral bone bridge is far more stable than
a complete osteotomy that cuts through the lateral
cortex. In terms of closing-wedge osteotomies of
the distal femur, an oblique, proximal to distal,
descending osteotomy will yield greater primary
stability than a transverse osteotomy since the
osteotomy surfaces are more congruent and the
medial cortical support is more secure (11, 14).
Primary stability is also markedly increased by
compression of the osteotomy surfaces, whereby
Chapter 58
optimal cortical contact is essential for effective
ff
compression otherwise there will be a risk of over-
correction due to subsidence of the distal fragment
into the proximal fragment. Compression also
accelerates bone healing and prevents pseudart-
hrosis and delayed union.
Indications and contraindications
Indications and contraindications for varus osteot-
omy of the distal femur have been formulated
before (13, 15, 16) and are summarized in Table 1.
Pre-operative work-up
Correction of axial deformity by osteotomy of the
distal femur requires thorough pre-operative plan-
ning. The preparation for surgery should prefer-
ably be part of a surgical plan that includes physi-
cal examination, radiological deformity analysis
and correlation with physical examination, defini-
fi
tion of deformity and aim of correction, planning
of correction, implant selection, and description
of surgical tactic (18). Th
This ensures predictable
results and protection of the patient as well as
the surgeon. A complete explanation of the pos-
sible complications and risks must be given to the
patient. The formation of a detailed surgical plan
for distal femoral varus osteotomies is beyond the
scope of this chapter. Clinical examination, radio-
logic examination, the use of brace treatment, and
radiologic planning are here described as part of
the pre-operative work-up (Fig. 1).
Clinical examination includes inspection of leg
alignment and walking pattern, assessment of the
range of motion and the laxity of the knee liga-
ments. The skin and soft-tissue situation should be
normal. Radiological diagnosis requires views of the
knee in three planes and an X-ray of the whole leg
under loading. Additional information about the
extent of damage to the knee can be derived from
a weight-bearing view in 45° flflexion, the so-called
654 The Degenerative Knee
Table 1 – Indications and contraindications for varusosteotomy of the distal femur.
Indications
Single compartment lateral joint degeneration
Valgus leg alignment
Bone deformity localized in the femur
Age 16–55 (female), 17–60 (male), no upper age limit in posttraumatic deformities
Active lifestyle
BMI < 30
Rom: flexion at least 90º, extension lag < 20º
Compliance for post-operative functional after treatment and partial weight-bearing
Contraindications
Medial compartment degeneration (grade 3–4 Outerbridge (17))
Medialmeniscectomy
BMI > 30
Reduced ROM: flexion < 90º, extension lag > 20º
Insuffi
fficient local soft tissue situation
Local acute or chronic infection
Fig. 1 – Valgus leg alignment of the left leg in a patient with lateral com-
partment osteoarthritis (left). Unloading knee brace produces a varus force
on the knee during stance and walking (right).
Rosenberg view, and MRI, but these procedures are
not essential. Stress views may be valuable if there is
also ligament laxity. It is essential to take soft-tissue
and ligament laxity with asymmetrical opening of
the joint into account during pre-operative planning
of the overall correction angle.
Until the indication is certain, pre-operative pre-
scription of an unloading brace may be helpful
(Fig. 1). Th
The brace must produce a varus force on
the knee during stance and walking therewith
unloading the lateral compartment. Application of
this brace should lead to a substantial decrease of
symptoms. Brace treatment can be used to find fi out
whether diffffuse symptoms in a valgus lateral com-
partment arthritic knee can primarily be attrib-
uted to the lateral compartment. Both the physi-
cian and patient may gain insight in the pathology
by unloading the lateral compartment. After a trial
period of 4–6 weeks of brace treatment the phy-
sician and patient may decide to extend the brace
treatment period as part of a conservative treat-
ment or plan the patient for surgery.
Radiological planning of a supracondylar closing-
wedge femoral osteotomy is shown in Fig. 2. Th The
correction angle for the osteotomy is calculated on
the basis of the pre-operative radiographs and is
reproduced intra-operatively with the help of an
appropriate saw guide and a calibrated goniome-
ter. In addition, the height of the osteotomy wedge
base can be determined by radiological planning
(taking into account the magnification
fi factor);
these measurements can be checked intra-opera-
tively with a ruler or depth gauge.
Patient positioning, implant, and instruments
Closing-wedge medial femoral osteotomy is per-
formed with the patient in the supine position and
under general anesthetic, or local anesthesia close to
the spinal cord, or single-leg anesthesia. The
Th patient
is positioned so that hip, knee, and ankle joints can
be assessed. Draping leaves at least the knee joint
free but preferably leaves the entire leg and iliac
crest free so that the leg axis can be assessed intra-
operatively. A sterile tourniquet is not generally
necessary but, if required, it should be placed as far
proximal as possible to leave sufficient
ffi room for the
surgical approach. Systemic antibiotic prophylaxis
is given pre-operatively as a single-shot. The image
intensifi
fier for intra-operative screening is posi-

Fig. 2 – Planning a medial closing wedge varus osteotomy of the distal
femur. The post-operative mechanical axis should be positioned passing
central to the knee or somewhat medial of the medial intercondylar emi-
nence. The hinge point of the closing wedge osteotomy is on the lateral
cortex of the distal femur. Left: pre-operative mechanical axis between
hip and ankle center. The mechanical axis crosses the knee in the lateral
compartment. Middle: step 1, the post-operative aimed mechanical axis is
drawn from the hip center through the center of the knee and ends at the
new ankle center (blue line); step 2, lines drawn from the old ankle center
(green line) and the new ankle center (purple line) to the hinge point of
the osteotomy define the correction angle. Right: the correction angle is
projected at the distal femur. Osteotomy width and level of the wedge base
can then be measured taking into account the magnification factor.
tioned on the side of the leg to be operated on the
surgeon stands on the contralateral side.
For osteotomy fixation the author uses the TomoFix
medial distal femur (MDF) plate that was developed
in collaboration with the Knee Expert Group of the
AO. It is a special “spoon-shaped” locking compres-
sion plate (LCP) that has four threaded holes in
the distal part and four combi-holes in the proxi-
mal shaft. Alignment and angulation of the distal
threaded holes are designed to fit the anatomy of
the supracondylar zone of the distal femur. Left
and right versions facilitate correct positioning of
Medial closing wedge varus osteotomy of the distal femur 655
the plate in the anteromedial segment of the dis-
tal femur and secure anchorage of the locking head
screws (LHSs) in the condylar block. Utilization of an
LCP guide sleeve to pre-drill the screw holes ensures
correct alignment of the distal LHSs. Th
The screws are
inserted with a torque screwdriver and locked at a
fixed angle in the conical threaded hole. Self-tap-
ping locking screws are inserted in the distal part
and self-tapping/self-drilling LHS combined with
self-tapping screws with pre-drilling in the proximal
part. The proximal LHS can be anchored mono- or
bicortically. Secondary correction loss during screw
tightening is avoided since the fixed-angle LHS do
not develop a lag screw effect.
ff This feature permits
stable fixation of the TomoFix plate fixator even in
osteoporotic bone. Temporary insertion of a 3 mm
spacer in the most proximal plate hole preserves the
periosteal blood flow.
fl
In addition to the standard instrument set for bone
surgery, the following instruments are required:
– TomoFix MDF plate with bicortical and mono-
cortical LHSs.
– Oscillating saw with 90 mm long, wide saw blade.
– Special saw guide or K-wires to mark the osteot-
omy.
– Image intensifier.
fi
– Sterile metal rod to evaluate leg axis.
– Sterile ruler or standard depth gauge to deter-
mine the height of the osteotomy wedge base.
Surgical technique
Arthroscopy is performed first
fi to assess the car-
tilage situation and to carry out arthroscopic
surgery as appropriate. The cartilage surfaces
and inner meniscus should be more or less intact
medially. Lateral cartilage damage is recorded in
detail and frayed body or cartilaginous tissue is cut
away. A varus osteotomy of the distal femur can
be combined with other regenerative measures
in the lateral compartment, e.g., microfractur-
ing, osteochondral autogenous transplantation
(OATS), autogenous chondrocyte transplantation
(ACT), and matrix-induced autogenous chondro-
cyte implantation (MACI).
Surgical approach
Surgery begins with the knee in extension (Fig. 3).
The anatomical landmarks are drawn on the skin.
Access is through a longitudinal incision that starts
a hand’s width above the patella and extends to the
upper one third of the patella.Th
This anterior longi-
tudinal incision is chosen so that wound healing
problems are avoided if subsequent operations are
656 The Degenerative Knee

required (e.g., total knee replacement). After divi-
sion of the subcutaneous tissue, the muscle fascia
is incised. The vastus medialis is stripped from the
intermuscular septum by partly sharp and partly
blunt dissection, and retracted cranially. A blunt
Hohmann retractor is passed over the femur to
expose the anteromedial aspect of the supracondylar
area of the femur. The intermuscular septum in the
metaphyseal area of the femur is carefully incised
longitudinally close to the bone. Th
The vessels beneath
are preserved. The posterior side of the femur is
approached subperiostially with a rasp and a blunt
Homann retractor is positioned after that to avoid
damage to the neurovascular structures. To enhance
exposure distally, part of the medial patellofemoral
ligament and the distal insertion of vastus medialis
may be incised to expose the medial femoral con-
dyle. Proximally, the shaft is exposed suffi
fficiently for
the plate to be positioned by dissection of the vastus
medialis from the septum. The periosteum should
not be violated.
Osteotomy
The oblique osteotomy begins in the medial supra-
condylar area and ends within the lateral femoral
condyle (Fig. 3). The distal osteotomy should run
laterally about 10 mm above the intercondylar
groove. The upper margin of the intercondylar
groove can be located with the image intensifier.
fi
The starting point for the distal osteotomy at the

Fig. 3 – Surgical approach and osteotomy technique. Upper left: the distal femur and knee joint are draped free. Upper right: the incision begin’s a hand’s
width above the patella and extends to the upper one third of the patella. After opening of the fascia of the vastus medialis a subvastus approach is per-
formed. Middle left: exposure after positioning Hohmann retractors anterior and posterior of the planned osteotomy area. Middle right: precise bone cuts
are made with the help of a sawguide mounted on the distal femur. Lower left: extracted bone wedge. Lower right: after intracutaneous skin closure.
 Medial closing wedge varus osteotomy of the distal femur 657

medial femur is best defi fined by temporary applica-
tion of the plate fixator.
fi The distal osteotomy should
be placed within the solid portion of the plate. ThThe
level of the osteotomy can be marked on the bone
with the electrocautery. The Th author uses a special,
precise saw guide (Balansys, the Mathys company)
(Fig. 3) for closing-wedge osteotomy of the distal
femur. The planned wedge for extraction can also
be marked by insertion of K-wires under image
fication, whereby these wires also serve to
intensifi
guide the saw. ThThe saw cuts should be made under
constant cooling and irrigation. At the posterior
aspect, attention must be paid to proper retraction
of the soft tissues, particularly the vessels.
The cuts for the osteotomy stop 5–10 mm before
reaching the lateral cortex where a K-wire is posi-
tioned protecting the lateral cortex. The wedge is
extracted and wedge height can be checked using
a sterile ruler. It is important that wedge extrac-
tion should be complete and that no fragments of
cortical bone persist in the posterior part of the
osteotomy. Two longitudinal lines are marked on
the medial shaft with the cautery in order to assess
rotational alignment. Alternatively, a K-wire can
be inserted proximal and distal to the osteotomy.
The osteotomy is now closed carefully by applying
consistent pressure on the lateral lower leg with
simultaneous stabilization of the joint region. It
may take several minutes to achieve complete clo-
sure of the osteotomy by plastic deformation of
the lateral cortex. The rotation markers are exam-
ined to check rotational alignment.
The alignment of the mechanical axis of the leg is
now evaluated by placing a long metal rod between
the radiologically determined center of the femoral
head and the center of the ankle. The axis should
pass at the center of the knee joint or slightly
medial to it, as planned pre-operatively.
Plate fixation
The osteotomy is stabilized with the TomoFix
MDF plate fixator (Fig. 4). The implant is prepared

Fig. 4 – Plate fixation shown in a sawbone model. Upper left: the implant is prepared by mounting the drill sleeves in the four distal threaded holes. The position-
ing device should be used to ensure precise insertion of the drill sleeves into the plate holes The plate shaft is aligned parallel to the femoral shaft and the plate is
temporarily stabilized in the distal part with a 2 mm thick K-wire. Upper middle: plate fixator with self-tapping (green) and self-drilling and self-tapping (blue)
locking head screws in final configuration. Upper right: plate position and orientation in the frontal plane. Lower left: final configuration of the plate mounted on
the distal femur. Lower middle and right: X-rays of plate fixation in frontal and sagittal planes of biplanar osteotomy distal femur osteotomy.
658 The Degenerative Knee
by mounting the drill sleeves in the four distal
threaded holes. The positioning device should be
used to ensure precise insertion of the drill sleeves
into the plate holes (Fig. 4). The Th plate with the
sleeves mounted is now slid under the vastus medi-
alis and the distal part of the plate is positioned
anteromedially on the distal femur. The Th solid part
of the plate should lie over the osteotomy. The
Th plate
shaft is aligned parallel to the femoral shaft and
the plate is temporarily stabilized in the distal part
with a 2 mm thick K-wire. This is guided by insert-
ing a guide sleeve into one of the pre-assembled
drill sleeves. Plate position and orientation of the
wire in relation to the osteotomy and the intercon-
dylar space of the distal femur are monitored under
image intensification.
fi The internal fixator has been
designed so that form-fi fit seating of the implant at
the distal femur is not necessary. However, it is
very important that the distal holes are correctly
aligned in the femoral condylar block so that the
optimal (longest) length of LHS can be achieved
later. If the condyles are deformed, the plate can be
positioned more anteriorly or rotated to alter the
angulation of the LHSs so that posterior penetra-
tion of the femoral condyles is prevented.
The holes for the self-tapping 5.0 mm LHSs are now
drilled through the drill sleeves with a calibrated
4.3 mm drill. The length of the LHSs can be read off ff
the scale on the drill, whereby lateral protrusion of
the screw tips should be avoided. Alternatively, the
drill sleeves can be removed and LHSs length can
be determined using the depth gauge for screws.
The depth gauge can also be used to examine the
integrity of the bone posteriorly before the LHSs
are inserted. The LHSs are locked manually with a
torque screwdriver. Finally, K-wire and guide sleeve
are removed and replaced by LHSs.
The osteotomy is compressed manually at this
Th
stage. Additional compression can now be applied
by eccentric positioning of a 4.5 mm self-tapping
cortex screw in the dynamic part of the combi-hole
directly above the osteotomy (19). If even greater
compression is desired, the AO tensioning device
can be inserted into the dynamic part of the last
combi-hole; however, this requires proximal exten-
sion of the approach. Screws are inserted into the
residual holes in the plate shaft from distal to
proximal. TheTh author works with monocortical,
self-drilling, and self-tapping LHSs. In general,
26–30 mm self-drilling, self-tapping LHSs are
used for monocortical fixation. The spacer in the
most proximal plate hole is removed and replaced
by a monocortical LHSs. Finally, the cortical lag
screw that was used for osteotomy compression is
replaced by a bicortical self-tapping 5.0 mm LHS.
Next, the stability of the osteotomy and the position
and length of the LHSs are assessed by image inten-
sifi
fication. The partially incised medial patellofemo-
ral ligament and the partially released distal inser-
tion of vastus medialis at the patella are carefully
reconstructed. Suction drains are placed beneath
the vastus medialis and brought out distally in
order to reduce hematoma formation beneath the
muscle, to prevent development of compartment
syndrome, and to monitor post-operative blood
loss. The fascia over the vastus medialis is closed,
followed by subcutaneous and skin suture. An elas-
tic compression bandage is applied and post-opera-
tive radiographs in two planes are obtained.
Post-operative rehabilitation
On the day of surgery gentle movements can
already be performed with the compression ban-
dage in place. Swelling can be reduced by cold ther-
apy and application of an intermittent vein pump.
The bandage is changed on post-operative day 1
and the soft-tissue situation evaluated. Mobiliza-
tion starts on post-operative day 1 with underarm
crutches and partial loading up to 15–20 kg body-
weight (monitored using a scale). Partial loading
should be prescribed for 6 weeks, range of motion
is unrestricted, and a splint is not generally neces-
sary. In week 7 after surgery, loading is increased up
to the pain threshold, whereby the load increments
depend on the extent of osseous consolidation as
confi
firmed by the post-operative X-rays at 6 weeks. If
the osteotomy is not fully closed or fixation stability
is not optimal, loading should be increased step-by-
step over two to four weeks. Immediate full weight-
bearing can be permitted if radiological assessment
shows the osteotomy to be fully consolidated.
Until full loading is possible, medication for throm-
boembolism prophylaxis should be continued in the
form of low-molecular heparin with regular checks
of the thrombocyte count. The physical therapy
program includes active and passive exercises.
Daily manual lymph drainage is recommended
due to the frequent occurrence of postoperative
lymph edema. Electrotherapy for muscle stimula-
tion (EMS device) is recommended, especially for
the vastus medialis.
Sutures are removed on post-operative days
10–12. Radiological assessment of the osteotomy
should take place immediately post-operatively,
after mobilization of the patient, and at 6 weeks
and 3 months post-operatively.
Complications
Performing a medial closing wedge distal femur
osteotomy pre-supposes knowledge of the local

anatomy and experience with performing osteoto-
mies. Application of the TomoFix plate fixator pre-
supposes an in-depth knowledge of the implant
and its specifific locking technique. More extensive
descriptions are to be found in books dedicated to
the subject (16, 10).
To prevent over- or undercorrection of the physi-
ological axis, thorough pre-operative planning is
absolutely essential. Intra-operative assessment
of the corrected axis is also highly recommended
prior to stabilization so that any planning errors
can be identifi fied and dealt with. Osteotomy of
the posterior femoral cortex is associated with a
signifi
ficant risk of injury to the femoral artery and
vein. The sciatic nerve and vascular bundle are
also situated near the bone at the posterior aspect
and can be injured. For this reason, the posterior
femoral cortex should only be cut if the soft tis-
sues beyond it are safely protected by a blunt bone
retractor or anatomically shaped spatula. In addi-
tion, the genicular arteries and veins are situated
directly posterior to the intermuscular septum
and are susceptible to bleeding if the septum is
divided with insufficient
ffi care. Therefore, the sep-
tum should only be incised directly at its bony
insertion. Hemorrhage must be coagulated imme-
diately.
Extensive post-operative soft-tissue swelling and
the formation of lymphatic edema can be prevented
to a large extent by early drug therapy and physi-
cal therapy. In addition to oral antiphlogistic treat-
ment, manual lymph drainage and use of an inter-
mittent vein compression pump is recommended.
The risk of crural thrombosis or lung embolism
Th
must be remembered and immediate clarification fi
initiated at the first signs. The medial subvastus
approach rarely leads to compartment syndrome.
However, a large post-operative hematoma may
cause compartment syndrome even with this
medial approach. The clinical signs are firm, elastic
swelling of the extremity, and disturbed sensation.
This condition requires immediate surgical relief of
Th
the hematoma.
Early post-operative infection is treated by surgi-
cal revision with debridement, systemic antibiosis,
and possible inlay of antibiotic carriers. Th The plate
fixator does not need to be removed if the osteo-
synthesis is stable and the soft tissue cover intact,
otherwise a change of management to an external
fixator, e.g., a ring fixator, is possible.
Delayed bone healing of the osteotomy is often
expressed by persistent pain on loading. In these
cases, a small amount of callus will be visible lat-
erally on the radiographs. Treatment consists of
secondary cancellous bone grafting, which we only
perform if no sign of bone healing can be seen
after more than 3 months. Otherwise the period
of partial loading should be extended.
Medial closing wedge varus osteotomy of the distal femur 659
Biplanar medial closing wedge technique
Recently, the medial closing wedge distal femur
osteotomy technique has been modified.
fi Based on
the experience with biplanar opening wedge high
tibial osteotomies a biplanar distal femur osteot-
omy technique was developed. In this technique,
the saw cuts for the closing wedge part of the pro-
cedure are made at the posterior 2/3 of the distal
femur after which the wedge is removed. TheTh sec-
ond part of the procedure consists of an ascend-
ing bone cut, made parallel to the posterior side of
the femur starting at the lower cut of the closing
wedge cuts (Fig. 4).
A detailed description of this technique can be
found in recent publications (1517, 16).
References
1. Paley, D (2000) Hardware and osteotomy considerations.
In: Paley, D (ed.) Principles of deformity correction.
Springer Verlag, Berlin Heidelberg, pp 291–410
2. Franco V, Cipolla M, Gerullo G, et al. (2004) Open
wedge osteotomy of the distal femur in the valgus knee.
Orthopäde 33(2):185–192 (German)
3. Cameron HU, Botsford DJ, Park YS (1997) Prognostic fac-
tors in the outcome of supracondylar femoral osteotomy
for lateral compartment osteoarthritis of the knee. Can J
Surg 40(2):114–118
4. Finkelstein JA, Gross AE, Davis A (1996) Varus osteotomy
of the distal part of the femur. A survivorship analysis. J
Bone Joint Surg Am 78(9):1348–1352
5. Healy WL, Anglen JO, Wasilewski SA, et al. (1988) Dis-
tal femoral varus osteotomy. J Bone Joint Surg Am
70(1):102–109
6. Learmonth ID (1990) A simple technique for varus supra-
condylar osteotomy in genu valgum. J Bone Joint Surg Br
72(2):235–237
7. Marti RK, Schröder J, Witteveen A (2000) Th The closed
wedge varus supracondylar osteotomy. Oper Tech Sports
Med 8:8–55
8. Mathews J, Cobb AG, Richardson S, et al. (1998) Distal
femoral osteotomy for lateral compartment osteoarthritis
of the knee. Orthopedics 21(4):437–440
9. McDermott AG, Finkelstein JA, Farine I, et al. (1988) Dis-
tal femoral varus osteotomy for valgus deformity of the
knee. J Bone Joint Surg Am 70(1):110–116
10. Miniaci A, Grossmann SP, Jakob RP (1990) Supracondylar
femoral varus osteotomy in the treatment of valgus knee
deformity. Am J Knee Surg 3:65–72
11. Miniaci A, Watson LW (1994) Distal femoral osteotomy.
In: Fu FH, Harner CD,Vince KG (eds.) Knee surgery.
Lippincott William & Wilkins, Philadelphia, pp 1173–
1180
12. Stähelin T, Hardegger F, Ward JC (2000) Supracondylar
osteotomy of the femur with use of compression. Osteo-
synthesis with a malleable implant. J Bone Joint Surg Am
82(5):712–722
13. Stähelin T, Hardegger F (2004) Incomplete, supracondylar
femur osteotomy. A minimally invasive compression oste-
osynthesis with soft implant. Orthopäde 33(2):178–184
14. Van Heerwaarden R, Wymenga A, Freiling D, et al. (2007)
Distal medial closed wedge varus femur osteotomy sta-
bilized with the Tomofi fix plate fixator. Oper Tech Orthop
17(1):12–21
660 The Degenerative Knee
15. Brinkman JM, Hurschler C, Agneskirchner JD, et al.
(2008) Axial and torsional stability of supracondylar
femur osteotomies: A biomechanical investigation of five
fi
diff
fferent plate and osteotomy confi
figurations. Clin Orthop
(submitted).
16. Outerbridge RE (1961) The etiology of chondromalacia
patellae. J Bone Joint Surg Br 43:752–757
17. Freiling D, Lobenhoffer
ff P, Staubli A, et al. (2008) Medial
closed-wedge varus osteotomy of the distal femur.
Arthroskopie 21:6–14 (German)
18. Van Heerwaarden RJ, Wymenga AB, Freiling D, et al.
(2008) Supracondylar varization osteotomy of the femur
with plate fixation.
fi In: Lobenhoff
ffer P, van Heerwaarden RJ,
Staubli AE, Jakob RP (eds) Osteotomies around the knee.
George Thieme Verlag, Stuttgart, New York, pp 147–166
19. Van Heerwaarden RJ, Mast JW, Paccola CAJ (2008) Diag-
nostics and planning of deformity correction: formation
of a surgical plan. In: Marti RK, van Heerwaarden RJ (eds)
Osteotomies for posttraumatic deformities. Georg Thieme
Th
Verlag, Stuttgart, New York, pp 33–55
Unicondylar knee arthroplasty

R. W. McCalden Technical considerations, results,
and complications of mobile-
bearing UKA
Introduction
T
here are two basic types of unicompartmental
knee designs, namely, fixed
fi and mobile-bear-
ing designs. Within the mobile-bearing genre,
the bearing can be either constrained (usually on a
track) or completely unconstrained. Since the late
1970s, there have been two major designs implanted
in patients; the low contact stress (LCS)™ implant
(Dupuy Orthopaedics Inc., Warsaw, Indiana) (1)
and the Oxford™ unicompartmental knee implant
(Biomet Inc., Warsaw, Indiana) (2). The Th LCS™ has
partial constraint of the bearing within an articulat-
ing tibial track, where as the Oxford™ system con-
sists of a freely moving bearing. More recently, the
Preservation™ mobile-bearing UKA (J&J/Depuy
Orthopaedics Inc., Warsaw, Indiana) has been intro-
duced with a similar design to the LCS, that is, hav-
ing partial constraint of the bearing.
As a result of this author’s personal experience and
the relative abundance of information in the litera-
ture, the focus of this chapter will be predominantly
on the Oxford™ system. However, many of the techni-
cal considerations and complications can be applied to
all mobile-bearing unicompartmental knee designs.
B is passively correctable (no fixed deformity) and
A
Chapter 59
Patient selection
Arguably the most important consideration for suc-
cess in the use of a mobile-bearing UKA relates to
proper patient selection. This implant was designed
primarily for use in patients with a distinct patho-
logical entity known as anteromedial arthritis
of the knee. This is well described by White et al.
(3) and characterized by arthritis involving pre-
dominantly the anterior two-thirds of the medial
compartment. It is felt that isolated anteromedial
osteoarthritis can only exist in patients with a pas-
sively correctable varus deformity and an intact
anterior cruciate ligament. These
Th two factors can-
not be under-estimated and are critical to the suc-
cess of this implant. ThTherefore, at the time of sur-
gery, it is imperative that the ACL is documented to
be intact and functional. As important, any exist-
ing varus deformity must be passively correctable
demonstrating that there is no fixedfi contracture
of the MCL complex. The MCL complex should not
be released in order to balance the knee. AP stress
views of the knee can be very helpful in the selection
of patients for mobile UKA. Application of a varus
and valgus stress to the knee, in a position of slight
Fig. 1 – (a and b) AP radiographs demonstrat-
ing pre-operative varus and valgus stress views.
Varus stress view (a) confirms significant OA with
complete joint space loss of medial compart-
ment. Valgus stress view (b) confirms the knee
good preservation of lateral joint space.
664 The Degenerative Knee

flexion (20°), will confi

firm the presence of medial Perhaps the most important step is the proper bal-
arthritis. More importantly, it will confirm
fi the ancing of the knee. This is done through a series
presence of adequate articular cartilage on the lat- of spacer blocks designed to measure the flexion
fl
eral compartment and the correctable nature of the and extension space. In essence, the flexion space
deformity (Fig. 1a and b). In addition, stress views
may demonstrate those rare cases when the knee
can be overcorrected (due to lateral cartilage thin-
ning or ligamentous laxity) in which a UKA (either
fixed or mobile-bearing) is contra-indicated.
Regarding the indications for a mobile-bearing
UKA, the specifi fic role of gender, the patient’s
weight, the age of the patient, and the location of
knee pain remains unclear. In addition, the status
of the patellofemoral joint remains somewhat con-
troversial although studies from the Oxford group
(4) have shown that the radiological and clinical
appearance of the patellofemoral joint does not
correlate to success of this implant. However, it
would seem intuitive that one should avoid the use
of any UKA in the setting of a patient with signifi-
fi
cant symptomatic patellofemoral arthritis.
Similar to all operative interventions, appropri-
ate training is very important to the success of a
mobile-bearing UKA. This concept is strongly sup-
ported by the work of the Robertsson et al. show-
ing clearly inferior results with the Oxford™ pros-
thesis in centers with limited experience (less than
23 cases/year) (5). Therefore, one might argue that
mobile-bearing UKAs should be limited to those
surgeons who are likely to maintain a large volume
of UKAs.
Fig. 2 – AP radiograph demonstrating failure of Oxford UKA implant due to
tibial component loosening. This resulted from excessive tibial resection at
index procedure leading to excessive residual varus deformity.
Technical considerations
There are a number of specifi fic technical consider-
ations when performing a mobile-bearing UKA. In
the author’s opinion, there are several key steps
which will dictate the success of the implant.
Firstly, it is important that an appropriate tibial cut
is made such that proper coronal and sagittal align-
ment is achieved. That being said, due to the highly
congruous articulation of the polyethylene bearing
against the femoral and tibial components, a small
amount of malalignment of the cut (up to 5°) can
be tolerated within the system (6). One must be
careful to resect enough tibial bone to allow the
minimum bearing (3 mm) to be used but one must
also avoid excessive bony resection which will lead
to under correction and residual varus (Fig. 2).
The next key step is the proper positioning and siz-
ing of the femoral component. It is critical that the
femoral component is aligned relative to the tibial
component such that the bearing will articulate
properly. The common pitfalls are oversizing the Fig. 3 – AP radiograph demonstrating poor articulation of the meniscal bearing
femoral bearing and malaligning it such that it sits in Oxford UKA. The bearing is lying subluxed medially relative to the tibial com-
either too medial or lateral (Fig. 3). ponent, likely a result of the femoral implant being implanted too medially.
 Technical considerations, results, and complications of mobile-bearing UKA 665

is created first by means of the tibial cut and pos- ing any two mobile-bearing UKAs or directly com-
terior femoral cuts. This is then measured with the paring a mobile to a fixed-bearing UKA.
trial implants in place and then the corresponding With respect to polyethylene wear, due to the high
extension space is measured. Dedicated reamers congruency and LCS of the polyethylene, one would
allow the gradual removal of distal femoral bone expect low wear. Several studies have looked spe-
(thus raising the joint line) until the extension cifi
fically at the wear from retrieved implants. Argen-
space is balanced with the flexion space. son and O’Connor demonstrated penetration rates
It is imperative to avoid overcorrection by means of ranging from 0.026 to 0.043 mm per year in 23
ffing the joint space with a polyethylene size
overstuffi meniscal bearings retrieved at an follow-up rang-
that is too large. While this will lessen the chance ing from 1 to 9 years (21). Similarly, Psychoyios et
of dislocation of the bearing, it can lead to over- al. (22) examined 16 retrieved unicompartmental
correction and subsequent failure of the relatively Oxford bearings showing a very similar low average
overloaded lateral compartment. It is imperative wear rate of 0.036 mm per year. Of interest, they
that the MCL complex (particularly the superficialfi demonstrate that bearings as thin as 3.5 mm had
fibers) are not released in order to balance the knee. no greater wear than the thicker bearings. However,
In the correctly selected patient, the removal of the their work demonstrated that those bearings with
medial tibial and femoral osteophytes should realign signs of impingement had greater wear (maximum
the knee and provide adequate soft tissue balance. wear of 0.08 mm) compared to those bearings with
Lastly, care must be taken when cementing the pros- no impingement, which had the lowest wear rate
thesis in place, especially when an MIS approach is (0.01 mm per year). In addition, Price et al. (23) con-
being used. Ideally, the tibial and femoral implants firmed an in vivo mean linear wear rate of 0.02 mm/
should be cemented separately, allowing adequate year using a radiostereometric technique.
time to remove excess cement and ensure a good
cementing technique. In particular, care must be
taken to remove any cement posteriorly from both Complications
the tibial and femoral implants which can lead to
impingement on the bearing. The specifi
fic complication unique to mobile-bearing
UKAs is dislocation of the bearing (Fig. 4). At early
follow-up, Cohen et al. reported no dislocations in
17 knees that received the LCS unicompartmental
Results knee designed (1). ThisTh is a constrained mobile-
bearing UKA and unfortunately there are no long-
There is relatively little in terms of long-term term results in the literature outlining its long-term
results regarding the LCS™ UKA design. In an ear-
lier paper, the designing authors outlined their
early experience with this implant (1). At later fol-
low-up, Keblish and Briard reported a 82% pros-
thetic survivorship at 11 years with 177 LCS UKAs
(7). Regarding the Preservation™ mobile-bearing
UKA, the results have been relatively poor as the
2007 Australian Joint Registry reported a cumula-
tive revision rate at 4 years of 17.5% (compared to
7.9% for the Oxford™ 3 prosthesis) (8).
Regarding the Oxford prosthesis, there are a con-
siderable number of long-term studies demon-
strating its success (9–13). In an earlier study, a
review of 121 consecutive Oxford knees showed a
99.1% survivorship at 8 year follow-up (14). More
recently, studies from both Murray et al. (10) and
Svard and Price (15) reported 10 year survivor-
ship rates of 98 and 95%, respectively. In addition,
ongoing reports from the Swedish Knee Arthro-
plasty Registry continue to show a 10 year survi-
vorship in excess of 90% (16). A number of other
studies have reported 10 year survivorships rang-
ing from 87 to 96% (12, 13, 17–20). To date, there Fig. 4 – Lateral radiograph demonstrating dislocation of meniscal bearing
is no randomized controlled trial directly compar- in Oxford UKA. Bearing is seen in supra-patellar space.
666 The Degenerative Knee
dislocation rate. In contrast, the Oxford™ knee
is completely unconstrained and there have been
reports of its dislocation, although infrequently.
Lewold et al. reported on 16 dislocated bearings in
699 components at 6 years follow-up (18). Svard
and Price reported on three dislocated bearings
occurring in 124 knees with a 10 year survivorship
rate of 95% (15). The exact reason for bearing dislo-
cation is not clear but probably relates to a number
of factors including failure to align or balance the
knee, posterior impingement from osteophytes or
meniscal remnants, maltracking of the femoral and
tibial components, or ligament imbalance issues.
The problem of bearing dislocation is far more com-
mon with the use of this implant for replacement
of the lateral compartment. Specifi fically, Gunther
et al. reported six lateral bearing dislocations in a
series of 53 knees at an average of 5 year follow-up
(24). This
Th finding was also confi firmed in laboratory
work by Weale et al. (4) In general, it is probably best
to avoid the use of mobile-bearing UKA for lateral
compartment disease.
There are other complications associated with the
use of a mobile-bearing UKA, although not neces-
sarily specifi
fic to this design. As indicated previ-
ously, wear of the bearing is generally not an issue
with the use of this design. Other problems, such
as, loosening of the femoral and/or tibial compo-
nent, malalignment of the component leading to
failure or mal-alignment of the extremity, and
retention of cement can all occur with this proce-
dure. Many of these would be considered technical
Fig. 5 – AP radiograph demonstrating stable radiolucency around tibial
Oxford UKA. The patient is asymptomatic with excellent knee scores.
issues and, for the most part, avoidable based on
the experience and expertise of the surgeon. One
curious finding with the Oxford™ UKA system is
the radiolucent line that often develops under/
around the tibial component by 1 year post-op
(Fig. 5). A very in-depth histological and clinical
examination of this phenomena by the designing
authors has concluded that this is a normal finding
and not associated with implant failure (4, 25).
As with all UKA designs, there is always the poten-
tial for progressive osteoarthritis, particularly of the
lateral compartment (Fig. 6). This
Th phenomena can
be accelerated by the overcorrection of the limb.
Lastly, it is the author’s experience that a small
proportion of patients in whom a mobile-bearing
UKA has been implanted may experience transient
anteromedial joint line pain. This may represent
synovitis as a result of anterior movement of the
mobile-bearing. This seems to be self-limiting
problem and has not resulted in failure or conver-
sion of any of the implants.
Summary
Mobile-bearing UKA represents one of several
designs that can be used by surgeons in treating
anteromedial osteoarthritis of the knee. The kine-
matic arguments and clinical success of mobile-
bearing UKAs support their use. It is evident that
wear of the mobile-bearing is very low because of
Fig. 6 – AP radiograph demonstrating progressive OA of lateral compart-
ment. The Oxford UKA remains well fixed.
 Technical considerations, results, and complications of mobile-bearing UKA 667
the high degree of congruency and decreased con-
tact stress. With proper patient selection, train-
ing, and technique one can expect good, long-term
results with the use of a mobile-bearing UKA.
References
1. Cohen M, Buechel F, Pappas MJ (1991) Meniscal-bearing
unicompartmental knee arthroplasty. An 11-year clinical
study. Orthop Rev 20(5):443–448
2. Goodfellow JW, O’Connor J (1986) Clinical results of the
Oxford knee. Surface arthroplasty of the tibiofemoral joint
with a meniscal bearing prosthesis. Clin Orthop Relat Res
20(5):21–42
3. White SH, Ludkowski PF, Goodfellow JW (1991) Antero-
medial osteoarthritis of the knee. J Bone Joint Surg Br
73(4):582–586
4. Weale AE, Murray DW, Crawford R, et al. (1999) Does
arthritis progress in the retained compartments after
‘Oxford’ medial unicompartmental arthroplasty? A clini-
cal and radiological study with a minimum ten-year fol-
low-up. J Bone Joint Surg Br 81(5):783–789
5. Robertsson O, Knutson K, Lewold S, Lidgren L (2001) TheTh
routine of surgical management reduces failure after uni-
compartmental knee arthroplasty. J Bone Joint Surg Br
83(1):45–49
6. Gulati A, Chau R, Pandit HG, et al. (2008) Unicompart-
mental knee arthroplasty: effffect of component alignment
on clinical and radiological outcomes. Paper Presented at
75th Annual Meeting of American Academy of Orthopae-
dic Surgeons, San Francisco
7. Keblish PA, Briard JL (2004) Mobile-bearing unicompart-
mental knee arthroplasty: a 2-center study with an 11-year
(mean) follow-up. J Arthroplasty 19(7 Suppl 2):87–94
8. Australian Orthopaedic Association National Joint Replace-
ment Registry (2007) Annual Report. AOA, Adelaide
9. Emerson RH Jr, Higgins LL (2008) Unicompartmental
knee arthroplasty with the oxford prosthesis in patients
with medial compartment arthritis. J Bone Joint Surg Am
90(1):118–122
10. Murray DW, Goodfellow JW, O’Connor JJ (1998) Th The
Oxford medial unicompartmental arthroplasty: a ten-year
survival study. J Bone Joint Surg Br 80(6):983–989
11. Price AJ, Waite JC, Svard U (2005) Long-term clinical
results of the medial Oxford unicompartmental knee
arthroplasty. Clin Orthop Relat Res (435):171–180
12. Skowronski J, Jatskewych J, Dlugosz J, et al. (2005) The
Th
Oxford II medial unicompartmental knee replacement.
A minimum 10-year follow-up study. Ortop Traumatol
Rehabil 7(6):620–625
13. Vorlat P, Putzeys G, Cottenie D, et al. The Oxford uni-
compartmental knee prosthesis: an independent 10-year
survival analysis. Knee Surg Sports Traumatol Arthrosc
14(1):40–45
14. Carr A, Keyes G, Miller R, et al. (1993) Medial unicom-
partmental arthroplasty. A survival study of the Oxford
meniscal knee. Clin Orthop Relat Res (295):205–213
15. Svard UC, Price AJ (2001) Oxford medial unicompartmen-
tal knee arthroplasty. A survival analysis of an indepen-
dent series. J Bone Joint Surg Br 83(2):191–194
16. Robertsson O, Lidgren L (2007) TheTh Swedish Knee Arthro-
plasty Register, Annual Report 2007. Dept. of Orthope-
dics, Lund University Hospital, Sweden
17. Koskinen E, Paavolainen P, Eskelinen A, et al. (2007)
Unicondylar knee replacement for primary osteoar-
thritis: a prospective follow-up study of 1,819 patients
from the Finnish Arthroplasty Register. Acta Orthop
78(1):128–135
18. Lewold S, Goodman S, Knutson K, et al. (1995) Oxford
meniscal bearing knee versus the Marmor knee in uni-
compartmental arthroplasty for arthrosis. A Swedish
multicenter survival study. J Arthroplasty 10(6):722–
731
19. Price AJ, Dodd CA, Svard UG, Murray DW (2005) Oxford
medial unicompartmental knee arthroplasty in patients
younger and older than 60 years of age. J Bone Joint Surg
Br 87(11):1488–1492
20. Rajasekhar C, Das S, Smith A (2004) Unicompartmental
knee arthroplasty. 2- to 12-year results in a community
hospital. J Bone Joint Surg Br 86(7):983–985
21. Argenson JN, O'Connor JJ (1992) Polyethylene wear in
meniscal knee replacement. A one to nine-year retrieval
analysis of the Oxford knee. J Bone Joint Surg Br
74(2):228–232
22. Psychoyios V, Crawford RW, O’Connor JJ, Murray DW
(1998) Wear of congruent meniscal bearings in unicom-
partmental knee arthroplasty: a retrieval study of 16 spec-
imens. J Bone Joint Surg Br 80(6):976–982
23. Price AJ, Short A, Kellett C, et al. (2005) Ten-year in vivo
wear measurement of a fully congruent mobile bearing
unicompartmental knee arthroplasty. J Bone Joint Surg
Br 87(11):1493–1497
24. Gunther T, Murray D, Miller R, et al. (1996) Lateral uni-
compartmental arthroplasty with the Oxford meniscal
knee. Knee 3:33–39
25. Tibrewal SB, Grant KA, Goodfellow JW (1984) The Th radio-
lucent line beneath the tibial components of the Oxford
meniscal knee. J Bone Joint Surg Br 66(4):523–528

G. Deschamps, C. Bussière ,
S. Donell Fixed bearing unicompartmental
knee prosthesis: results,
complications, and technical
considerations
Introduction
U
nicompartmental knee replacement (UKR)
is an attractive technique for managing uni-
compartmental arthritis of the knee since
it allows quicker recovery and has lower compli-
cations rates than total knee replacement (TKR).
However, questions remain over the long-term
functional results and long-term survival. Whilst
there are indubitably advantages of UKR over
TKR, the gains are unfortunately off ffset by the risk
of disease progression and pain from the other
compartments of the joint (1, 2) There
Th is also a risk
of long-term deterioration from wear of the tibial
polyethylene (PE) insert.
The experience of the senior author (GD) with
UKR began in the 1980s, using the Lotus prosthe-
sis (GUEPAR group, Howmedica®) and continued
using a fixed-bearing prosthesis (Tornier® HLS UNI
Evolution) since 1989. This prosthesis has a resur-
facing femoral component and an all-polyethylene
tibial component.
The resurfacing design replaces the worn articu-
lar surface only, with the metal bearing. ThThere are
resection designs where the distal femoral sur-
face is removed to fit the implant. The tibia can be
metal-backed, and the PE bearing mobile as well as
fixed. In this chapter we shall explain the mechani-
cal concepts behind choosing a fixed-bearing. We
shall use as evidence the results of a consecutive
case series and compare these to those reported in
the literature. Finally, we shall present details of
the technique and strategies to improve the out-
comes when using a Tornier® HLS UNI Evolution
prosthesis.
Fixed-bearing – the reasons for our choice
Laboratory studies have shown that point load-
ing of polyethylene leads to increased wear (3).
It follows that the greater the contact between
the bearing surfaces the lower the wear rate. It is
Chapitre 60
also clear that early fixed-bearing designs did have
problems with PE wear. To address this Goodfellow
and O’Connor, in the 1980s, designed the Oxford
UKR (Biomet®). The concept behind this is that
the femoral condyle can be considered part of a
sphere and therefore the shape of the bearing sur-
face can be part of a sphere. The bearing surface
then has perfect congruence (4, 5). This bearing is
mobile because the undersurface is flat; if it was
not mobile, the congruity would impart excessive
stresses at the implant bone interface. The
Th mobile-
bearing allows the femur to move without con-
straint by the implant and therefore normal kine-
matics can theoretically be achieved. It follows that
the knee ligaments, including the anterior cruciate
ligament must be normal and at normal tension. In
theory this implant should minimize PE wear (6).
Despite the reported success of the Oxford UKR (4),
with evidence to support minimal PE wear we have
continued to use a fixed-bearing design. At the
SOFCOT 1995 symposium (7) the outcome of more
than 600 UKRs was reported. In fact, PE wear was
not a major cause of failure in fixed-bearings (7).
In addition, it is also technically easier to implant
fixed rather than mobile-bearings. These diffi fficul-
ties have resulted in a signifificant number of early
failures (8, 9). This is not encouraging to either the
patient or the surgeon (10–12).
Subsequent research (13) based on the SOFCOT
series found evidence that the main cause of fail-
ure with modern fixed-bearing unicompartmen-
tal implants was not PE wear but was related to
errors in operating technique and patient selection
(14–17). The principal technical errors were over-
correction of the alignment axis and ligament insta-
bility. Overcorrection converts varus alignment to
valgus (18, 19) and also overstresses the contralat-
eral compartment. Initially this leads to pain, and
later to disease progression. This can occur rapidly
post-UKR. If ligament instability is present, either
pre-operatively or iatrogenically, this can cause
early (20) and, sometimes, catastrophic failure
(21). When a mobile-bearing prosthesis is used,
both causes of failure can occur simultaneously.
670 The Degenerative Knee
Fig. 1 – Retrieved flat tibial component (infected knee) demonstrating an
early superficial wear track.
Mobile-bearings also have a risk of dislocation (11).
This risk is greatest in lateral UKR such that it has
been a contraindication for the Oxford UKR (21).
More recently the Oxford group have been devel-
oping a domed tibial undersurface for the bear-
ing to reduce this risk and to match the increased
mobility of the lateral compartment.
Although there is perfect congruency in a mobile-
bearing which results in low wear rates, this can
also occur in fixed-bearing designs. Low wear does
occur with a flat tibial PE surface and a curved
metal femoral surface. This seems illogical given
the laboratory studies, but what actually happens
is that the implant when loaded in vivo results in
creep of the PE. The site where it occurs is patient-
dependent and reflects
fl their own kinematics. The
implant therefore beds in and becomes congruent.
Wear is then minimal. This is clearly seen when the
implant is revised for, say infection (Fig. 1). ThisTh
observation led a number of research teams to
develop a slightly concave shape for the PE insert
to produce a better match to the shape of the pros-
thetic femoral condyle (e.g., UKS Aston®). How-
ever, choosing this design causes problems with
kinematics that is related to the shape and orien-
tation of the femoral condyles, and the tibial pla-
teaux. The condyles have an oblique orientation,
which, coupled with automatic internal rotation of
the tibia during flexion,
fl means that there is then
a complex change in rotation between flexion
fl and
extension. This is impossible to determine intra-
operatively. This means that a congruent fixed
PE bearing, which is usually inserted in fl flexion, is
likely to create a torque at the tibial bony surface.
Because it is impossible to set an ideal average posi-
tion, signifi
ficant sheer forces are likely to be gener-
ated at the level of the tibial implant–cement–bone
Fig. 2 – “Overstuffed” Oxford medial UKR with overcorrection.
interface. There are therefore only two possible
options for the shape of the tibial PE insert:
– A flat bearing surface imposing no constraints on
rotational alignment and where the position dur-
ing rotation is not important.
– A congruent bearing surface which, to avoid con-
straints on the cement–bone interface caused by
the change in rotation when going from flexion
fl
to extension has a flat tibial surface and a mobile-
bearing.
Whilst the principle of the mobile-bearing design
seems attractive, and findings published have
indeed confi firmed there is less tendency to wear
(4), there is also a risk of dislocation (10, 11, 22).
If this occurs then re-operation is necessary, with
all its disadvantages for the patient. Rarely can this
be corrected by a bearing exchange with a larger
implant, as it is unusual to introduce too thin a
mobile-bearing. More often a technical error has
occurred with a significant
fi mismatch between the
flexion and extension gaps, and therefore complete
revision is needed. This problem is very common
with lateral mobile-bearing UKR, where fl flexion-ex-
tension gap balance is almost impossible. If a larger
bearing is inserted, not only is there the worry of
re-dislocation, but also overstuffi ffing may lead to
progression of arthritis in the contralateral com-
partment secondary to overload (Figs. 2 and 3).
The concern with bearing dislocation means that
inexperienced surgeons tend to oversize the bear-
ing. This is the main cause of overcorrection (9, 23),
although inadvertent release of the medial collat-
eral ligament (MCL) is also well recognized. Over-
correction has been reported in a number of publi-
cations comparing fixed and mobile-bearings (10,
22). The same occurs with some unicompartmental
“spacer” knees that we have had to revise (Fig. 4).
 Fixed bearing unicompartmental knee prosthesis: results, complications, and technical considerations 671
Fig. 3 – Operative view of the case corresponding to Fig. 2. Wear on the
central part of the lateral condyle.
For us the advantages of wear reduction with a
mobile-bearing are outweighed by the high risk
of early failure due to the technical demands of
the procedure (8). We prefer to consider the UKR
a joint “wedge.” If a fixed-bearing implant is cho-
sen, then a flat PE bearing surface is essential. This
allows the femoral condyle to find
fi its own contact
position. By allowing this, the unavoidably com-
plex adjustment of the rotation of the tibial insert
is dispensed with. Despite the initial incongruency,
the signs of PE wear have not been found at up to
10 years follow-up (24).
Results of fixed-bearing UKR
A number of distinct periods can be seen in the UKR.
In the 1970s and 1980s, pioneers such as Marmor
in the USA and Cartier (25) in France established a
number of rules for UKR such as the thickness of
the PE insert should be a minimum of 6 mm (4).
However, at this time the reported results show
variability between series and the age of patients
undergoing UKR. Papers by Laskin (16) and Insall
(14, 15) brought it into disrepute, but the differ-
ff
ent series included many errors in indications and/
or operating technique. Insall had overcorrected
the medial UKRs, and undercorrected the lateral
ones. The decision to use the same rules as applied
to osteotomies explains why the results with the
lateral UKR in his series were good compared to the
medial ones. This point is discussed later.
More recently, Deshmukh and Scott (24) noted a
distinction between failures occurring in the fi first
10 years, which are mainly due to errors of tech-
nique and/or indication, and failures in the second
10-year period, which are mostly related to wear
and component loosening. From this some have
concluded that UKR is an interim solution before
going on to TKR (26).
Fig. 4 – Similar wear as on Fig. 3 on the opposite compartment of a revised
“spacer” UKA.
Failures related to the design of the implants must
not be considered to be the same as failures of tech-
nique or with the overall concept. Quite clearly the
UKR is very vulnerable in the event of technical
error. Provided that a few simple rules are followed,
the results achieved with modern unicompartmen-
tal implants show them to be a satisfactory alter-
native to TKR, and in younger patients to upper
tibial osteotomy. Many series published in the lit-
erature have reported survivorship of over 90% at
10 years (1, 5, 25, 27–31).
Personal series
At the Isakos Congress in 2005 (32), the senior
author (GD) presented a series of 122 HLS UKRs
that were reviewed and assessed after a follow-up
period of 6–9 years. The
Th findings are presented
here as an example of outcomes achievable with a
fixed-bearing UKR.
Materials and methods
This was a retrospective series of UKRs implanted by
one surgeon (GD) between January 1995 and Novem-
ber 1997. The prosthesis used was the HLS UNI Torn-
ier®. This is a fixed-bearing resurfacing implant with a
cemented alloy (CrCo) femoral component and a full
polyethylene tibial insert (Fig. 5). In eight cases, the
bearing included a restraining polyethylene “Metal
Ring” designed to reduce the risk of creep but with-
out reducing the thickness of the PE insert.
The series consisted of 122 patients with an average
age of 71 years (range 51–91) at the time of the oper-
ation. Of these 61 were female, and 51% were on the
right side. There
Th were no bilateral cases. Of the 122
patients only four were lost to follow-up (3%), 16
died, 10 were contacted but did not undergo clinical
assessment for reasons of age or distance. Of these
10, none had been revised. Therefore, the study
672 The Degenerative Knee
Fig. 5 – HLS UNI Evolution (Tornier®).
population comprised 84 patients with an average
follow-up of 7.4 years (range 6–9). They were clini-
cally assessed and undertook an IKS score. Further-
more 74 had a full radiological assessment includ-
ing pre- and post-operative long-leg radiographs.
In all 76 (90%) had primary osteoarthritis classi-
fied as Ahlback Grade II (33), of which all except
nine (12%) were medial (88%). In eight cases
(10%), the pathology was aseptic necrosis.
Results
On subjective evaluation there was a high rate of
satisfaction with 96% satisfi
fied or very satisfi
fied.
Objective
The Knee Score went from 39 pre-operatively to 86
at the time of review, with 94% of patients experi-
Table I – Survival curve. overall series.
encing either no pain or occasional mild pain. We
must point out that the intentional post-operative
residual deformity (varus for medial and valgus
for lateral UKAs,) automatically reduced the knee
score by an average of 10 points.
The functional score went from 62 pre-operatively
to 77 at the time of review. The advanced age of
the patients at the time of review needs to be
taken into account here: 18% were IKS category C
for an average age of 78 years (range 68–97). The
Th
most noteworthy points included a high average
angle of flexion, from 128° pre-operatively to 133°
(90–150°) at the time of review.
Radiological
For the medial UKRs, the mechanical femorotib-
ial angle (mFTA) did not change staying at 173°
pre-operatively and at the time of review, with
a mechanical femoral angle (mFA) of 92° and a
mechanical tibial angle (mTA) of 83°. For the lat-
eral UKAs, the mFTA did not vary signifificantly at
184°. The mFA was 92° and the mTA 92.5°. Radio-
lucent lines were reported in 22% of cases, but
only beneath the tibial plateau in medial UKAs.
These lucencies did not change over time. One case
showed signs of polyethylene wear with loss of
height of the bearing surface.
Complications
There were only four cases of distal deep vein
thrombosis, which were successfully treated with
anticoagulants (5%). Th
There were no cases of stiff
ff-
ness requiring mobilization under anesthetic.
 Fixed bearing unicompartmental knee prosthesis: results, complications, and technical considerations 673

Table II – Survival curve medial HLS UNI evolution at 9-year maximal follow-up.

Eight patients (6.5%) required removal of the pros-
thesis. Two were deep-seated secondary infections
(1.6%), one after cholecystitis a year from opera-
tion, and the other after a severe lung infection
2 years post-operatively. Two cases of tibial loosen-
ing (1.6%) (v.i.) underwent revision to a TKR. There
Th
was one case of oversizing of the components in a
small female patient. A No. 1 (the smallest) femo-
ral component distalized the joint line and the
size 1 tibial component had a posterior overhang,
which caused posterior pain. ThThis was also revised
to a TKR as well as a further three patients with
unexplained pain. Two with unexplained pain had
undergone lateral UKR, with revision only improv-
ing but not abolishing the pain.
Overall the Kaplan–Meier survival analysis was
93% for the full series (Table 1) and 94% for the
series of 75 medial UKRs (Table 2).
that is ideal for all patients. The global deformity
depends on the structural deformity of the bone
and on the degree of wear. Therefore,
Th a patient
with 6° bone deformity and wear equivalent to an
angle of 4° has a total deformity of 10°. Th The pro-
portion of the angular deformity due to the bony
morphology, and unrelated to wear, can never
be corrected by a UKR. This Th was the reason for
the tibial component loosening in our series. Th The
patient was overweight and had a femoral bony
varus >10° from femoral bowing. Obviously this
was impossible to correct using a UKR (Fig. 6).
– The tibial radiolucent lines showed signifi ficant
correlation with excessive tibial bony resection
( = 0.009) (Fig.7). Th
(p This excessive resection also

Discussion
From this series important observations can be
made:
– In medial UKR a residual varus of 5–7° does not
adversely affect
ff the outcome. This finding cor-
roborates the results we published in 2004 (13).
Only residual varus superior to 10° have a risk of
wear on the PE tibial insert. Others have reported
similar findings (1, 28). The residual varus refl
flects
the anatomical or structural varus of the individ-
ual patient prior to the onset of medial tibiofem-
oral osteoarthritis. The UKR acts as a wedge and
replaces the wear created by the osteoarthritis,
but not the structural varus. Contrary to osteoto-
mies there is no pre-determined correction angle Fig. 6 – Femoral “bowing’’. fMA 80°. Incompatible with UKRs.
674 The Degenerative Knee

Fig. 7 – Femorotibial incongruency due to an excessive orthogonal tibial cut. Fig. 8 – Excessive medial tilting of the tibial plateau without penalty at
7 year follow-up.

contributed to excessive varus tilting of the pla- and thus require difffferent techniques. However,
teau (p
( = 0.047). This correlation was not signififi- the objectives are the same for both.
cant for excessive tilting alone (Fig. 8) (p
( = 0.62),
nor with the post-operative mFTA angle, even
when this was accentuated (p ( = 0.65). It was Objectives in unicompartmental replacement
noted that in some 25% of cases, the excessive
tibial resection was due to distalization of the Two factors need to be taken into account.
femoral replacement. This led to lowering of the
prosthetic joint line. Lowering the tibial bony UKR and ligament balance
cut, to make room for the tibial insert, then There is no intrinsic stability built into unicom-
compensated this for. Th This is a risk with femoral partmental knee prosthesis. Everything depends
resurfacing UKR, and is important to avoid. on the ligaments being intact, whether it is the
With medial UKRs, the average mFA was 91° pre-
operatively, only increasing to 92° on average at
follow-up. Th
This was not the case with lateral UKRs
where resurfacing lead to a good correction. Th The
wear or dysplasia of the lateral condyle was almost
fully corrected, with the mFA went changing from an
average of 94 to 91°. As a result of these findings we
can make a number of technical recommendations
on the diff
fferent choices of equipment and material.
There are important rules to stick to for medial UKRs,
Th
and in lateral UKRs it is essential to use resurfacing
rather than cutting designs on the femoral condyle.
These technical aspects will now be addressed.
Th

Unicompartmental knee replacement –

the technique
It is important to make a distinction between
medial and lateral unicompartmental arthro- Fig. 9 – Early failure due to ACL preoperative insuffi
fficiency. Pre- and post-
plasties as they do not present the same problems operative anterior drawer is present.
 Fixed bearing unicompartmental knee prosthesis: results, complications, and technical considerations 675
Fig.10 – Failure of a lateral UKA due to medial collateral laxity.
cruciates (20, 21) or the ligaments on the convex
side of the deformity. ThThus, as we reported more
than 20 years ago (20), no defect of the central
pivot (in particular of the ACL) can ever be stabi-
lized by a unicompartmental “wedge” (Fig. 9). In
the coronal plane, cases with laxity on the convex
side e.g., distension of medial soft tissues in genu
valgum (Fig. 10) or a lateral translation in genu
varum are contraindications for UKR (Fig. 11).
The pre-operative radiographic assessment with
frontal and lateral views, both weight-bearing and
stress X-rays, screen for these problems.
Care should be taken when excising the medial
meniscus to leave the rim, especially in its mid-
portion as it is confl
fluent with the deep MCL. This
can be inadvertently divided leading to excessive
medial opening. If after preparation the tibial com-
ponent measures much larger than anticipated,
Fig. 11 – Frontal weight-bearing X-ray demonstrating a lateral tibial translation. Contra-indication
to a UKA.
this has probably happened. Repair of the divided
deep fibres
fi of the MCL can be tried, or, more usu-
ally, immediate conversion to a TKR.
UKA and bone alignment
One of the keys to the success of the operation is
a proper understanding of the alignment correc-
tion. This will also set any limits to indications for
UKR. In TKR, the aim is to achieve the best pos-
sible correction of the defect in the structural bony
alignment as this reduces the risk of loosening and
wear. However in UKR, the implant can only, and
must only, be positioned on the concave side of
the deformity. This role as a “joint wedge” must do
nothing more than off ffset any wear. The goal there-
fore is only to restore the patient’s original structural
alignmentt (Fig. 12) to the degree of residual varus
or valgus that depends on the original alignment
of bone extremities. There is no ideal or average
pre-determined value.
The classical idea of “undercorrection” is a misno-
mer. The purpose of the operation is not to under-
correct for the sake of undercorrecting, but to
restore the patient’s original structural alignment
as accurately as possible (34). The axial alignment is
varus for medial UKAs and valgus for lateral UKAs.
There are occasionally patients with no structural
bony deformity who therefore have a final align-
ment of 180°. In this scenario, this would not be
overcorrection. Conversely, a post-operative mFTA
of 178° in a patient whose structural alignment
was originally 172° (before wear) is a case of over-
correction by 6°. This would occur by signifi ficant
overstuffi
ffing of the medial femorotibial joint space
Fig. 12 – Bilateral UKA. Frontal X-rays
illustrating the ideal alignment.
676 The Degenerative Knee
Fig. 13 – Overstuffed knee with contralateral involvement despite an over-
all neutral alignment.
(Fig. 13). To avoid this type of error, the ligaments
on the concave side should never be released. These
Th
ligaments are the sole reference to the original pre-
arthritic joint intra-operatively, and help to decide
on the thickness of the bearing. Th
The purpose of the
operation is to achieve proper balance of the liga-
ments without excessive tension (or even with 2 or
3 mm residual laxity as a safety margin). This
Th refer-
ence ensures proper, i.e., not excessive, correction
for wear, and is termed the “standard” correction
in relation to the patient’s own anatomy. This Th is
why stress X-rays correcting the varus (Fig. 14) or
valgus are useful for checking that the joint space
narrowing will not be overcorrected. TheTh two com-
ponents of the prosthesis, femoral and tibial, are
positioned to replace lost articular surface and
act as a composite wedge. It therefore should be
stressed that:
– Proper ligament balancing resulting in just fi fill-
ing the worn surface is the only way to effffectively
avoid progression of arthritis into the opposite
compartment. It guides the surgeon to the choice
of PE thickness.
– Correction of alignment measured on the post-
operative long-leg film must, in theory, match
the structural mFTA of the patient; as it was
before wear occurred (35).
As a consequence of this:
– By combining data from the pre-operative long-
leg film and stress X-rays, the target value of the
provisional post-operative mFTA can be mea-
sured. This can be used to predict the post-oper-
ative residual alignment discrepancy. ThisTh then
shows whether it is within the range tolerated
by a unicompartmental prosthesis. For instance
in medial UKAs the residual varus should be no
greater than 7°. The X-rays can also be used to
screen for bony deformities away from the joint.
An example of this is femoral bowing (Fig. 6).
With an mFA of 80° this obviously cannot be cor-
rected from within the joint.
– The restoration of the joint line in UKA depends
on the thickness of the femoral component, nota-
bly in extension, along with the amount of wear
on the distal femoral surface. Using a resurfacing
component in the presence of subchondral bone
loss will elevate the joint line, and increases the
thickness of the tibial component. Resurfacing
when there is residual articular cartilage lowers
the joint line. As said earlier this means that the
tibial cut must be lowered to allow space for the
tibial component. Raising or lowering the joint
line has no eff
ffect on the overall axial alignment,
as this has not been changed. However, our
series shows a significant
fi correlation between
tibial radiolucent lines and lowering the tibial cut
secondary to “distalization” of the femoral com-
ponent from residual articular cartilage (Fig. 7).
This eff
ffect was only found in medial UKRs. We
recommend great care in preparing the femoral
implant bed when using a resurfacing compo-
nent. The alternative is to choose a resection UKR
in cases where the pre-operative mFA is equal to
or greater than 90°. This,
Th however, is never the
case on the lateral side where the resurfacing
UKR technique works very well.
In conclusion two important objectives must be
stressed:
– Re-establish the patient’s original anatomy by
only correcting the loss of joint space by wear,
and do not correct any bony deformity.
– Restore the true tibiofemoral joint line. It is easy
to defi
fine the true joint line as it is at the level of
the meniscal bed.
Until recently we considered avoiding overstuffi ffing as
of primary importance and restoration of the joint
Fig. 14 –Schematic representation of the correction of medial wear.
 Fixed bearing unicompartmental knee prosthesis: results, complications, and technical considerations 677

frontally, which is in varus, and sagittally,

where the slope is posterior, the joint space has
to be measured in relation to the mechanical
tibial axis as seen on pre-operative correction
X-rays or weight-bearing long-leg film (Fig. 16).
The HLS UNI (Tornier®) instrument set has an
adjustable alignment guide fitted with a goni-
ometer that can be used to set the varus plane
of the upper tibia (Fig. 17). The
Th instrument has
pre-settings from 0° to 5°.
The cutting block is placed on the front of the knee,
with the patella displaced. It has three holes for
guide pins. These pins will subsequently be used

Fig. 15 – Minimally invasive approach.

line as secondary. However, following analysis of our

series we realize that the latter is equally important.
This has led to the view that the choice of implant
(resurfacing or resection) is determined by the pre-
operative radiological measurements of the mFA.

Medial UKR – the technique

Approach
Recently the minimal access approach has become Fig. 16 – Stress X-ray allowing to design the orientation of the tibial cut.
standard throughout the international orthope-
dic community. This
Th is not just a fashion but is
eminently suited to UKR. The Th approach is medial
parapatellar extending to the upper border of
the patella (Fig. 15). If more space is needed, the
muscle fibres of the vastus medialis can be divided
under the skin flap (36), but not between the vas-
tus and the rectus femoris where there is a much
greater risk of damaging the quadriceps tendon.
The distal end of the incision is the medial edge of
the tibial tubercle. After excising Hoffa’s
ff fat pad,
the patella can usually be displaced laterally leading
to adequate exposure of the medial compartment.
The cruciate ligaments and the lateral tibiofemo-
ral and patellofemoral joints surfaces can then be
inspected to confi
firm suitability for UKR.

Tibial preparation
With the HLS technique the tibial cut is performed
first. The same choice is made for most other
fi
implants. There are two objectives:
(1) To defi
fine the plane of the tibial cut according to Fig. 17 – HLS UNI Evolution (Tornier®). Tibial cutting guide with compass allow-
the patient’s anatomy: To defi
fine the plane both ing to restitute the frontal joint line direction.
678 The Degenerative Knee
to guide the blade during tibial resection. One
pin is placed in one of the most medial holes then
inserted in the joint space with the knee in fl flexion.
This pin determines the patient’s tibial slope. Next
Th
a central pin is inserted to set the position of the
guide to match the slope. This Th central fixation pin
will then be used as a reference for the depth of the
cut (thickness of tibial resection) (Fig. 18).
(2) To set the level of the tibial resection: The tech-
nique we recommend uses the pin in the joint
to set the level of tibial resection. The pin which
has already been inserted in the joint space to
set the slope is left in position. The Th knee is
then placed in extension and slight valgus. The Th
central cursor is positioned up against the cen-
tral pin. This is the reference point and is the
distal surface of the patient’s medial condyle
(Fig. 19).
Fig. 18 – Slope is determined by the pin introduced tangentially to the
tibial plateau.
Fig. 19 – Schematic representation of the evaluation of the tibial cut with
reference to the distal femur.
The knee is then moved back into flexion and the
pin inside the joint is removed. The cutting plate
is then lowered 14 mm as shown on the central
gauge display. The height of 14 mm is the sum
of the distal thickness of the femoral component
(3 mm) plus the space required for the thickness
of the tibial insert selected (usually 9 mm), adding
a further 1 or 2 mm laxity for “safety.” The Th total
thickness is thus (with a 2 mm laxity margin) 3 +
9 + 2 = 14 mm.
The advantage of this method is that the cuts
can always be altered without any risk of overfill-fi
ing the joint space. Controlled ligament balance
without any excess tension, and without ligament
release avoids overstuffi ffing. The disadvantage,
however, is that the level of the tibial resection
changes as a function of the position of the femo-
ral component. In theory this is not a problem,
but as our series showed very clearly, if there is
still residual cartilage (as may occur in aseptic
osteonecrosis of the femoral condyle) then there
is the risk of distalizing the femoral component
leading to an excessively low level for the tibial
resection. This, in turn, can aff ffect the load-bear-
ing capacity, by reducing the surface area for the
tibial component as well as loading the weaker
cancellous metaphyseal bone. Th This, as noted ear-
lier, increases the risk of radiolucent lines, and
also of tibial collapse (37–39). Our series showed
a signifificant correlation between the incidence
of radiolucent lines and the level of the tibial cut
which, in turn, correlated with distalization of
the femoral component.
Our analysis of cases of medial compartment
osteoarthritis has shown that the mFA is often
greater than 90°. The average mF angle in our
series was 91° (Table 3). In such cases wear is, in
eff
ffect, minimal. If the resection only removes a
few millimeters of the distal femoral cartilage then
the post-operative mF angle, using a resurfacing
design, is very likely to reach 93° or even more.
In these circumstances, and to avoid overstuffi ffing
the medial femorotibial space, the only option for
the surgeon is to over-resect the tibial plateau,
with all the risks described above. When there
is no exposed subchondral bone caused by wear,
we recommend careful “sanding” of the femoral
implant site to avoid distalization of the femo-
ral component (Fig. 20). Th This preparation must
be done with the knee in flexion before the level
of the tibial cut is set using the pin in the joint.
Of course these cases are perfect candidates for
a resection unicompartmental design. However,
in cases where there has been wear, producing a
natural bed for the condylar component (Fig. 21),
resurfacing is the best choice, and measurement
of the tibial cut, using the pin, stands as the ideal
option.
 Fixed bearing unicompartmental knee prosthesis: results, complications, and technical considerations 679
Fig. 20 – Preparation of the femoral component layer with high speed
shaver.
Table III
Femoral preparation
In addition to the distal (or extensor) surface
preparation as stated in the previous paragraph,
the femoral condyle requires a posterior cut. In
osteoarthritis suitable for UKR, there is never
wear on the posterior part of the femoral condyle.
Chamfer cuts also need to be performed.
The preparation is done with dedicated instru-
ments designed to fit the curve of the condyle
and its anteroposterior dimensions. ThThe HLS UNI
(Tornier®) system has a range of four sizes that can
Fig. 21 – Typical aspect of the femoral wear corresponding to a perfect
indication of resurfacing femoral component.
be aligned anteriorly with the anterior-most point
of contact of the tibial plateau on the patient’s
condyle. This
Th point is located before the tibial cut
is made and is marked using a diathermy. Before
defi
fining this point it is important to defifine the
orientation of the femoral component. The compo-
nent must be centered on the condyle in extension
and not impinge on the tibial spines. TheTh exten-
sion surface should lie in parallel with the frontal
plane alignment of the tibial plateau, which is in
slight varus. Th
The femoral component should also be
680 The Degenerative Knee

Fig. 23 – HLS UNI Evolution Femoral guide assessing the ideal disposition of the
future femoral component (rotational, mediolateral, and frontal positioning).

Fig. 22 – Perfect post-operative

frontal positioning of the UKA.

rotated to run along the femoral condyle’s extensor

surface (Fig. 22). Any impingement between the
anterior part of the femoral implant in extension
and the tibial spines, or, in flexion, any signifi
ficant
contact with the medial facet of the patella, must
be avoided. Both of these problems can be avoided
by proper adjustment of the position of the femo-
ral implant and checking by rotating the tibia dur-
ing flexion and extension. This is why the HLS UNI
instrument set has a femoral guide that is placed
between the tibial trial insert and the distal con-
dyle in extension (Fig. 23). The instrument is of key
importance as it sets the three fundamental param-
eters: coronal orientation, centering and rotation of
the femoral component (It is even more crucial for Fig. 24 – HLS UNI Evolution Femoral instrument used to make “postage
lateral UKRs where there is a greater risk of rotation stamp” for the fins.
errors). The cutting block has two holes for pins,
and once it is in place, can be used to set the posi-
tion. The knee is placed in flexion. The cutting block
is removed and replaced with a special guide that
can be used to make “postage stamp” perforations
of the area for implanting the anti-rotation fi fins of
the future defi finitive femoral implant (Fig. 24). At
this stage, slight adjustment can be made to correct
centering and rotation, but caution is required. TheTh
surgeon must not be misled by any excessive obliq-
uity of the patient’s condyle. If the alignment was
set in relation to the patient’s condyle, the future
femoral implant could be positioned with exces-
sive internal rotation, causing impingement on the Fig. 25 – HLS UNI Evolution Femoral instrument used to assess the coronal size.
tibial spines when the knee is in extension, or with
the patellar facet with the knee in flexion; precisely condyle. Three
Th basic principles must be followed
the problems we are trying to avoid. (Fig. 25). Th
There must be:
There are four sizes for the posterior cutting block – Lateral alignment between the handle and the
and chamfer covering the range needed to fit fi sagittal axis of the femur. It is essential to avoid
the anteroposterior dimensions of the patient’s any recurvatum.
 Fixed bearing unicompartmental knee prosthesis: results, complications, and technical considerations 681
– Perfect posterior contact between the posterior
flange of the jig and the surface of the posterior
fl
condyle. Any mismatch causes inadequate resec-
tion. This results in excessive compression in
flexion causing instability and the risk of tibial
component lift-off.
ff
– Smooth transition between prosthesis and tro-
chlear articular cartilage so as to avoid impinge-
ment with the patella.
In reality there is little problem in choosing the
curvature and size of the prosthesis. Once the cut-
ting block is set in place with one or two pins, the
posterior and chamfer cuts can be undertaken.
Trialling before cementation
It is essential to understand that any instability
of the trial pieces cannot be compensated for by
cementation. Moving the knee from flexion fl to
extension and back without any movement of the
components between implant and bone is crucial.
The contact of the trial tibial bearing with the tibial
cut must be exact. The tibial bearing must be stable
in flexion, without any lift-off ff or anterior expul-
sion. The femoral component should not rotate in
the sagittal plane in flexion (i.e., the anterior lip
lifting away from the condyle). Th This will not occur
if the posterior condylar cut is correctly aligned
(Fig. 25). This imparts stability to the femoral
insert and avoids any posterior protrusion of the
implant’s posterior condyle. By using the pin to
achieve proper alignment with the patient’s tibial
slope (Fig. 18), there is no excessive posterior com-
pression on the implant in flexion.
fl If this is not
avoided then it inevitably leads to early loosening
and/or pain. Provided that these principles are fol-
Fig. 26 – Contralateral progres-
sion of arthritis due to a slight
hyper correction in a lateral UKA.
lowed, then the implants will be set in place per-
fectly and that lead to reliable results. Cementa-
tion does not impart primary stability but ensures
reduced stress transfer between the bone and the
implant. It is important to avoid using massive
cement pegs to secure the prosthesis, particularly
at the tibial level. By not having a keel, the risk of
medial tibial plateau fracture is minimized.
Closure is performed in layers over a suction drain.
The patient is able to move and put weight on the
joint immediately.
Lateral UKR – the technique
The main principles are the same as for medial
UKR, but a number of specifi fic points require closer
attention.
The main problems concern:
– The correction of any anomaly in the mFTA, with
a greater risk of overfifilling the joint space and
therefore of overcorrection (Fig. 26) due to the
greater structural laxity of the lateral ligament
complex.
– The bone cuts which can lead to an excessively
oblique angle in varus for the tibial cut and defec-
tive rotation of the condylar component (Fig. 27).
The most logical choice and most appropriate
implant is a resurfacing model since the usual
cause of the deformity is femoral dysplasia.
Approach
In the 1990s, Dejour recommended access by tibial
tubercle osteotomy. However, our preferred tech-
nique is an anterolateral, mini-invasive approach,
Fig. 27 – Tibial and femoral malpositioning of a lateral UKR
ending to dislocation.
682 The Degenerative Knee
Fig. 28 – Cabot’s leg position to improve lateral exposure and preparation.
extending the incision proximally if necessary to the
junction of the fibres
fi of the vastus lateralis. Better
exposure is gained by partial resection of the Hoffa’s
ff
fat pad and by positioning the knee in the Cabot,
cross-legged, or figure-four position (Fig. 28).
Tibial preparation
The knee is positioned in flexion, with the patella
displaced medially using a Homan-type retractor.
The cutting block is placed on the extramedullary
alignment rod facing the joint line. The
Th caliper must
be angled slightly downwards and 2–3° outwards to
avoid a varus oblique cut. A varus cut might pro-
duce a tendency for the tibial component to slip
laterally and to a medial laxity (Fig. 29). As on the
medial side, a pin is placed on the femorotibial joint
line, at a tangent to the lateral plateau, which can
then be used to determine the slope. The same pin
provides a reference point in relation to the distal
condyle for setting the depth of the tibial cut.
Unlike the medial side, where there are fears of
overstuffi
ffing caused by residual cartilage, this risk
does not occur on the lateral side. This is because
the main problem encountered is lateral condylar
hypoplasia with excessive femoral valgus. In our
series, the average pre-operative mF angle was 94°,
and the post-operative angle was 91° (Table 4).
This finding suggests that on the lateral side pref-
Th
erence should be given to a resurfacing rather than
a resection UKR.
Femoral preparation
Femoral preparation is done using the same method
as for medial UKR. The problem specifi fic on the lat-
eral side often comes from excessive internal rota-
tion of the lateral condyle in relation to the medial
condyle. When setting rotation, choosing the long
axis of the condyle with the knee flexed for align-
ment has an unfortunate tendency to medialize
the anterior part of the femoral implant, and this
causes to two complications:
Fig. 29 – Excessive tibial varus of the tibial component of a lateral UKR.
– Impingement of the lateral articular facet of the
patella in flexion (40).
– A risk of impingement of the anterior part of the
femoral component and the tibial spines when in
extension (Fig. 29).
Therefore on the lateral side, we like to use the HLS
UNI instrument set, which off ffers the same facility
as for the medial side for adjusting the centering,
the coronal positioning and rotation, but doing
this in extension (Fig. 23). When moving back to
flexion, no attempt must ever be made to correct
any impression of excessive external rotation of
the cutting block (Figs. 30, 31). Early on we learnt
that to make this “correction” in flexion leads to
malalignment in extension. Although it looks
wrong it is important not to correct it. Cartier
emphasizes the fact that the lateral osteophyte of
the condyle is often the only supporting element
of the anterior part femoral component and that
every eff
ffort must be made to conserve it. The rest
of the preparation is done using the same method
and instruments as for the medial side.
At the end of the procedure, before cementing, the
parts must be perfectly stable, as is in the medial
side.
Conclusion
Provided that the operating technique is car-
ried out with strict compliance to the protocol,
the fixed-bearing unicompartmental prosthesis
is, in our opinion, a simple and elegant solution
 Fixed bearing unicompartmental knee prosthesis: results, complications, and technical considerations 683
Fig. 30 – Rotation of the femoral guide in flexion in the lateral condyle.
Table IV
for treating isolated unicompartmental medial or
lateral tibiofemoral osteoarthritis. Studies have
firmed that the rules that we have established
confi
lead to reproducible results with at least a 10-year
good clinical, functional, and radiological out-
come. The great advantages over TKR are a more
normal feeling knee, lower complication rates,
better range of motion including the ability to
squat and kneel.
There is a risk of PE wear becoming apparent
between 10 and 20 years post-implantation as our
follow-up time increases. However, our ideal popu-
lation group is over 80 years old where this will not
be a problem. In younger patients, we maintain
that revision of an all-polyethylene UKR, which
has avoided massive tibial resection and large tibial
Fig. 31 – Curious aspect of the fin preparation in case of a lateral UKR. This
is nevertheless the correct rotation to avoid an impingement between the
anterior part of the future femoral prosthetic condyle and the tibial spine.
and/or femoral pegs, leads to a revision procedure
of comparable diffi
fficulty to a primary TKR. We can
recommend the Tornier® HLS UNI Evolution with
its resection femoral component and all polyethyl-
ene tibial component for patients who have symp-
tomatic isolated unicompartmental tibiofemoral
osteoarthritis with intact ligaments.
References
1. Berger R, Nedeffff D, Barden R, et al. (1999) Unicompart-
mental knee arthroplasty: clinical experience at 6 to 10
year follow-up. Clin Orthop 367:50
2. Khan O, Davies JH, Newman JH, et al. (2004) Radiological
changes ten years after St Georg sled unicompartmental
knee replacement. Knee 11:403–407
684 The Degenerative Knee
3. Engh G, Dwyer K, Hanes C (1992) Polyethylene wear of
metal-backed tibial components in total and unicompart-
mental knee prosthesis. J Bone Joint Surg 74B:9–17
4. Argenson JN, O’Connor JJ (1992) Polyethylene wear in
meniscal knee replacement. A 1- 9 year retrieval analy-
sis of the Oxford knee. J Bone Joint Surg [Br] 74B:228–
232
4. Deshmuckh RV, Scott RD (2001) Unicompartmental knee
arthroplasty: long-term results. Clin Orthop 392:272–
278
5. Murray DW, Goodfellow JW, O’Connor JJ (1998) Th The
Oxford medial unicompartmental arthroplasty. A ten year
survival study. J Bone Joint Surg [Br] 80B:983–989
6. Goodfellow JW, Kershaw CJ, Benson MK, et al. (1988)
The oxford knee for unicompartmental osteoarthritis. The
first 103 cases. J Bone Joint Surg [Br] 70B:692–701
7. Hernigou P, Deschamps G (1996) Les prothèses unicom-
partimentales du genou. Symposium, 70th Annual SOF-
COT Meeting. Rev Chir Orthop 82(suppl I):23–60
8. Perkins TR, Gunckle W (2002) Unicompartmental knee
arthroplasty: 3 to 10 year results in a community hospital
setting. J Arthroplasty 17:293–297
9. Robertsson O, Knutson K, Lewold S, et al. (2001) The Th
routine of surgical management reduces failure after uni-
compartmental knee arthroplasty. J Bone Joint Surg [Br]
83B:45–49
10. Gleeson RE, Evans R, Ackroyd CE, et al. (2004) Fixed or
mobile bearing UKR? A comparative cohort study. Knee
11:379–384
11. Lewold S, Goodman S, Knutson K, et al. (1995) Oxford
meniscal bearing knee versus the Marmor knee in uni-
compartmental arthroplasty for arthrosis. A Swedish mul-
ticenter survival study. J Arthroplasty 10:722–731
12. Weale AE, Newman JH (1994) Unicompartmental arthro-
plasty and high tibial osteotomy for osteoarthrosis of the
knee. Comparative study with a 12 to 17 year follow-up
period. Clin Orthop 302:134-137
13. Hernigou P, Deschamps G (2004) Alignment influencesfl
wear in the knee after medial unicompartmental arthro-
plasty. Clin Orthop 423:161–165
14. Insall J, Aglietti P (1980) A five to seven year follow-up
of unicondylar arthroplasty. J Bone Joint Surg [Am]
62A:1329
15. Insall J, Walker P (1976) Unicondylar knee replacement.
Clin Orthop 120:83–85
16. Laskin RS (1978) Unicompartmental tibiofemoral resur-
facing arthroplasty. J Bone Joint Surg [Am] 60A:182
17. Marmor L (1979) Marmor Modular Knee in Unicompart-
mental disease. J Bone Joint Surg [Am] 61A:347
18. Hopgood P, Martin CP, Rae JP (2004) Th The eff
ffect of
tibial implant size on post-operative alignment follow-
ing medial unicompartmental knee replacement. Knee
11:385–388
19. Whiteside L (2005) Making your next UKA last. Th Three
keys to success. J Arthroplasty 20(suppl 2):2–3
20. Deschamps G, Lapeyre B (1987) la rupture du ligament
croisé antérieur. Une cause d’échec souvent méconnue des
prothèses unicompartimentales du genou. A propos d’une
série de 79 prothèses lotus revues au dela de 5 ans. Rev
Chir Orthop 73:544–551
21. Goodfellow JW, O’Connor JJ (1992) Th The anterior cruci-
ate ligament in knee arthroplasty a risk factor in uncon-
strained meniscal prosthesis. Clin Orthop 276:245-252
22. Emerson RH, Hansborough T, Reitman RD, et al. (2002)
Comparison of a mobile with a fixed bearing unicompart-
mental knee implant. Clin Orthop 404:62–70
23. Pandit H, Beard DJ, Jenkins C, et all (2006) Combined
anterior cruciate reconstruction and Oxford unicom-
partmental knee arthroplasty. J Bone Joint Surg [Br]
88B:887–892
24. Deshmuckh RV, Scott RD (2001) Unicompartemental knee
arthroplasty: long-term results. Clin Orthop 392:272-278
25. Cartier P, Sanouillet JL, Grelsamer RP (1996) Unicom-
partmental knee arthroplasty after 10-year minimum
follow-up period. J Arthroplasty 11:782–788
26. Engh GA (2002) Orthopedic crossfire:fi can we justify uni-
condylar arthroplasty as a temporizing procedure? In the
affi
ffirmative. J Arthroplasty 17 (suppl I):54–55
27. Ashraf T , Newman JH, Evans RL, et al. (2002) Lateral
Unicompartmental knee replacement. Survivorship and
clinical experience over 21 years. J Bone Joint Surg [Br]
84B:1126–1130
28. Berger R, Meneghini RM, Jacobs JJ (2004) Results of
unicompartmental arthroplasty at a minimum of 10 year
follow-up. J Bone Joint Surg [Am] 87A:999–1006
29. Pennington DW, Swienckowski JJ, Lutes WB, et all (2006)
Lateral unicompartmental knee arthroplasty. Survivor-
ship and technical considerations at an average follow-up
of 12.4 years. J Arthroplasty 21:13–17
30. Tabor OB (1998) Unicompartmental knee arthroplasty:
long-terms follow-up study. J Arthroplasty 13:373
31. Weale AE, Murray DW, Crawford R, et al. (1999) Does
arthritis progress in the retained compartments after
Oxford medial UKA. A clinical and radiological study with
a minimum 10 year follow-up. J Bone Joint Surg [Br]
81B:783–789
32. Deschamps G (2005) Results at 6 years minimum follow-
up of a continuous series of 122 HLS Uni. Communication
ISAKOS Meeting, Miami, FL
33. Ahlback S (1968) Osteoarthrosis of the knee: a radio-
graphic investigation. Acta Radiol Suppl 277:7–72
34. Deschamps G (2006) Prothèse Unicompartimentale du
genou: Objectifs radiologiques Post-Opératoires. L’UNI
Idéale. In: Chambat P, Neyret P, Deschamps G, et al. (eds)
La Prothèse du Genou, Sauramps Medical, pp 265–272
35. Deschamps G (1998) Le pangonogramme corrigé, pièce
maitresse du bilan préopératoire. In: Cartier P, Epinette JA,
Deschamps G, Hernigou P (eds) Prothèses Unicomparti-
mentales du Genou, Paris, Expansion Scientifi fique française
36. Engh GA, Parks NL (1998) Surgical technique of the mid-
vastus arthrotomy. Clin Orthop 351:270–274
37. Harada Y, Wevers HW, Cooke TDV (1998) Distribution of
bone strength in the proximal tibia. J Arthroplasty 3:2–3
38. Hvid I, Hansen SL (1988) Trabecular bone strength pat-
terns at the knee. Clin Orthop 227:210-222
39. Iesaka K, Tsumura H, Sonoda H, et al. (2002) TheTh eff
ffects of
tibial component inclination on bone stress after unicom-
partmental knee arthroplasty. J Biomech 35:969–974
40. Hernigou P, Deschamps G (2002) Patellar impingement
following unicompartmental arthroplasty. J Bone Joint
Surg [Am] 84A:1132–1137
41. Kozinn S, Scott R (1989) Unicondylar knee arthroplasty:
current concept review. J Bone Joint Surg [Am] 71A:145
42. Laskin R (2001) Unicompartmental knee replacement.
Some unanswered questions. Clin Orthop 392:267–271
43. Marmor L (1988) Unicompartmental knee arthroplasty.
Ten to 13 year follow-up study. Clin Orthop 226:14
44. Ridgeway SR, McAuley JP, Ammeen DJ, et al. (2002) The Th
eff
ffect of alignment of the knee on the outcome of uni-
compartmental knee replacement. J Bone Joint Surg [Br]
84B:351–355
45. Sculco TP (2002) Can we justify unicondylar arthroplasty
as a temporizing procedure. J Arthroplasty 17:56–58
46. Squire M, Callaghan J, Goetz D, et all (1999) Unicompart-
mental knee replacement: a minimum 15 year follow-up
study. Clin Orthop 367:61

C. L. Barnes,
R. D. Scott
Indications of unicompartmental
knee arthroplasty
T
here has been much variation concerning
indications for unicompartmental knee
arthroplasty (UKA). When the procedure
was still considered developmental, one study rec-
ommended reserving UKA as a last resort before
arthrodesis (1). Another study included patients
with patellectomy, an incompetent anterior cru-
ciate ligament (ACL), or other incompetent liga-
ments (2).
The ideal candidate for a UKA is thought to have
non-inflflammatory osteoarthritis and a mechanical
axis that deviates no more than 5° for a valgus knee
or no more than 10° for a varus knee. The knee
should be passively correctable and the ACL should
be intact. There should be no signs of mediolateral
subluxation of the femur on the tibia, and patel-
lofemoral pain should not be present. In addition,
flexion contractures may be diffi
fl fficult to correct if
greater than 10–15°.
Ideal indications have changed very little since
Kozinn and Scott (3) published indications in 1989.
Their criteria included a diagnosis of unicompart-
mental osteoarthritis or spontaneous osteonecro-
sis in either the medial or lateral compartment, a
low demand activity patient with a weight of less
than 82 kg (181 lbs), and a patient age of greater
than 60 years. Th The patient should have minimal
pain at rest, a range of motion arc that is greater
than 90° with less than 5° of flexion contracture,
and an angular deformity of less than 15° that is
passively correctable to neutral.
Kozinn and Scott considered the following to be
contraindications to UKA:
– Diagnosis of inflflammatory arthritis
– Patient age of less than 60 years
– High patient activity level
– Pain at rest (which could indicate an inflamma-
fl
tory component to the arthropathy)
– Patellofemoral pain
– Exposed bone in the patellofemoral joint or
opposite compartment
Ritter et al. (4) in 2004 applied these indications
to their databank of more than 4000 knee arthro-
plasties and found that only 6.1% of knees met the
anatomic/radiographic qualification
fi for UKA and
that only 4.3% also met the strict clinical standards
Chapter 61
for UKA as outlined by Kozinn and Scott. Excellent
results have been reported when stringent criteria
have been applied for selection of patients for UKA
(5). Indeed, UKA for non-infl flammatory arthritis
has been performed successfully for more than 30
years.
Despite these well-accepted guidelines, there has
been an expansion of indications for UKA. Demo-
graphically, the traditional criteria for age and
weight each have been challenged as contraindi-
cations. Pennington et al. (6) reported on a series
of patients between 35 and 60 years of age and
documented a 92% prosthesis survival rate at 11
years. Similarly, Tabor et al. (7) showed compa-
rable survival and similar clinical outcomes when
comparing obese and non-obese patients receiving
UKA. On the other hand, Berend et al. (8) showed
that patients with obesity had a higher failure rate
in unicompartmental replacements when treated
through a minimally invasive approach.
fically addressing this issue, Engh and McAu-
Specifi
ley (9) have presented UKA as an option for young,
high-demand activity patients with arthritis of
the knee. Their rationale is that although UKA is
generally not recommended for patients younger
than 60, unicompartmental replacement should be
compared to other options for these patients. They
point out that most orthopedic surgeons perform
total knee replacement for these same patients if
no non-arthroplasty management seems to be a
better alternative. They go on to emphasize that
unicompartmental arthroplasty is an acceptable
alternative for younger, active patients if the clini-
cal results for other arthroplasty and non-arthro-
plasty treatment methods are less predictable and
eff
ffective. And they point out that the revision of
a unicompartmental knee implant, if it fails, does
not compromise the durability of a subsequent
total knee replacement.
The ability to successfully perform a total knee
arthroplasty (TKA) subsequent to a failed or
worn-out UKA is important when indications are
expanded to a younger, more active patient popula-
tion. In a study of 31 failed UKAs revised to TKAs,
Levine et al. (10) reported that clinical results for
the revisions were comparable to results for pri-
686 The Degenerative Knee
mary TKAs when examined at the same follow-up
period. The UKAs in this study had improved poly-
ethylene wear profiles
fi compared to earlier models,
and they required less bone resection.
From this review of the literature, it seems that
UKA can provide a young, active patient excel-
lent function, and good pain relief for a number of
years. Engh and McAuley estimate the durability
of unicompartmental knee implants in younger,
active patients to be 80% at 10 years, provided the
surgeon uses a prosthesis with suffi fficiently thick
polyethylene and a proven design.9 They likewise
conclude that the morbidity and complication
rates for UKA are less than the rates for high tibial
osteotomy or total knee replacement.
Traditionally, patellofemoral arthritis was consid-
ered a contraindication to UKA. Price et al. (11),
however, suggested that radiographic or clini-
cal arthritis of the patellofemoral joint could be
ignored if the patient had no specific
fi anterior knee
pain. Beard et al. (12), from the Nuffieldffi Ortho-
paedic Centre in Oxford, England, concluded from
their data that “provided there is no bone loss and
grooving of the lateral facet, damage to the articular
cartilage of the patellofemoral joint to the extent of
full-thickness cartilage loss is not a contraindica-
tion to Oxford® mobile-bearing unicompartmental
knee replacement.” In a separate article, Beard et al.
(13) studied 91 patients (100 knees), looking spe-
cifi
fically at pre-operative clinical and radiographic
assessment of the patellofemoral joint and its
relation to medial unicompartmental replacement
with the Oxford implant. They concluded that nei-
ther anterior knee pain nor radiographically docu-
mented medial patellofemoral arthritis should be
considered a contraindication to the Oxford uni-
compartmental knee replacement.
The ACL-defi ficient knee remains another area of
controversy related to indications for UKA. Suggs
et al. (14), testing the kinematics of anterior–pos-
terior tibial loads in cadavers with unicompart-
mental knee replacement with and without intact
ACLs, showed signifi ficantly greater anterior tibial
translation in specimens with sectioned ACLs.
Others have shown paradoxical motion in patients
with unicompartmental replacement and ACL-
defi
ficient knees, which increases anterior sliding
of the femoral component on the tibial polyeth-
ylene (15). Either of these problems could lead to
increased wear of the polyethylene or more rapid
degradation of the other compartments. Others,
however, have reported good results for UKA in
ACL-defi ficient knees. Hernigou and Deschamps
(16) suggested placing the tibial component with
a posterior slope of less than 7°, which they found
resulted in good results for ACL-deficient
fi knees
receiving unicompartmental replacement. Simi-
larly, Christensen (17) reported results for UKA
that were equally good in patients with deficient
fi
ACLs and patients with intact ACLs.
Contradiction
There are two areas where ACL insuffi fficiency seems
to be a definite
fi contraindication to UKA. Lateral
unicompartmental replacement should not be
performed in patients who have ACL insuffi fficiency
(18). The lateral compartment has signifi ficantly
more motion than the medial compartment and
thus will have signifi
ficantly increased translation in
patients with ACL insuffifficiency. Similarly, mobile
meniscal bearing unicompartmental arthroplasties
have not fared well in ACL-insuffifficient knees (19).
In these procedures, there has been an increased
instance of meniscal bearing dislocation.
Controversies
Whether or not unicompartmental replacement
should be performed on patients with osteone-
crosis is also controversial. Osteonecrosis of the
knee may be divided into spontaneous or second-
ary osteonecrosis (i.e., secondary to corticosteroid
therapy, renal failure, etc.). While some suggest
that unicompartmental replacement is indicated
for patients with spontaneous but not second-
ary osteonecrosis, others such as Parratte et al.
(20) have seen no difffference in outcomes among
the two groups. Parratte et al. recently reported
on 30 patients – 31 knees – with osteonecrosis.
Twenty-one had spontaneous osteonecrosis and
10 had secondary osteonecrosis. Clinical results
and durability were excellent at 3 years for both
sub-groups. Survival at 12 years was 96.7%, and
patient selection was limited to osteonecrosis in a
single femorotibial compartment, a fully correct-
able deformity on stress radiographs, a healthy
patellofemoral joint, and an intact ACL.
Summary
Despte 40 years of patellofemoral arthroplasty, the
indications and contraindications for UKA remain
debatable. Fixed-bearings versus mobile-bearings
have diff
fferent indications, as do medial compart-
ment versus lateral compartment arthroplasties.
Additionally, less invasive surgical approaches as
described by Repicci et al. (21) and others, as well
as better implants and monitoring for wear and
bone loss, have expanded UKA as a possible “time

buying” operation prior to subsequent total knee
replacement (22). Even as surgical technique and
the technologies surrounding UKA implants and
procedures continue to evolve, attention should
continue to be paid to appropriate patient-spe-
cifi
fic indications if successful outcomes are to be
achieved in UKA. The data do seem to indicate
that the classic indications for UKA are expanding,
especially to younger and heavier patients.
References
1. Barck AL (1989) 10-year evaluation of compartmental
knee arthroplasty. J Arthroplasty 4(Suppl):S49–S54
2. Larsson SE, Larsson S, Lundkvist S (1988) Unicompart-
mental knee arthroplasty: a prospective consecutive series
followed for six to 11 years. Clin Orthop 232:174–181
3. Kozinn SC, Scott R (1989) Unicondylar knee arthroplasty.
J Bone Joint Surg Am 71:145–150
4. Ritter MA, Faris PM, Thong AE, et al. (2004) Intra-op-
erative findings in varus osteoarthritis of the knee: An
analysis of preoperative alignment in potential candidates
for unicompartmental arthroplasty. J Bone Joint Surg Br
86:43–47
5. Berger RA, Meneghini RM, Jacobs JJ, et al. (2005) Results
of unicompartmental knee arthroplasty at a minimum
of 10 years of follow-up. J Bone Joint Surg Am 87:999–
1006
6. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN
(2003) Unicompartmental knee arthroplasty in patients
sixty years of age or younger. J Bone Joint Surg Am
85:1968–1973
7. Tabor OB Jr, Tabor OB, Bernard M, Wan JY (2005) Unicom-
partmental knee arthroplasty: long-term success in middle-
age and obese patients. J Surg Orthop Adv 14:59–63
8. Berend KR, Lomardi AV, Mallory TH, et al. (2005) Early
failure of minimally invasive unicompartmental knee
arthroplasty is associated with obesity. Clin Orthop Relat
Res 440:60–66
9. Engh MD, McAuley MD, Gerard A, James P (1999) Unicon-
dylar arthroplasty: an option for high-demand patients
with gonarthrosis. AAOS Instructional Course Lectures, Vol.
48, Symposium 17
Indications of unicompartmental knee arthroplasty 687
10. Levine WN, Ozuna RM, Scott RD, Thornhill TS (1996) Con-
version of failed modern unicompartmental arthroplasty
to total knee arthroplasty. J Arthroplasty 11:797–801
11. Price AJ, Waite JC, Svard U (2005) Long-term clinical
results of the medial Oxford unicompartmental knee
arthroplasty. Clin Orthop Relat Res 435:171–180
12. Beard DJ, Pandit H, Gill HS, et al. (2007) The
Th inflfluence
of the presence and severity of pre-existing patellofemo-
ral degenerative changes on the outcome of the Oxford
medial unicompartmental knee replacement. J Bone Joint
Surg Br 89-B:1597–1601
13. Beard DJ, Pandit H, Ostlere S, et al. (2007) Pre-operative
clinical and radiological assessment of the patellofemo-
ral joint in unicompartmental knee replacement and its
infl
fluence on outcome. J Bone Joint Surg Br 89-B:1602–
1607
14. Suggs JF, Li G, Park SE, et al. (2004) Function of the
anterior cruciate ligament after unicompartmental knee
arthroplasty: an in vivo robotic study. J Arthroplasty
19:224–229
15. Argenson JN, Komistek RD, Aubaniac JM, et al. (2002)
In vivo determination of knee kinematics for subjects
implanted with a unicompartmental arthroplasty. J
Arthroplasty 17:1049–1054
16. Hernigou P, Deschamps G (2004) Posterior slope of the
tibial implant and the outcome of unicompartmental knee
arthroplasty. J Bone Joint Surg Am 86:506–511
17. Christensen NO (1991) Unicompartmental prosthesis for
gonarthrosis: a nine-year series of 575 knees from a Swed-
ish hospital. Clin Orthop Relat Res 273:165–169
18. Engh GA, Ammeen D (2004) Is an intact anterior cruci-
ate ligament needed in order to have a well-functioning
unicondylar knee replacement? Clin Orthop Relat Res
428:170–173
19. Goodfellow JW, Kenshaw CJ, Benson MK, O’Connor JJ
(1988) The Oxford knee for unicompartmental osteoar-
thritis: the first 103 cases. J Bone Joint Surg Br 70:692–
701
20. Parratte S, Argenson JA, Dumas J, Aubaniac J (2007) Uni-
compartmental knee arthroplasty for avascular osteone-
crosis. Clin Orthop Relat Res 464:37–42
21. Repicci JA, Eberle RW (1999) Minimally invasive surgi-
cal technique for unicondylar knee arthroplasty. J South
Orthop Assoc 8:20–27
22. Borus T, Thornhill TS (2008) Unicompartmental knee
arthroplasty. J Am Acad Orthop Surg 16:9–18

J. H. Newman
Introduction
M
ost knee surgeons are happy undertaking
medial UKR and accept that the result can
be good, thus justifying the procedure.
However, many are less happy about performing
lateral UKR as they feel it is infrequently indicated
and the results are less predictable. Th This attitude
is unfortunate as recent publications (1–3) have
demonstrated a high success rate with lateral UKR
and many patients are thus being denied the ben-
efits
fi of this operation.
The lateral side of the knee is difffferent in a num-
ber of ways and these must be appreciated if all
patients are to benefi
fit maximally.
Anatomy
Th tibial plateau on the lateral side is convex. Artic-
The
ulation with the femoral condyle is thus heavily
Fig. 1 – The lateral side of the knee showing (a) the normal articular car-
tilage on the extension facet and (b) eburnated bone on the flexion facet
seen with the knee bent at 90º.
Chapter 62
Lateral Unicompartmental Knee
Replacement
dependent on the presence of a meniscus to create
a degree of congruity. If this is removed stability is
lost and degenerate changes can occur rapidly, thus
accounting for the signifi ficant numbers of fairly
young patients who develop lateral arthritis after
lateral meniscectomy.
The pathology
Whereas on the medial side the pathological
changes initially occur anteriorly (4) the opposite
is true on the lateral side and the changes start
posteriorly (Fig. 1). Th
This has a profound eff ffect,
not only on the patient’s presentation but also on
the imaging needed to define
fi the problem and the
treatment of the condition.
On the medial side, the extent and severity of the
disease is easily assessed by a weight-bearing AP
and lateral X-ray where joint space narrowing will
be shown on the AP and the standing lateral will
690 The Degenerative Knee
usually show preservation of some articular carti-
lage posteriorly unless the ACL is deficient.
fi On the
lateral side, early disease will not be easily appre-
ciated since the cartilage wear is posterior and it
is only by taking a Schuss or Rosenberg view that
the true severity of the condition can be appreci-
ated (5) (Fig. 2). Since many surgeons do not rou-
tinely take these radiological views patients are
frequently denied treatment because the surgeon
failed to appreciate the degree of articular cartilage
wear and felt that UKR would be inappropriate.
Presentation
Most patients with a mildly varus knee and com-
plete loss of medial cartilage present with pain
and request treatment. For some reason this fre-
quently does not occur on the lateral side and many
patients appear to get little in the way of pain until
they eventually present with severe deformity and
instability, by which time lateral UKR may be an
insuffi
fficient operation.
At the other end of the spectrum, patients with
near normal standard X-rays present with signifi- fi
cant pain and catching, especially with flflexed knee
Fig. 2 – (a) Weight-bearing AP X-ray showing near normal appearance. (b) The appearance of the Schuss view taken weight-bearing with the knee in some
30º of flexion.
activities while they may have little in the way of
symptoms during level walking. This group usually
has posterior wear and can often be helped by lat-
eral UKR.
Examination
This too will yield diff
fferent findings since while the
disease is still confi
fined to the posterior part of the
joint there will be no deformity of the extended
knee and the tenderness to palpation will be
located posteriorly. In addition, any provocation
stress tests will not induce pain unless performed
with the knee in a flexed position (Fig. 3).
Alternative treatment
Once a patient has symptoms that have resisted
non-operative management the two main alter-
natives to UKR are re-alignment osteotomy and
total knee replacement (TKR). On the medial side
in early disease upper tibial osteotomy has long
been viewed as a reasonable procedure. On the lat-

Fig. 3 – Stress test in which the lateral compartment is being compressed
while the knee is put through a range of movement centered on 40º of flex-
ion. This will reproduce the patients’ pain.
eral side the situation is diff
fferent. Closing wedge
upper tibial osteotomy leads to a sloping jointline
when used for a valgus knee and I am unaware of
any series of opening wedge upper tibial osteoto-
mies for lateral compartment arthritis. To avoid
the problem of a sloping jointline distal femoral
osteotomy has been used instead and a number
of series have been published unfortunately with
relatively poor results (6–8). This, though is not
surprising since the osteotomy is offl ffloading the
extension facet of the lateral compartment while
in early disease it is the flexion
fl facet that is worn
and arthritic. To offl
ffload this signifi
ficantly would
require a complex osteotomy that few, if any, have
undertaken.
TKR has become a predictable procedure which
usually gives excellent pain relief. However, many
have found the results to be less good for a valgus
knee than for a varus one. In addition, it is a much
more major procedure than UKR and results in
more blood loss and a less satisfactory knee since
the ACL will have been sacrificed.
fi
Since neither osteotomy nor TKR is ideal for lateral
compartment arthritis there is a significant
fi place
for UKR.
Mechanics
Recent MRI studies have demonstrated a consid-
erable disparity between the amount of femoral
roll-back on the two sides of the knee (9). Medial
knee movement is in the order of 5 mm while on
the lateral side 10 mm or more is usual. This is of
Lateral Unicompartmental Knee Replacement 691
importance because with UKR all ligaments will
be left in situ. Thus with a fixed-bearing UKR the
pattern of wear is likely to extend over a relatively
large area but with a mobile device the meniscus
will move considerable distances sometimes caus-
ing problems with stability.
Lateral unicompartmental replacement
The majority of reported series of UKR fail to dis-
tinguish satisfactorily between medial and lateral.
In the last few years the true differences
ff between
the two sides have come to become appreciated.
Some older combined series of both medial and
lateral UKR have shown satisfactory results on the
lateral side (10–14), whilst others found the results
to be worse than on the medial side (15–17). In
addition, these older single implant UKR series
where the results of medial and lateral compart-
mental arthroplasties have been amalgamated
have not used contemporary outcome assessments
and tend to contain a very small numbers of lateral
UKRs.
However, recently there have been a few reports of
purely lateral UKR suggesting greater interest in
the procedure.
Mobile-bearings
Mobile-bearings on the lateral side have not fared
well. Gunter et al. (16, 17) found a 10 year sur-
vival rate of 67% in the follow-up of 53 Oxford
mobile-bearing UKRs with six patients (11%) suf-
fering a dislocation. A somewhat lesser dislocation
rate for the AMC Uniglide, (3 out of 46 (6%)), was
reported by Saxler et al. (18) but this is still con-
siderably higher than the same authors reported
on the medial side. Recently, Forster et al. (2) have
compared the short-term outcome of the tracked
mobile-bearing Preservation UKR with the fixed- fi
bearing variant of the same prosthesis and found
no diff
fference in performance but three of the 13
(23%) mobile-bearing devices had to be revised
within 2 years. These studies all suggest that using
a mobile-bearing on the lateral side with its greater
roll-back creates problems and is unwise.
However the extensive movement which occurs
on the lateral side should in theory result in sub-
stantial polyethylene wear (though this is seldom
seen in practice) and therefore efforts
ff to overcome
the problem of dislocation need to continue. With
this in mind the Oxford group have introduced the
lateral unicompartmental replacement in which
the tibial base is convex, thus replicating the shape
found in a normal knee (19). They report encour-
692 The Degenerative Knee
aging short-term results with respect to disloca-
tion (20) and longer-term reports will be awaited
with interest.
Fixed-bearings
In 1984, Marmor reported a series of 14 lateral
UKRs with 11 having an excellent outcome (13) but
there is then a dearth of publications for a number
of years. In 2001, Ohedera (21) reported an 86%
survival of lateral UKRs at 7 years and 2 years later
Ashraf reported a cumulative survival rate of 83%
at 10 years and 74% at 15 years for 88 lateral St
Georg sled UKRs despite four of the 16 failures
being due to the fracture of an overly thin femo-
ral component (22). These reports clearly suggest
that satisfactory mid-term result can be achieved.
Recently, universally good or excellent results
with 25 lateral Miller Galante UKRs followed for
between 1 and 5 years has been reported¹ and Rob-
inson records 29 fixed-bearing uniglide UKRs as
having a higher score at 1 year than a comparable
group of medial UKRs (23). Similarly, the fi fixed-
bearing Preservation UKR has given high scores
when reviewed at 2 years (2).
Using a variety of prostheses Sah reports good results
and no revisions after an average 5 year follow-up
of 48 cases but notes that the outcomes were bet-
ter when the procedure was performed for primary
osteoarthritis rather than post-traumatic arthritis
following a tibial plateau fracture (24), though the
outcome from this latter group was similar to that
seen following TKR for post-traumatic arthritis.
It therefore appears that good midterm results can be
achieved by lateral UKR with an acceptable survivor-
ship being seen. However, it must be noted that there
is a higher instance of progression of arthritis in the
medial compartment following lateral UKR (Fig. 4)
than in the lateral compartment following medial
Fig. 4 – Progression of arthritis in the medial compartment 17 years after
a lateral St Georg sled UKR. Note there are no signs of wear or loosening of
the prosthesis itself.
UKR (25). Thus great care must be taken to avoid
overcorrection of the original valgus deformity.
Quality of outcome
There has been debate about whether the qual-
ity of result achieved with lateral UKR is as good
as or better than the excellent results frequently
reported following medial UKR. In the early stud-
ies which combine both medial and lateral UKRs
the lateral arthroplasties tended to perform bet-
ter but subsequent reports suggested no differ- ff
ence (10, 14) or the opposite.
This question has recently been addressed in Bristol
where the short-term outcome of 29 lateral fixed-
fi
bearing AMC uniglide UKRs was compared with
the results of the 124 mobile-bearing and 51 fi fixed-
bearing medial AMC uniglide UKRs used during the
same 3 year period. Although not statistically signif-
icant, the American Knee Society score, Oxford and
WOMAC scores all showed slightly better results for
the lateral UKR than either the fixed or the mobile
medial UKR (23). Whether these results will be
maintained in the long-term remains to be seen.
Technique
The majority of authors recommend a lateral
approach to the knee which is logical and mini-
mizes tissue damage. A lateral approach extended
proximally beside the quadriceps tendon allows
the patella to be subluxed medially giving excel-
lent exposure. Alternatively, a minimally invasive
approach can be utilized, not subluxing the patella,
but this give less satisfactory visualization than a
comparable approach from the medial side.
Fig. 5 – Resected TKR specimen showing the direction of femoral tracking on
the medial and lateral tibial plateaus, thus on the lateral side the line of the
tibial sagittal cut needs to be considerably internally rotated. “The Cruciate cut.”

A medial approach can also be used (24) but more
retraction or a larger incision is required. However,
such an approach allows better inspection of the
whole joint and easier extension for TKR should that
be adjudged necessary. ThThere is also a neater capsu-
lar closure and less damage to the larger geniculate
vessels. Despite these advantages, a lateral approach
is recommended, not least because a more lateral
incision helps to preserve normal sensation over
the front of the knee which is important for kneel-
ing (26) and possibly other high level activities.
The precise technique will depend on the prosthe-
sis used but certain principles apply to all and make
the lateral site diff
fferent from the medial.
– Less posterior slope on the tibial cut is needed;
between 0 and 5° is usually adequate.
– Very limited bone usually needs to be taken from
the upper tibia as there is frequently a degree of
associated hypoplasia of the lateral femoral con-
dyle, creating the necessary space.
– • Rotation of the tibial component is important
and some 20° of internal rotation is frequently
required so that the cut is in line with the ante-
rior cruciate ligament (Fig. 5) (18). If this is not
done the screw home mechanism of the knee
Fig. 6 – (a) Moderately severe lateral compartment arthritis with a significant valgus deformity. (b) Following lateral UKR in which the deformity has
been suffi
fficiently corrected.
Lateral Unicompartmental Knee Replacement 693
means that the femoral component will be
likely to impinge in the notch as the knee comes
into extension.
• An alternative way of avoiding this impinge-
ment is to position the femoral component far
lateral on the femoral condyle and some sur-
geons favor this.
– The size of both components is likely to be smaller
than on the medial side.
– Balancing must be achieved between flexion
fl and
extension.
– Care must be taken not to overcorrect and put
the knee into relative varus. A final alignment
between 5 and 10° of valgus is usually acceptable
(Fig. 6).
– If a mobile-bearing is being used (which is not
recommended) consideration should be given to
dividing the popliteus tendon.
Indications for lateral UKR
Surgeons will differ
ff in their enthusiasm for lat-
eral UKR but broadly the indications are similar to
694 The Degenerative Knee
those for medial UKR except that one must bear in
mind that since the initial disease is posterior, cor-
rective osteotomy is a less satisfactory option and
routine weight-bearing AP radiographs may show
little disease.
Table 1 lists the indications but it should be
noted that at times the medial side remains well
preserved despite signifificant lateral changes and
deformity so lateral UKR can still be successfully
performed as the deformity is almost always
largely correctable.
Table 1
Indications for lateral UKR
Non-inflammatory lateral compartment arthritis
Good preservation of the medial side
Intact ligaments
No patellofemoral symptoms or gross wear changes
More than 90° of flexion
Not more than 10° fixed flexion
Largely correctable valgus deformity which at times
can be 15 or more degrees
Conclusion
Although isolated lateral compartment arthritis
is less common than medial, it accounts for 6% of
cases seen in the standard knee clinic as opposed
to 32% on the medial side (27). Not all these cases
will need, or be suitable for, UKR. Currently in the
UK 10% of knee replacements are unicompart-
mental but no record is even kept of whether the
medial or lateral side is replaced (28). Most series
suggest that only about 10% of UKRs are lateral,
probably because a number of surgeons do not
believe in the procedure. However, the reported
results, particularly in recent years, suggest that a
high quality result can be obtained and maintained
for many years.
References
1. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN
(2006) Lateral unicompartmental knee arthroplasty:
survivorship and technical consideration at an average
follow-up of 12.4 years. J Arthroplasty 21:13–17
2. Forster MC, Bauze AJ, Keene GC (2007) Lateral unicom-
partmental knee replacement: fixed or mobile bearing?
Knee Surg Sports Traumatol Arthrosc 15:1107–1111
3. Volpi P, Marinoni L, Bait C, et al. (2007) Lateral unicom-
partmental knee arthroplasty: indications, technique and
short-medium term results. Knee Surg Sports Traumatiol
Arthrosc 15:1028–1034
4. White SH, Ludkowski PF, Goodfellow JW (1991) Antero-
medial arthritis of the knee. J Bone Joint Surg 73-B:582–
586
5. Richie JFS, Al-Sarawan M, Worth R, et al. (2004) A parallel
approach: the impact of schuss radiology of the degenera-
tive knee on clinical management. Knee 11:283–287
6. Matthews J, Cobb AG, Richards S, Bentley G (1998) Distal
femoral osteotomy for lateral compartment osteoarthritis
of the knee. Orthopaedics 21:437–440
7. Stahelin T, Hardegger F, Ward JC (2000) Supracondylar
osteotomy of the femur with use of compression. J Bone
Joint Surg 82-A:712–722
8. Finkelstein JA, Gross AE, Davis A (1996) Varus osteot-
omy of the distal plot of the femur. J Bone Joint Surg
78-A:1348–1352
9. Pinskerova V, Johal P, Nakagaura S, et al. (2004) Does the
femur roll back with flexion? J Bone Joint Surg 86-B:925–
931
10. Broughton NS, Newman JH, Bailey RAJ (1986) Unicom-
partmental replacement and high tibial osteotomy for
osteoarthritis of the knee. A comparative study after 5-10
years’follow-up. J Bone Joint Surg 68-B:447–452
11. Laskin RS (1978) Unicompartmental tibiofemoral resur-
facing arthroplasty. J Bone Joint Surg 60-A:182–185
12. Insall J, Walker P (1976) Unicondylar knee replacement.
Clin Orthop Relat Res 120:83–85
13. Marmor L (1984) Lateral compartment arthroplasty of
the knee. Clin Orthop Relat Res 186:115–121
14. Mackinnon J, Young S, Bailey RAJ (1988) The St Georg
Sled for unicompartmental replacement of the knee. J
Bone Joint Surg 70B:217–223
15. Scott RD, Santore RF (1981) Unicondylar unicompart-
mental replacement for osteoarthritis of the knee. J Bone
Joint Surg 63-A:536–544
16. Heinert K, Englebrecht E (1988) Long-term comparison
of the “St Georg” knee endoprosthesis system. 10 year
survival rates of 2236 gliding and hinge endoprosthesis.
Chirurg 11:755–762
17. Gunter TV, Murray DW, Miller R, et al. (1996) Lateral uni-
compartmental arthroplasty with the Oxford meniscal
knee. Knee 3:33–39
18. Saxter G, Temmen D, Bontemps G (2004) Medium term
results of the AMC unicompartmental knee arthroplasty.
Knee 11:349–355
19. Barre JV, Gill MS, Beard DJ, Murray DW (2006) A convex
lateral tibial plateau for knee replacement. Knee 13:122–
126
20. Dodd C Personal communication
21. Ohdera T, Tokunaga J, Kobayashi A (2001) Unicompart-
mental knee arthroplasty for lateral gonarthritis: midterm
results. J Arthroplasty 16:196–200
22. Ashraf T, Newman JH, Evans RL, Ackroyd CE (2003) Lat-
eral unicompartmental knee replacement survivorship
and clinical experience over 21 years. J Bone Joint Surg
84-B:126–130
23. Robinson J Personal communication
24. Sah AP, Scott RD (2007) Lateral unicompartmental knee
arthroplasty through a medial approach. Study with an
average 5 year follow up. J Bone Joint Surg 89-A:1948–
1954
25. Walton MJ, Weale AE, Newman JH (2006) The progres-
sion of arthritis following lateral unicompartmental knee
replacement. Knee 13:347–377
26. Hassaballa MA, Porteous AJ, Newman JH, Rogers CA
(2003) Can knees kneel? Kneeling ability after total, uni-
compartmental and patellofemoral knee arthroplasty.
Knee 1:155–160
27. Davies AP, Glasgow MM (2000) Imaging in osteoarthri-
tis: a guide to requesting plain X-rays of the degenerative
knee. Knee 7:139–143
28. National Joint Registry for England and Wales (2007) 4th
Annual Report
III Primary Total Knee
Arthroplasty
Design and concept in TKA

A. S. Ranawat,
A. S. Ranawat,
The history of total knee
C. S. Ranawat
arthroplasty
Introduction
T
he advent of total knee arthroplasty (TKA)
was an important milestone in the history
of orthopedic surgery. The
Th development of
TKA began in the early 1970s when tibiofemoral
condylar replacements sprouted independently in
both the United States and abroad (Fig. 1). Numer-
ous surgeons and engineers were involved in this
process and it has now become a multibillion dollar
industry with millions of knees implanted world
wide (1). TKA has joined total hip arthroplasty
as an incredibly successful medical intervention
(2–4).
This chapter will trace the history of TKA from its
early designers to the institutions that adopted it,
and finally to the companies that have mass pro-
duced it.
Fig. 1 – Development of the condylar total knee (Modified with permission from Ref. (26)).
Chapter 63
Hinged prosthesis
Theophilus Gluck is credited with the implantation
of one of the earliest total knee replacements back
in the 1890s (5). His design was an ivory hinged
TKA which was fixed with plaster of Paris and colo-
phony (Fig. 2). Although a revolutionary concept,
these implants often failed due to high infection
rates, poor metallurgy, and inadequate fi fixation.
Later in 1951, Dr. Waldius developed a hinge made
of acrylic and then, in 1958 manufactured it from
cobalt chrome (Co-Cr) (6–9). This prosthesis was
in use until the early 1970s along with several
other hinged designs such as Dr. Shiers’(10) in the
United Kingdom and the Guepar prosthesis (11,
12) from France.
Although its use is on the rise again today for
complex primary, revision and tumor surgery,
the hinged prosthesis fell out of favor for primary
700 Primary Total Knee Arthroplasty
Fig. 2 – Gluck’s Ivory hinged total knee replacement. (A) Gluck’s Ivory total
knee arthroplasty held in place with cement of colophony, pumice, and
gypsum. (B) Component parts of Gluck’s knee prosthesis. (Reproduced from
Gluck T (1891) Arch Klin Chin 41:186).
arthritis of the knee because of high mechani-
cal failure rates due to its inherent constraint. As
a result, newer designs with less constraint were
developed simultaneously around the globe.
The race was on.
Condylar knee designs
Early era of condylar knee design
Condylar knee replacement is best described as
knee resurfacing of the entire tibiofemoral joint.
Unlike hinged prostheses, these implants are not
constrained, require less bone resection and ulti-
mately utilize instrumentation to aid in soft tissue
balancing.
One of the first implants was designed by Dr.
Frank Gunston, a Canadian orthopedic surgeon
who had worked with Sir John Charnley (13).
He first implanted the polycentric knee in 1968.
Although it was not a true condylar design, it was
a highly conforming implant with separate medial
and lateral stainless steel femoral components
articulating with plastic tibial runners (Fig. 3).
This implant was popularized by surgeons at the
Mayo Clinic (14). The
Th Gunston Knee was prone
to early failures due to small contact areas, mini-
Fig. 3 – Frank Gunston’s polycentric knee.
mal rotational freedom, and unforgiving surgical
technique.
Freeman and the ICLH
Dr. Michael Freeman and Sav Swanson, a professor
of mechanical engineering at Imperial College of
Science and Technology in London Hospital (ICLH)
were pioneers in early total knee design. Their Th
implant was first
fi known as the Freeman–Swanson,
but subsequently became known as the ICLH knee
(Fig. 4). The design required sacrifificing both cruci-
ates in order to correct large deformities and maxi-
mizing contact area to reduce wear (15–17). They
simplifi
fied knee kinematics by using a “roller-in-
trough” with a single radius of curvature.
Dr. Freeman, aided by his experiences with Dr.
MacIntosh from Boston, introduced the concept
of equal and parallel fl
flexion and extension spaces,
which would later be termed gaps by his long-term
boyhood friend, Dr. John Insall. Dr. Freeman then
introduced the concept of ligament balancing and
soft tissue releasing, which he had learned from
a South African surgeon, Dr. Van Vuren, who was
experienced in correcting fifixed deformities in polio.
Although the Freeman–Swanson implant had
numerous drawbacks such as minimal medial-lateral
stability, no option for resurfacing the patella, and a
small fixation peg on the tibia, Dr. Freeman’s revo-
lutionary concepts in surgical techniques opened up
a new frontier to the arthroplasty surgeon.
Perhaps more importantly, his long-term rela-
tionship with Dr. John Insall, who was now at the
Hospital for Special Surgery, fostered continued
communication between England and the United
States regarding TKA.
The hospital for special surgery experience
As Dr. Freeman was refi fining the ICLH knee, a
team of surgeons and engineers at the Hospital
for Special Surgery were simultaneously designing
implants. This began in 1968, when Dr. Lee Ramsey
Straub first
fi introduced the MacIntosh hemiarthro-
plasty to the Hospital, which had some, but lim-
Fig. 4 – ICLH knee (Reprinted with permission from Ref. (22)).
 The history of total knee arthroplasty 701

A
Fig. 6 – Duopatella knee
(Reprinted with permission
from Ref. (26)).

B
Fig. 5 – (A) Duocondylar and (B) clinical photo of first implantation of Duo- Fig. 7 – Total condylar knee
condylar knee implantation by Dr. Ranawat assisted by Drs. Insall and Hoff- (TC) (Reprinted with permis-
man in December 1971 (Reprinted with permission from Ref. (22).) sion from Ref. (22)).

ited success in rheumatoid patients (18). Inspired a round-on-round geometry of the load-bearing
by work in the United Kingdom, Drs. Chitranjan surfaces utilizing multiple radii of curvatures with
S. Ranawat, Allan Inglis, John Insall, and Peter partial conformity for improved rotational free-
Walker (Ph.D.) developed both the Duocondylar dom (Fig. 8) (19, 22).
(Fig. 5A and B) and Unicondylar prosthesis in 1971 By 1976, TC III (Fig. 9) (19) was designed for
(19). The Duocondylar was also not a true condylar patients with significant
fi deformities, which
design. It had no anterior femoral flange, two sepa- became the predecessor for future constrained
rate tibial components, and preserved both cruci- condylar knee replacements.
ates. Interestingly, it was subsequent research on Design features continued to evolve and in 1978,
the duocondylar knee that led to the Knee Disabil- Dr. John Insall and Al Burstein (Ph.D.) developed
ity Score Rating System (20) which later became the posterior-stabilized knee, which was an off- ff
known as the Hospital for Special Surgery Knee shoot of the stabilocondylar and TC knee (25).
Rating System. This rating system was ultimately The Insall-Burstein (IBI) (Fig. 10) knee sought
modifified and adopted by the Knee Society in the to address all of the defificiencies of present knee
Knee Society Scores for Pain and Function (21).
In 1974, the duocondylar was modifiedfi to include the
patellofemoral joint while still preserving the poste-
rior cruciate ligament. This design became known as
the Duopatella (Fig. 6), which was the predecessor of
many cruciate-retaining knee designs from Boston
including the Brigham and the Kinematic Cruciate
Retaining Knees (Johnson & Johnson – Braintree,
MA and Howmedica – Rutherford, NJ) (22).
Walker, Ranawat, and Insall identifiedfi a need for a
more stable prosthesis compared to the duocondy-
lar and led to the development of the total condy-
lar (TC) knee prosthesis in 1974 (19, 22, 23). Th The
TC (Fig. 7) knee became the first successfully mar-
keted and widely utilized total knee replacement in
the world due to design features that replaced all
components of the knee including all condylar sur-
faces and the patellofemoral joint. In addition, the
all-polyethylene tibial component incorporated a Fig. 8 – John Insall and Chit Ranawat in the 1970s at the Hospital for Spe-
central peg for improved tibial fixation (24), and cial Surgery (Reprinted with permission from Ref. (26)).
702 Primary Total Knee Arthroplasty

Fig. 9 – Total condylar knee Fig. 10 – Insall-Burstein I

(TC III) (Reprinted with per- (IB-I) (Reprinted with permis-
mission from Ref. (22)). sion from Ref. (22)).

designs including anterior instability, insufficient

ffi
flexion, and the unintended edge loading of the TC
II (26). It was research performed at HSS which
led to the ubiquitous use of metal-backing in most
total knee designs today (27). ThThe IB I (and later
the IBII) incorporated a metal tibial baseplate and
this has proven to be one of the most successful
posterior-stabilized total knee designs.
The Boston experience
In 1974, Ranawat and Walker traveled to Mas-
sachusetts General Hospital in Boston and pre-
sented their findings with the Duocondylar, Duo-
patella, and TC knees to a group of illustrious
surgeons including Drs. William Harris, ThThomas,
Clement Sledge, Bill Jones, and Richard Scott
(22). Because of their extensive experiences with
unicompartment implants such as the McKeever
and Marmor, the Boston group gravitated toward
the Duopatella since it resurfaced all three com-
partments while preserving the posterior cruciate
ligament. A few years later, Dr. Walker relocated
to Boston from HSS and helped develop the Kine-
matic Knee System at Howmedica (Rutherford,
NJ) and later in 1981 with the help of Sledge,
Ewald, Poss, Scott, and Thornhill, designed the
Kinemax system. By 1985, Scott and Thornhill
Th
joined Johnson and Johnson (Braintree, MA,
later Depuy – Warsaw, IN) and designed the
cruciate-saving PFC (press fit condylar), which
was subsequently joined by posterior-stabilized
and constrained design by Ranawat in 1989. This
Th
entire system was called the PFC Modular Knee
system which was applicable for both primary
and revision surgery (22).
tibia had a circular trough geometry permitting
motion in all three planes. This
Th rotation freedom
was unique in this cruciate sacrifificing design. Dr.
Eftekhar should be credited with introducing the
concept of modularity in knee designs which is still
in use today.
Like the Mark I knee, David Murray’s Variable Axis
knee in 1974 had a metal backed tibial stemmed
component (29, 30). In addition, this prosthesis
had significant
fi rotational freedom in flexion and
used a metal screw to secure the polyethylene
insert (Fig. 11).
Early cruciate retention designs
During the early 1970s, Dr. Yamamoto and Profes-
sor T. Kodoma implanted the fi first non-cemented
condylar cruciate-sparing total knee. Fixation
depended on fins on the femoral components and
staples for the tibia (31). There were many other
notable pioneers who focused on preserving both
cruciates. Most of their femoral components used
cemented fixation and were designed similar to
the mold arthroplasty and anatomic MGH com-
ponents of Smith Peterson Otto Aufranc (1950,
1964) (32).

Modularity and Eftekhar Mark Knees

and David Murray’s Variable Axis
In 1969, Dr. Nas Eftekhar and Randy Gand designed
and implanted the fifirst cemented total knee with
metal-backed tibial stemmed components (28).
The Eftekhar Mark I was later redesigned to a con-
dylar geometry with Eftekhar Mark II (Howmedica
(Rutherford, NJ), later Zimmer). The
Th femoral com- Fig. 11 – Variable axis modular knee (Reprinted with permission from Ref.
ponent had broad, round articular surfaces and the (26)).

In 1972, Dr. Theodore Waugh implanted the first
UCI that was specifi fically designed to provide rota-
tional freedom to improve fixation (33). The UCI
knee was manufactured by Wright Medical and
the design eventually evolved into the Gustillo and
Ram knee.
In 1970, Bahaa Seehom designed the Leeds knee,
which was first implanted in 1972 by Dr. Longton
(34). It was an anatomic design made of chromium
cobalt implant that preserved the posterior cru-
ciate ligament and included an option for patell-
ofemoral replacement as well. This design was later
adopted by Dr. J.M. Cloutier in Montreal, Canada,
who also introduced metal augmentations to the
tibial base plate to address tibial bone loss (35).
Similarly, in Boston, Dr. Frederick Ewald designed
a similar knee, which had limited marketing suc-
cess, but still a tremendous impact on future TKA
designs (36)
Most of these early anatomic knee designs had
many similar characteristics. Most had thin tibial
components with a cut out of the intercondylar
region to preserve one or both cruciates with a
thin anterior polyethylene bridge. Th The compo-
nents were fixed by cement (except for the Yama-
moto – Kodoma) and allowed significant fi rota-
tional and anterior–posterior laxity. Th The femurs
were anatomically designed similar to the MGH
femur where some did and other did not have a
trochlear flange. They commonly shared similar
failure mechanisms due to poor tibial fixation,
fi
thin polyethylene and inadequate medial-lateral
stability.
Dr. Townley and anatomic approaches
with cruciate retention
Concurrently, Dr. Charles Townley was busy
designing his anatomic version of a condylar
resurfacing knee in Port Huron, MI through the
early 1970s (36, 37). This
Th knee was the first cru-
ciate sparing cemented condylar knee design.
Dr. Townley had sketches of knee replacement
designs dating back to his Orthopedic Resi-
dency at the Henry Ford Clinic in Detroit in
1948 (38, 39). Townley’s knee was manufac-
tured by Depuy (Warsaw, IN) only after he was
turned him down by Howmedica (Rutherford,
NJ) since they were involved with the Geomedic
knee (26). The implant preserved both cruciates,
non-conforming surfaces with broad contact
areas and a replaced trochlea; however, he did
not resurface the patella at first. Subsequently, he
started to resurface the patella making it the first
fi
patella resurfaced implant. Besides the addition
of more sizing options, the implant design has
not changed signifificantly. Its main problem was
related to a thin polyethylene insert with small
fixation pegs. Townley’s cruciate saving Anatomic
The history of total knee arthroplasty 703
knee (Fig. 12) led to the development of several
other knees designs including the Synatomic and
AMK knees (Depuy – Warsaw, IN), the Cloutier
knee (Zimmer – Warsaw, IN), the AGC and Maxim
knees (Biomet – Warsaw, IN), the Orthomet
knees (Orthomet – Minneapolis, MN), the Axiom
knee (Wright Medical – Arlington, TN), and many
other PCL retaining designs (26).
Geomedic/metric knee and PCL retention
During the same period from 1970–1973,
another independent condylar knee designed was
also developed. The Geomedic (Fig. 13) prosthe-
sis was designed by a team of surgeons includ-
ing Drs. Mark Coventry, Roderick Turner, Ger-
ald Finerman, Lee H. Riley, and Jackson Upshaw
with Howmedica (Rutherford, NJ) engineers
including Robert Averill (Ph.D.). They believed
that conforming tibial and femoral design would
minimize polyethylene wear. They preserved both
cruciates but did not resurface the patellofemo-
ral joint with the femoral condyles only attached
to each other with a narrow metal bar. The tibial
component had several pegs to enhance fi fixation
but tibial loosening was still a problem. Th
The Geo-
medic knee was first implanted in 1971 with Sim-
plex (Howmedica – Rutherford, NJ) bone cement.
It was FDA approval of this cement that enabled
the early success of many knee designs.
Although the Geomedic spawned off ff many offff-
shoots including the Geometric II, Geopatellar,
Geotibial, Cloutier as well as Dr. Finerman’s Ana-
Fig. 12 – Anatomic knee
(Reprinted with permission
from (26)).
Fig. 13 – PCA (porous coated
anatomical) knee (Reprinted
with permission from Ref.
(26)).
704 Primary Total Knee Arthroplasty
metric knee (26, 40), it was discontinued by the
late 1970s.
PCA knee and porous coated non-cemented fixation
In 1978, Dr. David Hungerford and Robert V. Kenna
and later Dr. Kenneth Krackow designed the fi first
porous coated non-cemented fixation
fi total knee
(41, 42). Although there had been numerous knee
implants with press fit technique, this was the
first sintered porous coated non-cemented knee
fi
implant. The PCA (Porous Coated Anatomical)
was originally manufactured by North American
Medishield and then later Howmedica – Ruther-
ford, NJ) (Fig. 14). It was a PCL preserving knee
that was heat pressed with metal backing of all
three components. This landmark knee failed pri-
marily from polyethylene wear, inconsistent bone
ingrowth, and increased polyethylene wear of the
patella. Regardless, the PCA knee was a landmark
design because not only was it the first
fi porous
coated non-cemented knee implant but also it
introduced the first “universal instrumentation”
system for measured resection in knee arthro-
plasty (26).
Unicompartment and mobile-bearing knee design
Early unicompartment knee designs
Before the early development of condylar knee
design in the 1970s, there have been many effortsff
to address isolated compartment pathology. This Th
began in the 1950s with McKeever and MacIntosh
implants (43, 44). The latter being a disc inserted
into the diseased femoraltibial compartment with
no bony resections. In the early 1970s, numerous
surgeons had designed unicompartment fi fixed-
bearing knees. Engelbrecht at the Endo-Klink in
Hamburg, Germany designed the Sledge prosthe-
sis, a polycentric short-stemmed femoral com-
ponent and an all polyethylene tibial component
(45). This implant is still selectively used today and
has a 90% 10 year survivorship by the Swedish
Registry. At the Hospital for Special Surgery, Insall
Fig. 14 – Geomedic knee
(Reprinted with permission
from Ref. (22)).
implanted the first unireplacement which was the
medial part of the duocondylar knee in 1971 with
the help of engineer Walker (19, 22). Marmor also
designed and described indication, surgical tech-
nique, and contraindications of the Modular Uni-
compartment Knee (46).
In the late 1970s, Goodfellow and O’Connor in
Oxford, England (1976) designed the fifirst mobile-
bearing unicompartment replacement (47). This Th
implant was designed to address anteromedial
arthritis and requires functioning cruciates. It
signifi
ficantly reduced polyethylene wear by utiliz-
ing total congruity and freedom of motion and has
shown excellent survivorship over 10 years (48,
49). Concurrently in New Jersey, USA, Buechal and
Pappas (1978) began extensively implanting their
meniscal bearing mobile rotating platform total
knee. As early as 1975, they had designed a low-
contact-stress knee (LCS) (Fig. 15) that replaced
all three knee articulations, which has also has an
impressive long-term record (50).
Mobile-bearing knee technology appears to be
expanding. In the US, at present, the Oxford Uni-
replacement and LCS/PFC-rotating platform total
knees are the only FDA approved mobile-bearing
designs (51, 52). Many other mobile-bearing
implants are used outside the United States and
companies are attempting to get FDA approval for
these implants. Mobile-bearing hinged implants
have also had improved survivorship due to less
wear, better fixation, rotational freedom, and
improved patellofemoral articulation. These Th
implants are primarily used for complex primary
cases, tumor, and revision surgeries.
The Knee Society
In March 1983, during the annual meeting of the
American Academy of Orthopedic Surgeons in Ana-
heim, CA, a group of leading total knee surgeons
led by Ranawat founded the Knee Society (Fig. 16)
(22). The goal of the organization was to promote
the science and art of TKA and provide a forum
for further research and education similar to what
Fig. 15 – LCS (low contact
stress) rotating platform knee
(Reprinted with permission
from Ref. (26)).

Fig. 16 – The original founding members of the Knee Society in 1983 in Anaheim, CA (Reprinted with permission from Ref. (22)).
was happening with the Hip Society. Dr. Ranawat
was elected the founding president. This
Th landmark
event ushered in the modern era of TKA.
Conclusion and future
TKA has had a major impact in the field
fi of medi-
cine. The era of condylar knee replacement began
in the early 1970s. During this time, early innova-
tors, both surgeon and engineer alike, developed
the cornerstone principle of knee arthroplasty
surgery including ligament balancing, fi fixation,
deformity correction, posterior stabilization, PCL
retention, modularity, and instrumentation. ThThese
principles were developed independently across
the United States and the entire world.
Based on these principles, the future of TKA is
bright. Improvements in implant design and bear-
ing surfaces will hopefully continue to improve.
Enhanced non-cemented fixation with trabecular
metal or with other osteoinduction agents offerff a
viable option. Wear-resistant polyethylene, highly
cross-linked polyethylene or ceramic inserts
all great potential for wear reduction in total
knee replacement. Improve function and range
The history of total knee arthroplasty 705
of motion to up to 155° is another important
frontier especially for high flexion
fl communities
(Asian patients and high demand patients). One
such example is a unidirectional mobile-bearing
knee, incorporating a PS design and a modified fi
J-curve of the femoral component. In the pos-
terior cruciate-preserving knee design, adjusting
the J-curve and maintaining the proper contact
stresses in polyethylene may also provide an ROM
of up to 125°.
Other ground breaking technologies which will
improve outcomes is improved anesthesia, bet-
ter medical and pain management including the
elimination of systemic narcotic use, improved
infection control, and computer-navigation with
or without robotic surgery. TheTh latter seems to
hold most promise for revolutionizing TKA sur-
gery in the future. Use of computer navigation
restores frontal alignment in a reproducible man-
ner, and thus is superior to conventional tech-
niques. At present, however, navigation technol-
ogy remains more of a marketing tool, then a cost
eff
ffective user friendly device and its ultimate role
in the future is not certain. No documented stud-
ies exist that prove that a navigation-performed
TKR is functionally better than a conventional
706 Primary Total Knee Arthroplasty

TKR, nor is there proof that navigation surgery 17. Freeman MA, Todd RC, Bamert P, Day WH (1978) ICLH
improves the durability of TKR. When navigation arthroplasty of the knee: 1968–1977. J Bone Joint Surg
Br 60-B(3):339–344
technology becomes cost-effective,
ff reproducible, 18. Wilson PD Jr, Levine DB (2000) Hospital for special sur-
and user-friendly, its widespread assimilation gery. A brief review of its development and current posi-
into total knee replacement surgery may well be tion. Clin Orthop Relat Res 374:90–106
inevitable. 19. Ranawat CS, Scuclo TP (1985) History of the develop-
ment of total knee prosthesis at the Hospital for Special
The future of TKA is indeed bright. Hopefully, Surgery. In: Ranawat CS (ed.) Total condylar knee arthro-
advancements will continue to improve outcomes, plasty. Springer-Verlang, New York
functions, and durability. However, the most 20. Ranawat CS, Shine JJ (1973) Duo-condylar total knee
important factor for success, in the future as it is in arthroplasty. Clin Orthop Relat Res 94:185–195
21. Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale
the present and past, is refi
fined surgical techniques of the Knee Society clinical rating system. Clin Orthop
based on sound arthroplasty principles. Relat Res 248:13–14
22. Ranawat CS (2002) History of total knee replacement. J
South Orthop Assoc11(4):218–226
23. Insall J, Scott WN, Ranawat CS (1979) The total condy-
References lar knee prosthesis. A report of two hundred and twenty
cases. J Bone Joint Surg 61(2):173–180
1. Kane RL, Saleh KJ, Wilt TJ, et al. (2003) Total knee
24. Walker PS, Ranawat C, Insall J (1976) Fixation of the tib-
replacement. Evidence Report/Technology Assessment
ial components of condylar replacement knee prostheses.
(Summary), no. 86, 1–8
J Biomech 9(4):269–275
2. Kane RL, Saleh KJ, Wilt TJ, Bershadsky B (2005) ThThe func-
25. Insall JN, Lachiewicz PF, Burstein AH (1982) The poste-
tional outcomes of total knee arthroplasty. J Bone Joint
rior stabilized condylar prosthesis: a modification
fi of the
Surg 87(8):1719–1724
total condylar design. Two to four-year clinical experience.
3. Ethgen O, Bruyere O, Richy F, et al. (2004) Health-related
J Bone Joint Surg 64(9):1317-1323
quality of life in total hip and total knee arthroplasty. A
26. Robinson RP (2005) The early innovators of today's
qualitative and systematic review of the literature. J Bone
resurfacing condylar knees. J Arthroplasty 20(1 Suppl
Joint Surg86-A(5):963–974
1):2–26
4. Callahan CM, Drake BG, Heck DA, Dittus RS (1994)
27. Bartel DL, Burstein AH, Santavicca EA, Insall JN (1982)
Patient outcomes following tricompartmental total knee
Performance of the tibial component in total knee replace-
replacement. A meta-analysis. JAMA 271(17):1349–
ment. J Bone Joint Surg 64(7):1026–1033
1357
28. Eftekhar NS (1983) Total knee-replacement arthroplasty.
5. Verneuil A (1860) De la creation d’une fausse articula-
Results with the intramedullary adjustable total knee
tion par section ou re’ section partielle de l’os maxil-
prosthesis. J Bone Joint Surg 65(3):293–309
lairde infer’rier, comme moyen de re’ medier a l’ankylose
29. Murray DG (1979) Total knee replacement-state of the
vrai ou fausse de la machoire inger'ieure. Arch Gen Med
art. Jeff
fferson Orthop J IX:6
15(5):174
30. Murray DG (1982) Total knee replacement with a variable
6. Walldius B (1953) Arthroplasty of the knee joint employ-
axis knee prosthesis. Orthop Clin North Am 13(1):155–
ing an acrylic prosthesis. Acta Orthop Scand 23(2):121–
172
131
31. Yamamoto S (1979) Total knee replacement with the
7. Walldius B (1957) Arthroplasty of the knee using an endo-
Kodama-Yamamoto knee prosthesis. Clin Orthop Relat
prosthesis. Acta Orthop Scand Suppl 24:1–112
Res 145:60–67
8. Walldius B (1960) Arthroplasty of the knee using an
32. Robinson R (2001) History of total knee replacements.
endoprosthesis. 8 years' experience. Acta Orthop Scand
Orthopaedics, Virginia Mason Medical Center, Seattle,
30:137–148
Washington
9. Wilson FC (1972) Total replacement of the knee in rheu-
33. Waugh TR, Smith RC, Orofi fino CF, Anzel SM (1973) Total
matoid arthritis. A prospective study of the results of
knee replacement: operative technic and preliminary
treatment with the Walldius prosthesis. J Bone Joint Surg
results. Clin Orthop Relat Res 94:196–201
54(7):1429–1443
34. Seedham B, Longton E, Dowson D, et al. (1972) Designing
10. Shiers LG (1954) Arthroplasty of the knee; preliminary
a total knee prosthesis. End Med 1:28
report of new method. J Bone Joint Surg Br 36-B(4):553–
35. Cloutier JM (1983) Results of total knee arthroplasty
560
with a non-constrained prosthesis. J Bone Joint Surg
11. Deburge A, Aubriot JH, Genet JP (1979) Current sta-
65(7):906–919
tus of a hinge prosthesis (GUEPAR). Clin Orthop Relat
36. Townley C, Hill L (1974) Total knee replacement. Am J
Res(145):91–93
Nurs 74(9):1612–1617
12. Witovet J (1973) Guepar total knee prosthesis. Excertpa
37. Townley CO (1985) The anatomic total knee resurfacing
Med 298:28
arthroplasty. Clin Orthop Relat Res 192:82–96
13. Gunston FH (1971) Polycentric knee arthroplasty. Pros-
38. Townley CO (1988) Total knee arthroplasty. A personal
thetic simulation of normal knee movement. J Bone Joint
retrospective and prospective review. Clin Orthop Relat
Surg Br 53(2):272–277
Res 236:8–22
14. Jones WT, Bryan RS, Peterson LF, Ilstrup DM (1981)
39. Townley CO (1988) Articular-plate replacement arthro-
Unicompartmental knee arthroplasty using polycen-
plasty for the knee joint. 1964. Clin Orthop Relat Res
tric and geometric hemicomponents. J Bone Joint Surg
236:3–7
63(6):946–954
40. Finerman GA, Coventry MB, Riley LH, et al. (1979) Ana-
15. Freeman MA, Swanson SA, Todd RC (1973) Total replace-
metric total knee arthroplasty. Clin Orthop Relat Res
ment of the knee using the Freeman-Swanson knee pros-
145:85–90
thesis. Clin Orthop Relat Res 94:153–170
41. Hungerford DS, Kenna RV, Krackow KA (1982) The Th
16. Freeman MA, Swanson SA, Todd RC (1973) Total replace-
porous-coated anatomic total knee. Orthop Clin North
ment of the knee design considerations and early clinical
Am 13(1):103–122
results. Acta Orthop Belg 39(1):181–202

42. Hungerford DS, Krackow KA (1985) Total joint arthro-
plasty of the knee. Clin Orthop Relat Res 192:23–33
43. McKeever DC (2005) The classic: Tibial plateau prosthe-
sis.1960. Clin Orthop Relat Res 440:4–8 (discussion 3)
44. MacIntosh DL, Hunter GA (1972) The Th use of the hemi-
arthroplasty prosthesis for advanced osteoarthritis and
rheumatoid arthritis of the knee. J Bone Joint Surg Br
54(2):244–255
45. Engelbrecht E (1971) Sliding prosthesis, a partial pros-
thesis in destructive processes of the knee joint. Chirurg
42(11):510–514
46. Marmor L (1973) The modular knee. Clinical Orthop Relat
Res 94:242–248
47. Goodfellow J, O’Connor J (1978) Th The mechanics of
the knee and prosthesis design. J Bone Joint Surg Br
60-B(3):358–369
The history of total knee arthroplasty 707
48. Murray DW, Goodfellow JW, O’Connor JJ (1998) Th The
Oxford medial unicompartmental arthroplasty: a ten-year
survival study. J Bone Joint Surg Br 80(6):983–989
49. Murray DW (2000) Unicompartmental knee replacement:
now or never? Orthopedics 23(9):979–980
50. Buechel FF, Pappas MJ (1989) New Jersey low contact
stress knee replacement system. Ten-year evaluation of
meniscal bearings. Orthop Clin North Am 20(2):147–177
51. Ranawat AS, Rossi R, Loreti I, et al. (2004) Comparison of
the PFC Sigma fixed-bearing and rotating-platform total
knee arthroplasty in the same patient: short-term results.
J Arthroplasty 19(1):35–39
52. Ranawat CS, Komistek RD, Rodriguez JA, et al. (2004)
In vivo kinematics for fixed and mobile-bearing poste-
rior stabilized knee prostheses. Clin Orthop Relat Res
418:184–190

S. Parratte,
J.-M. Aubaniac,
Posterostabilized TKA: advantages
J.-N. A. Argenson
and disadvantages
Defifinition
T
he term “posterostabilized”(PS) total knee
arthroplasty (TKA) has been originally
defi
fined by the developers of the first poste-
rior cruciate ligament-substituting design using a
cam at the Hospital for Special Surgery in 1978 (1).
The original design of posterostabilized implant
Th
includes a post also named a cam to prevent fl flex-
ion instability and to allow posterior rollback of
the femur during flexion (1) (Fig. 1). The term
“posterostabilized” is then used in reference to this
original design and its descendents. In this way the
term “posterostabilized” implant do not refer to all
type of posterior substitution design.
History
Four decades ago, TKA represented an alternative
to arthrodesis or fascial arthroplasties in the treat-
ment of the arthritic knee (1–3). Initially, various
implants such as the Polycentric, the ICLH, and the
Freeman Swanson prostheses were developed. In
the early seventies, John N. Insall at the Hospital
for Special Surgery was working with Peter Walker
on the Duocondylar Prosthesis and the subsequent
Duopatellar prosthesis (1–3). Insall implanted the
first total condylar prosthesis (TCP) in February
fi
Fig. 1 – The original design of posterostabilized implant includes a post
also named a cam to prevent flexion instability and to allow posterior roll-
back of the femur during flexion.
Chapter 64
1974 and by 1976, he implanted more than 300
prostheses (1–3). As his clinical experience in TKA
matured, Insall realized that the successful TCP
required improvement and modification fi due to
reported cases of flexion instability, which were
most likely errors in surgical technique rather than
implant design. Insall concluded that to stabilize
the knee in flexion, the posterior cruciate ligament
that he resected would require some type of sub-
stitution (1–3). The
Th first design modifi fication leads
to the total condylar prosthesis II (TCP II) includ-
ing a high tibial post that was designed to be a pas-
sive stop against posterior displacement in flex- fl
ion. The TCP II was implanted between 1976 and
1977 but early loosenings were observed. At that
time, Albert Burstein came to New York to became
the chairman at the Hospital for special surgery.
Burstein and Insall started their collaboration to
create the PS-Knee design and the Insall–Burstein
(IB) posterior-stabilized knee prosthesis was intro-
duced in 1978 and has been the design against
which all future posterior cruciate-substituting
designs will be compared (1–3).
The IB I was designed with a dished articular surface
and a tibial spinefemoral cam mechanism that sub-
stituted for the resected posterior cruciate ligament.
The cam controlled the femoral rollback and improved
the range of motion (ROM). Initially, the IB I had an
all polyethylene tibial component; however, labora-
tory studies revealed that metal backed tibial compo-
nents transmitted the load better to the underlying
bone and potentially reduced the incidence of tibial
component loosening. By November 1980, Insall was
exclusively implanting the IB I prosthesis with a met-
al-backed tibial component. PS-TKA was born and if
many improvements have been performed since its
infancy, the basic concept still remain unchanged and
effi
fficient (1–3).
Biomechanical/Biological Basis
The basic biomechanical principal of the postero-
stabilized implants is the PCL substitution by a cam
mechanism (1–3). Initially, the point of contact of
710 Primary Total Knee Arthroplasty

B C

Fig. 2 – (A–C) The basic biomechanical principal of the posterostabilized implants is the PCL substitution by a cam mechanism.
The ccam mechanism was designed specifically to reproduce the progressive rollback function of the PCL. At this step, the femoral
A
contact area would approach the posterior edge of the tibial component around 110° of flexion maximizing knee flexion.

the joint was shifted from the middle to a more

posterior position. This shift induced a larger dis-
placement of the femoral component before ante-
rior displacement (1–5). The Th cam mechanism was
designed specifi fically to reproduce the progressive
rollback function of the PCL. The posterior roll-
back translates the extensor mechanism anteriorly
and this increases the extensor mechanism power
(1–5). At this step, the femoral contact area would
approach the posterior edge of the tibial compo-
nent around 110° of flexion maximizing knee flex-
ion (Fig. 2) Due to these particular features, achiev-
ing deep knee flexion with standard PS-TKA may
increase contact stresses at the posterior aspect
of the tibial plateau and thus unsafe as reported
in previous studies (6, 7). Furthermore, contact
stresses transmitted to the tibial plateau required
a tibial quill to stabilize the tibial plateau and the Fig. 3 – Furthermore contact stresses transmitted to the tibial plateau required
analogy to a boat quill is often use (Fig. 3) (6, 7). a tibial quill to stabilize the tibial plateau and the analogy to a boat quill is
The forces transmitted by the cam to the tibial pla- often use. The forces transmitted by the cam to the tibial plateau quill are com-
teau quill are compared to the forces transmitted pared to the forces transmitted by the boat main-sail to the quill of the boat.
by the boat main-sail to the quill of the boat (6, 7).
To limit potential drawbacks of deep flexion,
fl such to improve range of knee fl
flexion, first to restore
as excessive load on the tibial insert or a TKA dislo- patient function and second to minimize wear and
cation in posterostabilized implants, high-flexion
fl improve survivorship (7–13).
posterostabilized mobile-bearing TKA have been
design (8, 9). Specifific changes such as an increased
posterior offffset of the femoral condyle, an ante-
rior cut in the tibial insert to avoid patellar tendon Optimizing the technique
impingement and a greater size of the posterosta-
bilized cam to increase the jump distance have been The first step of this approach remains a complete
performed (Fig. 4) (8, 9). Furthermore, to reach pre-operative analysis including a careful clinical
deep flexion, the implant should allow an internal and radiological exam of the patient lower extrem-
rotation of the tibia below the femur (7–13). This Th ities as well as an evaluation of the patient motiva-
has been achieved in PS-TKA by the addition of a tion toward the procedure. The goal of this analysis
mobile-bearing design. The goals of these implants is to identify all the factors which could potentially
are to provide more normal knee kinematics and limit the post-operative results (2, 9, 14).

Fig. 4 – To limit potential drawbacks of deep flexion, such as excessive load
on the tibial insert or a TKA dislocation in posterostabilized implants, high
flexion posterostabilized mobile-bearing TKA have been design (8, 9). Spe-
cific changes such as an increased posterior offset of the femoral condyle, an
anterior cut in the tibial insert to avoid patellar tendon impingement and a
greater size of the posterostabilized cam to increase the jump distance have
been performed.
The etiology of the knee arthritis should be identi-
fied and in case of rheumatoid arthritis or systemic
disease, the medical management of this pathol-
ogy should be appropriate. Patient history and
previous surgery on the lower extremities should
be known and their potential impact on the post-
operative ROM should be evaluated. The patient
body mass index and the thigh circumference
should be registered as the fat tissue at the poste-
rior aspect of the thigh may limit the deep flexion
fl
(11). Flexion and extension strength of the knee
have to be evaluated. Pain or deformation of the
other joints including the feet should be searched
with attention as any associated trouble same
limb may be a potential extrinsic factor of knee
stiff
ffness. All potential factors of sepsis should
be eliminated and the oro-dental state should be
perfect. Urinary and nasal sample should be sys-
tematically performed pre-operatively to ensure
the absence of contamination. TheTh mechanical axis
of the lower limb should be evaluated clinically as
well as the stability of the knee and the reducibility
of the deformation in case of marked varus or val-
gus. After an exhaustive clinical exam, a complete
radiological exam is mandatory, including ML and
AP view of the knee, a full-limb radiograph, varus
and valgus stress, and sky-views radiography. An
intramedullary road will be used for the distal fem-
Posterostabilized TKA: advantages and disadvantages 711
oral bone cut. As one of the goal of the procedure
is to restore the mechanical axis of the lower limb,
the angle between the anatomical axis of the femur
and the mechanical axis (Hip Knee Shaft angle)
should be measured pre-operatively and reported
on the intramedullary jig during the procedure (2,
9, 14). Bony deformations, osteophyte, the height
of the patella, and the alignment of the lower limb
should be carefully analyzed.
The technique step-by-step
Instrumentation changed since the time of the
first PS-TKA implantation but the basic concept
behind PS-TKA remains unchanged (2, 9, 14). Th The
objective is to reproduce a knee that has equal soft-
tissue tension on the medial and lateral sides in
both flexion
fl and extension. Theoretically, the axis
of flexion is designed to be in the central portion
of the knee and shared equally by both the medial
and the lateral compartments.
Once the approach has been done and as well as
a minimum soft tissue release, bone cuts should
be performed to implant the prosthesis. As dem-
onstrated initially by Insall, when performing the
bone cuts to insert the prosthesis, the surgeon
should aim to create two balanced spaces that the
future prosthesis will fill (1, 2, 9, 14, 15). The first
space is the extension gap defined
fi when the knee
is fully extent between the tibial cut and the dis-
tal femoral cut (1, 2, 9, 14, 15). The second space
is the flexion gap defifined with the knee flexed at
90° between the tibial cut and the posterior femo-
ral cut. The prosthesis should properly fill the two
spaces. A space too tight may lead to limited range
of knee motion and a space too loose may lead to
instability after TKA (1, 2, 9, 14, 15).
To properly fill this space, surgeon can control step
by step: the tibial bone cut (including the amount
of bone resection and the tibial slope), the distal
femoral bone cut, the size of the femoral implant,
the anterior and posterior femoral bone cuts, the
femoral implant rotation, and finally the thickness
of the polyethylene tibial insert. Technically, the
surgeon is commonly using the implant dedicated
ancillaries to guide the cuts (1, 2, 9, 14, 15).
The tibial bone cut can be done first. Using an
extramedullary guide, the cut is done perpendicu-
lar to the anatomical axis of the tibia. The
Th amount
of bone resection is done according to the cartilage
wear on the most aff ffected compartment. A cut
too high may tight the space both in fl flexion and
in extension (1, 2, 9, 14, 15). A cut too low on the
tibia may lead to a loose knee and the tibial implant
will be fixed in a weaker bone (1, 2, 9, 14, 15). Tib-
ial slope is also considered as a factor infl fluencing
post-operative flexion. A slope lower than 0° may
712 Primary Total Knee Arthroplasty
tight the flexion
fl space and limits the post-operative
flexion. A down-slope around 6° leads to an aver-
age increase of 10° of flexion (11). Therefore, it is
recommended to perform a tibial cut with around
7° of tibial slope. Contemporary ancillaries include
this tibial slope. Care must be taken to not exceed
7° which may lead to anterior instability and cause
flexion instability (1, 2, 9, 14, 15).
The distal femoral cut is then considered. The goal
when performing the distal femoral cut is to cut
the amount of bone corresponding at the space
requested by the distal flange of the femoral implant
(1, 2, 9, 14, 15). During this step, the HKS angle
previously defi fined on the pre-operative full-length
radiograph should be integrated and reported on
the intramedullary road. After this cut, the gap
in extension is tested to verify the ability to fully
extend the leg on the tight. In case of pre-operative
lack of extension a greater amount of bone can be
cut to achieve full extension. The following step is
to determine the size of the femoral implant (1, 2,
9, 14, 15). Choosing an oversized femoral implant
may limit the range of knee flexion
fl and extension.
Using an anterior referencing system, the surgeon
is also going to check the anteroposterior place-
ment of the implant when performing the ante-
rior and the posterior cut. Positioning the femoral
implant to posterior will thigh the fl flexion space
and may create a notch on the anterior cortical of
the femur (1, 2, 9, 14, 15). During this step, the
rotation of the femoral implant should also be con-
trolled and an excess of external rotation may tight
the implant externally in flexion (1, 2, 9, 14, 15).
Several referential can be used: the posterior con-
dyles (3° of external rotation relatively to the pos-
terior condyle), the Whiteside line or the transepi-
condylar axis (1, 2, 9, 14, 15). Once all the cut have
been performed, the ROM can be tested using trial
implant and the adequate size of the tibial poly-
ethylene insert can be determined to obtain first fi
a satisfying ROM but also a proper stability of the
knee (1, 2, 9, 14, 15).
How improving the technique to obtain good results
Exposure and minimally invasive technique
Minimally invasive surgical (MIS) approaches are
now widely used in TKA (14). Using MIS technique
seems to allow a quicker recovery for the patient
due to less muscular damages and therefore may be
considered as a factor to achieve sooner a satisfying
range of knee motion (14). This
Th basis remains true
only if adequate technique and ancillaries, adapted
to MIS are used to allow a precise implant posi-
tioning through a limited approach (14). Indeed,
the main parameter to achieve durable functional
improvement remains the position of the implants
and the management of the extension and flexion
fl
spaces: the so-called “gap balancing” (2, 15).
Soft tissue release
Management of the extension and flexionfl spaces:
the so-called “gap balancing” may include soft
tissue release. In fact, the pre-operative angular
deformity of the knee and thus the correlated liga-
mentous asymmetry may require some correction
during TKA that are not managed only with bone
cuts (1, 2, 15, 16). An appropriate medial release
as initially described by Insall et al. (2) when nec-
essary should be performed using a true subpe-
riostal elevation of the superficial
fi MCL from the
tibia, leaving the Pes tendons intact in most cases.
The MCL should never be deliberately and improp-
erly stretched by the retractors, instead the MCL
should be released as a long sleeve from the proxi-
mal tibia (1, 2, 15, 16).
Under-correction of the valgus knee will leave the
knee still tight laterally with laxity or redundancy
in the MCL. Because there is no inherent ability for
the MCL to tighten over time the valgus deformity
progressively returns. Therefore,
Th minimal MCL lax-
ity should typically be accepted after correcting a
valgus deformity (1, 2, 15). To emphasize medial
and lateral soft tissue balance, Insall initially advo-
cated a sequential lateral ligamentous release tech-
nique (1, 2, 15). Insall’s original description was a
release sequence of the lateral collateral ligament
(LCL), popliteus tendon, and lateral head of the
gastrocnemius and stated that the iliotibial band
(ITB) generally should be preserved, unless a severe
external rotation deformity was present (1, 2, 15).
To more safely and sequentially eliminate lateral
contracture the “pie-crust” technique was later
proposed by Insall and is widely used (1, 2, 15, 17,
18). According to the initial technique described
by Insall (1, 2, 15, 17, 18), the knee should be in
full extension with a lamina spreader in the exten-
sion space. First a transverse incision should be
performed through the posterolateral joint capsule
at the level of the tibial bone cut with the number
15 surgical blade from just posterior to the LCL to
just anterior – lateral to the popliteus tendon. Dur-
ing this step and the following ones, the popliteus
tendon should be carefully protected. During the
second step, a series of horizontal stab incisions
with the number 15 surgical blade (pie crusting)
should be made along the lateral side of the knee
for those structures that feel tight (1, 2, 15, 17,
18). The surgeon simply palpates the lateral sided
structures and starts with punctures of the tight-
est band of tissue. This usually starts with the IT
band but in many fixed valgus deformities the LCL
itself may require pie crusting as well. Specific
fi iden-

tifi
fication of which structures are being pie-crusted
is not required provided that the release is titrated
by intermittently checking to determine when suf-
ficient release has been achieved. During the dif-
ferent steps, based on anatomical and in vivo study
the penetration of the surgical blade should be less
than 5 mm in order to minimize the risk of per-
oneal nerve injuries (1, 2, 15, 17, 18). Then
Th with aid
of lamina spreaders the lateral side should be gen-
tly and progressively stretched to effect
ff an in situ
lengthening (1, 2, 15, 17, 18). By pie crusting no
structure should be completely released but instead
lengthened in continuity. To ensure that you have
not over-released the lateral side the best test is to
perform a trial reduction and place the limb in the
“Fig. 4” position; that is 90° of flexion while holding
the foot and allowing the hip and knee to externally
rotate maximally (1, 2, 15, 17, 18). The
Th knee should
be stable in this position, if the post of a posterior-
stabilized insert subluxes from the femoral housing
in this position then a thicker or more constrained
tibial insert should be used.
Posterior space management: posterior recut and
osteophyte cleaning
Once the tibial and femoral cuts are performed, it
is important to do a posterior recut on the poste-
rior aspect of the femoral condyles (11, 13). ThThis
will limit any bony impingement during very high
flexion against the tibial insert (11, 13). A resec-
tion of all the posterior osteophytes and all soft-
tissue remnants in the backside of the knee, such
as meniscal remnants or synovial tissue, should
also be performed during this step of the procedure
(11, 13). During this step, using a lamina spreader
is very convenient to open alternatively the medial
aspect of the knee and then the lateral one.
Patellar tracking
An improper patellar course may also limit the
range of knee motion. The Th rotation of the femo-
ral implant is the main parameter and an excessive
internal rotation will cause lateral patellar tilt and
subluxation (11, 13). When a patellar resurfac-
ing is performed, the patellar cut should be sym-
metric on the lateral and the medial aspect of the
patella and the final thickness of the patella should
not exceed the thickness of the original patella
(11, 13). A patellar over-stuffi
ffing will limit the knee
flexion (11, 13).
Post-operative management
To improve patient recovery after TKA, mini-
mally invasive approaches have been evaluated
and become more widely used in TKA. During
the same time, contemporary anesthesia proto-
cols have been developed to improve post-oper-
Posterostabilized TKA: advantages and disadvantages 713
ative pain management (19). These Th protocols are
multi-modal and include low-dose opioids, local
anesthetic infifiltration, peripheral nerve block-
ade, non-steroidal anti-infl flammatory drugs, and
cryotherapy (19). A contemporary approach is to
use pre-operatively, peri-operatively, and post-
operatively various analgesic agents according to
a very precise schedule. Th This concept is based on
two fundamental principal: first fi the additive or
synergistic eff
ffects of diff
fferent analgesics in order
to use smaller doses of each drug to achieve a suf-
ficient analgesia and second being pre-emptive. To
be pre-emptive lead to reduce the central sensitiza-
tion that arises from noxious inputs experienced
throughout the entire peri-operative period and
not just from those occurring during the surgical
procedure (19). In practice, pre-emptive analgesia
involves the administration of analgesics prior to
painful stimuli. The goal is to stay ahead of the pain
to limit the total analgesia requirements for the
patients. Pain management problems after surgery
have been recognized as a patient specificfi cause of
stiff
ffness after TKA. Eff ffective pain management
improves patient satisfaction; decreases hospital
stays and allows early rehabilitation for a quicker
regain of range of knee motion. This pain manage-
ment approach associated with early rehabilitation
and careful patient education is a fundamental
point a contemporary approach in TKA (19).
Traps and pitfalls
– Excessive or insuffi
fficient bone cuts and unbal-
anced gaps related to improper surgical tech-
nique and implant malpositioning may lead to a
knee tight or loose in flexion
fl or in extension or
both. Pre-operative surgical planning, modern
ancillaries, and the use of dedicated spacer block
to check the flexion and extension gap during the
procedure can help to prevent this trap (15, 20)
(Fig. 5).
– The most common mistake is undercorrection
of a fixed angular deformity often out of fear for
creating ligamentous instability in the opposite
direction. For instance concerns of stretching,
cutting, or over-releasing the medial collateral
ligament (MCL) in a varus knee can lead to an
undercorrection of the varus deformity thus
leaving the knee still tight on the medial side.
This problem is exacerbated if the limb align-
ment is also left in varus. Over time that mala-
lignment and the associated excessive-tension
on the medial side will subsequently stretch out
the lateral side and/or lead to excessive medial
polyethylene wear from overload. In such cases,
the varus deformity will progressively recur and
the knee ultimately requires a revision (15, 20).
714 Primary Total Knee Arthroplasty

A B
Fig. 5 – Post-operative AP (A) and ML radiograph (B) showing a posterostabilized implant in proper position. Excessive or insufficient
ffi
bone cuts and unbalanced gaps related to improper surgical technique and implant malpositioning may lead to a knee tight or loose in
flexion or in extension or both. Pre-operative surgical planning, modern ancillaries, and the use of dedicated spacer block to check the
flexion and extension gap during the procedure can help to prevent this trap.

– In another hand, traditional technique of lateral

release may lead to over-release of the lateral lig-
aments in a substantial subset of patients. Early
reports of dislocation of posterior-stabilized
total knees were almost always related to knees
with a substantial valgus deformity that under-
went one of those types of traditional lateral
sided ligamentous releases (15, 20). A B
Fig. 6 – (A and B) More normal kinematics have been observed after
PS-TKA than after PCL-retaining designs during early (A) and full flexion
phases (B).
Advantages of the technique

Biomechanical/biological
– More normal kinematics have been observed
after PS-TKA than after PCL-retaining designs.
Fluoroscopic studies have shown more reliable
femoral rollback patterns than PCL-retaining
TKA (Fig. 6) (8, 9). Other studies have shown
that PS-TKA can replicate kinematics of the nor-
mal knee (Fig. 7). Furthermore, the paradoxal
anterior rollback pattern observed in flexion
fl for Fig. 7 – Fluoroscopic studies have shown more reliable femoral rollback
some PCL-retaining arthroplasties has not been patterns than PCL-retaining TKA. Other fluoroscopic studies have shown
observed for PS-TKA (1, 8, 9). that PS-TKA can replicate kinematics of the normal knee.

B C
D E
– Greater flexion angles in weight-bearing condi-
tions have also been observed with PS-TKA than
with PCL-retaining designs during fl fluoroscopic
evaluations (21).
– The risk of instability or luxation related to late
PCL rupture does not exist (15, 22, 23) (Fig. 8).
– The use of conforming articular polyethylene sur-
face is possible with PS design. The
Th increased con-
tact area provided by the conforming surface lim-
its the contact stress on the polyethylene and may
limit wear compared to PCL-retaining TKA where
less conforming surfaces are used (11, 21, 24)
Technical advantages
– The surgical technique is easy: PS-TKA is a
straightforward and reproducible surgical tech-
Posterostabilized TKA: advantages and disadvantages 715
Fig. 8 – (A and B) The risk of instability or luxation
related to late PCL rupture as shown in (A) (Ap-view)
and (B) (ML-view) does not exist after PS-TKA. When
a luxation following rupture of the PCL occurs, closed
reduction (C) may not be sufficient
ffi to stabilize the
knee and a revision using hinge prosthesis may be
required (D and E).
nique. The PCL is frankly sacrifi
ficed and therefore
the ligamentous balance is not limited by the
posterior structures (2, 3, 15, 25).
– Larger deformation can be easily corrected due
to PCL excision (2, 3, 15, 25).
– The tibial bone resection is not conditioned by
the PCL balance and minimal tibial bone resec-
tion can be performed. This point in important
and allows placement of the tibial component
in stronger host bone and not in the weaker
metaphysal cancellous bone as observed when a
greater amount of tibia is resected (2, 3, 15, 25).
Clinical evidence (8, 9)
We prospectively followed 516 primary high fl
flex-
ion mobile-bearing posterostabilized TKA on 445
716 Primary Total Knee Arthroplasty
consecutive patients operated between 2001 and
2005 in the same institution by the same surgeon
following the previously mentioned pre-operative,
peri-operative, and post-operative protocol. Th The
same cemented high flexion mobile-bearing pos-
terostabilized TKA (LPS Flex mobile-bearing) was
used for all the cases. The clinical evaluation was
performed between January 2004 and February
2007 (with a minimum follow-up of 2 years) by
two independent observers (SP and AA) including
the evaluation of patient range of knee flexion
fl and
the classical items to complete the Knee Society
score (26). At the same time, patients were also
asked to fill a specifi
fic survey including the KOOS
(27, 28), the UCLA score and specifi fic questions
concerning their recreational or sportive activi-
ties. There were 299 women (67%) and 146 men
(33%) in the series (256 right knees and 260 left
knees). The procedure was bilateral for 70 patients
(16%) and unilateral for 375 patients (84%). The Th
mean age of the patients at the time of surgery
was 71.6 ± 8 years (range 22–96 years). The Th mean
body mass index of the patients was 28.3 ± 4.6
kg/m2 (range 16–44 kg/m2). The etiology was pri-
mary osteoarthritis for 474 knees (92%), rheu-
matoid arthritis for 11 knees (2%), and another
cause (post-traumatic, avascular osteonecrosis,
systemic disease) for 31 knees (6%). The Th mean
delay before surgery was 39 ± 30 months. For 387
(75%), the pre-operative alignment was in varus.
In this group, the mean pre-operative alignment
was 171.4º ± 7º (range 164–179 º). TheTh pre-opera-
tive alignment was in valgus for 129 (25%) knees
and in this group the mean pre-operative align-
ment was 188.4º ± 8º (range 181–202º). Concern-
ing the activity level at the time of surgery, 173
(34%) patients were inactive, 274 (54%) were lim-
ited at their activity of the daily living, 46 (9%)
were still engaged in labor or sportive activities,
and the activity level was unknown for 14 (3%)
patients. Some patients were lost of follow-up or
died before the final evaluation, thus we were able
to analyze the objective and subjective data for a
total of 412 patients (483 knees).
Comparisons between pre-operative and post-
operative Knee Society Knee and Function scores
(26) at the time of the clinical evaluation (mean
3 years; range 2–4 years) showed a significant fi
improvement in function and pain relief after
TKA in our series. Furthermore mean active
knee flexion improved from 117° ± 13º (range
80–140º) pre-operatively to 128 ± 4º (range
85–155º) at the time of the clinical evaluation (p
< 0.0001). The
Th mean KOOS values at the time of
the evaluation were 82 ± 16 (range 21–100) for
the pain category, 80 ± 15 (range 27–100) for the
symptoms category, 79 ± 20 (range 21–100) for
the ADL category, 62 ± 32 (range 0–100) for the
sport category, 71 ± 28 (range 0–100) for the QOL
category. The results of the KOOS were signifi fi-
cantly better in the group with a flexion greater
than 125° for all the categories of the KOOS. In
the series, 337 patients (82%) reported to be
involved in a sportive activity at the time of the
evaluation. The mean UCLA score was 6.9 ± 1.6.
The delay reported by the patients before return-
ing to their sportive activity was 6 ± 4 months.
The more frequently practiced activities were
walking or hiking, gardening, swimming, exercis-
ing (including cardio-training), cycling, and golf-
ing. Among the group of 337 patients involved
in sportive activities, 86% reported to be at the
same level (47 patients, 14%) or at a better level
(243 patients, 72%) than before surgery and
14% (47 patients) at a lower level. Among the
group of 337 patients involved in sportive activi-
ties, 118 patients (35%) reported to percept no
knee-related limitation during their activities,
168 patients a slight limitation, and 51 patients
(14%) a major limitation.
Disadvantages of the technique
Biomechanical/biological
Specifi
fic complications related to PS-TKA have been
described and included component dislocations,
intercondylar fractures, patella fractures, “patellar
clunk” syndrome, and tibial spine wear and break-
age (1, 3, 15, 16, 20, 29).
Component dislocation is rare after PS-TKA but not
impossible. In fact, the cam mechanism does not
manage the frontal stability of the knee and par-
ticular care should be given to the collateral liga-
ments. Particular points related to instability will
be described carefully in the technical disadvan-
tage section (1, 3, 15, 16, 20, 29).
Interchondylar fractures can also occur when using
PS and particularly during the femoral compo-
nent impaction. This could be prevented by paying
attention to the component impaction. Equal pres-
sure should be applied on both the lateral and the
medial condyle when using the mallet (1, 3, 15, 16,
20, 29).
Patella fractures have been described with the
original IB PS knee. This design had particular
anteroposterior dimensions which pushed the
patella anteriorly and increase contact stress on
the patella. This is the explanation given to explain
the relatively high rate of patella fracture. Design
modififications have been performed and the rate
of patellar fracture frankly decreased since those
days (1).
 Posterostabilized TKA: advantages and disadvantages 717

Patellar clunk syndrome (1)

Deeper flexion obtained after PS-TKA has induced
an extension of the quad tendon beyond the tro-
chlear groove of the femoral component. When
the anterior edge of the femoral component termi-
nated abruptly, synovium or scar residing on the
tendon falls into the intercondylar groove. If this
has occurred, the same amount of soft tissue must
ride up out of the trochlear groove and “jump”
back onto the femoral trochlea when the patient
extent the knee. After arthroplasty, the concerned
tissue had become hypertrophic scar tissue and
creates a painful and noisy complication that has
been described as “patellar clunk.” Patellar clunk
treatment includes physical therapy, arthroscopic
débridement, or surgical removal of the nodule.
Once again, following design adaptation, the rate
of “patellar clunk syndrome” decreased over the
time.
Tibial spine wear and breakage: Recently spine-cam
mechanisms have been considered as a potential
source of wear debris. Recent studies reported
early aseptic loosening and osteolysis. However,
another study evaluating retrieval for early failure
of PS TKA, did not confirmed
fi that the cam was
responsible for the wear observed in these early
failures. To prevent potential cam wear, the HHS
group recommended to avoid femoral implant Fig. 9 – Most current posterior-stabilized designs have increased the so-
flexion and to limit posterior slope in the proximal called jump distance that is needed for the cam to ride over the post before
dislocating and in large series the incidence of frank dislocation is now
tibial resection (1).
much less than 0.5%.

Technical disadvantages stress and posterior translation (Fig. 10) The

Technically, PS-TKA required an optimal balance
of the knee joint to prevent instability. Flexion
instability after posterior-stabilized TKA is a
rare but dramatic and disconcerting problem for
patient and surgeon alike. The Th consequences of
flexion instability after posterior-stabilized TKA
may vary from a vague sensation of instability to a
frank dislocation (30). Most current posterior-sta-
bilized designs have increased the so-called jump
distance (Fig. 9) that is needed for the cam to ride
over the post before dislocating (30) and in large
series the incidence of frank dislocation is now
much less than 0.5%. However, when the so-called
jump distance is exceeded a posterior dislocation
of the tibia on the femur is the result. ThThis often
requires closed reduction under anesthesia. After
reduction, the knee typically functions well but of
course is prone to subsequent dislocation. Dislo-
cation often occurs with a specifi fic activity: most
commonly marked knee fl flexion plus a varus stress.
In fact, a posterior-stabilized knee can resist pos-
terior translation because of the tibial cam, but it
cannot always resist a combined varus or valgus
Th stan-
dard PS knee does not provide any varus–valgus
constraint and sometimes a loose flexion gap
associated with collateral ligament laxity (most
often LCL) is the cause flexion instability in pos-
terior-stabilized knees (1, 15, 16, 20, 31). At risk
patients include those who had correction of large
valgus deformity, particularly if they then quickly
regained knee flexion following aggressive rehabil-
itation. The first episode of dislocation should be
treated with closed reduction, a trial of bracing and
avoidance of the activity that induced the disloca-
tion. Recurrent dislocation should be addressed
with insertion of a thicker polyethylene insert (if
there is room in the extension space) or by conver-
sion to a constrained condylar implant. Th The new
construct should be checked in the Fig. 4 position
to establish that instability has been corrected (1,
15, 16, 20, 31).
Clinical evidence
After the successful introduction of the TCP in
1974, concern arose about cases of flexion
fl insta-
718 Primary Total Knee Arthroplasty
bility (2, 3). These cases were probably more
related to errors in surgical technique rather
than implant design. Following this observations,
Insall determined that to stabilize the knee in
flexion, the resected posterior cruciate ligament
fl
would require substitution (2, 3). Together with
Burstein, he designed the implant the IB posteri-
or-stabilized knee prosthesis (Zimmer, Warsaw).
The implant was introduced in 1978 and has been
the design against which all future posterior cruci-
ate-substituting designs are compared (2, 3). Over
the following 25 years, numerous clinical reports
have supported the use of a posterior cruciate-
substituting prosthesis and numerous studies
in the literature reported the results of PS-TKA.
Since the initial 2- to 4-year outcome of the origi-
nal IB prosthesis published in 1982, several stud-
ies compared PS versus CR design (2, 3). Results
of a meta-analysis published in 2005 concluded
that choice of whether to use a posterior cruci-
ate-retaining or a posterior-stabilized design for
TKA relies on limited scientifific evidence (32). The
meta-analyses showed only a difference
ff in ROM
favoring posterior-stabilized designs over PCL
Fig. 10 – A posterior-stabilized knee can resist posterior
translation because of the tibial cam, but it cannot always
resist a combined varus or valgus stress and posterior trans-
lation. The standard PS knee does not provide any varus–
valgus constraint and sometimes a loose flexion gap associ-
ated with collateral ligament laxity (most often LCL) is the
cause flexion instability in posterior-stabilized knees.
retention designs by 8° (32). These
Th data, however,
should be carefully interpreted as the difference
ff
between retention and sacrifice
fi of the PCL is infl
flu-
enced by factors which could not be investigated
with the limited data at hand (32). According to
the results of this meta-analysis and looking at
the best available evidence, individual, high qual-
ity, RCTs, there is strong evidence that there is no
diff
fference between PCL retention compared to
PCL sacrifi
fice in the same prosthesis (32). There is
also strong evidence that the PS design results in
a better ROM and reproduction angle (32, 33). As
usual in orthopedic surgery studies, several stud-
ies had inappropriate randomization techniques
or did not claim to be randomized and data from
these studies have not been included (32, 33.)
ROM was the parameter most measured. Only
one trial found a significant
fi diff
fference favoring
PCL sacrififice and the pooled result of six tri-
als was just signifificant (32). Stiehl (34) found a
superior ROM for a PCL-retaining implant and
Maloney for a PS design (35), both studies also
had, however, a higher pre-operative ROM for the
superior group. Hirsch (36) found a superior ROM

for a PS design over PCL sacrificefi as retention in
a prosthesis without posterior stabilization. All
these studies, however, did report the raw data
of post-operative ROM instead of considering
ROM improvement (32). As pre-operative ROM is
believed to have a large influence
fl in the post-op-
erative results, improvement of ROM should be
calculated and reported as well and this was done
in only three trials which found no diff fference (32,
33). Furthermore the method of assessment of
ROM was not described in the papers and it has
now been shown that measurement of ROM is
inaccurate when performed clinically (32, 33). In
another hand clinical rating scales are not very
sensitive tools to evaluate the difffference between
two implant designs when only total scores are
reported and that point may explain the absence
of diff
fference observed in the studies comparing PS
versus CR TKA (32, 33). This may be the case for
the latest prospective randomized study reported
in the literature comparing PS versus CR high
flexion TKA (37). The conclusions were that after
fl
a minimum duration of follow-up of 2 years, there
was no difference
ff in ROM or clinical and radio-
graphic results between knees that had received
a high-flflexion posterior cruciate-retaining total
knee prosthesis and those that had received a
high flexion posterior cruciate-substituting total
knee prosthesis (37).
Objective tools such as fluoroscopy revealed a more
natural anteroposterior femorotibial translation
for the PS design (8). Results concerning proprio-
ception are conflflicting and no final conclusion can
be done concerning this particular point (32).
Gait analysis could provide more meaningful
results; however, no study compared prospec-
tively the walking pattern in patients with both
type of implants. Dorr (38) evaluated gait anal-
ysis and found greater medial reaction forces
and higher joint reaction forces for PS implants,
which may lead to more wear and Ishii (39)
found increased abduction and adduction and
increased proximal and distal translation during
gait analysis for the PS design which may indicate
decreased stability. Th These results have not been
confi
firmed and no final conclusion on gait pattern
can be done (32).
Discussion
Since its introduction in 1978, the concept of
posterior cruciate ligament substitution had
gain in popularity (40). This is probably related
to the Insall work over the years. Insall became
the international spokesman based on scientificfi
information and clinical reports to defend poste-
Posterostabilized TKA: advantages and disadvantages 719
rior cruciate substitution against the proponents
of posterior cruciate retention (40). ThThe fears of
loosening and early failure in this semiconstrained
implant, as announced by the contrarians, never
materialized (40).
The choice of scarifying the PCL or not is still a
debate among the world of surgeons. Insall “fel-
lows” around the world are advocating the reli-
ability of PS TKA results. Arguments for a PS-TKA
design are biomechanical, surgical, and clini-
cal and even there is no defi finitive strong scien-
tifi
fic evidence for PS-TKA, results are more than
encouraging. New MIS instrumentation, mobile-
bearing surface, gender implants and fixation
fi
techniques, new bearing surfaces are others bias
that make the comparison harder between the dif-
ferent type of implants. Furthermore, more sen-
sitive tools are required to identify smaller clini-
cal or proprioceptive differences
ff and more work
should be done concerning this point. In another
hand, new solutions to conserve both ligaments
and more bone and not only the PCL have also
been proposed and may be back into the debate
during the next years. Almost 30 years after its
introduction, fact is that PS-TKA was a major step
in the story of TKA.
References
1. Scott WN (2006) Surgery of the knee. In: Scott, Insall (ed.)
Surgery of the knee
2. Insall JN, Binazzi R, Soudry M, Mestriner LA (1985) Total
knee arthroplasty. Clin Orthop Relat Res 13–22
3. Insall JN, Lachiewicz PF, Burstein AH (1982) The poste-
rior stabilized condylar prosthesis: a modification
fi of the
total condylar design. Two to four-year clinical experience.
J Bone Joint Surg Am 64:1317–1323
4. Kadoya Y, Kobayashi A, Komatsu T, et al. (2001) Effectsff of
posterior cruciate ligament resection on the tibiofemoral
joint gap. Clin Orthop Relat Res 210–217
5. Victor J, Bellemans J (2006) Physiologic kinematics as a
concept for better flexion in TKA. Clin Orthop Relat Res
452:53–58
6. Nagura T, Otani T, Suda Y, et al. (2005) Is high fl flexion
following total knee arthroplasty safe?: evaluation of
knee joint loads in the patients during maximal flexion.
fl J
Arthroplasty 20:647–651
7. Sharma A, Komistek RD, Scuderi GR, Cates HE Jr (2007)
High-flflexion TKA designs: what are their in vivo contact
mechanics? Clin Orthop Relat Res 464:117–126
8. Argenson JN, Komistek RD, Mahfouz M, et al. (2004) A
high flexion total knee arthroplasty design replicates
healthy knee motion. Clin Orthop Relat Res. 174–179
9. Argenson JN, Parratte S, Ashour A, et al. (2008) Patient-
reported outcome correlates with knee function after a
single-design mobile-bearing TKA. Clin Orthop Relat Res
466:2669–2676
10. Dennis DA, Komistek RD, Mahfouz MR, et al. (2005)
Mobile-bearing total knee arthroplasty: do the polyethyl-
ene bearings rotate? Clin Orthop Relat Res 440:88–95
11. Dennis DA, Komistek RD, Scuderi GR, Zingde S (2007)
Factors affffecting flexion after total knee arthroplasty. Clin
Orthop Relat Res
720 Primary Total Knee Arthroplasty
12. Komistek RD, Argenson JN, Scuderi G, Mahfouz M (2006)
In vivo determination of knee kinematics into deep fl flex-
ion. 72nd Annual Meeting of the AAOS, Chicago
13. Victor J, Ries M, Bellemans J, et al. (2007) High-flexion,
fl
motion-guided total knee arthroplasty: who benefits fi the
most? Orthopedics 30:77–79
14. Argenson JN, Parratte S, Flecher X (2005) Minimally inva-
sive total knee arthroplasty. Rev Chir Orthop Reparatrice
Appar Mot 91:28–30
15. Parratte S, Pagnano MW (2008) Instability after total knee
arthroplasty. J Bone Joint Surg Am 90:184–194
16. Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ
(1998) Flexion instability after primary posterior cruciate
retaining total knee arthroplasty. Clin Orthop Relat Res
39–46
17. Clarke HD, Fuchs R, Scuderi GR, et al. (2005) Clinical
results in valgus total knee arthroplasty with the «pie
crust» technique of lateral soft tissue releases. J Arthro-
plasty 20:1010.
18. Clarke HD, Schwartz JB, Math KR, Scuderi GR (2004) Ana-
tomic risk of peroneal nerve injury with the «pie crust»
technique for valgus release in total knee arthroplasty. J
Arthroplasty 19:40–44
19. Nuelle DG, Mann K (2007) Minimal incision protocols for
anesthesia, pain management, and physical therapy with
standard incisions in hip and knee arthroplasties: the
eff
ffect on early outcomes. J Arthroplasty 22:20–25
20. Brassard MF (2006) Surgery of the knee. In: Scott, Insall
(ed.) Surgery of the knee. pp 1745–1760
21. Yoshiya S, Matsui N, Komistek RD, et al. (2005) In vivo
kinematic comparison of posterior cruciate-retaining
and posterior stabilized total knee arthroplasties under
passive and weight-bearing conditions. J Arthroplasty
20:777–783
22. Montgomery RL, Goodman SB, Csongradi J (1993) Late
rupture of the posterior cruciate ligament after total knee
replacement. Iowa Orthop J 13:167–170
23. Pagnano MW, Cushner FD, Scott WN (1998) Role of the
posterior cruciate ligament in total knee arthroplasty. J
Am Acad Orthop Surg 6:176–187
24. Dennis DA, Komistek RD (2005) Kinematics of mobile-bear-
ing total knee arthroplasty. Instr Course Lect 54:207–220
25. Vail TP, Lang JE (2006) 84: Surgical techniques and instru-
mentation in total knee arthroplasty in surgery of the
knee. Churchill Livingstone Elsevier, Philadephia, PA, pp
1455–1521
26. Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale
of the Knee Society clinical rating system. Clin Orthop
Relat Res 13–14
27. Ornetti P, Parratte S, Gossec L, et al. (2007) Cross-cultural
adaptation and validation of the French version of the
Knee injury and Osteoarthritis Outcome Score (KOOS) in
knee osteoarthritis patients. Osteoarthr Cartil
28. Roos EM, Lohmander LS (2003) The Knee injury and
Osteoarthritis Outcome Score (KOOS): from joint injury
to osteoarthritis. Health Qual Life Outcomes1:64
29. Sharkey PF, Hozack WJ, Booth RE Jr, et al. (1992) Poste-
rior dislocation of total knee arthroplasty. Clin Orthop
Relat Res 128–133
30. Schwab JH, Haidukewych GJ, Hanssen AD, et al. (2005)
Flexion instability without dislocation after posterior sta-
bilized total knees. Clin Orthop Relat Res 440:96–100
31. Sierra RJ, Cooney WPt, Pagnano MW, et al. (2004) Reop-
erations after 3200 revision TKAs: rates, etiology, and les-
sons learned. Clin Orthop Relat Res 200–206
32. Jacobs WC, Clement DJ, Wymenga AB (2005) Reten-
tion versus sacrififice of the posterior cruciate ligament in
total knee replacement for treatment of osteoarthritis
and rheumatoid arthritis. Cochrane Database Syst Rev
CD004803
33. Piriyaprasarth P, Morris ME (2007) Psychometric proper-
ties of measurement tools for quantifying knee joint posi-
tion and movement: a systematic review. Knee 14:2–8
34. Stiehl JB, Voorhorst PE, Keblish P, Sorrells RB (1997)
Comparison of range of motion after posterior cruciate
ligament retention or sacrifi fice with a mobile bearing total
knee arthroplasty. Am J Knee Surg 10:216–220
35. Maloney WJ, Schurman DJ (1992) The Th eff
ffects of implant
design on range of motion after total knee arthroplasty.
Total condylar versus posterior stabilized total condylar
designs. Clin Orthop Relat Res 147–152
36. Hirsch HS, Lotke PA, Morrison LD (1994) The posterior
cruciate ligament in total knee surgery. Save, sacrifice,
fi or
substitute? Clin Orthop Relat Res 64–68
37. Kim YH, Choi Y, Kwon OR, Kim JS (2009) Functional out-
come and range of motion of high-flexion fl posterior cru-
ciate-retaining and high-flexion
fl posterior cruciate-substi-
tuting total knee prostheses. A prospective, randomized
study. J Bone Joint Surg Am 91:753–760
38. Dorr LD, Ochsner JL, Gronley J, Perry J (1988) Functional
comparison of posterior cruciate-retained versus cruciate-
sacrifi
ficed total knee arthroplasty. Clin Orthop Relat Res
36–43
39. Ishii Y, Terajima K, Koga Y, et al. (1998) Gait analysis after
total knee arthroplasty. Comparison of posterior cruciate
retention and substitution. J Orthop Sci 3:310–317
40. Scuderi GR, Scott WN, Tchejeyan GH (2001) The Insall leg-
acy in total knee arthroplasty. Clin Orthop Relat Res3–14

J.Y. Nordin, Guepar Group Conservation of posterior cruciate
ligament in fixed-bearing total knee
replacement
C
onservation of the posterior cruciate ligament
(PCL) in fixed-bearing total knee replace-
ment is still very controversial (30, 38). Th
The
following will be reviewed hereafter:
– anatomy, physiology, and presence of PCL in a
diseased knee joint;
– theoretical and practical advantages and draw-
backs of PCL retention;
– technical diffi
fficulties in cruciate-retaining total
knee arthroplasty;
– results of cruciate-retaining total knee replace-
ment (TKR).
Anatomy, physiology, and
presence of PCL in a diseased knee joint
PCL is the strongest ligament in the knee. It con-
sists of two bundles which originate from the
inferior portion of the lateral aspect of the medial
femoral condyle, within a curvilinear area. Th There
is more than 15 mm from the inferior portion of
this area to the cartilage rim of the condyle. PCL
is 38 mm long. Its tibial attachment begins on the
posterior surface of the proximal tibia and extends
to the superior portion of the popliteal surface
of the tibia, within the proximal most part of the
tibia (27). This
Th anatomic location allows reten-
tion of PCL insertions during the distal femoral
cut and proximal tibial cut. In cruciate-retaining
knee designs, the tibial cut is directed inferiorly
and posteriorly, reproducing the posterior slope of
the tibia while preserving the middle and posterior
portions of the PCL. Elasticity of the posterior cru-
ciate ligament has been studied by Kennedy (40)
who found that the percentage of elongation for
both bundles is 28.3% and 24% respectively. Race
and Amis (59) consider that PCL (length, 32.8
± 1.95 mm) is the knee ligament with the highest
ultimate strength; the maximum linear elongation
of its anterior bundle is 12.8 ± 5.9%. This elasticity
is a defi
finite advantage in total knee arthroplasty.
The PCL is tight in flexion and lax in extension.
Th
Biomechanically, the PCL acts in synergy with the
anterior cruciate ligament (ACL) and the lateral
Chapter 65
ligamentous structures. This role will inevitably be
aff
ffected by the absence of the ACL as illustrated by
Freeman (25): cruciates are like the two shanks of
scissors which cannot work independently. In flex- fl
ion, it prevents posterior translation of the tibia
and promotes femoral rollback on the tibia, thus
increasing quadriceps lever arm. It further acts as
a joint stabilizer in the AP plane, mainly in flflexion,
in cases where the lateral ligamentous structures
are overstretched (56). Resection of the PCL brings
the collateral ligaments to a more vertical position
and increases the joint space (more in flexion:
fl 2 to
4 mm on average, than in extension).
Whereas the ACL is often absent or deficient fi in
degenerative, infl flammatory or post-traumatic
knee pathologies amenable to total knee replace-
ment, it must be pointed out that in Scott’s series
(1982), the PCL was present in 99% of the knees,
and in Aubriot’s series, it was normal in 71% of the
knees or subnormal in 22%. Even in rheumatoid
patients, Sledge and Walker (37) found functional
posterior cruciate ligaments in more than 2,000
knees; only in 3 cases the PCL was absent, and in
other 3 cases it had to be sacrificed
fi to correct an
irreducible flexion
fl contracture.
The mechanical benefi fits of PCL in knees with
degenerative or infl flammatory joint disease are
very much debated. The impact of ageing of PCL
has been emphasized by Aglietti, Caton, and Gout-
allier (28) who noted histological changes to the
PCL whenever the ACL was defi ficient or absent,
which is generally the case in these pathologies.
However, this criticism should also apply to col-
lateral ligaments, and yet, their function as post-
operative stabilizers of knee prostheses has never
been called into question.
Theoretical and practical advantages
and drawbacks of PCL retention
Retention of the PCL has many theoretical advan-
tages:
– The PCL promotes femoral rollback which results
in increased flexion, provided that physiological
722 Primary Total Knee Arthroplasty
conditions are good and implant design, par-
ticularly the tibial component, is appropriate. It
further increases the quadriceps lever arm by 20
to 30%, which increases knee extension power
that is particularly useful where prior patellec-
tomy has been performed. However, Huang (35)
and Bolanos (12) did not note any difference
ff in
muscle power between cruciate-retaining and
cruciate-sacrifi
ficing prostheses;
– The PCL takes up most of shear forces in flex-
ion, thus decreasing the amount of shear forces
transferred to the prosthesis and, of course, to
the bone-cement interface, which reduces the
potential for loosening;
– According to Andriacchi (2) and as suggested by
the works of Mihalko, Miller and Krackow (53,
54) on fresh cadaver specimens, PCL maintains
a balanced flexion space at 90° and increases AP
stability of the prosthetic knee. Once ACL and
menisci have been excised and one centimeter of
the proximal tibia has been resected, resection
of the PCL results in increased flexion gap at 90°
with a mean distraction space of 5.26 ± 1.9 mm;
The PCL is a very important stabilizer of the
knee in the AP plane. Th This is confifirmed by the
fact that after release of the medial ligamentous
structures and resection of the PCL, valgus lax-
ity is 6.9° in extension and 13.4° at 90° of flexion.
fl
In contrast, when the PCL is retained, the same
release will only result in 5.2° of laxity in exten-
sion and 8.7° in flexion. Similarly, after release of
the lateral ligamentous structures and resection
of the PCL, varus laxity is 8.9° in extension and
18° in flexion, whereas when the PCL is retained,
the same release produces only 5.4° of laxity in
extension and 4.9° at 90° of flexion. Therefore,
the PCL acts as a third centrally positioned col-
lateral ligament that limits varus-valgus move-
ments (1) mainly in flexion,
fl but also in extension,
which likely explains the low rate of postopera-
tive instability in cruciate-retaining total knee
arthroplasty, except in the rare instances where
capsuloligamentous structures on the convex side
are severely overstretched;
– The PCL prevents posterior translation of the
tibia in flexion (posterior drawer) since it is tight
in flexion;
– The PCL helps maintain the instant center of
rotation and therefore automatic external rota-
tion and patellar tracking;
– The PCL resists lateral lift-off
ff of the tibial com-
ponent when loaded in flexion,
fl and varus shift
in a correctly aligned knee. As a result, stresses
on the medial tibiofemoral compartment and at
the tibial bone-cement prosthesis interface are
reduced. If large contact areas are maintained,
there is no increase in stresses on the PE tibial
bearing or PE tibial component;
– Retention of the PCL improves knee propriocep-
tion. As a matter of fact, although Barrett (5),
Franchi (24), and then Fuchs (26) claimed that
the number of receptors in the posterior cruci-
ate ligament is reduced in the elderly and even
lower in the arthritic patient, Del Valle (16) dem-
onstrated in his immuno-histochemical analysis
the presence of mechanoreceptors in PCL even
in arthritic patients. Warren (77) emphasized
the role of PCL in knee proprioception, contrary
to Cash (14), Lattanzio (45), Simmons (65),
and Laskin (43) in rheumatoid knees. In spite
of these confl flicting opinions, it seems logical to
consider that maintenance of proprioception,
even attenuated, is far more preferable to loss of
proprioception from resection of the PCL.
Knee replacement must provide restoration of the
preoperative PCL tension and native ligament’s ori-
entation. This is why the geometry of components
is of paramount importance. Walker and Garg (75)
showed that a taut PCL leads to decreased flexion,
and that some factors improve fl flexion. The most
important factor, as emphasized by Whiteside
(79), is restoration of the preoperative posterior
tibial slope. Singerman (66) also stressed its influ-fl
ence on PCL strain and its impact on flexion,
fl even
with variations as small as 5-8°. Conversely, severe
increase in the tibial slope may lead to anterior sub-
luxation of the tibia if the ACL is absent (according
to Migaud [52]), and to severe wear of the posterior
aspect of the tibial component (according to Besson
[10]). Booth (11) pointed out the significant
fi infl
flu-
ence of postoperative joint line level on PCL func-
tion: any change greater than 4 mm in the joint line
position is detrimental to kinematics of a cruciate-
retaining knee prosthesis, whereas a posterior sta-
bilized prosthesis can cope with a change greater
than 8 mm. One easily understands the critical
importance of using a rigorous surgical technique
and accurate instruments. Emodi (21) also agrees
with this. However, restoring PCL to normal ten-
sion is diffi
fficult. Incavo (36), in his cadaver study,
achieved restoration of adequate tension and near
normal femoral rollback in only 2 out of 8 cases,
whereas Mahoney (48) did not. Kim’s analysis (41)
is in agreement with this. Udomkiat (69) achieved
restoration of a physiological femoral rollback in
only 2 out of 10 cases in cruciate-preserving total
knee arthroplasty, and noted anterior translation
of the femur during fl flexion in the other cases.
Excessive PCL tightness causes anterior sublux-
ation and anterior lift-off ff of the trial tibial com-
ponent; Ritter (60), Worland (83), Arima (4),
Hofmann and Pace (31), as well as Whiteside (78)
suggested partly releasing the PCL to preserve
the benefifits of cruciate retention. In contrast, in
Besson’s study (10) involving 44 Miller Galante
cruciate-retaining prostheses, posterior laxity was
 Conservation of posterior cruciate ligament in fixed-bearing total knee replacement 723
evaluated using Telos™ arthrometer, and func-
tional results were compared with those in a con-
trol series; the conclusion was that where the PCL
is not tight enough and posterior laxity is equal
to or greater than 5 mm, an average of 9.8 points
decrease in the HSS score is noted.
To achieve all this, particularly restoration of near
normal knee kinematics using the adaptive capac-
ity of the PCL within physiological limits, and
despite the absence of the ACL, the design of the
prosthesis must be well thought out and feature
a truly diverging femoral component, and a tibial
component that is asymmetric in all three planes
(17, 68, 70, 71). One cannot evaluate the results
of a cruciate-retaining TKR and possibly compare
them with those of other knees, not knowing its
design (i.e., tibiofemoral and patellofemoral joint
design and contact areas).
One of the drawbacks of PCL retention is a poten-
tial ineffi
fficiency or secondary failure which some-
times leads to instability and pain.
Laskin (43) compared the results achieved in three
series of total knee replacements with a mean
follow-up of 8.2 years (minimum, 6 years). The Th
first series consisted of 98 knees with rheumatoid
fi
arthritis (RA) managed with cruciate-retaining
TKRs. The second series consisted of 80 RA knees
managed with posterior stabilized TKRs, and the
third one included 599 arthritic knees (OA knees)
managed with cruciate-retaining TKRs. In the first
fi
series, there was more than 10 mm of posterior
laxity in 50% of the knees and recurvatum in 13%.
In the second series, there was more than 10 mm
of posterior instability in 1% of the knees, but no
recurvatum. In the third series, there was more
than 10 mm of posterior laxity in 14% of the knees
and recurvatum in 0.2%. This study suggests that
PCL attrition occurs and may lead to secondary
rupture; attrition is more signifificant in RA knees
than in OA knees, whereas posterior stabilized
prostheses prevent recurvatum while minimizing
potential for posterior laxity.
In one of his presentations during a SOFCOT
meeting, Huten also emphasized the potential for
secondary laxity with Wallaby 1 cruciate-retaining
total knee prostheses, particularly in rheumatoid
patients.
Montgomery and Goodman (55), in 150 cruciate-
retaining total knee arthroplasties, reported 3 sec-
ondary ruptures of the PCL leading to instability.
Shai’s study (63) involved 61 press-fit fi cruciate
retaining total knee replacements in 38 patients,
with a mean follow-up of 11 years. No patient was
lost to follow-up. 14 patients died. Results suggest
a very mild impairment of the PCL function: 1 knee
had 5° of hyperextension with occasional instabil-
ity, and 4 asymptomatic knees had 3° of hyperex-
tension. Two knees were revised, one for synovec-
tomy, and the other one for a patellar problem, but
none for posterior instability.
Practical advantages of PCL retention
– In the majority of cases, retention of the PCL
allows maintenance of the joint line level, pro-
vided that the amount of bone removed from
the distal femur corresponds to the thickness of
the prosthetic condyles, thus avoiding the risk of
patella baja as often seen in posterior stabilized
TKA.
– Decreased tightness of collateral ligaments in
flexion as compared to PCL-sacrifi ficing TKA.
– Lower incidence of instability and prosthetic dis-
location than in posterior stabilized TKA (34, 46,
64, 76).
– Patellar clunk syndrome (8, 47) which is due to
wedging of a suprapatellar fi fibrous nodule into
the intercondylar notch is only exceptionally
observed in cruciate-retaining TKA, whereas the
rate of occurrence in posterior stabilized TKA
ranges from 1 to 3.5%.
– The design of the femoral component usually
makes it possible to perform retrograde femoral
nailing for treatment of a supracondylar fracture
(a currently very popular technique for treatment
of fractures after total knee arthroplasty).
– Krackow (42) claimed that retention of the PCL
simplifi fies soft tissue balancing since in TKA
indications, its length is almost unchanged and
can be used as a reference for ligament balanc-
ing, thus avoiding notable changes to the joint
line. But this assumption was questioned by
Sorger (67).
– As regards in vivo analysis of knee kinemat-
ics, Andriacchi’s study (in 1982) (1) showed the
advantage of retaining the PCL for stair climbing,
which was confi firmed in Dorr’s study (20) in 1988.
Kelman (39) showed the advantage of retaining
the PCL both for stair climbing and stair descend-
ing. Migaud (51) studied in 1995 the behaviour
of 19 total knee replacements of four differentff
designs (Hermes which retains both cruciates,
Osteonics which retains the PCL and has a rela-
tively constrained tibial component, Miller Gal-
ante which retains the PCL and has a flat tibial
design, IBS posterior stabilized total knee pros-
thesis). His results show that retention of both
cruciates does not have any positive influence
fl on
knee kinematics (particularly automatic external
rotation), and that prostheses which retain the
PCL provide higher flexion ROM during walking
and stair climbing/descending than those which
sacrifi
fice the PCL, although the diff fference is not
significant.
fi
724 Primary Total Knee Arthroplasty
Technical diffi
fficulties in cruciate-retaining
total knee arthroplasty
As Hungerford and Krackow with the PCA knee and
Whiteside with his own designs, for many years,
surgeons of the Guepar Group have tremendously
expanded the indications for PCL retention.
In a knee with mild bone deformity and good
range of motion, the femoral cuts are generally
performed before the tibial cut. The Th distal femo-
ral cut is referenced offff the more prominent distal
condyle and removes an amount of bone that cor-
responds to the thickness of the femoral compo-
nent. The posterior femoral cut is referenced off ff the
anterior surface of the distal femur, in the supratro-
chlear area. Owing to the off ffset design of femoral
components, the amount of bone removed from
the posterior femoral condyles corresponds exactly
to the thickness of the posterior part of the femoral
component, which places the femoral component in
external rotation. Some cutting guides are designed
to provide a 3° externally rotated femoral cut. Oth-
erwise, the amount of external rotation depends on
anatomic conditions; in a valgus knee, there will be
a necessary trade-off ff between the Whiteside line,
the transepicondylar axis, the posterior condyle
line, and even the tibial cut (in cases where the tib-
ial cut has been performed first
fi to balance the knee
in fl
flexion). The tibial cut slopes posteriorly between
3° and 5°, rarely 7°, to reproduce the preoperative
posterior tibial slope of the patient’s knee.
An irreducible varus deformity is generally not
a problem; as a matter of fact, convex-side laxity is
a rare occurrence. In knees with severe fixed
fi varus
deformities, after release of superficial
fi MCL from
its tibial attachment in continuity with the perios-
teum, hamstring tendons, semimembranosus and
posteromedial corner, possibly the posterome-
dial capsule, and exceptionally, the popliteus and
soleus arch, the PCL may be overly tensioned and
restrict range of motion. Some authors suggested
performing true PCL lengthening. As a matter of
fact, in our technique, we often perform partial
release of the anterior fibers of the PCL at the tibia
at the same time as we remove the resected tibial
bone fragment. We do not systematically try to
keep a small island of bone to protect the proximal
anterior insertion of the PCL. This reduces the risk
of complete detachment of the ligament or frac-
ture-avulsion of the distal insertion of the PCL.
But on the other hand, in flexion, the PCL loses the
“refl
flection pulley” formed by this bony island. The
tibial cut is performed with reference to the lateral
tibial condyle. Reconstruction of the medial bone
loss is sometimes necessary to preserve integrity
of the PCL fibers; this is performed using bone
grafts, a metal augment, or even cement if it is a
small-size bone defect.
An irreducible valgus deformity is technically
challenging, particularly if there is convex-side lax-
ity. In the most severe cases, a lateral approach is
used (Keblish technique). One critical technical
point is reconstruction of the knee with reference
to the medial tibiofemoral compartment. Lateral
release procedures which used to be performed
during the first surgical step are now performed
in two stages: mild release at the beginning of the
procedure, adjusted according to the tests per-
formed in extension and flexion; fine-tuning after
insertion of the trials. Release of lateral capsulo-
ligamentous structures involves the tensor fascia
lata which is released from its insertion on Gerdy’s
tubercle, taking care to maintain continuity with
the fascia of the leg; it is rarely lengthened by mak-
ing multiple incisions or so-called scarifications,
fi
or a true Z lengthening at the distal thigh. Release
of the LCL and popliteus, more rarely the biceps
femoris and lateral capsule, is necessary, espe-
cially if one selectively evaluates the structures
which prevent correction of the valgus deformity
in extension and flexion. Burdin’s technique (13) is
eff
ffective in relieving tension on the LCL and popli-
teus through release of their combined insertion
attached to a bone block that is moved to the cuta-
neous aspect of the lateral femoral condyle and
fixed with a screw, after correction of the valgus
deformity.
The distal femoral cut is equal to the thickness of
the prosthetic condyles and is referenced off ff the
medial femoral condyle. The Th posterior femoral cuts
are performed, based on the previously mentioned
criteria. The lateral tibial condyle may need to be
reconstructed with bone grafts or a metal aug-
ment. Sometimes, in severe valgus deformities,
distal and even posterior femoral bone defects
also need to be reconstructed on the lateral side,
since the distal femoral cut is referenced off ff the
medial femoral condyle and removes an amount of
bone that is equal to the thickness of the femoral
component. Whiteside (80) made a publication in
1999 in which he claimed that in 231 knees with
valgus deformities of up to 45°, 13 only could not
be managed with a cruciate-retaining prosthesis
and received a posterior stabilized implant. He fur-
ther emphasized that in valgus deformities greater
than 25°, tibial and femoral bone grafts were used
in many cases, 100% of the time sometimes in the
most severely affected
ff knees.
One of the major issues when implanting a cruci-
ate-retaining TKR in a severe fixed valgus defor-
mity is overstretching of the medial capsuloliga-
mentous structures which may require tightening
of the superfi ficial MCL, using various tricks such
as: bone block with the attached femoral inser-
tion of PCL, reattached and secured with screws or
staples; tightening of MCL on the proximal tibia;
 Conservation of posterior cruciate ligament in fixed-bearing total knee replacement 725
suturing of MCL using the overlapping technique.
But of course, despite the stabilizing effect
ff of the
PCL, all these techniques carry a risk of secondary
laxity. In view of the diffi
fficulty to correct a valgus
deformity after extensive lateral release, and the
risk of secondary laxity, surgeons often prefer to
use a posterior stabilized knee (more or less con-
strained) rather than a cruciate-retaining knee.
In flexion contractures greater than 25°,
restoration of full extension may require more
than simple capsular release, resection of poste-
rior osteophytes, and a thicker distal femoral cut
flush with the condylar insertions of the PCL. In
this situation, rather than lengthening the PCL (a
possible option), implanting a posterior stabilized
prosthesis seems more appropriate (11).
It must be reminded that PCL retention requires
careful assessment of its status: if too lax, a thicker
tibial insert must be used; if too tight, it must be
released, at least partly. Should rupture or detach-
ment of the PCL occur intraoperatively, an ultra-
congruent tibial insert (32) can be used in prefer-
ence to a posterior stabilized prosthesis.
In conclusion, we can say that, most of the time,
PCL retention is technically possible in total knee
arthroplasty. In knees with severe fixed valgus
deformities, particularly with overstretched medial
capsuloligamentous structures, in knees with fi fixed
varus deformities, and in knees with fl flexion con-
tractures greater than 25°, the use of a posterior
stabilized prosthesis is more reasonable and some-
times necessary (Pereira [58]).
Results of cruciate-retaining
total knee replacement
To be in a position to support PCL retention, one
must keep in mind the excellent results reported
in Insall’s series of cruciate-sacrifi
ficing TKRs which
are the “gold standard” in total knee arthroplasty.
The published results of some series of cruciate-
retaining TKRs show survivorship rates and good/
very good results which compare favourably with
those in cruciate-sacrifificing TKRs:
– AGC (Anatomic Graduated Components): Med-
ing (44) published in 2001 the 10-year results of
387 TKRs with a tibial insert only 4.4 mm thick.
Using revision or loosening as the endpoint, the
survivorship rates were 98.7%, 95.4%, and 94.3%
at 5 years, 10 years, and 15 years, respectively;
– Vazquez-Vela Johnson (72) studied patient
demographics as a predictor of the ten years sur-
vival rate in 562 primary TKRs implanted from
November 1986 to September 1990. Th The overall
results showed a survival of 96.8% at 14 years
with 1.44% lost to follow-up. The Th best results
were seen in nonobese women with osteoarthri-
tis who were less than 60 years of age in whom
there was 10 years follow-up of 99.4%; the worst
results were observed in obese men with osteoar-
thritis who were less than 60 years: 10 years sur-
vival of 35.7%;
– Berend and Ritter (7) highlighted 4 distinct fail-
ures mechanisms in tibial component revision
after reporting a survival rate of this implant of
98.9% at 10 and 15 years with no knees revised
for PE wear or osteolysis;
– Meding (50) published a series of 212 TKR in
rheumatoid arthritis. Excluding infections and
failed metal-backed patellas the survival rate
at 10, 15 and 20 years were 99.5%, 97.9% and
96.5% respectively;
– GENESIS: Laskin (44) studied 100 total knee
replacements for treatment of osteoarthritis,
with a 10-year follow-up. TheTh PCL was excised
in 44 knees for combined fl flexion contracture
and frontal deviation greater than 15-20°. The Th
survivorship rate was 96% in cruciate-retaining
TKRs, with a mean ROM of 117°, 76% of excel-
lent results, and 20% of good results. In con-
trast, the 56 cruciate-sacrifi
ficing posterior stabi-
lized TKRs had a survivorship of 97%, with 114°
of flexion, 75% of excellent results, and 23% of
good results;
– KALI (Guepar Group): in a series of 698 TKRs,
using all indications for revision surgery, except
sepsis, as the endpoint, the survivorship rates
were 96%, 90% and 86% at 10 years, 12 years,
and 15 years, respectively;
– KINEMATIC: In 1998, Ansari (3) reported the
results achieved in 445 TKAs: survivorship rate
was 96% at 10-year follow-up, using revision or
indication for revision as the endpoint; there
were 84% of excellent and good results (accord-
ing to the HSS score); mean ROM was 100°. In
1999, Ewald (19) evaluated the results of 306
TKRs with a mean follow-up of between 10 and
14 years: the survivorship rate was 96%, and
there were 81.3% of excellent and good results. In
2001, Sextro (62) published the 15-year results
of 168 Kinematic I knees implanted at the Mayo
Clinic: mean HSS score was 87.9; the survivor-
ship rate was 88.7% (excluding infections), and
mean flexion was 106°;
– KINEMAX: Wright (84) reported a series of 523
knees which had primary TKR between Janu-
ary 1988 and April 1991. The mean age of the
patients at time of the surgery was 69 years. The
Th
probability of survival at 10 years was 96.1%
with revision for any reason as the end point and
97.2% when only aseptic failures were consid-
ered;
– MILLER GALANTE: Berger (9) compared 172
Type I TKRs with a mean follow-up of 11 years
726 Primary Total Knee Arthroplasty
versus 109 Type II TKRs with a 9-year follow-up.
The difffferences essentially involved the tibiofem-
oral compartment and resulted in an increase
in the 10-year survivorship rate from 84.1% to
100%. This shows that sometimes the outcome
of total knee arthroplasty is not related to reten-
fice of the PCL;
tion or sacrifi
– NATURAL KNEE: Hoff ffman (32) reported a series
of 176 uncemented prostheses out of 300 TKRs
with a mean follow-up of 12 years. Th The survivor-
ship rate, including revision for infection and
simple tibial insert replacement, was 93.4%, or
95.1% when excluding these two criteria; mean
flexion was 120°;
fl
– ORTHOLOC I (porous coated knee, without met-
al-backed patellar component): in 2001, White-
side (81) reported a survivorship rate of 98.6% at
18-year follow-up in a series of 265 prostheses, 5
of which had been lost to follow-up. Mean flexion
fl
was 112°;
– PRESS FIT CONDYLAR CRUCIATE RETAINING:
• Rodricks (61) reported 160 consecutive TKRs
with this device implanted between 1986 and
1989 with mean age of the patients being 70.5
years at the time of index procedure. At mean
of 15.8 years the overall survival rate of the
knee was 91.5% with revision for any reason
and 97.2% with aseptic loosening as estimate
the end point;
• Fehring (23) studied the factors infl fluencing
wear and osteolysis in this type of prosthesis.
For the 1,287 of 2,016 knees with more than 5
years follow-up, the prevalence of wear-related
failure was 8.3%. The 13-year survivorship for
all patients was 82.6%. It was impossible to
identify one factor as the defi fining reason for
these wear-related failures;
• Dixon (19) reported a consecutive series of 139
TKAs performed by one surgeon. Th The survival
rate without revision or a need for any reopera-
tion was 92.6% at 15 years;
• Vessely (73) reviewed 1,008 consecutive TKRs
from January 1987 to August 1989. Mean fol-
low-up of living patients with their TKA com-
ponents in situ (244 patients, 331 knees) was
15.7 years. Survivorship at 15 years for revision
for any reason, revision for mechanical failure,
and revision for aseptic loosening were 95.9%,
97.0%, and 98.8% respectively;
– PROFIX Cementless: Hardeman (29) reported a
consecutive series of 115 TKRs. The estimate of
implant survival at 10 years was 97.1%;
– TOTAL CONDYLAR (cruciate-retaining design):
Ritter (60) evaluated a series of 394 prostheses
followed for 1 to 18 years (mean, 8 years): the sur-
vivorship rate was 96.8% at 12-year follow-up;
– WALLABY I (assymetrical and divergent femoral
condyles as well as asymmetrical plateaus): Wit-
woët and GUEPAR (82) evaluated the results of a
prospective series of the first 425 TKRs implanted
from December 1992 to February 1995. Mean
patient age at implantation was 70.5 years. 315
prostheses were followed for more than 5 years
(5-9 years) with mean follow-up of 6.3 years.
Prosthesis survival at 8 years was 97.7% con-
sidering all reasons for prosthesis removal and
98.5% for removal for aseptic loosening.
Dejour (15), Pagnano (57), Vinciguerra (74), pub-
lished comparative studies of two series of cruci-
ate-retaining and cruciate-sacrifi ficing prostheses.
The clinical and/or radiological results did not
show any significant
fi diff
fference in favor of cruciate-
retaining prostheses. Becker’s study (6) involving
30 patients with a cruciate-retaining prosthesis on
one side and a cruciate-substituting prosthesis on
the contralateral side, did not show any significant
fi
diff
fference at 5-year follow-up.
Conclusion
Retaining or sacrifificing the PCL is above all a mat-
ter of personal convictions, and practical and theo-
retical benefi
fits, most of which have not been con-
tradicted by clinical experience despite paradoxical
anterior femoral translation during deep flexion
fl
commonly observed by Dennis and Komistek (18)
in PCL staring, TKA. Although the retained PCL
does not consistently reproduce the femoral roll-
back on the tibia, it seems to decrease the incidence
of prosthetic instability. On the other hand, PCL
retention carries the risk, although rare, of second-
ary rupture. Difffferent views regarding retention or
sacrifi
fice of the PCL in fixed-bearing knee designs
are perfectly acceptable, even though from a tech-
nical standpoint, almost every knee is amenable to
cruciate-retaining TKA if performed by a surgeon
who has enough experience to expand its indica-
tions.
But a longer follow-up will be necessary to check
the validity of the cruciate-retaining option, par-
ticularly as regards quality of fixation and polyeth-
ylene wear, provided that prosthetic components
have an appropriate design.
References
1. Andriacchi TP, Galante JO, Fermier RW (1982) The Th infl
flu-
ence of total knee replacement design on walking and stair
climbing. J Bone Joint Surg 64-A:1328-35
2. Andriacchi TP, Galante JO (1988) Retention of the poste-
rior cruciate in total knee arthroplasty. J Arthroplasty 3
oct suppl. 13-9
3. Ansari S, Ackroyd CE, Newman JH (1998) Kinematic pos-
terior cruciate ligament-retain total knee replacements. A
ten-year survivorship study of 445 arthroplasties. Am J
Knee Surg 11 (1):9-14
 Conservation of posterior cruciate ligament in fixed-bearing total knee replacement 727
4. Arima J, Whiteside LA, Martin JW et al. (1998) Effect ff of
partial release of the posterior cruciate ligament in total
knee arthroplasty. Clin Orthop 353:194-202
5. Barrett DS, CobbAG, Bentley G (1991) Joint propriocep-
tion in normal osteoarthritic and replaced knees. J Bone
Joint Surg 73-B:53-6
6. Becker MW, Insall JN, Faris PM (1991) Bilateral total knee
arthroplasty. One cruciate retaining and one cruciate sub-
stituting. Clin Orthop 271:122-4
7. Berend ME, Ritter MA, Meding JB et al. (2004) Tibial
component failure mechanisms in total knee arthroplasty.
Clin Orthop Relat Res Nov (428):26-34
8. Beight JL, Binnan Yao, Hozack WJ et al. (1994) The patel-
lar clunk syndrome after posterior stabilized total knee
arthroplasty. Clin Orthop 299:139-42
9. Berger RA, Rosenberg AG, Barden RM et al. (2001) Long-
term follow-up of the Miller-Galante total knee replace-
ment. Clin Orthop 388:58-67
10. Besson A, Brazier J, Chantelot C et al. (1999) Laxity and
functional results of Miller-Galante total knee prosthesis
with posterior cruciate ligament sparing after a 6-year fol-
lowup. Rev Chir Orthop 85:797-802
11. Booth RE Jr (1999) The price of PCL retention in TKA is
too high. Orthopedics 12:1125
12. Bolanos AA, Colizza WA, McCann PD et al. (1998) A com-
parison of isokinetic strength testing and gait analysis in
patients with posterior cruciate-retaining and substitut-
ing knee arthroplasties. J Arthroplasty 13:906-15
13. Burdin P (1996) L’équilibre ligamentaire dans les pro-
thèses de genou. Ann Orthop Ouest 28:19-30
14. Cash RM, Gonzalez MH, Garst J et al. (1996) Propriocep-
tion after arthroplasty: role of the posterior cruciate liga-
ment. Clin Orthop 331:172-8
15. Dejour D, Deschamps G, Garotta L et al. (1999) Laxity in
posterior cruciate sparing and posterior stabilized total
knee prostheses. Clin Orthop 364:182-93
16. Del Valle ME, Harwin SF, Maestro A et al. (1998) Immuno-
histochemical analysis of mechanoreceptors in the human
posterior cruciate ligament: a demonstration of its prop-
rioceptive role and clinical relevance. J Arthroplasty 13,
8:916-22
17. Dennis DA, Komistek RD, Colwell CE et al. (1998) In
vivo anteroposterior femorotibial translation of total
knee arthroplasty: a multicenter analysis. Clin Orthop
356:47-57
18. Dennis DA, Komistek RD, Mahfouz MR et al. (2003) Multi-
center determination of in vivo kinematics after total knee
arthroplasty. Clin Orthop Relat Res Nov (416):37-57
19. Dixon MC, Brown RR, Parsch D et al. (2005) Modular
fixed-bearing total knee arthroplasty with retention of
the posterior cruciate ligament. A study of patients fol-
lowed for a minimum of fifteen years. J Bone Joint Surg
Am March 87(3):598-603
20. Dorr LD, Ochsner JL, Gronley J et al. (1988) Functional
comparison of posterior cruciate-retained versus cruciate-
sacrifi
ficed total knee arthroplasty. Clin Orthop 236:36-43
21. Emodi GJ, Callaghan JJ, Pedersen DR et al. (1999) Pos-
terior cruciate ligament function following total knee
arthroplasty: the effect
ff of joint line elevation. Iowa Orthop
J 19:8292
22. Ewald FC, Wright RJ, Poss R et al. (1999) Kinematic total
knee arthroplasty: A 10 – to 14-year prospective follow-up
review. J Arthroplasty 14 (4):473-80
23. Fehring TK, Murphy JA, Hayes TD et al. (2004) Factors
infl
fluencing wear and osteolysis in press-fi
fit condylar mod-
ular total knee replacements. Clin Orthop 428:40-50
24. Franchi A, Zaccherotti G, Aglietti P (1995) Neural system
of the human posterior cruciate ligament in osteoarthri-
tis. J Arthroplasty 10:679-82
25. Freeman MA, Railton GT (1988) Should the posterior cru-
ciate ligament be retained or resected in condylar nonme-
niscal knee arthroplasty? The
Th case for resection. J Arthro-
plasty 3 Suppl: 3-12
26. Fuchs S, Thorwesten L, Niewerth S (1999) Proprioceptive
function in knees with and without total knee arthro-
plasty. Am J Phys Med Rehabil 78:39-45
27. Girgis FG, Marshall JL, Al Monajem ARS (1975) The Th cruci-
ate ligaments of the knee joint. Clin Orthop 106:216
28. Goutallier D, Allain J, Le Mouel S et al. (1998) Évalua-
tion de l’état histologique du ligament croisé postérieur
en fonction de l’état macroscopique du ligament croisé
antérieur: Intérêt pour l’indication des prothèses con-
servant le ou les ligaments croisés. Rev Chir Orthop 84
suppl 2:30
29. Hardeman F, Vandenneucker H, Van Lauwe J et al. (2006)
Cementless total knee arthroplasty with Profix: fi a 8 – to
10-year follow-up study. Knee December 13(6):419-21;
Epub 2006 Oct 24
30. Hirsch HS, Lotke PA, Morrison LD (1994) The posterior
cruciate ligament in total knee surgery. Save, sacrifice,
fi or
substitute? Clin Orthop 309:64-8
31. Hofmann AA, Pace TB (1994) Cruciate ligament retention
in total knee arthroplasty. Knee surgery. Edited by Fu FH,
Harner CD, Vince KG. Williams & Wilkins. Vol 2:1313-20
32. Hofmann AA, Tkach TK, Evanich CJ et al. (2000) Poste-
rior stabilization in total knee arthroplasty with use of
an ultracongruent polyethylene insert. J Arthroplasty
15:576-83
33. Hofmann AA, Evanich JD, Ferguson RP et al. (2000) Ten
to 14-year clinical follow-up of the cementless natural
knee system. Clinical Orthopaedics 388:85-94
34. Hossain S, Ayeko C, Anwar M et al. (2001) Dislocation
of Insall-Burstein II modifi fied total knee arthroplasty. J
Arthroplasty 16:233-5
35. Huang CH, Lee YM, Liau JJ et al. (1998) Comparison of
muscle strength of posterior cruciate-retained versus
cruciate-sacrifi
ficed total knee arthroplasty. J Arthroplasty
13:779-83
36. Incavo SJ, Johnson CC, Beynnon BD et al. (1994) Poste-
rior cruciate ligament strain biomechanics in total knee
arthroplasty. Clin Orthop 309:88-93
37. Insall JN (1984) Surgery of the knee. Churchill Living-
stone New York, Edinburgh, London, and Melbourn
38. Insall JN (1998) Presidential adresss to the Knee Society.
Choices and compromises in total knee arthroplasty. Clin
Orthop 226:43-8
39. Kelman GJ, Biden EN, Wyatt MP et al. (1989) Gait labo-
ratory analysis of a posterior cruciate-sparing total knee
arthroplasty in stair ascent and descent. Clin Orthop
248:21-5
40. Kennedy JC, Hawkins RJ, Willis RB et al. (1976) Tension
studies of human knee ligament. J Bone and Joint Surg
(Am) 58:350-5
41. Kim H, Pelker RR, Gibson DH et al. (1997) Rollback in pos-
terior cruciate ligament-retaining total knee arthroplasty.
A radiographic analysis. J Arthroplasty 12:553-61
42. Krackow KA (1990) The surgical procedure of total knee
arthroplasty. In: Krakow KA (ed) Total Knee Arthroplaty.
CV Mosby, Philadelphia: 168-237
43. Laskin RS, O’Flynn HM (1997) The Th Insall Award. Total
knee replacement with posterior cruciate ligament reten-
tion in rheumatoid arthritis. Problems and complications.
Clin Orthop 345:24-8
44. Laskin RS (2001) The genesis total knee prosthesis: a
10-year follow-up study. Clinical Orthopaedics 388:95-
102
45. Lattanzio PJ, Chess DG, MacDermid JC (1998) Effect ff of
the posterior cruciate ligament in knee-joint propriocep-
tion in total knee arthroplasty. J Arthroplasty 13:580-5
46. Lombardi AV, Mallory TH, Vaughn BK (1993) Dislocation
following primary posteriorstabilized total knee arthro-
plasty. J Arthroplasty 8:633-9
728 Primary Total Knee Arthroplasty
47. Lucas TS, DeLuca PF, Nazarian DG (1999) Arthroscopic
treatment of patellar clunk. Clin Orthop 367:226-9
48. Mahoney OM, Noble PC, Rhoads DD et al. (1994) Poste-
rior cruciate function following total knee arthroplasty. A
biomechanical study. J Arthroplasty 9:569-78
49. Meding JB, Ritter MA, Faris PM (2001) Total knee
arthrosplasty with 4.4 mm of tibial polyethylene: 10-year
follow-up. Clinical Orthopaedics 388:112-7
50. Meding JB, Keating EM, Ritter MA et al. (2004) Long-term
follow-up of posterior cruciate retaining TKR in patients
with rheumatoid arthritis. Clin Orth 428:146-52
51. Migaud H, Gougeon F, Diop A et al. (1995) Kinematic in
vivo analysis of the knee: a comparative study of 4 types of
total knee prostheses. Rev Chir Orthop 81:198-210
52. Migaud H, de Ladoucette A, Dohin B et al. (1996) Influence
fl
of posterior tibial slope on anterior tibial translation and
mobility after a non constrained total knee arthroplasty.
Rev Chir Orthop 82:7-13
53. Mihalko WM, Krackow KA (1999) Posterior cruciate liga-
ment eff ffects on the flexion space in total knee arthro-
plasty. Clin Orthop 360:243-50
54. Mihalko WM, Miller C, Krackow KA (2000) Total knee
arthroplasty ligament balancing and gap kinematics with
posterior cruciate ligament retention and sacrifice.
fi Am J
Orthop 29:610-6
55. Montgomery RL, Goodman SB, Csongradi J (1993) Late
rupture of the posterior cruciate ligament after total knee
replacement. Iowa Orthop J 13:167-70
56. Newmann A (1993) Postoperative return of motion in
MCL/ACL injuries. Th The eff
ffect of MCL rupture location.
Ann J Sports Med 21 1:20-5
57. Pagnano MW, Hanssen AD, Lewallen DG et al. (1998) Flex-
ion instability after primary posterior cruciate retaining
total knee arthroplasty. Clin Orthop 356:39-46
58. Pereira DS, Jaffffe FF, Ortiguera C (1998) Posterior cruci-
ate ligament-sparing versus posterior cruciate ligament-
sacrifi
ficing arthroplasty. Functional results using the same
prosthesis. J Arthroplasty 13:138-44
59. Race A, Amis AA (1992) Mechanical properties of the two
bundles of the human posterior cruciate ligament. Trans
Orthop Res Soc 17:124
60. Ritter MA, Berend ME, Meding JB et al. (2000) Long-term
follow-up of anatomic gratuated components posterior
cruciate-retaining total knee replacement. Clinical Ortho-
paedics 388:51-7
61. Rodricks DJ, Patil S, Pulido P et al. (2007) Press-fit
fi con-
dylar design total knee arthroplasty. Fourteen- to sev-
enteen-year follow-up. J Bone Joint Surg Am January
89(1):89-95
62. Sextro GS, Berry DJ, Rand JA (2001) Totol knee arthro-
plasty using cruciate-retaining kinematic condylar pros-
thesis. Clinical Orthopaedics 388:33-40
63. Shai PA, Scott RD, Thornill TS (1999) TKR with PCL reten-
tion in rheumatoid arthritis, problems and complications.
Clin Ortho 367:96-106
64. Sharkey PF, Hozack WJ, Booth RE et al. (1992) Poste-
rior dislocation of total knee arthroplasty. Clin Orthop
278:128-33
65. Simmons S, Lephart S, Rubash H et al. (1996) Propriocep-
tion following total knee arthroplasty with and without
the posterior cruciate ligament. J Arthroplasty 11:763-8
66. Singerman R, Dean JC, Pagan HD et al. (1996) Decreased
posterior tibial slope increases strain in the posterior cru-
ciate ligament following total knee arthroplasty. J Arthro-
plasty 11:99-103
67. Sorger JI, Federle D, Kirk PG et al. (1997) The posterior
cruciate ligament in total knee arthroplasty. J Arthro-
plasty 12:869-79
68. Stiehl JB, Komistek RD, Dennis DA (1999) Detrimental
kinematics of a flat on flat total condylar knee arthro-
plasty. Clin Orthop 365:139-48
69. Udomkiat P, Meng BJ, Dorr LD et al. (2000) Functional
comparison of posterior cruciate retention and substitu-
tion knee replacement. Clin Orthop 378:192-201
70. Uvehammer J, Karrholm J, Brandsson S (2000) In vivo
kinematics of total knee arthroplasty: Concave versus pos-
terior stabilized tibial joint surface. J Bone Joint Surg (Br)
82-B:499-505
71. Uvehammer J, Karrholm J, Brandsson S et al. (2000) In
vivo kinematics of total knee arthroplasty: fl flat compared
with concave tibial joint surface. J Orthop Res 18:856-64
72. Vazquez-Vela Johnson G, Worland RL, Keenan J et al.
(2003) Patient demographics as a predictor of the ten-year
survival rate in primary total knee replacement. J Bone
Joint Surg Br January 85(1):52-6
73. Vessely MB, Whaley AL, Harmsen WS et al. (2006) The Th Chi-
tranjan Ranawat Award: Long-term survivorship and fail-
ure modes of 1,000 cemented condylar total knee arthro-
plasties. Clin Orthop Relat Res November 452:28-34
74. Vinciguerra B, Pascarel X, Honton JL (1994) Results of
total knee prostheses with or without preservation of the
posterior cruciate ligament. Rev Chir Orthop 80:620-5
75. Walker PS, Garg A (1991) Range of motion in total
knee arthroplasty, a computer analysis. Clin Orthop
262:227-35
76. Wang CJ, Wang HE (1997) Dislocation of total knee
arthroplasty. A report of 6 cases with 2 patterns of insta-
bility. Acta Orthop Scand 68:282-5
77. Warren PJ, Olanlokun TK, Cobb AG et al. (1993) Proprio-
ception after knee arthroplasty. Clin Orthop, 297:182-7
78. Whiteside LA, Saeki K, Mihalko WM (2000) Functional
medical ligament balancing in total knee arthroplasty.
Clin Orthop 380:45-57
79. Whiteside LA, Amador DD (1988) The Th eff
ffect of posterior
tibial slope on knee stability after ortholoc total knee
arthroplasty. J Arthroplasty 3 suppl: 51-7
80. Whiteside LA (1999) Selective ligament release in total
knee replacement of the knee in valgus. Clin Orthop
367:96-106
81. Whiteside LA (2001) Long-term follow-up of the bone-
ingrowth ortholoc knee system without a metal-backed
patella. Clinical Orthop 388:77-84
82. Witvoet J, Huten D, Groupe GUEPAR et al. (2005) Mid-
term results of Wallaby I posterior cruciate retaining total
knee arthroplasty: a prospective study of the first fi 425
cases. Rev Chir Orthop December 91(8):746-57
83. Worland RL, Jessup DE, Johnson J (1997) Posterior cru-
ciate recession in total knee arthroplasty. J Arthroplasty
12:70-3
84. Wright, RJ, Sledge CB, Poss R et al. (2004) Patient-re-
ported outcome and survivorship after kinemax total knee
arthroplasty. J Bone Joint Surg (Am) 86A(11):2464-70

P.-F. Leyvraz. V. Leclercq Deep dish TKA: advantages
and disadvantages
Introduction
A
TKA is considered successful after achieving
the traditional goals of restoring the func-
tion, improving the stability, and stopping
the pain. However, the anatomic motion and the
stability of the normal knee are generally not well
reproduced. This
Th defi ficit becomes most apparent
when patients attempt to perform activities that
place biomechanical or kinematics demands on the
knee joint (1).
Conventional knee prostheses have been proved
to be clinically successful. However, most of the
patients involved in these follow-up studies have
been elderly individuals with low activity levels,
and thus low demands have been placed on the
prosthesis. Th
There is little evidence that the same
results can be duplicated in more active people.
The main reason for knee revision is the polyeth-
ylene wear leading to osteolysis and loosening (2).
The amount of wear is well known to be closely
infl
fluenced by the knee kinematics but also by some
biomechanical, biomaterial, and manufacturing
considerations. There is a common agreement that
the reduction of the polyethylene wear will signifi-
fi
cantly contribute to increase the longevity of knee
implant for elderly population and respond to the
demand of younger and more active population.
The challenge of new knee implants is to recover
the healthy knee function, in order to reproduce
so close as possible the anatomic motion as well as
the stability of the knee joint. This
Th will be reach-
able only with new concept of prosthetic knee
kinematics.
Kinematics of healthy and pathological knees
Researchers have used in vitro approaches (involving
cadavers), non-invasive approaches (involving stud-
ies done at gait laboratories), and in vivo approaches
(involving roentgen stereophotogrammetry and
fluoroscopy) to assess human knee motion.
The in vivo measurement of dynamic knee kine-
matics is important for understanding how the
Chapter 66
knee functions under in vivo weight-bearing condi-
tions, for analyzing the effects
ff of joint injuries and
diseases and finally for evaluating the outcome of
surgical procedures. It clearly appears that:
In the normal knee, the femur fl flexes around the
transepicondylar axis (TEA). During the perfor-
mance of a deep knee-bend, the normal knees
demonstrate posterior femoral translation of the
lateral condyle and minimal change in the position
of the medial condyle. Th Therefore, a medial pivot
kinematics pattern is present because the poste-
rior translation of femorotibial contact is greater
laterally than it is medially (3).
In the pathological knee with anterior cruciate
ligament defi ficiency, a paradoxical anterior femo-
ral translation and internal tibial rotation occur
during deep knee flexion, leading to undesirable
consequences. First, this phenomenon results in a
more anterior axis of flexion and can reduce maxi-
mum knee flexion. Second, the quadriceps moment
arm is decreased, resulting in reduced quadriceps
effi
fficiency. Third, articular cartilage shear forces
will likely be increased, enhancing the risk of pre-
mature degenerative change, which is commonly
observed in those with chronic anterior cruciate
ligament injuries.
Classifification of prosthetic knees
The issue of retaining or sacrifi
ficing the posterior
cruciate ligament (PCL) remains controversial. The
Th
important point about the PCL following cruciate
retaining TKA is not its physical presence, but its
functional role. It is, however. generally accepted
that both cruciate ligaments balance the oppos-
ing needs for stability and mobility in the complex
kinematic system of the knee joint. They are the
main stabilizers limiting anterior–posterior trans-
lation. Furthermore they control rollback and tibial
rotation. In addition, both cruciate ligaments also
have proprioceptive functions.
Numerous knee prostheses are currently used in
the market (Table 1). They are ranged into two main
groups depending on whether they retain or sacri-
730 Primary Total Knee Arthroplasty
Table 1 – Classification of knee prostheses.
fice the PCL. Then, they are available with a fix or a
mobile insert in cemented or cementless version.
With an ``anatomical approach,’’’ the prosthetic
knee joints try to reproduce the anatomical knee
kinematics by retaining the PCL:
– Some of them have a central pivot knee kinemat-
ics with a mobile congruent insert.
– Some attempt to mimic the normal knee kine-
matics “medial pivot knee.”
– Some others attempt to mimic the ACL deficient
fi
knee kinematics “lateral pivot knee.”
With a “functional approach”, the prosthetic knee
joints try to reproduce the function of both
removed ACL and PCL, thanks to a mechanism
stabilizing the knee:
– Some have a post-cam mechanism and are called
“posterior substituting knee.”
– Some other have higher anterior and posterior
lips and are called “deep dish knee.”
– At least some have a central bearing surface and
are called “third condyle knee.”
Kinematics of prosthetic knees
The result of a TKA is infl
fluenced by a complex inter-
action between the geometry of an implant design,
the positioning of the implant, and the active and
passive soft-tissue structures around the joint (1).
This interaction, in turn, determines the prosthetic
knee kinematics.
Many think an objective of TKA is to reproduce the
kinematics of a normal knee. Numerous in vivo,
weight-bearing, fluoroscopic analyses have shown
that normal knee kinematics is diffi
fficult to obtain
after TKA.
Posterior Cruciate Retaining (PCR) knee kinematics
In total knee arthroplasty, whether the PCL should
be retained or resected has been the subject of argu-
ment for many years (4) and continues to be clini-
cally unresolved. Convincing arguments on both
sides of the issue have been raised. Although those
who favor retention of the PCL insist on the signif-
icance of preserving its function (4, 5) (anatomical
femoral rollback), in practice its physiological func-
tion cannot always be preserved after TKA. Post-
operative alteration in joint line level, alignment,
and surface geometry can affect
ff the function of the
PCL, resulting in abnormal knee kinematics, with
forward slide of the femoral component. Multiple
kinematics abnormalities (reduced posterior femo-
ral rollback, paradoxical anterior femoral transla-
 Deep dish TKA: advantages and disadvantages 731

tion, reverse axial rotational patterns, and femoral
condylar lift-offff ) commonly are present after using
PCR implants. It is likely that abnormal kinematics
is detrimental to the performance of a TKA. Exces-
sive wear has been seen in polyethylene inserts
from TKA retrievals.
The diff
Th fferent authors point the loss of stability in
fl
flexion as a result of this abnormal kinematics.
Posterostabilized (PS) knee kinematics
Thus, resection of the PCL and use of the posterior
stabilized (PS) design components is considered as
an option by those who see the potential disadvan-
tages of PCL retention. They believe that the range
of movement is increased in TKA when the PCL is
sacrifi
ficed and a posterior-stabilized implant is used
to maintain femoral rollback. The femoral rollback
is meant to improve anterior–posterior stability, to
increase ROM, to reduce quadriceps force in exten-
sion, to improve stair-climbing ability, as well as
patellofemoral function (6–8).
However, the PS type shows abnormal kinematics
too described as followed (9–11):
– Abnormal femoral translation in early flexion.
fl
– Axial rotation between the rotating insert and
the femoral component.
– Impingement on the post anteriorly with the
femoral shield.
The difffferent authors point the loss of congruency in
early fl
flexion as a result of this abnormal kinematics.
increases the articulating surface area and expands
the circumference to accommodate and stabilize
the femur during flexion and stair climbing. Addi-
tionally, the anterior build-up in the ultra congru-
ent design eliminates the need for a metal cam,
allowing the trochlear notch in the femoral compo-
nent to remain extended distally. The
Th insert is also
called “ultra congruent.”
The main advantage of the deep dish insert is to
stabilize the knee joint after TKA in extension in
order to avoid the paradoxical anterior femoral
sliding in early flexion
fl as observed in PCR and PS
type knee implants.
The characteristics favoring a deep dish type are
described as follows:
– Large contact area and low contact stress in
extension (Fig. 1).
– Stability until midflflexion given by the higher
anterior and posterior lips (Fig. 2).
– Tolerance to dislocation in rotation (Fig. 3).
The use of a dished polyethylene insert in primary
total knee arthroplasty provides good to excellent

The ““deep dish” type

In the deep dish type, the polyethylene insert has
a highly conforming anterior build-up to increase
surface area contact, compared with the semi-con- Fig. 2 – Innex UC, Zimmeer.
forming PCL-sparing insert. The anterior build-up

Fig. 3 – Kheops, Tran-

Fig. 1 – LCS, DePuy. systeme.
732 Primary Total Knee Arthroplasty

Fig. 4 – Innex UC, Zimmer. Fig. 5 – Shear stress at mid flexion. Fig. 6 – Kheops, Transysteme.

midterm results regardless of whether the PCL is
recessed or sacrifificed (12, 13).
However, both the deep-dished fixed-bearing and
rotating mobile-bearing TKR demonstrate some dis-
advantages, lead to higher risk of increased osteoly-
sis or progressive radiolucent zones on radiographic
analysis (14, 15):
– No posterior femoral translation after midflex-
fl
ion (Fig. 4).
– Shear stress at the interface after midfl flex-
ion (Fig. 5).
– Limited ROM due to the anterior femoral trans-
lation during in deep flexion (Fig. 6).
– Low contact area after 15° if the J-curve has more
than two radii of curvature (16).
Conclusion
It clearly appears that the current conventional knee
prostheses do not fulfill
fi the needs of kinematics in
term of restoring the function and signifi ficantly
Fig. 7 – Innex UCOR, Zimmer midstance: 2.0 BW, 20° flexion, surface
area: 294 mm2.
improving the stability. Even though, conventional
knee prostheses have been proved to be clinically suc-
cessful, the studies highlight the weakness of conven-
tional implants. The abnormal paradoxical anterior
femoral sliding is observed for the PCR implant dur-
ing the whole flexion, for the PS implant in early flex-
ion and for the deep dish implant after midflexion.
fl
The main consequence of this abnormal kinematics
is the loss of joint stability perceived by the patient
during daily activities, particularly during the gait
or the stair descent.
In order to better recover the knee function, it is abso-
lutely necessary to stabilize the primary prosthetic
knee joint during the whole movement, in order to
allow better quadriceps effifficiency, a good mobility in
term of flexion and a respect of the knee kinematics.
A new concept of kinematics allowing an antero-
posterior stabilization during the whole flexion fl
should be defi fined and the resulting implant design
should closely respect the biomechanical laws.
As a conclusion, the authors propose as a possible
solution, the combination of a deep dish type with
a posterostabilized type (Fig. 8). The ultra-congru-
ence of the polyethylene in extension will lead to a
good joint stability, low contact stresses as well as a
preservation of the cam-post mechanism, whereas
after midflflexion the posterostabilization will lead
to a good joint stability as well as a deep fl flexion.
This concept has sense only with a rotating plat-
form, because the second interface is necessary to
permit rotation without conflict fl with the central
post. The rotating platform will also allow that the
stability in rotation as well as in varus/valgus will
be driven by the collateral ligaments and the soft
tissue envelope surrounding the knee joint.
Clinical prospective studies of such implant type
have to be done with ambulatory gait analysis sys-
tem to check the improvements of subjective and
objective results.

Fig. 8 – Authors proposition.
References
1. Callaghan JJ, Insall JN, Greenwald AS, et al. (2000)
Mobile-bearing knee replacement. Concept and results. J
Bone Joint Surg (Am) 82:1020
2. Engh GA, Lounici S, Rao AR, Collier MB (2001) In vivo
deterioration of tibial baseplate locking mechanisms in
contemporary modular total knee components. J Bone
Joint Surg (Am) 83:1660–1665
3. Iwaki H, Pinskerova V, Freeman MAR (2000) Tibiofemo-
ral movement 1: the shapes and relative movements of
the femur and tibia in the unloaded cadaver knee. J Bone
Joint Surg [Br] 82-B:1189–1195
4. Mahfouz MR, Komistek RD, Dennis DA, Hoff ff WA (2004)
In vivo assessment of the kinematics in normal and ante-
rior cruciate ligament-defi
ficient knees. J Bone Joint Surg
86:56
5. Sathappan S, Wasserman B, Jaffe ff WL, et al. (2006) Mid-
term results of primary total knee arthroplasty using
a dished polyethylene insert with a recessed or resected
posterior cruciate ligament. J Arthroplasty 21:1012
6. Stiehl JB, Komistek RD, Dennis DA, et al. (1995) Fluoro-
scopic analysis of kinematics after posterior cruciate retain-
ing knee arthroplasty. J Bone Joint Surg 77B:884–889
7. Yoshiya S, Matsui N, Komistek RD, et al. (2005) In vivo kine-
matic comparison of PCR and PS TKA under passive and
weight-bearing conditions. J Arthroplasty 20(6):777–783
8. Banks AS, Hodge WA (2004) Implant design affects ff
knee arthroplasty kinematics during stair-stepping. Clin
Orthop Relat Res 426:187–193
Deep dish TKA: advantages and disadvantages 733
9. Shi K, Hayashida K, Umeda N, et al. (2008) Kinematic
comparison between mobile-bearing and fixed-bearing
inserts in NexGen legacy posterior stabilized fl flex total
knee arthroplasty. J Arthroplasty 23(2):164–169 (Epub
24 September 2007)
10. Garling EH, et al. (2007) Limited rotation of the mobile-
bearing in a rotating platform total knee prosthesis. J Bio-
mech 10:1016
11. Hamai S, Miura H, Higaki H, et al. Evaluation of impinge-
ment of the anterior tibial post during gait in a posteri-
orly-stabilised total knee replacement. J Bone Joint Surg
[Br] 90-B(9):1180–1185
12. Hofmann AA, Tkach TK, Evanich CJ, Camargo MP (2000)
Posterior stabilization in total knee arthroplasty with use
of an ultracongruent polyethylene insert. J Arthroplasty
15:576
13. Hofmann AA, Evanich JD, Ferguson RP, Camargo MP
(2001) 10 to 14 year clinical followup of the cementless
natural-knee system. Clin Orthop Relat Res (388)
14. Siebold R, Louisia S, Canty J, Bartlett RJ (2007) Posterior
stability in fixed-bearing versus mobile-bearing total knee
replacement: a radiological comparison of two implants.
Arch Orthop Trauma Surg 127(2):97–104
15. Wada M, Tatsuo H, Kawahara H, et al. (2001) In vivo kine-
matic analysis of total knee arthroplasty with four differ-
ff
ent polyethylene designs. Artif Organs 25(1):22–28
16. Morra EA, Postak PD, Helm CS, Grennwald AS (2002)
Tibial plateau abrasion in mobile bearing knee systems
during walking gait II: a finite element study. Orthop Res
Lab – AAOS
 Chapter 67

J. Bellemans, K. Corten
J. Vanlauwe,
Bicruciate retaining TKA: the future?
H. Vandenneucker

Introduction

T
here is a general consensus amongst knee
surgeons that the cruciate ligaments have an
important role in the function and kinemat-
ics of the normal knee.
Since the introduction of TKA, the debate on the
infl
fluence of the cruciate ligaments on surgical out-
come after prosthetic replacement of the knee has,
however, mainly been focused on the PCL. Despite
the fact that numerous biomechanical, kinematic,
and clinical studies have been performed, so far no
consensus exists on the question whether the PCL Fig. 1 – Having to resect the ACL during TKA is a sorrowful act in the mind
should best be retained or replaced during TKA. of many knee surgeons.
Some surgeons advocate to routinely resect the PCL
and duplicate its function by a cam-post mechanism
tion has not been high on the priority list of TKA
built-into the prosthetic design, or by using dished
designers, mainly since issues such as component
or more sagitally conforming inserts, whereas oth-
fixation, implant longevity, and range of motion,
ers swear to the principle of PCL retention and bal-
had to be solved first.
fi
ancing its tension carefully during range of motion,
Third, compensating for the resected ACL through
especially deep flexion
fl of the knee.
implant design is not obvious from an engineering
Looking from a distance at this unsolved debate,
standpoint. Also, avoiding its resection during TKA
not so much the fact that the issue still remains
seems almost undoable and would require a tibial
unsolved is surprising, but rather the fact that it is
component with specifi fic geometric and strength
the PCL – and not the ACL – which has continued
characteristics that would pose new challenges to
to intrigue knee surgeons over these decades.
designing engineers and surgeons.
The ACL is indeed probably much more impor-
New insights in the kinematic behavior of the nor-
tant than the PCL with respect to the functional mal and replaced knee, together with improvements
and kinematic performance of the knee joint. And in implant longevity and component fi fixation, have
unlike the PCL, it is inevitable to resect the ACL altered the focus and interest of knee surgeons
during standard TKA. (Fig. 1) towards improving the functionality and outcome
One would therefore expect that numerous of prosthetic knee replacement. Th The work of Noble
attempts have been made in the past decades to et al. has further elucidated this, by demonstrating
mimic ACL function by prosthetic design or by that patients with well-functioning TKAs still expe-
alternative surgical solutions. History has, how- rienced important functional shortcomings com-
ever, learned us that this has been far from true, pared to their peers without knee pathology (1, 2).
apart from some brave designers and surgeons that Patients with a well-replaced knee also seem to do
have focused on ACL and PCL retaining designs in worse when compared to patients after total hip
the early eighties. arthroplasty, who tend to forget about their new
It is therefore fair to state that so far the ACL has hip after a while.
been grossly neglected amongst knee arthroplasty
surgeons.
The reasons for this are probably multiple. The What is the problem?
specifi
fic role of the ACL in standard TKA has for a
long time not really well, or at least only poorly, Since the introduction of video fluoroscopy our
been understood. Secondly, mimicking ACL func- understanding of how a prosthetic knee functions
736 Primary Total Knee Arthroplasty

has improved enormously. Thanks Th to the work

of Komistek et al. and Banks et al., it has become
possible to evaluate in vivo the three-dimensional
behavior of the knee during activities of daily life,
including walking, stepping up and down a chair or
a stair, deep knee bending, etcetera (3–8). At the
same time, the relative positions of the femoral
and tibial components during the entire range of
motion can be determined with great precision, as
well as many other relevant parameters such as the
location of the femorotibial contact points, centers
of rotation, etcetera.
Video fluoroscopy has therefore learned us a lot,
especially about the suboptimal and even erratic
kinematic patterns of femorotibial motion that Fig. 2 – Terminal swing phase during walking in a patient with standard
can be noted in the majority of patients with con- PCL retaining TKA, demonstrating anterior tibial translation as a conse-
temporary TKAs. From these studies it has become quence of ACL absence.
clear that the majority of today’s TKA patients
demonstrate unnatural kinematic patterns, with
phenomena that are at least in part the conse-
quence of cruciate ligament insuffi fficiency or mal-
function.
One of the best known of these patterns is the so-
called paradoxical motion that is noted in almost
every PCL retaining knee, indicating a forward
translation of the femoral component during flex- fl
ion, instead of the normal rollback of the femur
on the tibia that is present in the normal knee.
Today it has been well established that the rea-
son for such paradoxical motion is the inability
to reproduce normal PCL tension. It is indeed the
PCL that is responsible (at least in part) for pull-
ing backwards the femur in flexion, by becoming Fig. 3 – The patellar tendon has an anterior directed vector, pulling the
tighter as the knee bends further. Failure to retain tibia forward during the swing phase. The resulting anterior tibial transla-
or reproduce normal PCL tension during TKA will tion will induce roll forward of the femur as soon as flexion occurs (PCL is lax
due to the anterior tibial translation).
therefore jeopardize or even prevent normal femo-
ral rollback.
Another, equally important but so far grossly the (posteriorly positioned) distal femur is there-
overlooked phenomenon present in contempo- fore to migrate forward onto the tibia (paradoxical
rary TKA patients, is ACL defi ficiency. This is most roll-forward), further helped by contraction of the
obvious when studying TKA patients during nor- hamstrings (which pull the tibia backwards). One
mal gait, especially at the end of the swing phase could therefore conclude that since the ACL is no
(Fig. 2). longer present, not only ACL but also PCL func-
At this specifific stage of the gait cycle the quadri- tion is jeopardized in patients with contemporary
ceps swings the tibia forward through the patellar TKA.
tendon, which has an anteriorly directed vector, Moreover, there is a second and maybe even more
causing anterior translation of the tibia relative to important negative consequence to the fact that
the femur (Fig. 3). In the normal knee, such ante- the ACL is no longer present in contemporary TKA
rior tibial translation is limited by the ACL. In the patients. We know that the ACL has an important
TKA patient, however, this is obviously not the case role with respect to knee joint stability, and that
since the ACL is no longer present, and in fact the patients develop protective mechanisms after ACL
only restraint against anterior tibial translation is rupture. One of these is cocontraction of the ham-
provided by the posterior upslope in the dishing of strings. Especially in the situation of a knee joint
the tibial insert, which has only a limited effect.
ff where the cartilage layers have been replaced by
As a consequence to the anterior tibial subluxation metal and plastic prosthetic components serving
occurring during the terminal swing phase, the PCL as artifi
ficial gliding layers, such need for permanent
looses tension and relaxes. After heel strike, when muscular cocontraction required to stabilize the
the knee starts to flex, the natural tendency of joint, could be a signifificant (unconscious) burden

to the patient, and in fact could be the explanation
why many TKA patient never seem to be able to
“forget” their new knee.
How to solve the issue of the ACL?
As stated above, bicruciate retaining total knee
designs have been implanted and investigated in
the past (Fig. 4). Unfortunately, they were aban-
doned in the mid-nineties due to reasons related
with mechanical implant failure as well as techni-
cal diffi
fficulties during surgical implantation.
Despite this, however, the limited research avail-
able on these designs seems to confi firm the great
potential of the concept of retaining both cruciate
ligaments.
Stiehl et al. have reported on the kinematic results
of a series of bicruciate retaining total knee arthro-
plasties, using the so-called Cloutier prosthesis,
and noted an improved (more natural) femorotibial
pattern compared to posterior cruciate retaining
implants in about 50% of the cases. TheTh remainder
demonstrated a less optimal pattern and probably
had a non-functioning ACL, possibly due to inac-
curate prosthesis placement or ligament balancing.
A number of cases also had a flexion
fl contracture of
10–15° which could represent a minor imbalance or
tightness of the anterior cruciate ligament (9, 10).
Several other surgeons have reported their clinical
results on bicruciate retaining TKA (11–18).
Buechel and Pappas reported a 91% survival at 12
years follow-up with comparable clinical results to
PCL retaining or posterior stabilized knees (11).
Cloutier reported on his data in two papers, with
95% survival rate at an average of 10 years post-op-
eratively, and with good to excellent clinical results
Fig. 4 – Bicruciate retaining TKA.
Bicruciate retaining TKA: the future? 737
in 97% of the patients (12, 13). Pritchett reported
on 50 cases that underwent bilateral TKA with
bicruciate retention on one side and PCL reten-
tion on the other side (16). All BCR knees were
considered stable in the sagittal plane, whereas six
of the PCL retaining knees had greater than 1 cm
laxity on anterior drawer testing. Seventy per cent
of the patients preferred their BCR knee, 20% had
no preference, and only 10% preferred their PCL
retaining knee.
The largest patient series with bicruciate knee
arthroplasties has been presented by Hamelynck
et al. in their multi-center outcome study on the
LCS knee (18). In this study a total number of 4743
TKAs were followed for an average of 5.7 years
(maximum 18 years), amongst which 324 bicruciate
retaining (BCR) TKAs. The average range of motion
was 110° (versus 112° for PCL retaining TKAs),
and the survivorship rate at 10 year follow-up was
89% (versus 91% for PCL retaining TKAs). Asep-
tic loosening of the tibial component occurred in
7.4% of the cases (versus only 1.1% for PCL retain-
ing TKAs), bearing problems in 2.2% (versus 3.0%
for PCL retaining TKAs), and instability requiring
revision was noted in 0.3% of the BCR cases (ver-
sus 0.9% in the PCL retaining TKAs).
The published results of bicruciate retaining TKAs
can therefore be considered as comparable to those
of standard PCL retaining TKAs, except for tibial
loosening rates.
Fixation of the tibial component is indeed one of
the concerns in BCR knees, due the limited sur-
face area for fixation options that are technically
possible. Due to the fact that the ACL remains in
situ, the baseplate design does indeed not allow
the use of a (standard) centromedullary fi fixation
stem or keel. Instead, fixation must be provided by
alternative (smaller) fins or pegs, which jeopardize
fixation strength. It is interesting to note that in
the study by Hamelynck et al., even when the tibial
component was cemented, loosening was still a
problem in 2.2% of the cases (18).
However, not only tibial fixation
fi is a problem,
also the intrinsic strength of the tibial component
poses technical challenges (Table 1). Th The central
bridge connecting the medial and lateral plateaus
is subject to severe bending stress and should be
suffi
fficiently strong to withstand these loads over a
long time period (Fig. 5). Increasing the thickness
or width of the connecting bar, in order to achieve
fficient strength, might however compromise
suffi
bone stock or might jeopardize the ACL insertion,
possible leading to insertional avulsion or tearing
of the ACL.
It is interesting to note that since the renewed
interest of surgeons in unicondylar replacements,
the concept of bi-condylar unireplacement has
been introduced. This in fact can be considered
738 Primary Total Knee Arthroplasty

Table 1 – Problematic issues in bicruciate retaining TKA

Design related:
– tibial component fixation
(loosening/subsidence)
– tibial component fracture
(interconnecting bar)
– mediolateral tibial
dimensions (intercondylar
bone block)
– differential slope medial
Fig. 5 – On the tibial component, the central bridge connecting the medial and lateral tibial plateau
and lateral tibial plateau is a weak link and subject to severe bending – trochlear design (high
stress. intercondylar notch)
– 3° varus joint line
Surgical technique related:
– diffi
fficult exposure of the tibia
(keep ACL intact)
– careful bone block preparation
(avoid fracture)
– mediolateral positioning of the
tibial component (avoid overhang)
– perfect ligament balancing
required
– perfect joint line restoration
required
– Avoid impingement onto the
central bone block (Fig. 6)

References
Fig. 6 – Impingement of the femoral component against the central bone
bridge is a potential cause of pain and should be avoided.
as a bicruciate retaining bicondylar replacement,
without an interconnecting tibial bar. So far, only
anecdotal reports exist on the use of these, but
it will be interesting to note how this concept of
bicondylar unireplacement will evolve over the
next years.
Another issue that requires specific fi attention
in BCR knees is the intimate interaction of the
articular femorotibial geometry and the cruciate
ligaments. (Table 1) An anatomic implant confi figu-
ration with precise reproduction of the femoral
condylar and tibial curves, the oblique nature of
the joint line (average 3° varus), the differential
ff
slope of the medial and lateral tibial plateau are all
factors that are of importance when one is aiming
to reproduce natural kinematics of the knee. At
the same time, an exact surgical technique will be
required to fulfi
fill this goal.
In view of these challenges, bicruciate TKAs may
not become immediately the standard of care, but
are clearly an attractive option in view of the short-
comings that are well known and documented with
the contemporary implants that we are using.
1. Noble P, Gordon M, Weiss J, et al. (2005) Does total knee
replacement restore normal knee function? Clin Orthop
Rel Res 431:157–165
2. Weiss J, Noble P, Conditt M, et all (2002) What functional
activities are important to patients with knee replace-
ments? Clin Orthop Rel Res 404:172–188
3. Komistek R, Dennis D, Mahfouz M (2003) In vivo fluoro- fl
scopic analysis of the normal human knee. Clin Orthop
Rel Res 410:69–81
4. Dennis D, Komistek R, Mahfouz M, et al. (2003) Multi-
center determination of in vivo determination of knee
kinematics after total knee arthroplasty. Clin Orthop Rel
Res 416:37–57
5. Dennis D, Komistek R, Mahfouz M (2004) A multicenter
analysis of axial femorotibial rotation after total knee
arthroplasty. Clin Orthop Rel Res 428:180–189
6. Banks S, Markovich G, Hodge W (1997) In vivo kinematics
of cruciate-retaining and substituting knee arthroplasties.
J Arthroplasty 12:297–304
7. Victor J, Banks S, Bellemans J (2005) Kinematics of pos-
terior cruciate ligament-retaining and -substituting total
knee arthroplasty. A prospective randomised outcome
study. J Bone Joint Surg 87B:646–655
8. Bellemans J, Banks S, Victor J (2002) Fluoroscopic analy-
sis of the kinematics of deep fl
flexion in total knee arthro-
plasty. Infl
fluence of posterior condylar off
ffset. J Bone Joint
Surg 84:50–53
9. Stiehl J, Komistek R (2002) Kinematics of the LCS mobile
bearing total knee arthroplasty. In: Hamelynck K, Stiehl
J (eds) LCS mobile bearing knee arthroplasty. 25 years
of worldwide experience. Springer Verlag, Heidelberg, pp
57–66
10. Stiehl J, Komistek R, Cloutier J, Dennis D (2002) The Th
cruciate ligaments in total knee arthroplasty: a kine-
matic analysis of 2 total knee arthroplasties. J Arthropl
15:545–550
11. Buechel F, Pappas M (1990) Long-term survivorship anal-
ysis of cruciate sparing versus cruciate sacrifi ficing knee
prosthesis with meniscal bearing. Clin Orthop Rel Res
260:162–169
12. Cloutier J (1991) Long-term results after nonconstrained
total knee arthroplasty. Clin Orthop Rel Res 274:63–65
13. Cloutier J, Sabouret P, Deghrar A (1999) Total knee arthro-
plasty with retention of both cruciate ligaments: a 9 to 11
year follow-up study. J Bone Joint Surg 81A:697–702
14. Migaud H, Deladoucett A, Dohin B, et al. (1996) Influence
fl
of posterior tibial slope on anterior tibial translation and
mobility after a nonconstrained total knee arthroplasty.
Rev Chir Orthop 82:7–13

15. Jenny J, Jenny G (1998) Preservation of the anterior cru-
ciate ligament in total knee arthroplasty. Arch Orthop
Trauma Surg 118:145–148
16. Pritchett J (1996) Anterior cruciate retaining total knee
arthroplasty. J Arthropl 11:194–197
17. Jacofsky D (2005) Bicruciate retaining total knee arthro-
plasty. In: Bellemans J, Ries M, Victor J (eds) Total knee
Bicruciate retaining TKA: the future? 739
arthroplasty: a guide to get better performance. Springer
Verlag, Heidelberg, pp 291–294
18. Hamelynck K, Stiehl J, Voorhorst P (2002) Worldwide
multicenter outcome study. In: Hamelynck K, Stiehl J
(eds) LCS mobile bearing knee arthroplasty. 25 years of
worldwide experience. Springer Verlag, Heidelberg, pp
212–224

R. H. Kim,
D. A. Dennis
Mobile-bearing total knee
arthroplasty: advantages
and disadvantages
Introduction
A
ccording to the Centers for Disease Control
and Prevention, it is estimated that 46 million
American adults are affl fflicted with clinically
signifi
ficant arthritis. In 2003, 402,100 primary total
knee arthroplasties and 32,700 revision total knee
arthroplasties were performed in the United States
(1). With a predicted increase in life expectancy and
an increasingly active population, the number of
patients who will seek treatment for significant
fi pain
and disability secondary to knee arthritis will con-
tinue to escalate. Kurtz et al. performed a statistical
projection demonstrating that the demand will grow
from 450,000 total knee arthroplasties performed
in 2005 to 3.48 million procedures by 2030 (1).
In addition to an increasingly aging population, the
indications for total knee arthroplasty (TKA) have
expanded as prosthetic designs, implant materi-
als and surgical techniques have improved. While
early total knee designs were generally reserved
for elderly and sedentary patients with debilitating
pain and loss of function, the excellent 10-to-15 year
outcomes with TKA (2–8) has encouraged many
surgeons to consider performing TKA on younger
patients who have increased activity requirements
and performance expectations. Patient expecta-
tions for a more functional and longer lasting result
following TKA continue to drive advances in both
surgical technique and component design.
Advances in TKA design are dependent on isolation
of specifific factors associated with success or failure
of current implant technology and to combine this
knowledge with an expanding understanding of
knee kinematics, biomaterials, and surgical tech-
nique improvements. Integrating established and
successful TKA design concepts with the current
kinematic and biomechanical discoveries will con-
tinue to answer the public’s demand for improve-
ments in TKA stability, function, component lon-
gevity, and patient satisfaction.
One successful design concept that has developed over
the last three decades to meet the increased demands
discussed above is the use of mobile-bearing TKA.
This review discusses how the careful integration of
clinical and laboratory studies have led to advances in
Chapter 68
development of mobile-bearing TKA systems. After
a brief historical review, the advantages, disadvan-
tages, clinical outcomes, and important design fea-
tures of mobile-bearing TKA will be reviewed.
Knee kinematics
In vivo fluoroscopic studies demonstrate that kine-
matics of the normal knee are determined by the
integrity of the supporting soft tissues (ligaments,
capsule, myotendinous units, etc.) and the condy-
lar geometry of the articular surfaces. In the nor-
mal knee, there is a complex pattern of motion that
occurs between the femoral and tibial articular sur-
faces during flflexion and extension. For example,
due in part to the stabilizing nature of the relatively
immobile medial meniscus and various complicated
interactions between surrounding ligamentous
structures, flexion of the intact knee produces a rel-
atively predictable controlled posterior rollback of
the lateral femoral condyle on the lateral tibial pla-
teau. These in vivo fluoroscopic analyses of normal
knees during a deep knee bend have demonstrated
posterior femoral rollback ranges of 14.1–19.2 mm
(9, 10) of the lateral femoral condyle while the
medial condyle typically translates posteriorly less
than 5 mm (9, 10) (Fig. 1). The majority of nor-
mal knees (80%), therefore, demonstrate a medial
pivot axial rotational pattern in which the lateral
femoral condyle rotates around a relatively station-
ary medial femoral condyle. Under weight-bearing
conditions, an average of 16.5–16.8 degrees of axial
femorotibial rotation occurs in the normal knee
from full extension to 90° of flexion (10, 11). There-
fore, with flexion of the normal knee, the tibia typi-
cally internally rotates relative to the femur, and
conversely, externally rotates with knee extension
(i.e. screw home mechanism) (12, 13).
While component design engineers and surgeons
continue to collaborate in an effffort to develop TKA
systems that reproduce normal knee kinematic
patterns, fluoroscopic studies of multiple implant
designs have shown much less predictable and
reproducible knee kinematics after TKA. Violation
of the complex interactions between the natural
742 Primary Total Knee Arthroplasty
Fig. 1 – Graph demonstrating the average anteroposterior contact positions
of the medial and lateral femoral condyles in the normal knee during a deep
knee bend maneuver from full extension to 90° of knee flexion (Reprinted
with permission from Medscape. Available at:http://www.medscape.com/
viewprogram/3133. © 2004 Medscape.
stabilizing joint surface anatomy and surrounding
ligamentous structures make it difficultffi to com-
pletely reproduce normal knee motions following
TKA. Numerous kinematic variances from normal
knee kinematic patterns have been demonstrated,
including paradoxical anterior femoral translation
during deep knee flexion (9, 14–19), reverse axial
rotational patterns (11, 14, 17, 20–22), femoral
condylar lift-off
ff (17, 21–25), and reduced range of
motion (18, 26).
Paradoxical anterior femoral translation during
deep knee flexion (femoral component sliding
anteriorly during deep fl flexion rather than poste-
rior femoral rollback) has numerous potential neg-
ative consequences. First, anterior femoral trans-
lation results in a more anterior axis of flexion,
lessening maximum knee flexion (12, 14, 18, 26).
Second, the quadriceps moment arm is decreased,
resulting in reduced quadriceps effi fficiency. Third,
anterior slidingg of the femoral component on the
tibial polyethylene surface risks accelerated poly-
ethylene wear (15, 27). Blunn et al. (15), in a labo-
ratory evaluation of polyethylene wear, reported
dramatically increased wear with cyclic sliding
as compared with compression or rolling, due to
increased subsurface shear stresses.
Reverse axial rotation is undesirable, risking patell-
ofemoral instability due to lateralization of the tibial
tubercle and an associated increase in the Q-angle
during deep flexion, as well as lessening maximum
knee flexion due to reduced posterior femoral roll-
back of the lateral femoral condyle (11).
Femoral condylar lift-off ff creates excessive loads
on both the polyethylene bearing, risking prema-
ture polyethylene wear, as well as increased load
transmission to the underlying subchondral bone
(21, 23, 28) which increases the risk of prosthetic
loosening. These
Th adverse eff
ffects are amplifified in
TKA designs which have reduced conformity in the
frontal (coronal) plane (i.e. flat-on-fl
fl flat designs)
due to edge loading of the prosthetic components
(21, 23, 27–29).
The future goals of TKA are to more closely recreate
normal knee kinematics through implant geometry
and surgical technique while maintaining stability,
durability of fixation,
fi and patient satisfaction.
History
Prior to fully understanding the principles of lower
extremity alignment and meticulous ligamentous
balancing, early clinical TKA failures resulted from
malalignment, instability, and the use of exces-
sively constrained prostheses. These early failures
were often due to premature component loosening.
Much of this could be attributed to implantation
of these early TKA designs using first generation
instrumentation which lacked alignment guides or
size-specifi
fic cutting blocks.
While the increase in constraint provided by
hinged or overly conforming unlinked TKA sys-
tems improved the stability of TKA, torsional,
coronal, and sagittal stresses normally shared by
the surrounding soft tissue stabilizing structures
were transferred through the implant to the bone-
cement fixation interface (27), resulting in prema-
ture TKA failure secondary to aseptic component
loosening (20, 30–32).
With knowledge that the highly constrained
implant designs of the 1970s increased the risk
of early aseptic loosening, a newer generation of
implant designs were subsequently developed that
relied more on the load-sharing and stabilizing roles
of the native retained capsuloligamentous soft tis-
sue structures. This was accomplished by creating
less conforming and less constrained articular sur-
face designs which typically incorporated the use of
round-on-fl flat or flat-on-fl
flat articular geometries.
These designs allowed for rotation and multi-plane
translations to occur at the articulating interface
and relied more on the surrounding soft tissue
structures than conformity of the articular surfaces
for stability and dispersion of applied loads.
Although these low conformity TKA designs
reduced stresses transmitted to the fixation inter-
face, this also resulted in a reduction in the con-
tact area between the femoral component and the
polyethylene bearing surface, leading to prema-
ture TKA failure due to polyethylene wear (33, 34).
Contact stresses experienced at the polyethylene
surface are inversely proportional to the extent
of conformity between the femoral condyles and
the tibial polyethylene insert. The greater the con-
formity at the articulating counter-surfaces, the
 Mobile-bearing total knee arthroplasty: advantages and disadvantages 743
greater the contact area between these surfaces.
Increased articular congruity reduces detrimen-
tal subsurface contact stresses experienced by the
polyethylene. Use of round-on-flat fl and flat-on-flflat
bearings produce point and line loading conditions
at the articular interface, respectively, with an
overall reduction in contact area through which
polyethylene loads are distributed. In addition,
fluoroscopic kinematic evaluations of round-on-
flat and flat-on-flflat articulations have shown an
increased incidence of both paradoxical anterior
femoral translation during deep flexion (instead of
controlled posterior femoral rollback) and reverse
axial rotation patterns. These
Th abnormal kinematic
patterns are likely secondary to reduced knee sta-
bility from a reduction in implant articular confor-
mity (9, 11, 14, 16, 17, 20) and produce detrimen-
tal cyclical tensile shear stresses at the articulating
surface, further increasing the risk of accelerated
wear of the polyethylene material (15, 27).
In summary, early TKA designs failed predominately
due to premature aseptic loosening and were often
associated with malalignment, ligamentous insta-
bility, or the use of excessively constrained implant
devices. Improvements in surgical instrumenta-
tion and techniques (ligamentous balancing, etc.)
resulted in a dramatic reduction in implant loosen-
ing. Use of lower conformity TKA designs further
reduced loosening by lessening stresses generated
at the fixation interfaces but at the expense of
producing detrimental effects
ff on the articular sur-
face and promoting accelerated polyethylene wear.
The current and future goals of TKA design aim to
minimize polyethylene wear while protecting the
integrity of the fixation
fi interface.
Polyethylene wear reduction strategies
Development of strategies for optimizing poly-
ethylene longevity requires both laboratory and
clinical studies to identify factors that cause
accelerated polyethylene wear. Surgical technique
embracing meticulous attention to ligament bal-
ancing, reproduction of anatomic extremity align-
ment, restoration of the proper joint line level, and
balanced flexion-extension gaps are necessary to
minimize polyethylene wear. Proper attention to
each of these will encourage more uniform loading
of the articular surface rather than placing exces-
sive eccentric loads on either the medial or lateral
aspects of the polyethylene surface.
Design factors shown in various analyses to reduce
polyethylene wear include use of thicker polyethyl-
ene bearings (27, 35), improvements in polyethyl-
ene locking mechanisms of modular tibial compo-
nents to reduce potential backside wear (36–38),
use of better sterilization techniques (39–44),
returning to use of TKA designs with increased
articular surface conformity (2–5, 45, 46) and the
use of mobile-bearing TKA systems (2–5, 45, 46).
Contact stress studies that have demonstrated
rapidly increasing polyethylene stresses with
decreases in polyethylene thickness (27, 35). Initial
recommendations to incorporate a tibial polyeth-
ylene thickness of at least 4–6 mm (35) have been
updated to recommend at least 8–10 mm to avoid
rapid increases in polyethylene stresses associated
with thinner polyethylene inserts (27).
Backside polyethylene wear (wear of the inferior sur-
face of modular fixed-bearing polyethylene inserts)
and its’contribution to microscopic polyethylene
particle generation and osteolysis has been clearly
demonstrated (36–38). Engh et al. (36, 37) and
Waseilewski et al. (38) have determined that back-
side micromotion as a result of inadequate locking
mechanisms of modular, fixed-bearing polyethyl-
ene inserts is common in many currently utilized
fixed-bearing TKA designs. It has been estimated
that the amount of debris released from this back-
side articulation may be 2–100 times greater than
the debris generated at the femorotibial articula-
tion (37). Recommendations for improvements
in locking mechanisms and preventative steps to
minimize undersurface wear in the situation of
unavoidable backside micromotion (use of cobalt-
chromium tibial trays, highly polished modular
baseplate surface, etc.) have been initiated.
Various reports have documented the association
of gamma irradiation sterilization techniques in
the presence of oxygen with accelerated polyethylene
wear due to increased oxidation of polyethylene and
disruption of polyethylene polymer chains due to
oxidative chain scission (39–44). Modernized poly-
ethylene sterilization techniques have been shown
to reduce the rate of polyethylene oxidation and
thus reduce associated polyethylene degradation
and wear (39, 42–44). Sterilization utilizing gamma
irradiation in an inert environment (inert gas or
vacuum) or utilizing ethylene oxide sterilization
have each shown decreases in wear when compared
to sterilization techniques incorporating gamma
irradiation in the presence of oxygen. In an analysis
of retrieved tibial polyethylene components, Wil-
liams et al. (44) demonstrated an 84% reduction
(0.09 vs. 0.55 mm/year) in wear penetration rate
when utilizing ethylene oxide sterilization com-
pared to components sterilized with gamma irra-
diation in air. When compared to gamma irradia-
tion in an oxygen environment, Hamilton et al. (47)
have shown in a knee simulator analysis that a 20%
reduction in polyethylene wear can be accomplished
when incorporating ethylene oxide sterilization and
a 50% reduction in wear when utilizing gamma irra-
diation in a vacuum environment (Fig. 2).
744 Primary Total Knee Arthroplasty
Fig. 2 – Histogram demonstrating average polyethylene wear rates (mg/
million cycles) when comparing sterilization techniques utilizing gamma
irradiation in air versus ethylene oxide versus gamma irradiation in an
inert vacuum environment (Reprinted with permission from Medscape.
Available at:http://www.medscape.com/viewprogram/3133. © 2004
Medscape).
More recently, tibial polyethylene inserts manufac-
tured with increased levels of polymer cross-link-
ing have been developed in hopes of reducing wear.
Wear analyses of both knee simulator studies and
early in vivo clinical retrievals have demonstrated
favorable reductions in polyethylene wear (48, 49).
Longer follow-up evaluation of these materials is
necessary to assure that reduction in mechanical
properties (fatigue strength, ductility, etc.) associ-
ated with increased cross-linking will result in pre-
mature failure of these polyethylene formulations
with increased cross-linking.
As previously discussed, an important component
design concept for reducing contact stresses at
the articulating surface and eff ffectively reducing
polyethylene wear is increasing conformity. The Th
higher the conformity of the articular surfaces
(i.e., the closer the radius of curvature of the two
surfaces match each other), the greater the articu-
lar surface contact area, the less the subsurface
polyethylene contact stress per unit area, and the
less polyethylene wear seen. Analysis of contact
area vs. contact stress demonstrates a dramatic
reduction of contact stress as contact area is
increased; at least until a contact area of 300–350
mm2 is reached. Increasing contact area beyond
this level does reduce contact stresses further but
to a much lesser extent (50) (Fig. 3). Conformity
can be achieved in multiple planes. For example, a
ball-in-socket articulation, as in a total hip arthro-
plasty, is conforming in all planes (1:1 radius of
curvature). In TKA, focus primarily is placed on
sagittal and coronal plane conformities. It has
been demonstrated that increasing coronal plane
conformity is the most critical plane to reduce
peak polyethylene stresses (27, 28). This Th is par-
ticularly true in the presence of femoral condylar
ff (21, 27–29).
lift-off
Fig. 3 – Graph demonstrating experimental and finite element analyses of
polyethylene contact area (mm²) and resultant contact stresses (MPa) (50).
Kinematically, the native knee joint is much more
complicated than a simple “hinge” joint. During
TKA, surgeons strive to achieve appropriate range
of motion, multi-plane stability and maximal
articular surface contact area while attempting to
recreate the complicated sagittal and rotational
plane kinematic motions that occur during range
of motion in the normal knee. Early TKA designs
cited above have already shown that highly con-
forming fixed-bearingg systems are at increased risk
of component loosening due to increased implant
constraints and stress transferred to the fixation
interface (20, 31, 32). Biomechanical studies have
also shown that highly conforming fixed-bearing
TKA designs are intolerant of higher rotational and
anteroposterior translational kinematic motion
patterns that are commonly encountered after
TKA, with increased polyethylene wear frequently
observed (20, 28, 29, 51–53). Lastly, subsurface
polyethylene stresses experienced in situations of
malalignment have been shown to be signifi ficantly
higher in highly conforming fixed-bearing TKA sys-
tems than in less conforming fixed or highly con-
forming mobile-bearing TKA designs (18,47,72].
Therefore, in highly conforming (highly con-
strained) fixed-bearing TKA systems, the relatively
unpredictable kinematics of the implanted knee
often generate unacceptable increased stresses at
both the fixation interface and polyethylene sub-
surface. In order to capitalize on the benefits
fi of a
highly conforming articular interface, alternative
design concepts such as the use of a mobile-bear-
ing TKA have been adopted.
Advantages of a mobile-bearing TKA
Mobile-bearing TKA designs off ffer the advantage
of allowing increased implant conformity and con-
tact area without dramatically increasing stresses
transmitted to the fixation interface. The incorpo-
 Mobile-bearing total knee arthroplasty: advantages and disadvantages 745

ration of polyethylene bearing mobility, such as in a

rotating platform TKA design, allows smooth rota-
tion through the tibial tray-polyethylene bearing
articulation and eff ffectively minimizes the trans-
fer of torsional stresses to the fixation interface
that have been associated with fixed-bearing TKA
implants (54). This is supported by the excellent
long-term clinical results with minimal loosening
reported in numerous studies of mobile-bearing
TKA. Callaghan et al. (5) evaluated the 15 year
results of the LCS rotating platform design and
reported no failures secondary to loosening, oste-
olysis, or wear. In the initial early combined expe-
rience with the LCS meniscal bearing and rotat-
ing platform systems, Buechel et al. (4) reported
95.1 and 98.2% (cemented and cementless) good
to excellent results at a follow-up period of up to
10-years. When evaluating only the rotating plat-
form LCS system, Buechel et al. (2, 3) reported
survivorship rates of 97.7 and 98.3% (cemented Fig. 4 – Histogram demonstrating peak polyethylene contact stresses
(MPa) of high versus low conformity TKA designs in neutral and 3° varus
and cementless) at both 10 and 20-years with end-
alignment.*
points defifined as revision for any mechanical rea-
son or a poor clinical knee score. Survivorship of
the cementless LCS rotating platform system with area, reduce contact stresses, and lower polyeth-
loosening as the endpoint was determined to be ylene wear in numerous evaluations (15, 27, 29,
99.4% at 20 years (2). Sorrels et al. (55) reported 53, 56–60). Greenwald (57) has demonstrated
a similar excellent survivorship of 90.3% with this contact areas of mobile-bearing TKA during gait
design 13 years following operation. Various stud- range from approximately 400–800 mm2 which
ies evaluating primary TKA using the rotating plat- keeps contact stresses at 14 MPa or less (Fig. 5).
form system reported no evidence of radiographic This magnitude of contact area is substantially
loosening, even at 20-year radiographic follow-up greater than is typically seen in mostt fixed-bearing
(2–5) and report that revision TKA was required in TKA designs (200–250 mm²) (Fig. 6). Additional
0–0.2% due to aseptic loosening (2–5). finite element evaluations demonstrating reduced
By increasing sagittal plane conformity in mobile- polyethylene contact stresses as a direct result of
bearing TKA, in vivo fluoroscopic analyses have increased contact areas further support the find-
fi
demonstrated improved control of anteroposterior ings of Greenwald (60–63). The advantage of this
translation with reduced paradoxical anterior fem- increase in contact area is refl
flected in knee simu-
oral translation, particularly when tested during lator wear studies of fixed versus mobile-bearing
gait (9). The increased coronal plane conformity TKA. McNulty et al. (59) and McEwen et al. (58),
typically present in mobile-bearing TKA increases in separate laboratory evaluations, have demon-
the contact area and lessens the increased contact strated signifi
ficantly diminished polyethylene wear
stresses which are present if femoral condylar lift- rates with highly conforming rotating platform
ff occurs (21, 27–29, 56). This has been demon-
off designs when compared to similarly designed
strated using TekScan analysis (56). When a fl flat- fixed-bearing systems. McNulty (59) observed a
on-flflat design is tested in good alignment with 94% wear reduction, when analyzing a highly con-
equal loading of each condyle, peak polyethylene forming rotating platform design versus a similar
stresses reach approximately 16 MPa. When the fixed-bearing TKA design whereas McEwen et al.
same design is loaded in 3° of varus malalignment, (58) noted over a fourfold reduction in wear with
shifting load to one condyle as occurs with femo- testing of a rotating platform TKA (Fig. 7).
ral condylar lift-off
ff, the peak stresses dramatically
increase to 38 MPa, which far exceeds the yield
strength of polyethylene (20–22 MPa). When
similar testing was performed with a TKA design Additional benefifits of a rotating platform TKA
with increased coronal conformity, peak polyethyl-
ene stresses increased to only 16 MPa when tested Rotating platform systems utilize a flat tibial tray-
under varus loading conditions (Fig. 4). polyethylene counter-surface that allows unim-
The increased conformity of mobile-bearing designs peded freedom of the polyethylene insert to rotate
has been shown to substantially increase contact around a central post on a highly polished, cobalt-
746 Primary Total Knee Arthroplasty
Fig. 5 – Contact area and stress analysis demonstrating high polyethylene contact areas (mm2) and low peak stresses
(MPa) of three mobile-bearing TKA designs (57).
Fig. 6 – Contact area and stress analysis demonstrating a lower polyeth-
ylene contact area (mm2) and higher peak stress (MPa) in a fixed-bearing
TKA design (57).
chrome surface with a very low surface roughness.
In vivo fluoroscopic kinematic studies conducted
have confifirmed that rotation in rotating platform
TKA systems predictably occurs in all subjects
tested (64, 65). Since the polyethylene bearing
is transparent during fluoroscopy, four metallic
beads were inserted at known positions into each
polyethylene bearing by the implant manufacturer.
Computer assisted design (CAD) models were then
created for the polyethylene inserts having the
four strategically placed beads. Using a computer
assisted model-fifitting algorithm, orientation of
femoral component and tibial tray were initially
determined. The polyethylene insert was then made
transparent and only the four beads were visible
Fig. 7 – Histogram of a high kinematic knee simulator analysis demonstrat-
ing polyethylene wear (mg) per million cycles in the mobile versus fixed-
bearing PFC Sigma TKA (58).
in the CAD model. The best fit of the CAD model
of the four metallic beads onto the four beads vis-
ible in the fluoroscopic image was then determined
using the same automated computer model fitting
process (Fig. 8). Once the process determined the
best-fi
fit match, the polyethylene insert is visualized
and axial rotation measurements of the rotating
platform bearing relative to the femoral compo-
nent and tibial tray were determined. These analy-
ses have demonstrated that the majority of axial
rotation in these rotating platform designs occurs
 Mobile-bearing total knee arthroplasty: advantages and disadvantages 747
Fig. 8 – Fluoroscopic images demonstrating strategically placed metallic
beads within a rotating platform polyethylene insert (left) and the com-
puter automated model fitting process (right) utilized to determine poly-
ethylene bearing mobility.
at the polyethylene bearing-tibial tray interface as
the polyethylene bearing “follows” the rotation of
the femoral component (20, 64, 65).
Rotation of the rotating platform polyethylene
insert with the femoral component, independent
of the rotation of the firmly fixed tibial tray, creates
the potential for self-alignmentt of the polyethylene
bearing with the femoral component. Self-align-
ment is advantageous both for optimal kinematics
of the TKA and for maintenance of acceptable poly-
ethylene surface stresses and stresses on posterior
cruciate substituting tibial posts. This self-aligning
behavior with a highly conforming design has been
shown to maintain large, centrally located surface
contact areas at the femorotibial articulation dur-
ing both flexion-extension
fl and axial rotation of the
knee (53) which is much more difficult
ffi to achieve in
fixed-bearing TKA designs.
fi
An additional advantage of the self-aligning feature
of rotating platform TKA systems is facilitation
of central patellar tracking (5). In a fixed-bearing
TKA, if substantial malrotation of the tibial com-
ponent relative to the femoral component is pres-
ent (especially tibial component internal rotation),
the tibial tubercle can become lateralized, enhanc-
ing the risk of patellar subluxation. A rotating plat-
form design, through bearing rotation, typically
provides for greater self-correction of the compo-
nent malalignment, allowing better centralization
of the extensor mechanism.
The authors reviewed 1318 consecutive primary
TKA performed by the senior author (D.A.D.) over
a 6 year period. All subjects were implanted using a
single posterior-stabilized knee design (Sigma Press-
Fit Condylar; Depuy, Warsaw, IN) utilizing bone
cement. The femoral and patellar components were
identical and the tibial component type was either
a mobile-bearing rotating platform tibial design or
a fixed-bearing tibial design (all-polyethylene or
modular metal-backed tibial component). Th The selec-
tion of a fixed versus mobile-bearing TKA was pri-
marily based on patient age with subjects less than
70 years of age receiving a mobile-bearing TKA.
Mobile-bearing TKA devices were implanted in 940
cases (71.3%; 940 of 1318) and fixed-bearing knees
were implanted in 378 cases (28.7%; 378 of 1318).
The overall prevalence of lateral release was 7.9%
(104 of 1318 knees). The
Th incidence of lateral release
in the fixed-bearing group (14.3%; 54 of 378) was
found to be signifi
ficantly higher (p < 0.0001) than in
the mobile-bearing group (5.3%; 50 of 940) (76).
The magnitude of axial rotation occurring during
deep flexion activities is an important factor in knee
implant design. An in vivo fluoroscopic evaluation
of over 1000 TKAs incorporating 33 different
ff fixed
and mobile-bearing TKA designs has demonstrated
that most TKAs will experience less than 10° of
axial rotation with normal post-operative activi-
ties. However, in this large multi-center analysis,
a number of subjects experienced either normal or
reverse axial rotational magnitudes greater than
20° during these same activities which are beyond
the rotational boundaries of most fixed-bearing
TKA designs (26). Therefore, mobile-bearing TKA
designs which provide more freedom of rotation
should reduce rotational polyethylene impinge-
ment with the potential for reduction of polyeth-
ylene wear. In addition, recent studies examining
the contribution of posterior cruciate substituting
(PS) polyethylene post wear to TKA failure have
shown that excessive axial rotation in PS fixed- fi
bearing designs can pre-dispose to premature poly-
ethylene wear and compromise the integrity of the
central post due to lateral and medial post impinge-
ment with attempted excessive rotation of a fixed fi
square tibial polyethylene post in a fixed
fi femoral
intercondylar housing (66) (Fig. 9). Th
The freedom of
rotation present in rotating platform designs allow
Fig. 9 – Photograph of a retrieved posterior stabilized fixed-bearing tibial
insert at 9 years post-operatively demonstrating anteromedial and anterolat-
eral polyethylene post wear (arrows) secondary to rotational impingement.*
748 Primary Total Knee Arthroplasty
them to adapt to a greater range of axial rotation
without the creation of rotational impingement
and wear on posterior cruciate stabilizing posts. In
conclusion, the phenomenon of rotational medial
and lateral post impingement in PS systems can
be reduced in rotating platform TKA systems due
to post rotation with the femoral box rather than
attempts to rotate againstt it.
In summary, the rotational freedom provided in
mobile-bearing TKA designs assists in maintaining
alignment of both the patellofemoral and femo-
rotibial articulations throughout knee flexion.
fl
Self-alignment via polyethylene bearing rotation
improves post-operative TKA kinematics, lessens
polyethylene surface stresses and minimizes PS
post impingement, increasing the potential for
enhanced polyethylene longevity.
Mobile-bearing revision total knee arthroplasty
Revision TKA presents numerous additional chal-
lenges beyond those in the primary arthroplasty
setting. It is not uncommon to encounter signifi- fi
cant bone loss secondary to osteolysis or iatrogenic
resection. As a result, fixation naturally becomes
increasingly difficult
ffi in the context of diminished
bone stock. Disrupted or unbalanced soft tissues
supporting structures may also be encountered
which often begs the use of revision components
with increased constraint. Although increased con-
straint may accommodate for ligamentous insta-
bility, this bears the burden of increased stresses at
the fixation interface which may lead to premature
component loosening and increased polyethylene
post-wear secondary to increased torque on the
constraining mechanism. Potential advantages of
use of mobile-bearings in the revision TKA setting
include reduction in polyethylene wear, decreasing
fixation stresses, and protection of the constrain-
fi
ing mechanisms.
Between January 2000 and October 2006, a total
of 341 revision TKA procedures were performed
by two surgeons at our institution. Of the 341
revisions, 145 revisions (139 patients) were
performed using a mobile-bearing TKA system
(PFC Sigma and LCS posterior-stabilized rotat-
ing platform implants; Depuy, Warsaw, IN). The Th
factors used to determine the use of a mobile-
bearing implant design were patient’s age, activ-
ity requirements, longevity expectations, and the
ability to achieve both a symmetrical extension
and flexion gap balance as deemed appropri-
ate by the senior authors. ThisTh represented 43%
(145 of 341 knees) of all the revision TKA proce-
dures performed at our institution by the senior
authors. All patients were followed with a clinical
and radiographic protocol. The average follow-up
was 37.7 months (range 5.2–76.8 months). Indi-
cations for revision were instability (54 knees)
(Fig. 10a–d), loosening (47 knees), arthrofibrosis
fi
(9 knees), chronic hemarthrosis (3 knees), failed
patellofemoral replacements (2 knees), failed
unicompartmental knee replacement (16 knees),
infection reimplantation (13 knees), and non-
union of a supracondylar femur fracture (1 knee).
There were 129 PFC Sigma revision implants and
16 LCS revision implants used in the study. Both
the tibia and femoral components were revised
in 118 knees, tibial component only in one knee,
and femoral component only in 26 knees. A pos-
terior-stabilized rotating platform prosthesis
was implanted in 90 knees and more constrained
condylar-type rotating platform prosthesis was
implanted in 55 knees (10 varus–valgus condy-
lar constrained and 45 Rotating Platform Total
Condylar III).
The average range of motion at latest follow-up
was 0.4–116° (range 0–6° of extension and
85–145° of flexion). The post-operative alignment
averaged 5° (range 4–6°). The Knee Society clini-
cal scores improved from 49 pre-operatively to
92 points (range 70–100 points) post-operatively
while the Knee Society functional scores improved
from 48 points pre-operatively to a mean of 79
points (range 35–100 points) at latest follow-up.
There were no cases of bearing instability and no
revision procedures were required for prosthetic
loosening. Longer follow-up is necessary to see if
the theoretical benefi
fits of mobile-bearing use in
revision TKA are clinically observed.
Fears associated with mobile-bearing TKA
Despite the many demonstrated advantages of use
of a mobile-bearing TKA, several concerns have
been expressed with their use including the need
for a more exacting surgical technique, the occur-
rence of bearing instability (4, 31, 45, 67), the risk
of enhanced polyethylene wear resulting from the
creation of a second articulating surface, and will
the polyethylene particles generated from the infe-
rior aspect of the bearing be smaller with greater
osteolytic potential.
The surgical goals and techniques utilized (align-
ment, bone resections, ligamentous balancing, etc.)
for implantation of a mobile-bearing TKA are typi-
cally no different
ff from preparations utilized with
fixed-bearing TKA systems. Soft-tissue balanc-
ing, creation of equal flexion and extension gaps
and precise component positioning are extremely
important in both fixed and mobile-bearing TKA
systems.
 Mobile-bearing total knee arthroplasty: advantages and disadvantages 749

A B

C D

Fig. 10 – (a–d) Pre-operative anteroposterior (11a)

and lateral (11b) radiographs of a failed total knee
due to instability and painful lateral tibial component
overhang. Post-operative anteroposterior (11c) and
lateral (11d) radiographs following revision TKA with
constrained mobile-bearing components and a tibial
metaphyseal sleeve.

Extension and flexion gap balance is of particular
importance in use of a mobile-bearing TKA because
imbalance risks bearing dislocation or “spin out”
where the polyethylene bearing is no longer con-
gruous with the femoral component. Gap balance
can be achieved by several methods. Th The authors
utilize a spacer block to initially evaluate and bal-
ance the extension gap prior to addressing the
flexion gap and the directly related femoral com-
ponent rotation. Proper rotation of the femoral
component is essential to obtain a balanced flflexion
gap. Numerous methods are available to assist in
gaining correct rotation of the femoral component
(68–72). These include use of cutting jigs which
automatically rotate the femoral component 3°
externally relative to the posterior condylar axis,
femoral component placement either parallel to
the transepicondylar axis or perpendicular to the
anteroposterior axis, or by utilizing the flexion gap
method in which the femoral component is placed
parallel to the tibial resection with each collateral
ligament equally tensioned (Fig. 11). All methods
750 Primary Total Knee Arthroplasty
have been shown to have potential shortcom-
ings and use of all rotational landmarks is wise.
With the use of mobile-bearing TKA systems, the
authors have found that use of some type of ten-
sioning device (laminar spreaders, spacer blocks,
or a specifi
fic gap tensioning device) provides the
most reliable and reproducible balance and tension
of the flexion gap. Specifific gap tensioning devices
provide an additional advantage of facilitating
equalization of the flexion gap width to the pre-
viously established extension gap (Fig. 12). Th These
tensioning devices have been specifi fically designed
to allow measurements (width and tension)
obtained from a balanced extension gap to deter-
mine and direct flexion gap resections and femoral
component rotation. Obtaining 1–2 mm of medial
and lateral laxity in fl
flexion is desired with the use
of mobile-bearing TKA systems. Inability to obtain
flexion-extension gap balance or substantial
incompetence of the collateral ligamentous struc-
Fig. 11 – Intraoperative photograph of an equalized flexion gap achieved
by placement of the anteroposterior femoral cutting jig parallel to the tibial
resection with each collateral ligament equally tensioned using laminar
spreaders.*
Fig. 12 – Intraoperative photographs of a flexion-extension gap balancer
(Knee Balancer, Depuy Orthopaedics, Warsaw, IN) placed into the extension
(left) and flexion (right) gaps to determine both gap symmetry, width, ten-
sion, and balance with the other gap.*
tures should prompt consideration of using either
a fixed-bearing TKA or varus-valgus constrained
rotating platform TKA to lessen the risk of poly-
ethylene bearing instability.
Reports of polyethylene bearing “spin-out” in
rotating platform TKA have traditionally described
this phenomenon as occurring during deep knee
flexion. Most commonly, the polyethylene bearing
rotates 90° around its central axis in the tibial tray
as the posterolateral polyethylene lip slips poste-
riorly underneath the lateral femoral condyle and
the anteromedial polyethylene lip slips anteriorly
underneath the medial femoral condyle. This may
be irreducible by closed attempts and require oper-
ative reduction. While this is a legitimate concern
with the use of rotating platform designs, the high-
est incidence of bearing spin-out (3.3% (5/149)
to12% (2/17); (4, 30) have most commonly been
associated with early outcome evaluations of rotat-
ing platform TKA, when attention to flexion gap
tension and balance was less emphasized. Advances
in component design, surgical implantation instru-
mentation, and an increased understanding of the
importance of flexion and extension gap tension
and balance, accurate ligamentous balancing, and
proper femoral component rotation have decreased
the incidence of bearing instability following
mobile-bearing TKA. Several recent outcome evalu-
ations have reported a 0–2.2% incidence of bearing
spin-out in primary TKA at up to 20 years follow-
ing the operative procedure (2, 4, 5, 67).
The additional polyethylene-metal interface at
the undersurface of the polyethylene bearing has
raised concerns about the generation of additional
polyethylene particles and accelerated polyethyl-
ene wear. With fixed-bearing TKA systems, “back-
side” polyethylene motion against a rough tibial
tray that is not designed to accommodate motion
has shown signifi ficant polyethylene wear and
subsequent periprosthetic osteolysis (36–38). In
rotating platform systems, a rotating, yet flat poly-
ethylene bearing is matched against a flat, highly
polished, cobalt chromium surface with extremely
low surface roughness. To date, backside polyeth-
ylene wear has not emerged as a clinically signifi- fi
cant issue in rotating platform designs. Studies
that have physically examined the backside bear-
ing surface of retrieved rotating platform polyeth-
ylene inserts have reported only limited evidence
of signifi
ficant undersurface wear (67, 73).
One explanation for the lack of clinically signifi- fi
cant backside polyethylene wear is the decou-
pling of multi-directional motions occurring at
the articular interfaces with rotating platform
TKA designs (43, 58). In fixed-bearing systems,
all rotational, translational, and flexion-exten-
fl
sion motion patterns are experienced at a single
(superior) articular surface. Therefore, the supe-
 Mobile-bearing total knee arthroplasty: advantages and disadvantages 751
rior aspect of a fixed-bearing polyethylene insert
experiences multi-directional motion pathways.
In a rotating platform design which allows no
anteroposterior translation, the inferior, or tibial
tray-polyethylene counter-surface, is designed to
experience purely rotational (reciprocal/unidi-
rectional) motion patterns. Since the polyethyl-
ene bearing tracts with the femoral component
(64, 65), the superior articular surface (femoral
component-polyethylene interface) primarily
experiences flexion-extension (reciprocal/uni-
directional) motion since rotation is occurring
on the inferior aspect of the bearing. Pooley and
Tabor (74) have reported when high density poly-
ethylene is subjected to unidirectional sliding,
the molecules tend to align along the direction of
sliding, resulting in lowering of the coefficient
ffi of
friction, potentially reducing wear of the mate-
rial. Conversely, when the material is exposed to
multi-directional wear pathways, increased cross
shear stresses are created which enhance wear of
polyethylene. Additional laboratory studies have
shown that the multi-directional shear stresses
typically experienced at the single polyethylene
interface in fixed-bearing systems may contribute
to the generation of 4–10 times the polyethylene
wear experienced at the unidirectional interfaces
in rotating platform designs (45, 54, 58). There-
Th
fore, use of rotating platform TKA designs can
reduce polyethylene wear by decoupling multi-
directional motions to more mono-directional
motion patterns at two diff ffering interfaces, thus
reducing cross shear stresses and wear occurring
at both interfaces (45, 54, 58).
In contrast to a purely rotating platform TKA
design, additional mobile-bearing TKA systems
exist which permit both rotation and anteropos-
terior translation to occur on the inferior aspect
of the polyethylene bearing. In these designs,
the inferior aspect of the polyethylene bearing
is exposed to multi-directional motion patterns.
Close follow-up evaluation of this type of mobile-
bearing TKA is merited to see if premature fail-
ure due to backside wear occurs secondary to the
multi-directional motion on the inferior aspect of
the mobile polyethylene bearing.
Another explanation for minimal undersurface
polyethylene wear is related to the high contact area
(typically >700 mm²) that has been demonstrated
at the inferior mobile articulation (63) (Fig. 13).
This high contact area has been shown in labora-
tory studies to generate peak subsurface stresses of
less than 17 MPa and mean subsurface stresses of
less than 8 MPa at this articulation when subjected
to forces up to five times body weight (52). These
low subsurface stresses experienced at the inferior
polyethylene surface when articulating against a
smooth, highly polished cobalt-chromium tibial
Fig. 13 – Contact area analysis of the superior and inferior aspects of a
rotating platform TKA demonstrating the high contact areas (mm2) present
at the articular (superior) and mobile (undersurface) interfaces throughout
knee flexion (63).
tray with very low surface roughness result in min-
imized polyethylene wear (5).
Lastly, the fear that polyethylene wear micropartic-
ulate debris created in mobile-bearing designs will
result in increased osteolysis has yet to be clinically
relevant. Fisher et al. (75) analyzed wear debris cre-
ated in both fixed-bearing and rotating platform
TKA designs in a knee simulator analysis under
high kinematic conditions, attempting to simulate
the activity patterns of the younger patient. They
observed no diff fferences in microparticulate size
but felt the osteolytic potential was much higher
in fixed-bearing designs due to substantially more
debris particle generation was observed in the
fixed-bearing TKA subgroup.
Summary
Use of mobile-bearing TKA allows the incorpora-
tion of increased coronal and sagittal implant con-
formity without an associated increase in fixation
fi
interface stresses and resultant aseptic loosening.
The increase in sagittal conformity has also allowed
more predictable and controlled anteroposterior
motion while increased coronal conformity pre-
vents excessively high polyethylene stresses if fem-
oral condylar lift-off
ff occurs. The overall increase in
conformity additionally increases surface contact
area, decreases subsurface polyethylene stresses,
and should ultimately decrease polyethylene wear.
The rotating articulation is more forgiving of tibial
component rotational malalignment and patient
outliers who demonstrate excessive axial rota-
tion following TKA. It facilitates some correction
of patellar alignment through optimization of the
Q-angle. Rotation of the polyethylene insert with
the femoral component also minimizes medial and
lateral tibial post wear in situations where a poste-
rior stabilizing system has been utilized.
752 Primary Total Knee Arthroplasty
The kinematics of mobile-bearing TKA, however,
are not perfect. There still exist situations in which
femoral condylar lift-offff and reverse rotational pat-
terns occur (20, 22) and paradoxical anterior slid-
ing during deep flflexion can occur in non-stabilized
designs (18). Future goals include the development
of mobile-bearing TKA designs which create better
control of bearing mobility patterns.
The exactt indications for the use of the mobile-
bearing TKA are still unclear. Clinically, fifixed and
mobile-bearing TKA systems have performed simi-
larly in outcome studies (2–8, 55). However, due
to the potential for reduced polyethylene wear and
enhanced fixation longevity, mobile-bearing TKA
designs are to be considered particularly for younger
and higher demand patients with longer life expec-
tancies. Rotational polyethylene post wear seen in
fixed-bearing posterior stabilized systems should
fi
be minimized in rotating platform designs and
may be another indication for mobile-bearing TKA
use. Lastly, rotating platform TKA systems should
be considered in revision or extremely complicated
primary TKA situations where constrained or
hinged components are needed. Rotating platform
designs would help reduce the high torque stresses
typically seen at the fixation and hinge interfaces
when using a fixed-bearing TKA system.
While mobile-bearing TKA designs demonstrate
a number of favorable features when compared to
fixed-bearing systems, it is important to remem-
fi
ber that all mobile-bearing systems are not the
same. Difffferences exist both in condylar geom-
etry and bearing mobility patterns. To date, the
purely rotating platform design has emerged as
the most clinically successful, reliable, and predict-
able among mobile-bearing designs. Future studies
are indicated to determine and compare the kine-
matic and clinical eff ffects associated with multi-
directional (anteroposterior translation and bear-
ing rotation) versus unidirectional (rotation only)
mobile-bearing TKA systems.
References
1. Kurtz S, Ong K, Lau E, et al. (2007) Projections of pri-
mary and revision hip and knee arthroplasty in the
United States from 2005 to 2030. J Bone Joint Surg Am
A89(4):780–785
2. Beuchel FF Sr (2002) Long-term follow-up after mobile-
bearing total knee replacement. Clin Orthop 404:40–50
3. Buechel FF Sr, Buechel FF Jr, Pappas MJ, et al. (2002)
Twenty-year evaluation of the New Jersey LCS rotating
platform knee replacement. J Knee Surg 15:84–89
4. Buechel FF, Pappas MJ (1989) New Jersey low contact
stress knee replacement system: ten-year evaluation of
meniscal bearings. Orthop Clin North Am 20:147–177
5. Callaghan JJ, O’Rourke MR, Iossi MF, et al. (2005)
Cemented rotating-platform total knee replacement. A
concise follow-up, at a minimum of fifteen years, of a pre-
vious report. J Bone Joint Surg (Am) 87(9):1995–1998
6. Dennis DA, Clayton ML, O’Donnell S, et al. (1999) Pos-
terior cruciate condylar total knee arthroplasty. Average
11-year follow-up evaluation. Clin Orthop 281:168–176
7. Ranawat CS, Boachie-Adjei O (1988) Survivorship analy-
sis and results of total condylar knee arthroplasty: eight-
to 11-year follow-up period. Clin Orthop 226:6–13
8. Schai PA, Thornhill TS, Scott RD (1998) Total knee arthro-
plasty with the PFC system: results at a minimum of ten
years and survivorship analysis. J Bone Joint Surg (Br)
80:850–858
9. Dennis DA, Komistek RD, Mahfouz MR, et al. (2003) Mul-
ticenter determination of in vivo kinematics after total
knee arthroplasty. Clin Orthop 416:37–57
10. Komistek RD, Dennis DA, Mahfouz M (2003) In vivo fluo- fl
roscopic analysis of the normal human knee. Clin Orthop
410:69–81
11. Dennis DA, Komistek RD, Mahfouz MR, et al. (2004) A
multicenter analysis of axial femorotibial rotation follow-
ing total knee arthroplasty. Clin Orthop 428:180–189
12. Nordin M, Frankel VH (1980) Biomechanics of the knee.
In: Frankel VH, Nordin M (eds) Basic biomechanics of the
musculoskeletal system. Lea & Febiger, Philadelphia
13. Rosenberg A, Mikosz RP, Mohler CG (1994) Basic knee
biomechanics. In: Scott N (ed.) The knee. St Louis, Mosby,
pp 75–94
14. Banks S, Bellemans J, Nozaki H, et al. (2003) Knee motion
during maximum fl flexion in fixed and mobile-bearing
arthroplasties. Clin Orthop 410:131–138
15. Blunn GW, Walker PS, Joshi A, et al. (1991) TheTh dominance
of cyclic sliding in producing wear in total knee replace-
ments. Clin Orthop 273:253–260
16. Dennis DA, Komistek RD, Colwell CE, et al. (1998) In vivo
anteroposterior femorotibial translation of total knee arthro-
plasty: A multicenter analysis. Clin Orthop 356:47–57
17. Dennis DA, Komistek RD, Mahfouz MR (2003) In vivo
fluoroscopic analysis of fixed-bearing total knee replace-
ments. Clin Orthop 410:114–130
18. Haas BD, Komistek RD, Stiehl JB, et al. (2002) Kinematic
comparison of posterior cruciate sacrifi fice versus substitu-
tion in a mobile bearing total knee arthroplasty. J Arthro-
plasty 17:685–692
19. Stiehl JB, Dennis DA, Komistek RD, et al. (1997) In vivo
kinematic analysis of a mobile bearing total knee prosthe-
sis. Clin Orthop 345:60–66
20. D’Lima DD, Trice M, Urquhart AG, et al. (2001) Tibiofem-
oral conformity and kinematics of rotating-bearing knee
prostheses. Clin Orthop 386:235–242
21. Scuderi GR, Komistek RD, Dennis DA, et al. (2003) The Th
impact of femoral component rotational alignment on
condylar lift-off.
ff Clin Orthop 410:148–154
22. Steihl JB, Dennis DA, Komistek RD, et all (1999) In vivo
determination of condylar lift-off ff and screw-home in a
mobile-bearing total knee arthroplasty. J Arthroplasty
14:293–299
23. Dennis DA, Komistek RD, Walker SA, et al. (2001) Femoral
condylar lift-off
ff in total knee arthroplasty. J Bone Joint
Surg (Br) 83:33–39
24. Insall JN, Scuderi GR, Komistek RD, et al. (2002) Corre-
lation between condylar lift-off ff and femoral component
alignment. Clin Orthop 403:143–152
25. Stiehl JB, Komistek RD, Haas B, et al (2001) Frontal plane
kinematics after mobile bearing total knee arthroplasty.
Clin Orthop 392:56–61
26. Dennis DA, Komistek RD, Stiehl JB, et al. (1998) Range of
motion after total knee arthroplasty: the effect
ff of implant
design and weight-bearing conditions. J Arthroplasty
13:748–752
27. Bartel DL, Bicknell VL, Ithaca MS, (1986) The Th eff
ffect of
conformity, thickness and material on stresses in ultra-
high molecular weight components for total joint replace-
ment. J Bone Joint Surg (Am) 68:1041–1051
 Mobile-bearing total knee arthroplasty: advantages and disadvantages 753
28. Liau JJ, Cheng CK, Huang CH, et al. (2002) The Th eff
ffect of
malalignment on stresses in polyethylene component of
total knee prostheses – a finite element analysis. Clin Bio-
mech 17:140–146
29. D’Lima DD, Chen PC, Colwell CW Jr (2001) Polyethylene
contact stress, articular congruity, and knee alignment.
Clin Orthop 392:232–238
30. Bert JM (1990) Dislocation/subluxation of meniscal bear-
ing elements after New Jersey low-contact stress total
knee arthroplasty. Clin Orthop 254:211–215
31. Dendrinos GK, Mavropoulou A, Polyzoides AJ (1991) Late
failure and revisions of old-type total knee replacements.
Acta Orthop Belg 57:274–284
32. Ivarsson I, Myrnerts R, Tkaczuk H (1986) Long-term fol-
low-up of patients with geomedic prosthesis. Arch Orthop
Trauma Surg 105:353–358
33. Lonner JH, Siliski JM, Scott RD (1999) Prodromes of fail-
ure in total knee arthroplasty. J Arthroplasty 14:488–492
34. Sharkey PF, Hozack WJ, Rothman RH, et al. (2002) Why
are total knee arthroplasties failing today? Clin Orthop
404:7–13
35. Bartel DL, Burstien AH, Toda MD, et al. (1985) The
Th eff
ffect of
conformity and plastic thickness on contact stress in metal
backed plastic implants. J Biomech Eng 107:193–199
36. Engh GA, Lounici S, Rao AR, et al. (2001) In vivo deterio-
ration of tibial baseplate locking mechanisms in modular
total knee components. J Bone Joint Surg (Am) 83:1660–
1665
37. Rao AR, Engh GA, Collier MB, et al. (2002) Tibial inter-
face wear in retrieved total knee components and correla-
tion with modular insert motion. J Bone Joint Surg (Am)
84:1849–1855
38. Wasielewski RC, Parks N, Williams I, et al. (1997) Tibial
insert undersurface as a contributing source of polyethyl-
ene wear debris. Clin Orthop 345:53–59
39. Bargmann LS, Bargmann BC, Collier JP, et al. (1999) Cur-
rent sterilization and packaging methods for polyethyl-
ene. Clin Orthop 369:49–58
40. Bell CJ, Walker PS, Abeysundera MR, et al. (1998) Effectff
of oxidation on delamination of ultrahigh-molecular-
weight polyethylene tibial components. J Arthroplasty
13:280–290
41. Blunn G, Brach del Preva EM, Costa L, et al. (2002) Ultra
high molecular-weight polyethylene (UHMWPE) in total
knee replacement: fabrication, sterilization and wear. J
Bone Joint Surg (Br) 84:946–949
42. Collier JP, Satula LH, Currier BH, et al. (1996) Over-
view of polyethylene as a bearing material. Clin Orthop
333:76–86
43. McNulty DE, Liau YS, Haas BD (2002) Th The infl
fluence of
sterilization method on wear performance of the low con-
tact stress total knee system. Orthopaedics 25(S):243–
246
44. Williams IR, Mayor MB, Collier JP (1998) The Th impact of
sterilization method on wear in knee arthroplasty. Clin
Orthop 356:170–180
45. Murray DW, Goodfellow JW, O’Connor JJ (1998) Th The
Oxford unicompartmental arthroplasty: a ten-year sur-
vival study. J Bone Joint Surg (Br) 80:983–989
46. Psychoyios V, Crawford RW, O’Connor JJ, et al. (1998)
Wear of congruent meniscal bearings in unicompartmen-
tal knee arthroplasty: a retrieval study of 16 specimens. J
Bone Joint Surg (Br) 80:976–982
47. Hamilton JV, Schmidt MB, Greer KW (1996) Improved
wear of UHMWPE using a vacuum sterilization process.
Transactions 42nd Annual Meeting, Orthopaedic Research
Society, Atlanta, GA
48. Akagi M, Asano T, Clarke IC, et al. (2006) Wear and tough-
ness of crosslinked polyethylene for total knee replace-
ments: a study using a simulator and small-punch testing.
J Orthop Res Oct 24(10):2021–2027
49. Asano T, Akagi M, Clarke IC, et al. (2007) Dose effects
ff of
cross-linking polyethylene for total knee arthroplasty on
wear performance and mechanical properties. J Biomed
Mater Res B Appl Biomater 83(2):615–622
50. Rullkoetter PJ, Gabriel SM, Colleran DP, et al. (1999) TheTh
relationship between contact stress and contact area with
implications for TKR evaluation and design. Transactions
45th Annual Meeting. Orthopaedic Research Society, Ana-
hiem, CA
51. Cheng CK, Huang CH, Liau JJ, et al. (2003) TheTh inflfluence
of surgical malalignment on the contact pressures of fi fixed
and mobile bearing knee prostheses-a biomechanical
study. Clin Biomech 18:231–236
52. Matsuda S, White SE, Williams VG II, et al. (1998) Contact
stress analysis in mobile bearing total knee arthroplasty. J
Arthroplasty 13:699–706
53. Stukenborg-Coleman C, Ostermeier S, Hurschler C, et al.
(2002) Tibiofemoral contact stress after total knee arthro-
plasty: comparison of fixed and mobile-bearing inlay
designs. Acta Orthop Scand 73:638–646
54. Jones VC, Barton DC, Fitzpatrick DP, et al. (1999) An
experimental model of tibial counterface polyethylene
wear in mobile bearing knees: the inflfluence of design and
kinematics. Bio-Med Mater Eng 9:189–196
55. Sorrels RB, Stiehl JB (2004) Long-term outcomes of a
rotating platform mobile bearing prosthesis after TKA. J
Arthroplasty 19:255
56. Sharma A, Komistek RD, Ranawat CS, et al. (2007) In vivo
contact pressures in total knee arthroplasty. J Arthro-
plasty 22(3):404–416
57. Greenwald AS, Heim CS (2005) Mobile-bearing knee sys-
tems: ultra-high molecular weight polyethylene wear and
design issues. Instr Course Lect 54:195–205
58. McEwen HM, Barnett PI, Bell CJ, et al. (2005)The influ-
ence of design, materials and kinematics on the in vitro
wear of total knee replacements. J Biomech (2):357–
365
59. McNulty D, et al. (2002) The effect of crosslinking
UHMWPE on in-vitro wear rates of fixed and mobile
bearing knees. From the ASTM Symposium on Cross-
linked and Thermally Treated UHMWPE for TJR,
November 2002
60. Otto JK, Callaghan JJ, Brown TD (2003) Gait cycle fi finite
element comparison of rotating-platform total knee
designs. Clin Orthop 410:181–188
61. Bartel DL, Rawlinson JJ, Burstein AH, et al. (1995)
Stresses in polyethylene components of contemporary
total knee replacements. Clin Orthop 317:76–82
62. Miller GJ, Petty W, Goll C (1995) Congruency and varus/
valgus loading effect
ff on prosthetic knee contact stress.
Combined Orthopaedic Research Society (English Speak-
ing World), San Diego, CA, 6–8 November 1995
63. Otto JK, Callaghan JJ, Brown TD (2001) Mobility and
contact mechanics of a rotating platform total knee
arthroplasty. Clin Orthop 392:24–37
64. Dennis DA, Komistek RD, Mahfouz MR, et al. (2005)
Mobile-bearing total knee arthroplasty: do the polyethyl-
ene bearings rotate? Clin Orthop 440:88–95.
65. Komistek RD, Dennis DA, Mahfouz MR, et al. (2004) In
vivo polyethylene bearing mobility is maintained in pos-
terior stabilized total knee arthroplasty. Clin Orthop
428:207–213
66. Puloski SKT, McCalden RW, MacDonald SJ, et all (2001)
Tibial post wear in posterior stabilized total knee arthro-
plasty. J Bone Joint Surg (Am) 83:390–397
67. Huang CH, Ma HM, Liau JJ, et al. (2002) Late dislocation
of rotating platform in New Jersey low-contact stress
knee prosthesis. Clin Orthop 405:189–194
68. Akagi M, Matsusue Y, Mata D, et al. (1999) The Th eff
ffect of
rotational alignment on patellar tracking in total knee
arthroplasty. Clin Orthop 366:155–163
754 Primary Total Knee Arthroplasty
69. Arima J, Whiteside LA, McCarthy DS, et al. (1995) Femo-
ral rotational alignment, based on the anteroposterior
axis, in total knee arthroplasty in a valgus knee: a techni-
cal note. J Bone Joint Surg (Am) 77:1331–1334
70. Fehring TK (2000) Rotational malalignment of the femo-
ral component in total knee arthroplasty. Clin Orthop
380:72–79
71. Poilvache PL, Insall JN, Scuderi JR, et al. (1996) Rota-
tional landmarks and sizing of the distal femur in total
knee arthroplasty. Clin Orthop 331:35–46
72. Yoshioka Y, Siu D, Cooke TD (1987) The anatomy and
functional axes of the femur. J Bone Joint Surg (Am)
69:873–880
73. Huang CH, Ma HM, Liau JJ, et al. (2002) Osteolysis in
failed total knee arthroplasty: a comparison of mobile-
bearing and fixed-bearing knees. J Bone Joint Surg (Am)
84:2224–2229
74. Pooley C, Tabor D (1972) Friction and molecular struc-
ture: the behavior of some thermoplastics. Proc R Soc
Lond 329A:251
75. Fisher
F h J, McEwen H, Tipper J, et al. (2006) Wear-simula-
tion analysis of rotating-platform mobile-bearing knees.
Orthopedics 29(9 Suppl):S36–S41
76. Yang CC, Mc Fadelen LA, Ignus DA, et al. (2000) Lateral
net nacular release rates mobile- versus fixed-bearing
TKA. Clin orthop Relat Res 466:2656-61

D. Kohn, M. Kusma Fixed-bearing total knee
arthoplasty: advantages
and disadvantages
Introduction
D
isadvantages of mobile-bearings have us
made aware of many advantages that can
be attributed to the fixed type bearings.
Consequently, advantages and disadvantages of
fixed-bearings in total knee arthroplasty (TKA)
cannot be discussed isolated but often in contrast
to mobile-bearings (Table I).
Historically, in TKA a rigid fixation
fi of the tibial
polyethylene was the first and only type, whether
directly cemented on the proximal tibia or fifixed on
a metal tibial implant. Due to theoretical disadvan-
tages in load transmission (see Design and Kine-
matics), mobile-bearings have been developed.
However, the fixed-bearing is still the standard
implant for many surgeons, and the theoretical
advantages of mobile-bearings are yet to be proven
in clinical practice.
Designs of fixed-bearings
Low vs. high conformity designs
Fixed-bearing designs with a high conformity
bearing surface decrease local contact stress,
but produce high torque at the bone-implant
interface, pre-disposing to component loosen-
ing. Contrarily, prothesis with a low conformity
bearing surface produce less constraint stress
decreasing the risk for early component loos-
ening, but generate high contact pressures of
the polyethylene (Bartel et al.1986). Addition-
ally, the kinematic conflict between low stress
articulations and free rotation cannot be solved
by any fixed-bearing design (Callaghan 2001). It
has been proposed that mobile-bearings (Bott-
lang et al. 2006) can reduce shear forces in the
proximal tibia in 10° of internal and external
rotation. However, this amount of rotation is
normally not achieved in a patient with TKA,
whether with fixed- nor with mobile-bearing
(Dennis 2004).
Chapter 69
Kinematics of fifixed-bearings
In vitro kinematics of fixed-bearings
Most et al. evaluated the in vitro kinematics of
intact knees as well as of reconstructed knees with
a fixed-bearing posterior-stabilized (PS) knee (LPS-
Flex, Zimmer, IN, USA) and a mobile-bearing PS
knee (LPS-Mobile, Zimmer, IN, USA). Th Their results
indicated that during flexion,
fl the intact knee
showed posterior femoral translation and internal
tibial rotation. This was only partially restored in
reconstructed knees. Most interestingly, despite
the variations in design, femoral translation and
tibial rotation were similar.
In vivo kinematics of fixed-bearings
In a multi-center study including 1027 knees,
an internal tibial rotation of 16.5° during deep
knee-bend and 5.7° during gait was shown (Den-
nis 2004). During deep knee-bend fixed-bearing
PS knees and fixed-bearing PCR knee demon-
strated a reduced internal tibial rotation of 3.1
and 3.7°, respectively. During the stance-phase of
gait, rotation was reduced to 1.4° (fifixed-bearing
PS) and 2.1° (fi
fixed-bearing PCR). However, also
mobile-bearing TKA showed limited rotation
compared to normal knees. Accordingly, patients
with any design of TKA have smaller femoral roll-
back as well as internal tibial rotation than nor-
mal knees.
Tibiofemoral contact stress under malalignment
conditions
Several biomechanical studies showed increased
contact stresses in malrotated tibial components
(Fig. 1). Mobile-bearings have shown a self-align-
ment effffect, reducing shear forces, and contact
pressure on the proximal tibia during in vitro
experiments (Stukenborg-C). Th This has not been
shown clinically to date.
756 Primary Total Knee Arthroplasty
Fig. 1 – Fixed-bearing polyethylene showing severe wear. The wear is
asymmetric with posterior wear on the left inlay and anterior wear on the
right inlay probably caused by malrotation of the femoral versus the tibial
component.
Wear rate of fixed-bearings
A potentially higher wear rate in fixed-bearings in
comparison to mobile-bearings has been discussed
frequently, due to the theoretically higher contact
stresses in fixed-bearing articulations. On the
other hand, mobile-bearings have the disadvan-
tage of “backside wear” between the tibial compo-
nent and the mobile polyethylene, in addition to
the wear between femoral component and polyeth-
ylene (Fig. 2). Several authors studied the in vitro
wear rate of fixed and mobile-bearings. Haider et
al. presented their results of measuring in vitro
wear rates of fixed- and mobile-bearing TKA (PFC
DePuy, Warsaw, IN, USA) in simulated walking.
They demonstrated only slightly more polyethyl-
ene wear after 6 million cycles in the fixed-bear-
fi
ing knees (fi
fixed-bearing: 8.14 ± 2.63 mg/million
cycles; mobile-bearing 6.78 ± 1.74 mg/million
cycles). The authors concluded that the “rotating
platform bearing design of the PFC did not produce
A B
Fig. 2 – Mobile-bearing polyethylene a superior surface b inferior surface. In addition to the severe wear of the superior surface, backside wear on the
inferior surface can be seen.
less wear when compared with the… fixed-bearing
version of the same implant.” However, in contrast
to these results, Fisher et al. found signifi
ficantly
higher wear rates of fixed-bearings compared to
mobile-bearings in simulation of higher demand
activities as stair climbing.
Costs
The mobile-bearing implants are more expensive
than the fixed-bearing implants. This is particu-
larly interesting in a surrounding with increasing
demand for TKA but limited funding. Th Thus, there
is an increasing demand for proving the superior
performance of mobile-bearing knees. So far, this
prove has not been given.
Dislocation/subluxation of inlay
Whereas mechanical problems as dislocations or
subluxations of fixed tibial inlays are quite rare, this
has remained an issue for mobile-bearings. In litera-
ture, problems with subluxating/dislocating mobile
inlays are said to occur in approximately 1% (0.9%
Sansone et al. 2004; 1.2% Hooper et al. 2009, 2%
Huang 2003); however, Bert (1990) reports a rate
as high as 9%.
Operative technique
Both, the fixed- and mobile-bearing variants can
be inserted following standardized operative pro-
tocols. However, to avoid mechanical problems, in
mobile-bearings, the flexion and extension gaps
have to be precisely balanced. The
Th fixed-bearing is
more forgiving according to this point.
 Fixed-bearing total knee arthoplasty: advantages and disadvantages 757

Modularity high molecular weight components for total joint replace-

ment. J Bone Joint Surg Am 68:1041–1051
2. Bert JM (1990) Dislocation/subluxation of meniscal bear-
PS inlays for posterior cruciate deficient
fi knees are ing elements after New Jersey low contact stress total
available for both, fixed-and mobile-bearings. How- knee arthroplasty. Clin Orthop Relat Res 254:211
ever, in case of secondary instability, several fi
fixed- 3. Bhan S, Malhotra R, Kiran EK, et al. (2005) A comparison
bearing tibial component designs allow for changing of fixed-bearing and mobile-bearing total knee arthro-
plasty at a minimum follow-up of 4.5 years. J Bone Joint
in a PS or total stabilized situation without replace- Surg Am 87:2290–2296
ment of the tibial component compulsorily. 4. Bottlang M, Erne OK, Lacatusu E, et al. (2006) Mobile-
bearing knee prosthesis can reduce strain at the proximal
tibia. Clin Orthop Relat Res 447:105–111
5. Callaghan JJ, Insall JN, Greenwald AS, et al. (2001)
Clinical outcome Mobile-bearing knee replacement – concept and results.
Instr Course Lect 50:431–449
6. Cheng CK, Huang CH, Liau JJ, Huang CH (2003) Th The inflflu-
Several authors evaluated the clinical outcome ence of surgical malalignment on the contact pressures of
after TKA with fixed versus mobile-bearings. In fixed and mobile bearing knee prostheses – a biomechani-
both designs, 15–20 year survival rates higher cal study. Clin Biomech 18:231–236
than 90% were demonstrated (Huang 2003). How- 7. Dennis DA, Komistek RD, Hoff ff WA, Gabriel SM (1996) In
vivo knee kinematics derived using an inverse perspective
ever, to date there is no study showing a higher technique. Clin Orthop 331:107–117
survival rate in mobile-bearings compared to fi
fixed- 8. Dennis DA, Komistek RD, Mahfouz MR, et al. (2004) A
bearings. Few studies compare the performance multicenter analysis of axial femorotibial rotation after
of fixed-bearings and mobile-bearings in patients total knee arthroplasty. Clin Orthop 428:180–189
with bilateral TKA. After a minimum follow-up of 9. Fisher J, McEwen H, Tipper J, et al. (2006) Wear-simula-
tion analysis of rotating-platform mobile-bearing knees.
4.5 years, Bhan et al. (2005) as well as Kim et al. Orthopedics 29:S36–S41
(2008) could not demonstrate a significant
fi diff
ffer- 10. Haider H, Garvin K (2008) Rotating platform versus fixed-
fi
ence between the two designs with respect to Knee bearing total knees. An in vitro study of wear. Clin Orthop
Society Score and range of motion. So far, the the- Relat Res 466:2677–2685
11. Hasegawa M, Sudo A, Uchida A (2009) Staged bilateral
oretical advantages of mobile-bearing design have mobile-bearing and fixed-bearing total knee arthroplasty
not been demonstrated by any outcome study. in the same patients: a prospective comparison of a pos-
terior-stabilized prosthesis. Knee Surg Sports Traumatol
Table 1 – Pros and cons of the fixed-bearing design. Arthrosc 17:237–243
12. Hooper G, Rothwell A, Frampton C (2009) Th The low contact
Pros Cons References stress mobile-bearing total knee replacement: a prospec-
Load transmission 0 X Bottlang et al. 2006 tive study with a minimum follow-up of ten years. J Bone
Joint Surg Br 91:58–63
Contact stress under 0 X Stukenborg-Colsman 13. Huang CH, Liau JJ, Cheng CK (2007) Fixed or mobile-
tibial malalignment et al. 2002 bearing total knee arthroplasty. J Orthop Surg Res 2:1–8
14. Huang CH, Ma HM, Lee YM, Ho FY (2003) Long-term
results of low contact stress mobile-bearing total knee
Wear rate 0 0 Haider, Garvin 2008 replacements. Clin Orthop Relat Res 416:265–270
Clinical outcome 0 0 Bhan et al. 2005, 15. Kim YH, Kim DY, Kim JS (2007) Simultaneous mobile-
Kim et al. 2008 and fixed-bearing total knee replacement in the same
patients. A prospective comparison of mid-term outcomes
using a similar design of prosthesis. J Bone Joint Surg Br
Costs X 0 89:904–910
Modularity X 0 16. Most E, Li G, Schule S, Sultan P, et al. (2003) The
Th kinemat-
ics of fixed- and mobile-bearing total knee arthroplasty.
Inlay X 0 Bert 1990 Clin Orthop 416:197–207
subluxation/dislocation Hooper et al. 2009, 17. Sansone V, da Gama Malchèr M (2004) Mobile-bearing
Huang et al. 2003, total knee prosthesis: a 5- to 9-year follow-up of the fi first
Sansone et al. 2004 110 consecutive arthroplasties. J Arthroplasty 19:678–
685
Operative technique X 0 Huang et al. 2007 18. Stiehl JB, Komistek RD, Hoff ff WA, Gabriel SM (1995)
Fluoroscopic analysis of kinematics after posterior-
cruciate-retaining knee arthroplasty. J Bone Joint Surg
77:884–889
References 19. Stukenborg-Colsman C, Ostermeier S, Hurschler C, Wirth
CJ (2002) Tibiofemoral contact stress after total knee
1. Bartel DL, Bicknell VL, Wright TM (1986) The
Th effffect of arthroplasty: comparison of fixed and mobile-bearing
conformity, thickness, and material on stresses in ultra- designs. Acta Orthop Scand 73:638–646
 Chapter 70

J. D. Jackson,
M. W. Pagnano
Cement fixation for total knee
arthroplasty

Defifinition 2–11 years follow-up (1). The majority of failures

resulted from the patellar and tibial components.

F
ixation with cement in total knee arthro- Scoring and radiographic grading systems were in
plasty (TKA) remains the gold standard. Many there infancy in the orthopedic literature at this
series in the literature show between 90 and time. Regardless, these results were promising for
98% survivorship of modern cemented, condylar the future of TKA.
total knee arthroplasties at 15-plus years. While Subsequently, several large series using cemented
uncemented fixation has become the predominant fixation have set the standard for longevity in
method in contemporary total hip arthroplasty, TKA (2–4) (Fig. 1). These series containing 1000–
uncemented TKA has not yet gained wide accep- 11,000 cemented knees show survival of 91–96%
tance. While durable biologic fi fixation remains a with survival analysis or follow-up ranging from
laudable goal for TKA that aim has not yet been 10 to 21 years. These large cohorts have taught us
consistently demonstrated. It is illustrative that that aseptic loosening is an infrequent event, while
in reviewing the available comparable long-term the majority of failures result from infection, wear,
studies in no case has it been shown that an unce- and periprosthetic fracture.
mented total knee component has better survival Prior to the availability of these long-term out-
than a cemented component of the same make and comes, concern arose regarding the durability of
model. cement fixation and surgeons started to investi-
Cement fixation
fi refers to the use of polymethyl- gate uncemented forms of prosthesis fixation.
fi They
methacrylate (PMMA) bone cement as an adher- believed that by eliminating cement there would be
ent for prosthesis attachment to bone. Uncemented
fi
fixation refers to the application of the prosthesis
to bone without a cement interface in an attempt
to obtain bone ingrowth. Another option used in
uncemented fixation is application of a biologic
coating such as hydroxyapatite to the prosthesis.
Hybrid fifixation describes the use of a cemented
tibial component and a cementless femoral com-
ponent. This was developed in response to implant
retrieval studies, which found higher rates of
fibrous ingrowth and loosening of the tibial com-
ponent compared to the femoral component. More
recently a so-called reverse hybridd option was intro-
duced with the use of a cemented femoral compo-
nent and an uncemented, porous metal tibial com-
ponent.

History
PMMA cement fixation has been used since the
beginning of knee arthroplasty in the late 1960s.
Results using cement were relatively positive from
the beginning. Townley designed the “Anatomic Fig. 1 – Early condylar knee designs often included cemented all-poly-
Total Knee” in 1972 and reported good to excel- ethylene tibial components yet the durability of those implants has been
lent results in 89% of 532 cemented knees at outstanding at 15–21 year follow-up.
760 Primary Total Knee Arthroplasty
one less interface for possible failure. In addition,
in the 1980s, in total hip arthroplasty the popular-
ity of cementless porous ingrowth femoral stems
began to grow. ThThere were several cementless knee
implants introduced during the 1980s and 1990s;
however, many were withdrawn due to poor results.
Some knee designs using cementless fi fixation have
demonstrated satisfactory longevity with results
more comparable to cemented knee designs.
Hybrid TKA was developed later in the 1980s as a
possible solution for the higher incidence of tibial
component failure in uncemented designs. Results
of retrieval studies indicated a greater likelihood of
fibrous ingrowth on the tibial side compared to the
femoral side (5, 6). Surgeons began using a hybrid
technique cementing the tibia with an uncemented
femur. Hybrid designs have been slow to catch on as
results have fallen short of cemented fixation. Also,
when using hybrid fi fixation one loses the benefifit of
time, as cementing is still required, and cost, as the
cementless femoral component is more expensive.
Biomechanical/biologic basis
Polymethyl methacrylate is a synthetic polymer of
methyl methacrylate. In the industrial world, the
most commonly used form of PMMA is transparent.
It is used as an alternative to glass, taking advantage
of its higher impact strength and lower density (Plexi-
glas). It is a biologically inert compound and it has
various other uses including replacement intraocular
lenses for the eye. PMMA bone cement is white and
opaque. The opacity of bone cement is due to numer-
ous small gas bubbles in the cement, low crystallin-
ity, and the addition of barium sulfate (or sometimes
zirconium dioxide) to make it radiopaque for X-ray.
The PMMA bone cement functions as a space-
filling, load transferring material with adhesive
fi
qualities that depend on the surface characteris-
tics of the two materials that it joins. Its adjoin-
ing properties are more analogous to grout rather
than glue. Mechanical bonding to the prosthesis is
increased when the surface is textured or porous.
Cancellous bone is an excellent surface for cement
adherence because of the natural porosity and the
resultant interdigitation of cement into bone.
PMMA is a relatively brittle solid with the inher-
ent possibility of fracture. It can withstand greater
compressive forces and shear forces than tensile
forces. The cement acts to distribute the force
seen by the prosthesis over a larger surface area
of bone. Without cement it is more likely that the
load would be distributed over small points of con-
tact resulting in an uneven distribution of stress.
The biomechanical properties of PMMA bone
cement can change depending on the handling and
preparation of the cement. Pores or voids caused
by air bubbles decrease the fatigue properties and
encourage crack propagation. Cement porosity
can be decreased by centrifugation or by mixing
the cement in a vacuum. While porosity reduction
has been shown to be of value in cemented total
hip applications no such benefit
fi has been demon-
strated in cemented TKA.
Optimizing the technique
Cementation is an integral part of performing a reli-
able TKA. A secure mechanical bond is extremely
important because it prevents motion at the bone–
cement interface. Micro- or macro-motion at the
bone–cement or cement–implant interface can result
in bone resorption, component loosening, compo-
nent migration, and ultimately bone or component
fracture. Adequate bone preparation and sound sur-
gical technique can minimize the risks of implant
loosening or failure associated with cementing.
The first step in the cementation process is cement
preparation. The surgeon should anticipate the time
needed for initial cement preparation, allowing one
member of the team to begin cement preparation
while the other members make the final prepara-
tions of the bone surfaces. The most commonly used
PMMA cements are supplied as two sterile compo-
nents, a powder and a liquid. TheTh packet of powder
contains particles of PMMA, radiopaque barium sul-
fate or zirconium dioxide (10%), and approximately
1% of benzoyl peroxide, which is a polymerization
initiator. The liquid vial contains methylmethacry-
late monomer and an activator (about 3% of DMP
toluidine) which promotes the cold-curing process.
The method of mixing the powder and liquid var-
ies depending on the manufacturer and those spe-
cifi
fic manufacturer instructions should be followed.
Cement for TKA can be mixed in a bowl or mixed in
a vacuum at approximately 500 mm Hg. The Th vacuum
removes air bubbles, which decreases the porosity
and theoretically decreases the risk of cement frac-
ture propagation.
It is important to clean the surface of the bone from
any debris prior to cementation. If an area of sclerotic
bone is present, a small burr may be used to create
small holes on the cut surface for cement inter-
digitation. The
Th surface of the bone is cleaned with
mechanical pulse-lavage with normal saline followed
by meticulous drying. Cement is then applied to the
bone when it is in slightly doughy state (Fig. 2). Using
a clean, wet finger, the cement can be pressed into
the cancellous bone. This allows good interdigitation
into the interstices of the cancellous bone. Keller et al.
found that applying cement before and at the onset
of the dough stage formed superior interfaces for
 Cement fixation for total knee arthroplasty 761

Fig. 2 – Careful preparation of the cancellous bone surface should be done Fig. 3 – Some surgeons apply a thin layer of cement to the implant itself.
prior to cementing. The bone should be dried after being cleansed with a The implant should then be inserted and axially loaded to pressurize the
pulsatile lavage system and then bone cement in the early doughy stage underlying cement. Extruded cement should be carefully removed to avoid
can be applied directly to the bone surface and pressurized. third-body wear at the implant articular surface.

implantation compared to those formed in the late studies show a low rate of aseptic loosening with
doughy stage (5). Enough cement should be supplied cemented fixation at long-term follow-up (Fig. 4).
to completely cover the bone–prosthesis interface. Whereas, with uncemented fixation, historically
Some surgeons also choose to add a thin layer of there is a higher possibility of not obtaining a solid
cement to the undersurface of the tibial component. fixation interface, resulting in micromotion and
A small amount of cement should ooze from the
interface edge as the prosthesis is compressed into
place. Push the prosthesis all the way down, extrud-
ing as much cement as possible (Fig. 3).
For cementation of the femur, apply cement to
the distal and the anterior surfaces of the femur.
A small amount of cement should be placed on the
posterior condyles of the prosthesis. Th This mini-
mizes cement extrusion into the back of the knee.
If using an all-poly tibial component, cement the
femoral component first and remove any excess
cement from the back of the knee, then cement the
tibial component. After both the tibia and femur are
cemented, bring the knee into extension and apply
a steady, axial load until the cement is dry. Survey
the edges of the bone prosthesis interface and chip
off
ff any extruded cement with a small osteotome.

Advantages of technique
The most important advantage of using bone Fig. 4 – Improvements in instrumentation and implant design allow sur-
cement is the reliability in obtaining immedi- geons to routinely produce excellent cement mantles around modern, con-
ate, consistent fixation. As noted herein, several dylar total knee designs.
762 Primary Total Knee Arthroplasty
subsequent fibrous ingrowth. Because of the pos-
sibility of micromotion causing fibrous ingrowth,
some surgeons require patients to modify their
weight-bearing for up to 6 weeks after surgery in
hopes to minimize micromotion at the bone–pros-
thesis interface. This modifi fication in post–opera-
tive activity has its own drawbacks for the patient’s
rehabilitation and return to independent activity.
In addition, the interface of cementless designs is
diffi
fficult to evaluate post–operatively with stan-
dard radiographs. Th This can further complicate the
diagnosis of fibrous ingrowth or micromotion as
a possible source of pain in evaluating the patient
with a painful total knee.
Cement fixation has practical benefi fits. Cement
may decrease blood loss by tamponade or heat
coagulation of the bleeding cancellous bone. Most
orthopedic surgeons are familiar with its use and it
can fill small defects in the bone. In addition, many
arthroplasty patients are elderly with osteoporo-
tic or osteopenic bone that may not provide the
immediate structural support needed for an unce-
mented component. Osteoporotic bone increases
cement interdigitation resulting in improved
fixation compared to cementless designs, which
require bone ingrowth. Most consider substan-
tial osteoporosis to be a contraindication to using
cementless fixation.
Another important advantage of cement fixation fi
is the cost. Prostheses using cement fi fixation are
typically much less expensive than those using
uncemented fixation. The cost of health care in
countries around the world continues to rise with
increasing burden being passed on to the patient
and the physician. Much of the financial
fi burden
is secondary to the increasing size of the elderly
population and this patient population continues
to be the predominant recipients of total knee
arthroplasties. Current generation uncemented
TKA designs have not proved cost effective
ff in the
elderly population.
Another advantage of cement is that it may accom-
modate small cutting imperfections better than
cementless prostheses. Cuts when using cement-
less fixation must be precise, with less than 1 mm
gaps between the bone and prosthesis. Currently,
a large percentage of TKA is performed by gen-
eral orthopedic surgeons who perform total knee
arthroplasties less often than arthroplasty subspe-
cialists. Error in technique may be more common
when performed by surgeons who do not perform
the operation frequently. Finally, powdered anti-
biotics can be readily added to bone cement and
many surgeons choose to use such antibiotic con-
taining bone cement to minimize the risk of deep
prosthetic infection either selectively in high risk
patients (diabetes mellitus, immune compromise)
or routinely.
Disadvantages
The primary disadvantage of using cement fixation
during TKA is that it prolongs the operative time.
This time delay is a result of cement preparation,
application, removal, and drying. Also, the use of a
tourniquet is less important using cementless fi
fixa-
tion as one does not need to worry about bleeding
cancellous bone preventing cement interdigitation.
Some argue cementless fifixation is more conducive
to minimally invasive surgery because one does
not need to access the back of the knee to remove
loose cement. However, many surgeons success-
fully perform minimally invasive surgery using a
cemented technique.
Discussion
Excellent durability with cemented fi fixation has
been demonstrated in several long-term studies
of modern, condylar TKA. Direct comparison of
diff
fferent cohorts using either cemented fixation
or cementless fixation is diffi
fficult due to the het-
erogeneity of the patients, prostheses, surgical
technique, outcome measures, and other variables.
While some outcomes for cementless fixation fi
have been inferior, a few cementless trials have
outcomes comparable to cement fi fixation in short
to mid-term follow-up. Interpretation of these
improved cementless results is hindered to some
degree because many were written by developers
of the knee designs that were evaluated (7–11).
Insall presented his results of 2629 primary,
cemented total knee arthroplasties performed from
1974 to 1994 (2). They demonstrated an 85–91%
21-year success rate. Results were calculated with
an actuarial method and success was defined fi as
not having a revision performed or recommended.
The majority of these implants were posterior sta-
bilized with a metal-backed tibial component.
Rand et al. at the Mayo Clinic performed survi-
vorship analysis on over 11,000 total knees per-
formed between 1978 and 2000 (4). Th The cemented
knees performed markedly better than cementless
knees. At 10 years, the survivorship was estimated
at 92% for cemented knee arthroplasties compared
to 61% for cementless, and 84% for hybrid fixa- fi
tion. All three were signifi
ficantly diff
fferent from the
other (p
( < 0.0001).
Other studies performed at the Mayo Clinic have
had similar results. Duff ffy et al. retrospectively
matched 55 cementless Press Fit Condylar knees to
51 cemented Press Fit Condylar knees at a mean of
10 years after surgery (12). The 10-year survivor-
ship with revision for aseptic loosening or radio-
graphic signs of loosening was 94% for cemented

components versus 73% for cementless compo-
nents (p
( = 0.0008).
More recently, the Mayo Clinic presented survival
analysis on 1000 cemented, cruciate-retaining
knees (3). TheTh survival rate for revision due to
aseptic loosening was 98.8% at a mean follow-up
of 16 years while the survival rate for revision for
any reason was 95.9%. These and several other
medium to long-term studies have set the stan-
dard for comparison of implant survivorship.
Barrack studied 158 rotating platform total knees,
comparing 82 consecutive cementless knees to 76
consecutive cemented knees of the same design
(13). Eight per cent of the cementless group
required revision for symptomatic subsidence and
failure of ingrowth, while none of the cemented
group required revision (p ( < 0.05). The
Th cementless
group also had statistically signifi ficant higher pain
scores and lower Knee Society clinical scores.
The success of cementless fixation knee arthro-
plasty has been variable based on knee design.
Short and mid-term follow-up results using the
Miller-Galante design were initially comparable
to cemented designs, but with longer follow-up
results have been less favorable (14–17). The Th Rush
University group reported their results using the
Miller-Galante I cementless knee in 131 consecu-
tive knees with an 11-year mean follow-up (18).
Five tibial trays were revised for loosening and more
than 50% of the tibial trays had radiolucent lines
on beneath the tray. Eight per cent of tibial trays
never achieved ingrowth. Th The authors also noted
that revision of the cementless tibial trays was
more diffi
fficult that revising a well-fifixed cemented
tibia and resulted in more tibial bone loss. Th The
authors subsequently abandoned all cementless
fixation for TKA. In comparison, the same group
published the results of 109 consecutive cemented
knees with the Miller Galante II prosthesis (19).
The Kaplan–Meier survivorship was 100% at 10
years with no evidence of osteolysis, loosening, or
revision at up to 15 years follow-up.
Randomized control trials have been performed
in an eff
ffort to find a potential difffference between
cemented and cementless fixation. A 10-year
survival analysis was performed on 501 consecu-
tive press-fifit condylar knee replacements; 277
cemented and 224 cementless (20). No patients
were lost to follow-up. They showed 95% survival
for both cemented and cementless knees. Similarly,
a mid-term, 5-year, follow-up study of 81 patient
randomized to either a cemented or hydroxyapa-
tite-coated, uncemented tibia showed no differ- ff
ence in knee pain or survival after 5 years (21). Of
note, there were higher pain scores in the unce-
mented group at the 6 month follow-up. Some
have speculated that early pain could be second-
ary to micromotion and/or lack of fi fixation in this
Cement fixation for total knee arthroplasty 763
early postop period. Another randomized control
trial evaluating cemented, porous coated, and
hydroxyapatite coated implants measured move-
ment of the prosthesis with radiostereometry (22).
They found less movement in the cemented group
than either cementless group. Longer follow-up in
these groups may be benefi ficial. Without showing
any improved benefi fit at 5–10 years, this calls into
question the use of cementless fi fixation with its
additional cost.
Most proponents of cementless fixation agree that
it should be reserved for the younger population as
bone quality and the ability to obtain ingrowth is
improved in this population. This principle may be
correct; however, the idea of a conferred advantage
over cemented TKA in the young patient is purely
theoretical. No comparative data exist for improved
outcomes in younger patients with cementless
fixation compared to cemented fixation. In fact,
in a community joint registry with over 1000 knee
arthroplasties performed in patients under 55
years old, cemented knees performed superior to
cementless knees (23). Over a 14-year period, the
cumulative revision rate was 15.5% with cemented
versus 34.1% with cementless designs.
Hybrid fifixation with a cemented tibia and unce-
mented femur has been adopted by a small sub-
group of surgeons. Currently, the longest follow-up
of hybrid TKA in the literature is by Duff ffy et al.
(24). They reported their results on 65 hybrid TKA
performed with mean follow-up of 15 years. Th The
overall survival rate with revision as the endpoint
was 64% and the survival rate of the femoral com-
ponent alone was 72%. Parker et al. reported some-
what better results on 100 TKA randomized to
either cementless or hybrid fixation
fi with a Miller-
Galante 1 TKA (25). At 14 year follow-up, survival
rates were 85% for both groups with no significant fi
diff
fference between the groups. With the hybrid
technique one seems to lose some benefits fi of both
cementless fixation and cemented fixation. There
is an added cost for the cementless femoral com-
ponent and there is no significant
fi time benefi
fit, as
one still needs to cement the tibia. In addition, iso-
lated femoral loosening of a cemented component
is a relatively rare complication.
Highly porous metals have recently been intro-
duced as an alternative mode of fixation in TKA.
These porous metals made of tantalum or titanium
have been introduced as a possible future mode of
implant fixation. Porous tantalum is nearly twice as
porous as the previous surfaces used in cementless
TKA fixation. Theoretically, the lower modulus of
elasticity should improve stress shielding beneath
the tibial implant. Extremely short-term results
with a porous coated, monoblock tibia in 101 knees
showed no evidence of loosening and no revision
in up to 2 years follow-up (26). Longer follow-up is
764 Primary Total Knee Arthroplasty
required before conclusion can be made regarding
the utility of this new form of fi
fixation.
While uncemented fixation has assumed a greater
and greater role in total hip arthroplasty the same
cannot be said for TKA. Cement fi fixation of all three
components of TKA remains the gold standard in
contemporary practice. The advent of porous met-
als and the introduction of biologically active sur-
face treatments may change this situation in the
future but for now cement remains the favored
method of fixation for most surgeons performing
TKA.
References
1. Townley CO (1985) The anatomic total knee resurfacing
arthroplasty. Clin Orthop 192:82–96
2. Font-Rodriguez DE, Scuderi GR, Insall JN (1997) Survi-
vorship of cemented total knee arthroplasty. Clin Orthop
345:79–86
3. Vessely MB, Whaley AL, Harmsen WS, et al. (2006) Long-
term survivorship and failure modes of 1000 cemented
condylar total knee arthroplasties. Clin Orthop 452:28–34
4. Rand JA, Trousdale RT, Ilstrup DM, Harmsen WS (2003)
Factors aff
ffecting the durability of primary total knee pros-
theses. J Bone Joint Surg Am 85:259–265
5. Keller JC, Lautenschlager EP, Marshall GW Jr, Meyer PR
Jr (1980) Factors aff ffecting surgical alloy/bone cement
interface adhesion. J Biomed Mater Res 14:639–651
6. Cook SD, Thomas KA, Haddad RJ Jr (1988) Histologic
analysis of retrieved human porous-coated total joint
components. Clin Orthop 234:90–101
7. Hofmann AA, Evanich JD, Ferguson RP, Camargo MP
(2001) Ten- to 14-year clinical followup of the cementless
Natural Knee system. Clin Orthop 388:85–94
8. Hofmann AA, Heithoff ff SM, Camargo M (2002) Cementless
total knee arthroplasty in patients 50 years or younger.
Clin Orthop 404:102–107
9. Whiteside LA, Viganò R (2007) Young and heavy patients
with a cementless TKA do as well as older and lightweight
patients. Clin Orthop 464:93–98
10. Whiteside LA (1994) Cementless total knee replacement.
Nine- to 11-year results and 10-year survivorship analy-
sis. Clin Orthop 309:185–192
11. Whiteside LA (2001) Long-term followup of the bone-
ingrowth Ortholoc knee system without a metal-backed
patella. Clin Orthop 388:77–84
12. Duffffy GP, Murray BE, Trousdale RT (2007) Hybrid total
knee arthroplasty analysis of component failures at an
average of 15 years. J Arthroplasty 22:1112–1115
13. Barrack RL, Nakamura SJ, Hopkins SG, Rosenzweig S
(2004) Early failure of cementless mobile-bearing total
knee arthroplasty. J Arthroplasty 19(Suppl 2):101–106
14. Kobs JK, Lachiewicz PF (1993) Hybrid total knee arthro-
plasty. Two- to five-year results using the Miller-Galante
prosthesis. Clin Orthop 286:78–87
15. Nilsson KG, Kärrholm J, Linder L (1995) Femoral
component migration in total knee arthroplasty: ran-
domized study comparing cemented and uncemented
fixation of the Miller-Galante I design. J Orthop
Res13:347–356
16. Rorabeck CH, Bourne RB, Lewis PL, Nott L (1993) Th The
Miller-Galante knee prosthesis for the treatment of
osteoarthrosis. A comparison of the results of partial fixa-
fi
tion with cement and fixation without any cement. J Bone
Joint Surg Am 75:402–408
17. Rosenberg AG, Barden RM, Galante JO (1990) Cemented
and ingrowth fixation
fi of the Miller-Galante prosthesis.
Clinical and roentgenographic comparison after three- to
six-year follow-up studies. Clin Orthop 260:71–79
18. Berger RA, Lyon JH, Jacobs JJ, et al. (2001) Problems with
cementless total knee arthroplasty at 11 years followup.
Clin Orthop 392:196–207
19. Berger RA, Rosenberg AG, Barden RM, et al. (2001) Long-
term followup of the Miller-Galante total knee replace-
ment. Clin Orthop 388:58–67
20. Khaw FM, Kirk LM, Morris RW, Gregg PJ (2002) A ran-
domised, controlled trial of cemented versus cementless
press-fi
fit condylar total knee replacement. Ten-year sur-
vival analysis. J Bone Joint Surg Br 84:658–666
21. Beaupré LA, al-Yamani M, Huckell JR, Johnston DW
(2007) Hydroxyapatite-coated tibial implants compared
with cemented tibial fixation in primary total knee arthro-
plasty. A randomized trial of outcomes at five years. J
Bone Joint Surg Am 89:2204–2211
22. Carlsson A, Björkman A, Besjakov J, Onsten I (2005)
Cemented tibial component fixation performs better
than cementless fixation: a randomized radiostereometric
study comparing porous-coated, hydroxyapatite-coated
and cemented tibial components over 5 years. Acta Orthop
76:362–369
23. Gioe TJ, Novak C, Sinner P, et al. (2007) Knee arthroplasty
in the young patient: survival in a community registry.
Clin Orthop 464:83–87
24. Duffffy GP, Berry DJ, Rand JA (1998) Cement versus
cementless fixation in total knee arthroplasty. Clin Orthop
356:66–72
25. Parker DA, Rorabeck CH, Bourne RB (2001) Long-term
follow-up of cementless versus hybrid fixation
fi for total
knee arthroplasty. Clin Orthop 388:68–76
26. Bobyn JD, Poggie RA, Krygier JJ, et al. (2004) Clinical
validation of a structural porous tantalum biomaterial
for adult reconstruction. J Bone Joint Surg Am 86(Suppl
2):123–129
Surgical techniques

P. Beaufils Pre-operative imaging techniques
in primary total knee replacement:
role for computed tomography
Introduction
T
he objective of imaging studies in patients
who are being considered for total knee
replacement (TKR) is threefold: to confirm fi
the need for the surgical procedure; to supply
information that will help plan the procedure by
showing sources of potential diffi
fficulties (e.g., flex-
ion contracture, posterior osteophytes, ligament
imbalance, unusual bone deformities, and bony
defects); and to assist in determining the optimal
position of the implant in the coronal, sagittal, and
axial planes. Available imaging techniques include
standard radiographs, stress radiographs, bilateral
total-leg radiographs in the standing or supine posi-
tion, magnetic resonance imaging (MRI), and com-
puted tomography (CT). Imaging studies should be
selected based solely on their usefulness.
Standard radiographs
Standard radiographs that should be obtained rou-
tinely include a standing anteroposterior view of
Chapter 71
both knees, a standing view with the knee in 30° of
flexion (Rosenberg view), a lateral view, and a patel-
lofemoral (skyline) view (Fig. 1). Enlargement of the
radiographs by 100% is preferable, most notably
to allow implant size prediction by drawing traces.
Although the lateral radiograph is most informative
when obtained during weight-bearing, unsteadiness
is common among candidates to TKR, and therefore
a strict lateral view in the supine position with the
knee in 20° of flexion is often taken instead.
Standard radiographs provide information on the
severity of the degenerative lesions. They ensure
identifi
fication of large bony defects, whose pres-
ence may infl fluence the choice of the prosthesis
design (e.g., stem or wedge).
The anteroposterior view provides a rough assess-
ment of the varus or valgus deformity. Further-
more, the relative contributions of bony defor-
mities and ligament laxity (gap) to the coronal
misalignment can be evaluated on the anteropos-
terior radiograph. In patients with a history of
osteotomy or metaphyseal-epiphyseal fracture,
these radiographs show the extent of metaphyseal
or epiphyseal deformity.
Fig. 1 – Standard radiographs obtained pre-
operatively.
768 Primary Total Knee Arthroplasty
The lateral views are used to measure the tibial slope,
to determine the height of the patella (a very low
patella may cause technical problems), and to look
for anterior or posterior tibial translation (best seen
on weight-bearing views) indicating defi ficiency of
the central pivot. In addition, posterior osteophytes
are best characterized on the lateral view.
Patellar wear can be evaluated on the patellofemo-
ral view. Abnormalities in patellar position should
be looked for, as they may affect
ff the choice of the
surgical approach (e.g., lateral incision in patients
with lateral subluxation of the patella).
Thus, standard radiographs provide a large amount
Th
of data for a modest financial cost. Nevertheless,
they fail to supply detailed information on the
condition of the ligaments, most notably the col-
lateral ligaments, and they do not allow accurate
measurements of the deformity.
Condition of the ligaments: stress radiographs
Evaluation of the ligaments, most notably in the
coronal plane, is crucial to determine the risk of
soft tissue laxity or increased constraint within
the prosthesis.
The physical examination is crucial but fails to
provide objective information on laxity. Antero-
posterior stress radiographs in forced valgus and
varus objectively document the degree of laxity
(1) by showing the difference
ff in joint space width
between the maximum and minimum deformities
(Fig. 2). Th
This measure is of special interest for the
compartment on the convex side of the deformity,
where ligament distention is most likely to occur.
The usefulness of stress radiographs before TKR
remains controversial, however. Some surgeons
obtain stress radiographs routinely and others very
rarely. True ligament laxity necessitating ligament
release is uncommon (15% of knees in a case-series
study of patients with genu valgum (1)). TheTh deci-
sion to release the ligaments is often made intra-
Fig. 2 – Valgus and varus stress radiographs used to assess the degree of
ligament stretch on the convex side. In this example of valgus knee, the
stress radiographs assess the status of the medial collateral ligament.
operatively when the surgeon finds evidence of liga-
ment imbalance, whether a tension-dependent cuts
or -independent cuts are used. More importantly,
although the negative predictive value (NPV) of
stress radiographs for ligament release is good, their
positive predictive value (PPV) is poor. In the above-
mentioned case-series of patients with genu valgum
(1), a joint-space-width difference
ff smaller than 7 mm
consistently indicated absence of ligament release,
whereas a diff fference greater than 7 mm was asso-
ciated with ligament release in only 5 of 14 knees.
These data indicate that stress radiographs should
not be obtained routinely. Stress radiographs may
be helpful when the physical examination and stan-
dard radiographs leave doubt regarding the degree
of prosthesis constraint. They are also useful when
distention of both the medial and the lateral liga-
ments is anticipated, for instance in patients with
severe deformities, previous trauma to the bone or
ligaments, or a history of osteotomy.
Axis measurements on total-leg radiographs
Accurate measurement of the knee axes is manda-
tory before TKR. The mechanical axis is of greater
relevance than the anatomical axis of the lower limb,
which varies, particularly at the femur. The Th implants
should be positioned perpendicularly to the mechani-
cal axis so that the joint line is also perpendicular.
The total-leg radiograph is the best investigation for
measuring the mechanical axis of the knee (2, 3). It
is usually obtained in the bipedal stance. Although
the single-leg stance may allow a more accurate
assessment of the ligaments on the convex side,
it may be unsafe, as candidates for TKR are often
unsteady older patients. A total-leg radiograph in
the supine position eliminates effects ff due to the
knee ligaments but is technically difficult
ffi to obtain.
Several variables can be measured on the total-leg
radiograph. The hip–knee–ankle angle (HKA) can
be determined (Fig. 3a) and accurate assessments
can be made of factors involved in the deformity:
cartilage wear, constitutional, or post-traumatic
bone deformity, and ligament distention on the
convex side. The degree of obliquity of the femo-
rotibial joint space is of particular importance in
patients who have a history of knee osteotomy.
The HKS angle at the femur dictates the angle of
distal femoral section when a conventional guid-
ing system is used (Fig. 3b), since the intra-oper-
ative landmark is the femoral diaphysis. The angle
between the mechanical axis of the femur and the
joint space should be determined. At the tibia, the
angle between the mechanical axis and the ana-
tomical axis should be evaluated, as it may not
be equal to 0, particularly in patients with severe
 Pre-operative imaging techniques in primary total knee replacement: role for computed tomography 769
B gical plan must be developed (e.g., because of a
A major deformity that may require osteotomy in
Fig. 3 – (a) Total-leg standing radiograph: determination of the hip–knee–
ankle (HKA) mechanical axis. (b) Measurement of the HKS angle between
the mechanical axis and the anatomical axis. This angle is very important
since it is reproduced during surgery (distal femoral cut) with the intramed-
ullary rod.
deformities (Fig. 4); this angle may govern the
choice between an intramedullary (when there is
no divergence between anatomical and mechanical
axes) or an extramedullary tibial stem.
The usefulness of total-leg radiographs is depen-
dent on the accuracy of the measurements. There
Th
is abundant evidence that flexion
fl contracture of
the knee or poor limb positioning with inappropri-
ate rotation leads to major measurement errors (4,
5). Therefore, a stringent and reproducible protocol
should be used for obtaining total-leg radiographs.
For instance, the protocol described by Ramadier
et al. (3) involves using fluoroscopy to check that
the two femoral condyles are superimposed on
each other on the lateral view then turning the
machine by 90° to take an anteroposterior total-
leg radiograph.
When discussing whether the total-leg radiograph
is mandatory, it is important to bear in mind that
the overall mechanical axis does not need to be
measured before performing TKA, since the final fi
goal is always to achieve a 180° HKA regardless of
Fig. 4 – The mechanical and anatomical tibial axes are not always super-
imposed. Pre-operative assessment on a total-leg standing radiograph is
important when an intramedullary tibial rod is used.
the initial deformity. In contrast, the femoral and
tibial axes must be measured to adjust the bone-
cut guiding system. The total-leg radiograph pro-
vides this information with a single view. Another
option is to obtain long anteroposterior views of
the femur and the tibia.
In everyday practice, except when a specificfi sur-
addition to TKA or because of diaphyseal-frac-
ture malunion), the usefulness of the total-leg
radiograph depends on the type of guiding sys-
tem that will be used. For the above-listed rea-
sons, the total-leg radiograph is mandatory when
using a conventional mechanical system. Except
for two long views of the tibia and femur, respec-
tively, there is no other option at present. Stan-
dardized digital photographs of the lower limbs
seem reliable for measuring the overall limb axis
but fail to allow determination of the femoral
and tibial axes. Therefore, they are useful only
for diagnostic purposes. The EOS digital system,
which has the dual advantage of 3D imaging and
very low radiation exposure, will probably play a
major role in the future; preliminary experimen-
tal results are promising (6). When a computer-
assisted navigation system is used, the pre-oper-
ative total-leg radiograph is less helpful, as the
system supplies intra-operative measurements
of the femoral and tibial mechanical axes (Fig. 5).
However, it was important to demonstrate that
data from a pre-operative total-leg radiograph
correlated with data from intra-operative com-
puter-assisted navigation prior to bone cutting.
We found a strong correlation (Fig. 6) in a study
of 70 knees (7). Further support for computer-
assisted navigation comes from the strong cor-
770 Primary Total Knee Arthroplasty
relation reported between the intra-operative
computer-generated total-leg view after implan-
tation of the prosthesis and the post-operative
total-leg radiograph (8, 9).
However, the radiographic work-up, even when it
includes a total-leg radiograph, supplies data only
in the sagittal and coronal planes. CT, in contrast,
supplies axial images.
Fig. 5 – The mechanical axis, which is seen on pre-operative total-leg
standing radiographs, can be measured accurately during surgery using a
computer-assisted navigation system.
Fig. 6 – The posterior condylar angle is the angle between the posterior condylar axis and the transepicondylar axis.
Imaging in the axial plane: computed
tomography
Rotation of the femoral and tibial components has
long been known to play a key role both in balanc-
ing the compartments and in ensuring adequate
patellofemoral tracking (10–12). Expanding on
this concept is not the goal of this paper.
Rotational alignment of the femoral component
depends on the degree of distal femoral torsion,
which is measured as the posterior condylar angle
between the posterior bicondylar line and the tran-
sepicondylar axis (Fig. 6). Flexion-extension of the
knee occurs roughly around the transepicondylar
axis (13, 14), which diverges from the posterior
bicondylar line. Accurate rotational alignment
of the femoral component must receive as much
attention as accurate positioning in the coronal
plane. With the ligament-tension method, the
degree of femoral-component rotation is given
“automatically” by the tension placed on the liga-
ments when the knee is flexed.
fl Therefore, good lig-
ament balance must be achieved, either spontane-
ously or by releasing the ligaments. Severe ligament
imbalance before surgery (most notably associated
with valgus deformity or prior osteotomy) can lead
to excessive medial rotation of the femoral com-
ponent. With the tension-independent method,
external rotation of the femoral component is
adjusted by the surgeon, who positions the poste-
rior edge of the femoral component parallel to the
transepicondylar axis. A standardized guiding sys-
tem can be used, usually with 3° rotation, which is
the mean value of distal femoral torsion. However,
this torsion angle shows considerable interindivid-
ual variability, from 0 to 9° (10, 14–17) (Table 1).
In our experience, the standardized “automatic” 3°
device results in optimal rotation (±2°) in only 40%
of cases (18). In addition, distal femoral torsion cor-
 Pre-operative imaging techniques in primary total knee replacement: role for computed tomography 771

Table 1 – Mean values of the posterior condylar angle in previous studies Table 2 – Mean value of the posterior condylar angle, anterior trochlear
according to whether measurements were obtained by anatomic cadaver stud- angle, and global trochlear angle according to whether the patella is cen-
ies or by computed tomography or magnetic resonance imaging in patients. tered or lateralized.
Authors Journal Year Measurement Mean Patella PCA ATA GTA
method angle ° Centered 6.5° −7.74° −1.15°
Berger CORR 1993 Anatomic study M: 3.5 ±1.2 3-5 mm lateral 8.04° −10.32° −2.28°
Sulcus as reference F: 0.3 ±1.2 displacement
Boisrenoult Rev Chir 2001 CT 5.4 ± 1.9 >5 mm lateral 8° −8.57°° −0.571°
Orthop displacement
Griffi
ffin J Arthropl 2000 MRI 3.7 ± 2.2 p = 0.04 p = 0.004 NS
Katz J Arthropl 2001 Anatomic study 6.1 ± 3.3 PCA, posterior condylar angle; ATA, anterior trochlear angle; GTA, global
Akagi 4.2 ± 2.1 trochlear angle.
Yoshioka JBJS 1987 Anatomic study 3.0 ± 1.6

relates with the position of the patella. In a study
of 118 CT scans (19), a higher posterior condylar
angle was associated with more lateral positioning
of the patella (Table 2), whereas the global trochlear
angle remained unchanged (Fig. 7). Th Thus, within
the constant global trochlear angle, the degree of
obliquity of the transepicondylar axis determines
the position of the patella. A low posterior condy-
lar angle is associated with a centered patella and a
high angle with a laterally displaced patella. In the
same study, the tibial tuberosity-trochlear groove
(TTTG) distance increased with lateral displace-
ment of the patella (19). In contrast, no correlation
was found between the position of the patella and
the degree of tibial torsion. Given that the TTTG
distance and posterior condylar angle increase in
lockstep, changes in the TTTG distance must be
related to the femur, as opposed to the tibia: patel-
lar position is dependent solely on the degree of
distal femoral torsion. Therefore, when performing
TKA, the trochlea must be brought into congru-
ence with the patella, not the reverse (Fig. 8).
The variability of the posterior condylar angle and its
correlation with patellar position support individu-
ally tailored alignment of the femoral component.
Reliable intra-operative data would allow the deter-
mination of the optimal position during surgery.
However, in a comparison of pre-operative CT data
(taken as the reference standard) and data obtained
intra-operatively using a computer-assisted naviga-
tion system, we found that intra-operative determi-
nation of the transepicondylar axis was unreliable
(7). This
Th finding contradicts one previous study (20)
but agrees with several others (15, 18, 21, 22). The
Th
mean posterior condylar angle measured on pre-
operative CT scans was 6.9° (range +1.5 to +15°)

Fig. 7 – The posterior condylar angle (PCA), anterior trochlear angle (ATA), and position of the patella are linked. (a) When the patella is centered, the PCA
and ATA are low. (b) When the patella is lateralized, the PCA and ATA are high. The global trochlear angle computed as the sum of the PCA and ATA is constant
and not influenced by the position of the patella.
772 Primary Total Knee Arthroplasty
Fig. 8 – The relationship between the posterior condylar angle (PCA)
and the position of the patella indicates that lateral patellar subluxation
requires a larger degree of lateral femoral-component rotation, rather than
displacement of the patella to a more central position.
compared to 3° (−7.3 to +17°) by intra-operative
computer-assisted navigation, and the coefficient
ffi of
correlation between these two values was low (rr =
0.299) (Table 3) (Fig. 9). A single study suggested
that intra-operative computer-assisted navigation
might improve femoral component rotation (23).
These data support the use of indirect measures, of
which three can be determined intra-operatively.
Whiteside’s line, drawn from the deepest part of the
trochlear groove to the center of the intercondylar
notch (24), was described by Whiteside and Arima
as being perpendicular to the transepicondular
axis. However, determination of Whiteside’s line
may be diffi
fficult or poorly reproducible, most nota-
bly in patients with trochlear dysplasia. No studies
have been published on possible variations in the
position of Whiteside’s line according to differences
ff
in distal femoral geometry. Bonnin (25) found a
relationship between the distance of the distal cut-
ting guide at the condyle (d)d and femoral compo-
nent rotation (posterior condylar angle=1° + d/2).
d with angles on CT scans (26). MRI (17) has been used
In theory, this formula should consistently provide
optimal positioning of the femoral component.
Table 3 – Mean values of the posterior condylar angle measured before
surgery by computed tomography and during surgery by a computer-as-
sisted navigation system.
PCA Mean SD Range
CT 6.9° 2.9° 1.5–15°
CANS 3° 4.2° −7.3–12.7°
PCA, posterior condylar angle; CT, computed tomography; CANS,
computer-assisted navigation system
Finally, distal femoral torsion can be evaluated by
considering the HKA changes produced by flexing
the knee. A reasonable hypothesis is that the HKA
at 90° of flexion refl flects distal femoral torsion, as
the side-to-side diff fference in condylar length (with
the medial condyle being longer) results in gradu-
ally increasing valgus as fl flexion increases. There-
fore, the difference
ff in HKA values between 0 and
90° of flexion may indirectly refl flect the degree of
distal femoral torsion. Computer-assisted naviga-
tion systems can measure the HKA at 0 and 90° of
flexion. However, we found that posterior condylar
angle values measured on pre-operative CT scans
showed very little correlation (rr = 0.238) with HKA
values measured at 90° of flexion using intraopera-
tive computer-assisted navigation (7).
Axial imaging to measure the degree of distal femoral
torsion is thus desirable, since the posterior condylar
angle varies across individuals and computer-assisted
navigation systems fail to provide reliable intra-oper-
ative measurements. Axial imaging can be achieved
using a specifi fic standard-radiograph view (26), MRI
(17), or CT (16). The kneeling view (26) is a standard
posteroanterior radiograph taken with the beam par-
allel to the joint surface and the knee in 80° of flexion.
fl
Both the transepicondylar axis and the posterior con-
dylar line are visible on this view. Angles on the kneel-
ing view showed statistically significantfi correlations
to describe the normal anatomy of the distal femoral
condyles. MRI shows the thickness of the cartilage
Fig. 9 – Graph demonstrating the very poor correla-
tion between the posterior condylar angle values
measured pre-operatively by computed tomography
(taken as the reference standard) and intra-operatively
by a computer-assisted navigation system.
 Pre-operative imaging techniques in primary total knee replacement: role for computed tomography 773
covering the posterior condyles, providing an exact
match with intra-operative findings. Advantages of
CT include widespread availability and low cost. Mea-
surement of the posterior condylar angle on CT scans
is reproducible (16) provided the section level used
for the measurement is clearly defined.
fi However, CT
exposes the patient to ionizing radiation and fails to
show the thickness of the posterior cartilage, which
must be taken into account intra-operatively. In con-
trast to MRI, CT can be repeated post-operatively to
evaluate the degree of femoral component rotation
(Fig. 10) (18, 27), thereby allowing comparisons of
pre-operative and post-operative values.
Regardless of the method used to obtain axial
images, several angles can be measured (Fig. 11).
The anatomical angle described by Yoshioka et al.
(14) is based on the transepicondylar line drawn
from the medial epicondylar prominence to the lat-
eral epicondylar prominence. These
Th landmarks can
Fig. 11 – The posterior condylar angle can be measured as the anatomical
angle (Yoshioka) between the posterior condylar axis and the transepi-
condylar axis connecting the two epicondylar prominences (solid line) or
as the surgical angle (Berger) between the posterior condylar axis and the
transepicondylar line connecting the lateral epicondylar prominence to the
medial sulcus of the medial epicondyle (dotted line).
Fig. 10 – Computed tomography can
be performed before and after surgery.
In this example, the femoral implant is
parallel to the epicondylar axis.
be reliably and reproducibly identifi fied, making the
line easy to draw (16). The surgical epicondylar axis
described by Berger et al. (15) connects the lateral
epicondylar prominence to the medial sulcus of the
medial epicondyle. Although the sulcus may be dif-
ficult to identify, this axis more closely replicates
the axis of knee flexion and should therefore be
used as the reference line for rotational alignment
of the femoral component. Because Berger’s line is
diffi
fficult to draw but is correlated to the anatomical
axis, we suggest drawing the anatomical transepi-
condylar line, measuring the posterior condylar
angle, and subtracting 2° to approximate the surgi-
cal angle described by Berger et al.
The posterior condylar angle measured on pre-op-
erative imaging studies can be thus used to deter-
mine the appropriate degree of external rotation
of the femoral component during surgery. In our
experience, intra-operative rotational alignment
of the femoral component based on the pre-oper-
atively measured posterior condylar angle yields a
final anatomical angle of 1.56°, with 78% of cases
being within the ±2° range (18).
In conclusion, imaging studies obtained to plan TKA
should include not only anteroposterior and lateral
views, but also axial images, which are indispens-
able for rotational alignment of the femoral compo-
nent. Standard radiographs including an anteropos-
terior standing view, a standing view with the knee
flexed, a lateral view, and a 30° skyline view must
be obtained routinely. Stress radiographs are rarely
necessary. They should be reserved for knees with
unusual laxity that cannot be fully assessed by the
physical examination. The need for a total-leg radio-
graph and CT scan depends on two intertwined sur-
gical factors (Table 4), namely, whether bone cuts
will be determined based on a tension-dependent or
-independent method and whether the guiding sys-
tem will be mechanical or a computer-assisted.
With a tension-dependent system, rotational align-
ment of the femoral component is usually deter-
mined based on ligament tension with the knee
774 Primary Total Knee Arthroplasty
Table 4 – Use of pre-operative computed tomography or total-leg standing
radiographs according to the surgical technique (conventional mechanical guid-
ance system or computer-assisted navigation system and tension-dependent
or –independent bone cuts). Standard X-rays are always necessary.
Tension-dependent Independent
bone cuts bone cuts
Total-leg
Mechanical
Total-leg radiographs radiographs
guiding system
CT
Computer-assisted
– CT
navigation system
CT, computed tomography.
fl
flexed and on transfer of the extension gap to the
flexion gap. Therefore, pre-operative measurement
fl
of the degree of femoral torsion is not required.
When a conventional mechanical guiding system
is used, the axes must be measured pre-operatively
on long-leg (preferably total-leg) radiographs. Com-
puter-assisted navigation systems provide reliable
measurements intra-operatively, obviating the need
for pre-operative measurements. Thus, a total-leg
radiograph is unnecessary, except when surgery is
likely to be made diffi
fficult by a severe deformity (e.g.,
a major constitutional deformity or malunion).
With a tension-independent system, the surgeon
adjusts the rotation of the femoral component
based on the degree of femoral torsion measured
pre-operatively. We advocate routine CT of the knee
prior to TKA in this situation. A pre-operative total-
leg radiograph is required when a conventional
mechanical guiding system is used but is unneces-
sary with a computer-assisted navigation system.
References
1. Michaut M (2004) Protheses totales de genou. Faut-il utiliser
les clichés en stress? Thèse Médecine Université de Caen
2. Moreland JR, Bassett LW, Hanker GJ (1987) Radiographic
analysis of the axial alignment of the lower extremity. J
Bone Joint Surg Am 69:745–749
3. Ramadier JO, Buard J, Lortat-Jacob A, Benoit J (1982)
Radiological assessment of knee deformity in the frontal
plane. Rev Chir Orthop 68:407–413
4. Hunt MA, Fowler PJ, Birmingham TB, et al. (2006) Foot
rotational effffects on radiographic measures of lower limb
alignment. Can J Surg 49:401–406
5. Specogna AV, Birmingham TB, DaSilva JJ, et al. (2004)
Reliability of lower limb frontal plane alignment measure-
ments using plain radiographs and digitized images. J
Knee Surg 17:203–210
6. Dubousset J, Charpak G, Skalli W, et al. (2007) EOS Sys-
tem: whole body simultaneous antrior posterior and lat-
eral radiographs with very low radiation dose. Rev Chir
Orthop 93(suppl6):141–143
7. Galaud B, Beaufi fils P, Michaut M, et al. (2008) Distal Femo-
ral Torsion: comparison of CT scan and intra operative
navigation measurements during Total Knee Arthroplasty.
A report of 70 cases. Rev Chir Orthop 94(6):573–9
8. Chauhan S, Clark G, Llooyd S, et al. (2004) Computer
assisted total knee replacement: a controlled cadaver
study using a multi-parameter quantitative CT assess-
ment of alignment. J Bone Joint Surg 86B:818–823
9. Saragaglia D, Picard F, Chaussard C (2001) Computer-as-
sisted knee arthroplasty: comparison with a conventional
procedure: results of 50 cases in a prospective randomised
study. Rev Chir Orthop 87:18–28
10. Akagi M, Matsusue Y, Mata T, et al. (1999) Effect
ff of rota-
tional alignment on patellar tracking in total knee arthro-
plasty. Clin. Orthop 366:155–163
11. Barrack RL, Schrader T, Bertot AJ, et al. (2001) Compo-
nent rotation and anterior knee pain after total knee
arthroplasty. Clin Orthop 392:46–55
12. Berger
g R A, Crossett LS, Jacobs JJ, Rubash HE (1998) Mal-
rotation causing patellofemoral complications after total
knee arthroplasty. Clin Orthop Relat Res 356:144–153
13. Churchill DL, Incavo SJ, Johnson CC, Beynnon BD (1998)
The transepicondylar axis approximate the optimal flexion
axis of the knee. Clin Orthop 356:111–118
14. Yoshioka Y, Siu D, Cooke DV (1987) The anatomy and
functional axis of the femur. J Bone Joint Surg (Am)
69: 873–880
15. Berger RA, Rubash HE, Seel MJ, et al. (1993) Determin-
ing the rotational alignment of the femoral component
in total knee arthroplasty using the epicondylar axis. Clin
Orthop 286:40–47
16. Boisrenoult P, Scemama P, Fallet L, Beaufilsfi P (2001) Epi-
physeal distal torsion of the femur in osteoarthritic knees.
A computed tomography study of 75 knees with medial
arthrosis. Rev Chir Orthop 87:469–476
17. Griffi
ffin FM, Math K, Scuderi GR, et al. (2000) Anatomy of
the epicondyles of the distal femur: MRI analysis of nor-
mal knees. J Arthroplasty 15:354–359
18. Michaut M, Baufi fils P, Galaud B, et al. (2008) Accuracy of
rotational alignment of femoral component with com-
puted assisted surgery during total knee arthroplasty. Rev
Chir Orthop 94 (accepted).
19. Abadie P, Galaud B, Michaut M, et al. (2007) Torsion
fémorale distale et subluxation patellaire. Etude scan-
nographique sur 118 genoux arthrosiques symptoma-
tiques. Rev Chir Orthop 93(Suppl 7): S78–79
20. Poilvache PL, Insall JN, Scuderi GR, Font-Rodriguez DE
(1996) Rotational landmarks and sizing of the distal femur
in total knee arthroplasty. Clin Orthop 331:35–46
21. Jenny JY, Boeri C (2004) Low reproducibility of the intra-
operative measurement of the transepicondylar axis dur-
ing total knee replacement. Acta Orthop Scand 75:74–77
22. Jerosh J, Peuker E, Philipps B, Filler T (2002) Interindivid-
ual reproducibility in perioperative rotational alignment
of femoral components in knee prosthetic surgery using
the transepicondylar axis. Knee Surg Sports Traumatol
Arthrosc 10:194–197
23. Stockl B, Nogler M, Rosiek R, et al. (2004) Navigation
improves accuracy of rotational alignment in total knee
arthroplasty. Clin Orthop 426:180–186
24. Whiteside LA, Arima J (1995) The anteroposterior axis for
femoral rotational alignment in valgus total knee arthro-
plasty. Clin Orthop 321:168–72
25. Bonnin M, Neyret P, Carrillon Y, et al. (2006) Rota-
tion Fémorale adaptée à la morphologie fémorale dans
les prothèses totales de genou. In: Chambat P, Neyret P,
Deschamps G et all (ed.) Total knee arthroplasty. Sauranps,
Montpellier France, pp 13–22 (ISBN2-84023-479-3)
26. Takai S, Yoshino N, Isshiki T, Hirasawa Y (2003) Kneel-
ing view: a new roentgenographic technique to assess
rotational deformity and alignment of the distal femur. J
Arthroplasty 18:478–483
27. Suter T, Zanetti M, Schmid M, Romero J (2006) Repro-
ducibility of measurement of femoral component rotation
after total knee arthroplasty using computer tomography.
J Arthroplasty 21:744–748

J. D. Jackson,
M. W. Pagnano
The mini-subvastus approach
for total knee arthroplasty
Definition
fi
T
he mini-subvastus approach to the knee is a
reliable, reproducible, and safe way to access
the knee joint. Contrary to other approaches,
the subvastus is the only approach that maintains
the integrity of the entire extensor mechanism.
Other common approaches, such as the medial
parapatellar, midvastus, and “quadriceps sparing”
approaches, violate some portion of the quadriceps
tendon. The level of the distal-most attachment of
the vastus medialis obliquus (VMO) is at the mid-
pole of the patella (1). Therefore, any approach
that extends proximally to the midpoint violates
a portion of the quadriceps tendon and should not
be considered “quadriceps sparing.”
The mini-subvastus approach meets the basic
tenets of so-called minimally invasive surgery
(MIS). It allows the use of a smaller incision, does
not require eversion of the patella, minimizes dis-
ruption of the suprapatellar pouch, preserves the
quadriceps tendon, and allows for a reliable closure
of the arthrotomy. The
Th mini-subvastus approach
involves an oblique L-shaped arthrotomy along
the inferior border of the VMO that is carried to
the level of the mid-pole of the patella and is then
turned distally paralleling the medial border of the
patella and patellar tendon. The
Th clinical results to
date with the mini-subvastus approach have been
encouraging.
History
The earliest known description of the subvastus
approach to the knee joint is from the German lit-
erature in 1929 (2). It was later described in the
English literature in 1945 as a method to access
the medial compartment of the knee (3). Despite
these early descriptions, the subvastus approach
has been used infrequently and only recently has
been re-introduced as surgeons sought less inva-
sive methods to perform total and unicompart-
mental knee arthroplasties. The popularity of the
subvastus approach has slowly increased as more
Chapter 72
data demonstrate some advantages compared
to other common approaches used for total knee
arthroplasty (TKA). Several prospective, random-
ized trials have now demonstrated earlier straight
leg raise, greater knee fl
flexion, improved extension
strength, and decreased narcotic use after TKA
when compared to a medial parapatellar or “quad-
sparing” approach (4–7).
Indications
The mini-subvastus approach can be used for the
majority of patients for both total and medial uni-
compartmental knee arthroplasty. Historically, the
standard subvastus approach was discouraged in
obese and muscular patients because everting the
patella was either markedly difficult
ffi or caused dam-
age to the VMO and the surrounding soft tissues
(8). With the mini-subvastus approach the patella
is not everted and with minimal release, the patella
can be translated relatively easily into the lateral
gutter. This makes the mini-subvastus approach
thus applicable to a wider range of patients.
Contraindications
A mini-subvastus approach can be performed on
the vast majority of standard total knee arthro-
plasties. However, we do not use this approach
in patients with substantial patella baja, marked
knee stiff
ffness, or in the setting of revision arthro-
plasty. In those circumstances, the patella is often
scarred to the anterior portion of the knee and it is
markedly difficult
ffi to then translate the patella lat-
erally. In addition patients with compromised skin
(chronic steroid use, poorly controlled diabetes, or
substantial peripheral vascular disease) are poor
candidates for any small-incision approach to TKA.
There is substantially more tension placed on the
skin edges during the small incision approaches
and that puts patients with compromised skin at
risk for wound healing problems. Obesity or mus-
776 Primary Total Knee Arthroplasty
cularity of the patient is not an absolute contrain-
dication to using the mini-subvastus approach
though it will certainly add some technical dif-
ficulty. Simple maneuvers such as extending the
skin incision by 2 or 3 cm often can markedly ease
the mini-subvastus approach in these more diffi- ffi
cult patients.
Pre-operative physical findings
fi
Pre-operatively it is important to note the condi-
tion of the skin overlying the knee, the presence
of prior knee incisions, mobility of the patella, and
the vascular status of the limb. As noted previ-
ously we do not use the mini-subvastus approach
in patients with substantial patella baja, marked
knee stiff
ffness, or compromised skin. The pre-oper-
ative physical exam should be targeted to identify-
ing these problems and most patients with one or
more of those issues would be better served with
a traditional medial parapatellar approach for the
total knee.
Imaging and other diagnostic studies
Prior to surgery, we obtain multiple radiographic
views of the knees to evaluate the patient for
arthritis and lower extremity deformity. Each
patient has a full-length, standing, hip to ankle,
radiograph performed. From this radiograph we
can identify any varus or valgus deformity at the
knee and make pre-operative plans accordingly.
This full-length view also gives us a chance to evalu-
ate the hip joints to rule out any hip pathology that
may masquerade as knee pain. We also obtain dedi-
cated AP, lateral, Merchant, and PA flexion
fl views of
the knees. This series of radiographs are eff ffective
in detecting arthritis in each compartment of the
knee and assist with surgical planning. TheTh lateral
radiographic is specififically evaluated for the pres-
ence of substantial patella baja that would make a
mini-subvastus approach contraindicated.
Surgical technique
Pre-operative planning
Pre-operative templating is performed for each
patient and does not diff
ffer based on the approach.
Templating the implant size on the radiographs is
performed to facilitate intra-operative effi
fficiency.
Templating also helps determine the location and
orientation of the bone cuts.
Positioning of the patient
The patient is positioned in the supine position.
We do not use a leg holder or bump beneath the
drapes to hold the knee (Fig. 1). This gives the sur-
geon the ability to change the position of the knee
easily and frequently throughout the surgery. A
tourniquet is placed on the proximal thigh and the
knee is sterilely prepped and draped. Transverse
lines are drawn on the knee prior to placing iodine-
impregnated drapes on all exposed skin.
Approach
A straight, midline incision is made starting
0–3 cm proximal to and centered over the supe-
rior pole of the patella. TheTh incision is extended
distally to the medial aspect of the tibial tubercle.
The length of the skin incision does not aff ffect the
outcome, but is important for cosmesis. Initially,
surgeons should make a 6–8 inch incision and then
shorten it as they become more comfortable with
the approach (Fig. 2). A medial skin flap fl is raised
exposing the distal border of the VMO, while pre-
serving its overlying fascia. ThThe inferior border is
frequently more distal and more medial than the
surgeon would expect. It is essential to understand
the anatomy of the distal VMO and its tendinous
insertion onto the patella. The
Th VMO muscle fibers
insert into the quadriceps tendon at a 50° angle and
the tendon consistently inserts at the mid-pole of
the patella (1) (Fig. 3). A skin flap
fl is also raised lat-
erally to the lateral border of the patella. ThThis lat-
eral flap will assist with the patella’s mobility at the
time of patellar translation. The arthrotomy starts
along the inferior border of the VMO. Establish a
plane between the undersurface of the VMO and
capsule prior to making your arthrotomy. This may
Fig. 1 – The leg is draped free without a leg holder.

Fig. 2 – The mini-subvastus incision extends from the superior pole of the
patella to the top of the tibial tubercle in full extension.
help with identifying your layers at the time of clo-
sure (Fig. 4). The arthrotomy is extended laterally
to the mid-pole of the patella then turns, creating
a corner, and extends distally along the medial bor-
der of the patella and medial border of the patellar
tendon to the level of the tibial tubercle.
After the arthrotomy, release the anterior horn of
the medial meniscus and perform a standard medial
release of the soft tissues exposing the medial joint
line. Place a Kocher clamp on the capsule above the
level of the medial meniscus. This will assist with
exposure throughout the case. Remove the retro-
patellar fat pad and release the anterior horn of
the lateral meniscus. Release the soft tissue on the
proximal tibia just distal to the lateral joint line to
assist with retractor placement later in the case. At
this point it is important to test the mobility of the
patella by translating it into the lateral gutter with-
out everting it. The patella should be able to slide
with its medial border sitting below, or posterior,
to the anterior surface of the lateral femoral con-
dyle. If the patella cannot completely translate into
the gutter, ensure that the medial patellofemoral
ligament is released and there are no adhesions
anchoring the fascia overlying the VMO to the sub-
cutaneous connective tissue above it.
After assuring suffifficient patellar mobility, place a
90° bent-Hohmann retractor in the corner of the
arthrotomy at the level of the superior-pole and
The mini-subvastus approach for total knee arthroplasty 777
Fig. 3 – The vastus medialis extends more distal and more medial than
most surgeons anticipate. The distal insertion is at a 50° angle and extends
to the midpole of the patella.
place the tip of the retractor in the lateral gutter and
retract the patella laterally (Fig. 5). Flex the knee to
90° (Fig. 6). Drill the femoral canal and insert the
intra-medullary femoral cutting guide (Fig. 7). We
make the distal femoral cut first, followed by the
tibia cut, and then we finish the remaining femoral
cuts. This sequence creates more space for the fem-
oral sizing and rotation guide, and thus problems
with femoral sizing encountered in some MIS TKA
techniques can be minimized.
Exposure of the tibia is performed by flexing the
knee to 90° and using three, carefully placed retrac-
tors (Fig. 8). Bent-Hohmann retractors are placed
medially and laterally on the tibia to expose the
bone perimeter and protect the collateral ligaments.
A PCL retractor is placed posteriorly to sublux the
tibia forward and expose the posterior perimeter of
the tibial surface. The tibial resection is performed
using an extra-medullary guide designed for MIS
(Fig. 9). Care is taken to ensure the cut is made in
the correct plane, noting both the coronal and sag-
ittal alignment of the tibial cutting block.
The rotation of the femoral component can be
determined by referencing the transepicondylar
axis, Whiteside’s line, or the posterior condyles
(Fig. 10). ThThe mini-subvastus approach allows
the use of any or all of these referencing systems
(Fig. 11). To make the anterior femoral cut with the
4-in-1 finishing guide it is useful to extend the knee
778 Primary Total Knee Arthroplasty
Fig. 4 – The dissection into the subvastus space can be facilitated by sliding
a finger under the belly of the vastus medialis muscle.
Fig. 6 – With placement of two 90° bent homan retractors both condyles of
the distal femur can be visualized without diffi
fficulty.
to 60° and return the bent-Hohmann retractors to
the medial and lateral sides of the femur. Extend-
ing to 60° eases the tension in the extensor mecha-
nism and allows better visualization of the anterior
cortex of the distal femur. Clear the synovial tissue
where the anterior cut will be made. Visualizing the
anterior cortex will help prevent notching.
After the femoral cuts are finished, a laminar
spreader is placed laterally for debridement of the
medial meniscus, residual ACL and PCL (for a pos-
terior stabilized knee system), and removal of any
Fig. 5 – A 90° bent homan retractor is a key instrument. It should rest
against the robust edge of vastus medialis tendon and be used to retract
the patella laterally into the gutter without eversion.
Fig. 7 – The distal femoral cutting guide can be positioned against the
anterior femur best when the leg is extended slightly to take tension off
the extensor mechanism.
posterior osteophytes. The
Th laminar spreader is then
switched to the medial side and a similar debride-
ment is performed laterally. Ligamentous balancing
is then performed in flexion and extension (Fig. 12).
Resurfacing of the patella is reserved for the end.
With the subvastus approach, the patella does not
need to be resurfaced sooner for visualization. In
addition, this prevents inadvertent damage to the
cut surface of the patella during the other steps. Th
The
patella can then be cut free-hand or with a patella
cutting guide. Waiting to place the femoral and

Fig. 8 – Tibia exposure is obtained with three carefully positioned retractors.
Fig. 9 – A smaller tibial cutting guide designed for minimally invasive sur-
gery is of benefit to work around the patellar tendon and within the smaller
skin incision.
tibial trials until after the patella is cut allows the
entire limb to shorten, relaxes the extensor mecha-
nism, and makes it easier to position the patella for
the cut. A trial reduction can then be done.
The tibial tray is cemented first. The tibia again is
Th
exposed with a bent-Hohmann placed medially
and laterally and a PCL retractor posteriorly to
sublux the tibia forward. The bone is cleaned with
a pulsatile lavage system and dried prior to cement-
ing. After inserting the tibial component, care is
taken to clean any remaining cement from around
the prosthesis. To cement the femur, the tibia is
The mini-subvastus approach for total knee arthroplasty 779
Fig. 10 – Femoral sizing is best done with a contemporary guide that acco-
modates a smaller incision.
Fig. 11 – Contemporary femoral 4-in-1 finishing guides are lower profile
with tapered edges and corners that are soft-tissue friendly.
translated posteriorly under the posterior femo-
ral condyles. Care should be taken to not dislodge
the freshly cemented tibial tray when pushing the
tibia back under the femur. The 90° bent-Hohmann
retractors are placed medially and laterally, proxi-
mal to the insertions of the collateral ligament on
the femur. A knee retractor is place under the exten-
sor mechanism to expose the anterior surface of the
femur. Cement is applied to both the exposed bony
surfaces and to the posterior condyles and anterior
femoral flange. The patella is cemented last. After
the cement has cured the tibial insert is placed.
780 Primary Total Knee Arthroplasty
Fig. 12 – The flexion and extension gaps and medial versus lateral soft-
tissue tension can be assessed with spacer blocks or with trial components
as per the surgeons preference.
The tourniquet is deflflated and any small bleeders
are found and cauterized. Next, ensure correct
tracking of the extensor mechanism by flexing
and extending the knee, allowing the patella to
track freely. A lateral retinacular release should
rarely be required in association with the mini-
subvastus technique. TheTh closure of the subvastus
arthrotomy begins at the mid-pole of the patella,
as this and the opposing corner of the capsule are
easy to find (Fig. 13). The arthrotomy is closed
with the knee in flexion to avoid over-tightening
of the medial aspect of the extensor mechanism.
When closing the medial aspect of the arthro-
tomy along the border of the VMO, avoid sutur-
ing large amounts of muscle. Ideally, the suture
repair should include the VMO fascia, the joint
capsule deep to it, and the corresponding capsule.
We use three interrupted 0-vicryl sutures to close
this part of the arthrotomy. Th
The rest of the arthro-
tomy is also closed with 0-vicryl suture. The
Th skin
and subcutaneous tissue are closed in layers with
interrupted 0-vicryl and 2-0 monocryl, followed
by closely spaced skin staples. Th
The incision is then
covered with Xeroform gauze and 4 × 4’s, then
wrapped with soft roll cast padding. Lastly, the
extremity is wrapped with a 6-inch ACE bandage
from the foot to mid-thigh.
Fig. 13 The closure of the mini-subvastus arthrotomy is relatively quick and
begins by re-aproximating the corner of tissue created at the intersection
of the subvastus dissection with the midpole of the patella. Sutures can be
placed with the knee in extension but should be tied after the knee is flexed
to 90° to avoid overtightening the medial soft tissue sleeve.
Pearls and pitfalls
– The medial skin flap must be elevated far enough
to clearly identify the inferior border of the
VMO.
– The arthrotomy should never extend proximal to
the mid-pole of the patella.
– After making the arthrotomy, ensure patellar
mobility by translating the patella into the lateral
gutter while the knee is extended. Ensure release
of the medial patellofemoral ligament and any
soft tissue attachments overlying the quadriceps
to assist with patellar mobility.
– Start the closure at the corner of the arthrotomy
at the level of the mid-pole of the patella and tie
the sutures with the knee flexed
fl to 90°.
– Do not evert the patella. Suffi fficient exposure
can be obtained by translating it into the lateral
gutter.
Post-operative care
After the surgery, the patient is allowed to bear
weight as tolerated on the operative extremity.
A physical therapist sees the patient starting the
morning after surgery to assist with mobilization.

Almost all patients require a walker for several
days and later progress to a cane. Patients are able
to leave the hospital when they can ambulate over
150 feet, go up and down two or three stairs, and
have their pain controlled with oral pain medica-
tion. We ask our patients to see a physical thera-
pist for 2 weeks after dismissal to monitor their
progress with knee range of motion. Patients may
return to driving after they can ambulate with a
cane and they are off
ff all daytime narcotics. Patients
return to clinic at 2 months for formal evaluation
with full-length, standing radiographs.
Outcomes
The results of an MIS subvastus approach per-
formed on 103 consecutive patients by the senior
author (MWP) were reported (9). Every incision
was 3.5 inches (88 mm) or less. The mean opera-
tive time from incision to final closure was 58 min
(range 32–115). The mean hospital stay was 2.8 days
and 82% of the patients were dismissed directly to
home. Each patient recorded their functional mile-
stones in a diary. The average time to stop using a
walker was 14 days and a cane 21 days. On average,
patients stopped using narcotic pain medication at
14 days, were able to ascend and descend a flight
of stairs at 14 days, drive a car at 28 days, and walk
a mile at 42 days after surgery. The mean range of
motion at 2 months was 116° and at 1 year was
119°. At 2 months after surgery full length, stand-
ing radiographs were obtained. The Th mechanical
axis passed through the central third of the knee in
102 out of 103 knees. Similarly, every tibial com-
ponent was placed in 90 +/- 2° relative to the long
access of the tibia and every femoral component,
except two, were placed in 6 +/- 2° relative to the
long axis of the femur. These
Th results demonstrate
the subvastus approach is an effective,
ff reliable, and
effi
fficient method to perform a TKA.
Other series have compared the subvastus approach
to other approaches used for TKA. Aglietti et al. per-
formed a blinded, randomized control trial on 60
patients who underwent either a “quad-sparing” or
mini-subvastus approach for TKA (5). The Th subvas-
tus group of patients experienced earlier straight
leg raise (1.4 vs. 1.9 days). Th
There was also a trend
toward increased early flexion
fl in the subvastus
group. Other outcomes were similar in both groups.
The same institution compared the mini-subvastus
approach to a medial parapatellar arthrotomy (7).
They found the subvastus group to have an earlier
straight leg raise, earlier 90° flexion,
fl and less intra-
operative blood loss. However, on average, the
The mini-subvastus approach for total knee arthroplasty 781
subvastus group required an additional 15 min of
tourniquet time. Roysum et al. also compared the
standard subvastus approach to a medial parapatel-
lar approach in 89 randomized patients (4). They
found earlier straight leg raise (3.2 vs. 5.8 days),
less opiate consumption, greater knee flflexion at 1
week, and less blood loss. Th
These studies confi
firm an
added benefifit to subvastus approach in the early
post-operative period. The long-term advantages
of this approach have not yet been established.
Complications
Fortunately, complications with the subvastus
approach are rare. The complication that is unique
to this approach is a subvastus hematoma. This Th
occurs when the blood vessels that course through
the adductor canal and branch through the VMO
are torn. This is minimized by translating the
patella and not everting it, as this decreases the
tension on this area. Prior to closing the arthro-
tomy the tourniquet is released and this area is
examined for possible bleeding. If present, the
bleeding vessels can be cauterized. If the surgeon
is concerned about bleeding, he can leave a deep
drain in this area.
References
1. Pagnano MW, Meneghini RM, Trousdale RT (2006) Anat-
omy of the extensor mechanism in reference to quadri-
ceps-sparing TKA. Clin Orthop Relat Res 452:102–105
2. Erkes F (1929) Weitere Erfahrungen mit phyisiologis-
cher Schnitt fuhrung zur Eroff ffnung des Kniegelenks.
Bruns’Beitr zur Klin Chir 147:221
3. Abbott LC, Carpenter WE (1945) Surgical approaches to
the knee joint. J Bone Joint Surg 27(A):277–310
4. Roysam GS, Oakley MJ (2001) Subastus approach for
total knee arthroplasty: a prospective, randomized, and
observer-blinded trial. J Arthroplasty 16:454–457
5. Aglietti P, Baldini A (2006) Quadriceps-sparing versus
mni-suvastus approach in total knee arthroplasty. Clin
Orthop Relat Res 452:106–111
6. Faure BT, Benjamin JB, Lindsey B, et al. (1993) Compari-
son of the subvastus and paramedian surgical approches
in bilateral total knee arthroplasty. J Arthropasty 8:511–
516
7. Boerger TO, Aglietti P, Mondanelli N, Sensi L (2005) Mini-
subvastus versus medial parapatellar approach in total
knee arthroplasty. Clin Orthop 440:82–87
8. Hofmann AA, Plaster RL, Murdock LE (1991) Subvastus
(Southern) approach for primary total knee arthroplasty.
Clin Orthop Relat Res 269:70–77
9. Pagnano MW, Leone JM, Hanssen AD, et al. (2005) Mini-
mally invasive total knee arthroplasty with an optimized
subvastus approach: a consecutive series of 103 patients.
Presented at the American Academy of Orthopedic Sur-
geons Annual Meeting, Washington, DC

C. Stukenborg-Colsman,
S. Ostermeier,
The degenerative knee – surgical
H. Windhagen
techniques: “gap balancing”
Introduction
L
igament balancing is an integral part of total
knee arthroplasty and depends on correct
alignment of the knee in fl flexion and exten-
sion. Since the mid-1970s, the concepts of releas-
ing the medial collateral ligaments in knees with
varus deformity and the lateral ligaments in knees
with valgus deformity have been widely taught and
practised (1, 2).
In the literature, correct implant positioning com-
bined with the reconstruction of the mechanical
axis within +/−3° seems to correlate with good
long-term results. Nevertheless, unbalanced liga-
ment can cause a lift-off ff, excessive rollback, and
instability and therefore lead to an increased load
on the inlay (3, 4).
Today the main reason for revision is aseptic loos-
ening and instability (4). Mulhall et al. report about
29% revision arthroplasties due to instability (5).
Instability and decreased functional ability are in
general often the result of insuffi fficient “ligament
balancing.”
Ligament balancing cannot be addressed isolated
since it stands in context with the deformity, the
functional defificit as well as the operation tech-
nique.
The aim of total knee arthroplasty is to have equal
pressure in the medial and lateral compartment
with balanced ligaments in fl flexion and extension.
Surgical principle in total knee arthroplasty
The concept of unconstraint total knee arthroplasty
is to substitute the osteoarthitic joint surface by
keeping the anatomical motion and stability.
The amount of bone resection is determined by the
thickness of the implant. This is important since
the capsule and ligaments surrounding the knee
can only function if they are not stretched more
than 5% of their anatomical length (6). In order
to avoid stretching of the ligaments it is necessary
to create a rectangular extension and flexion gap
of the same size (7, 8). Therefore, one of the most
Chapter 73
important issues in total knee arthroplasty is an
adequate creation of the flexion
fl and extension
gap. The gap is defi
fined as the opening of the knee
joint space after completion of the bone cuts, while
the knee is held in extension (0°; extension gap)
or flexion (90°; flexion gap). These gaps are sub-
sequently filled up by the prosthetic components,
and their size is therefore critical, since a gap that
is too small may make it difficult
ffi to squeeze the
components into the created space without caus-
ing excessive tension on the soft tissue. Likewise,
when the gap is too large, underfi filling of the gap by
prosthetic components will occur, with insufficient
ffi
soft tissue tension and results in instability (9).
Since modern knee arthroplasty designs have an
identical metal thickness on their extension and
flexion regions, the flexion and extension gap cre-
ated should therefore be equal size. Moreover they
should be rectangular to allow for comparable ten-
sion in the medial and lateral soft tissue (Fig. 1).
Pre-operative deformity and function deficit
fi
The pre-operative deformity of the knee can be in
the sagittal plan (extension-and flflexion defi
ficit)
and/or in the coronal plane (varus- and valgus
deformity). This deformity is often a combination
of bone and soft tissue disorders.
Operating technique
There are two main operating techniques to implant
the prostheses and creating an equal rectangular
flexion and extension gap. One is the “femur fi first
technique with measured resection.”” This is probably
the technique that is most done worldwide right
now. Bone cuts are based on the bony anatomy.
The technique is based on the primary distal femo-
ral cut followed by posterior femoral referencing.
The amount of bone that is resected is determined
by the thickness of the implant. In most varus
knees the component is externally rotated 3° to
784 Primary Total Knee Arthroplasty
the posterior condylar axis and confi firmed by the
transepicondylar and anterior–posterior axis of
the femur (Whiteside line). In the valgus knees,
hypoplasia of the lateral femoral condyle renders
the posterior axis inaccurate, and one must rely on
the transepicondylar and anterior–posterior axis
of the femur (Whiteside line). Since the size of the
femoral component in most knee systems deter-
mines the amount of bone that is resected of the
posterior femoral condyles it influences
fl also the
size of the flexion gap indirectly. Proper femoral
component rotation is essential to achieve proper
soft tissue balance.
The tibial cut is perpendicular to the mechanical
Th
axis of the tibia. The axis is not between the mal-
leoli, but lies in the center of the talus, which is
medial to the intermalleolar point. Only after bone
cuts are made the soft tissue is addressed. All tech-
niques and studies described by Whiteside et all are
based on the “femur first technique with measured
resection” (2, 10).
Th “tibia first technique with balanced resection”” is
The
described by Insall et al. (7). With this technique
the soft tissue balancing is either done with the
approach or after the tibial cut has been done
perpendicular to the mechanical axis of the tibia.
The femoral rotation of the implant is then deter-
mined by putting spacer blocks on the tibial cut.
Therefore, the rotation of the femoral implant can
vary. The amount of anterior and posterior femoral
resection is defi
fined by the size of the implant. The
anterior femoral cut is tangential to the femoral
cortex. The distal cut is then based on the anterior
resection. The amount of resection is defi fined by
Fig. 1 – Rectangular and equal flexion
and extension gap.
the spacer blocks in order to create an equal flexion
fl
and extension gap. Insall et al. said “on no account
should the release be left until the femoral bone
cuts are made” (7).
Both techniques have advantages and disadvan-
tages. The femur first technique has the disad-
vantage of having more or less always a femoral
rotation of 3°. In fact does the anatomical femo-
ral rotation vary individually. This could lead to
soft tissue releases without pathological defor-
mation.
The tibial first technique has the disadvantage on
depending entirely on the accuracy of the first fi
tibial cut since further steps are all based on this
cut.
Therefore, in the case of a pre-operative extension
defi
ficit, this defi
ficit has to be corrected with a soft
tissue release to avoid excessive distal femur resec-
tion. Often osteophytes at the dorsal femoral con-
dyle cause the extension deficitfi in osteoarthritic
knees. Removal of these osteophytes have to be
done to correct this deformity and to avoid exces-
sive distal femoral resection also.
Ligament function
The lateral gastrocnemius tendon and capsule of
the posterolateral corner, the lateral collateral liga-
ment, and popliteus tendon attach near the lateral
femoral epicondyle and are stabilizers of the lateral
side throughout the flflexion arc. The lateral poste-
rior capsule and iliotibial band attach far away
 The degenerative knee – surgical techniques: “gap balancing” 785

from the epicondylar axis and are effective

ff lateral Ligament tensors
stabilizers only in extension (11).
On the medial side, the medial collateral ligament In order to determine the tightness of ligaments and
(anterior and posterior portions) is attached to the the height of the flexion and extension gap ligament
epicondyle, and is effffective throughout the flexion tensioning devices are used. Tensors go from simple
arc. The epicondylar attachment is wide enough spacer block of difffferent sizes to a dynamic tensor
that there is a diff
fference in function of the ante- with a torque meter (12). With the “tibia firstfi tech-
rior and posterior part of this ligament in flexion
fl nique with balanced resection” the device is put into the
and extension. Therefore, the anterior part of the flexion and extension gap after the tibial bone cut.
medial collateral ligament tightens in flexion
fl and With the “femur first technique with measured resec-
loosens in extension. The posterior part of the tion” the tensioning device is used to perform the
medial collateral ligament loosens in flexion
fl and soft tissue balancing after at least the distal femoral
tightens in extension. The
Th medial posterior capsule and tibial bone cuts are made. The advantage of the
attaches far from the epicondylar axis, and is tight device is to detect the deformity/tightness and allow
only in extension. The posterior cruciate ligament a stepwise ligament release. Th The authors use a bal-
is attached slightly distal and posterior to the epi- ancer without torque meter that measures the height
condylar axis, so it loosens in full extension and (mm) of the flexion and extension gap as well as the
tightens in flexion.
fl degree of varus and valgus deformity (°) (Fig. 2).
“Knowing this information, the surgeon can, after
positioning the implants properly with the axes
of the knee, assess knee stability in flexion
fl and
extension and release the structures that are tight. Release techniques
The surgeon also can adjust the tightness of intact
ligaments by changing the position and size of the The release of the ligament itself can be done in dif-
femoral component, altering the slope of the tibial ferent techniques. Every surgeon should develop
surface, and adjusting the thickness of the tibial his/her own personal workfl flow. Soft tissue and liga-
polyethylene spacers. Anterior–posterior stability ments can be elongated by cutting through, detach-
can be altered by changing the confi figuration of the ment, or pie crusting (13, 14). Pie crusting means to
polyethylene component (11). do multiple horizontal incisions (stitching) into the
A number of factors in the osteoarthritic knees ligament. Neyret et al. recommend to use a scalpel
aff
ffect the functions of ligaments. Osteophytes no. 11 and report that the medial collateral ligament
deform them, causing them to be excessively tight, can be elongated up to 6–8 mm. They prefer this
or restrict sliding, causing flexion
fl contracture and technique up to varus tightness to 6°. With a varus
restriction of flexion. As the joint surfaces collaps, tightness of 6–8° they detach the anterior part of
their attachment points come closer together and the MCL at the tibial insertion with a raspatory.
the ligaments shorten irreversibly. When the joint Higher degrees of deformity sometimes need to
surface separate on the convex side of a deformity, be addressed by a combined bone and soft tissue
the ligaments usually are elongated permanently. release technique. For these high degree deformities
All these abnormalities can be addressed by thor-
ough debridement of the joint, choice of size and
position of the implants, and release of contracted
ligaments.
When ligaments are released to correct deformity,
other ligaments, which are not so severely con-
tracted, are brought into play to stabilize the knee.
The posterior cruciate ligament and posterior cap-
sule are the most important secondary static stabi-
lizing structures in varus and valgus knees. When
ligaments must be released to correct deformity, as
in the varus knee, the secondary stabilizing struc-
tures are called in action.
Contracture or elongation of these secondary sta-
bilizing structures may aff ffect ligament balance
as well, and sometimes these structures must be
adjusted. Because the posterior cruciate ligament
is a medial structure, it often is contracted in
the varus knee and stretched in the valgus knee”
(11). Fig. 2 – Balancer® (Stryker, USA).
786 Primary Total Knee Arthroplasty

Fig. 4 – Removal of osteophytes at the tibia.

tight anterior fibers are released subperiostly with

Fig. 3 – Epicondylar osteotomy and distal sliding of the epicondyle to elon- an ostetome (e.g., 10 mm) at the tibial insertion.
gate the lateral or medial soft tissue structures. The insertion of the medial collateral ligament
is about 7–8 cm distal at the tibia. No hammer
a displacement or sliding of the epicondyle can be should be used. Instead tap gently the ostetome
necessary (Fig. 3) (15). with the hand (Fig. 5). ThThe posterior part of the
A variety of instruments of personal preference medial collateral ligament now acts as a secondary
can be used to release. The authors prefer to use stabilizer.
a scalpel (no. 15 or 11) for pie crusting, a chisel
(10 mm) to do plane detachments (e.g., medial col-
lateral ligament) and the capsule and curved raspa-
tory (10 mm) for bony detachment (e.g., posterior Tight in extension
cruciate ligament).
In case of extension tightness, the posterior
medial capsule and the posterior part of the
medial collateral ligament can be released. Th The
Whiteside technique with “femur first
fi posterior part of the medial collateral ligament
technique with measured resection” can be released just as the anterior part with
a straight or curved osteotome. The Th fibers are
released again subperiostly. These
Th two structures
Varus algorithm should also be released in case of an extension
defi
ficit. In addition, it is sometimes necessary to
First of all osteophytes have to be removed from release the semi-menbranosus tendon on its tib-
the medial and lateral side both at the femur and ial insertion.
the tibia. Then osteophytes at the posterior femo-
ral condyles must be removed (Fig. 4). Th
This can be
cut free with a curved or straight osteotome and
removed. Only after these steps a tensor should be
used in order to detect the size of the flexion and
extension gap as well as the varus and valgus tight-
ness. In varus deformity the medial structures are
often tight compared to lateral soft tissue struc-
tures. In order to address the right structure to
release it is important to analyze if they are tight
uniformly or only in flexion
fl or in extension.

Tight in flexion
fl
In case of a flexion tightness the anterior part of Fig. 5 – Release of the anterior part of the medial collateral ligament in
the medial collateral ligament can be released. Th
The case of medial flexion tightness (e.g., varus deformity).

Posterior cruciate ligament
Because the posterior cruciate ligament is a medial
structure, it often is contracted in the varus knee
and strechted in the valgus knee. The tight pos-
terior cruciate ligament causes excessive femoral
rollback. It can be separated in two parts with dif-
ferent functions. The posteromedial part of the
PCL is anatomically tight in extension and loose in
flexion. The anterolateral part of the PCL is tight in
flexion and loose in extension. The two parts of the
PCL can be released separately. It can be released
on the tibial as well as on the femoral insertion.
The posterior cruciate ligament can be released
with a small portion of bone from its tibial attach-
ment. This can be done with an osteotome (e.g.,
10 mm) or a raspatory (Fig. 6). The
Th bone slides
proximally 0.5–1 cm loosening the PCL. The syn-
ovial membrane remains intact (11). After the PCL
release and implanting the trials the tibia slides
posteriorly, and the femur and tibia articulate in
the normal position (Fig. 7).
Fig. 6 – Release of the posterior cruciate ligament on its tibial insertion.
A B
Fig. 7 – Workflow for varus soft tissue deformity.
The degenerative knee – surgical techniques: “gap balancing” 787
Valgus algorithm
Correct alignment and positioning of the implant in
the valgus knee remains challenging. In valgus defor-
mity the lateral structures are often tight compared
to medial soft tissue structures. In order to address
the right structure to release it is again important to
analyze if they are tight uniformly or only in flexion
fl
or in extension. In case of tightness in flexion
fl the
popliteus tendon and collateral ligament has to be
addressed. Often in this case there is a rotational
component around the lateral structures in addition.
In case of tightness in extension, the posterior lateral
capsule and the iliotibial band have to be released.
Tight in flexion
fl
In case of tightness in 90° of fl flexion, the popli-
teus tendon is released on its attachment at the
lateral epicondyle with a knife in a v-shape fash-
ion. Because the popliteus tendon is attached to
the capsule and lateral collateral ligament, the
popliteus tendon retracts only 5–10 mm (Fig. 8a
and b). If there is still tightness in flexion
fl the lat-
eral collateral ligament has to be released also. It is
also released on its bony attachment at the lateral
epicondyle, leaving the capsular attachment just
behind it intact (Fig. 9a and b).
Tight in extension
If the knee remains tight laterally in extension,
the iliotibial band and the posterior lateral capsule
must be released. The iliotibial band is addressed
extra-articullary. The synovial membrane is left
intact. Mutiple v-shaped stitches are made into the
iliotibial band and therefore released in a stepwise
fashion (Fig. 10). Whiteside suggests to release
the iliotibial band just above the joint line (11).
788 Primary Total Knee Arthroplasty

A B
Fig. 8 – (a and b) Preparation of the popliteus tendon and its release.

Fig. 10 – V-shaped incisions into the iliotibial band.

Fig. 9 – (a and b) V-shaped incision and release of the lateral collateral

ligament.

The posterior cruciate ligament, the posterior lat-
eral capsule as well as the biceps femoris remain
as lateral stabilizers. Whiteside et al. suggest that
if all static lateral stabilizing structures require
release, the biceps femoris muscle, gastrocnemius
muscle, and deep fascia can support the knee
until capsular healing occurs. Because external
rotational and posterior constraint are then not
provided by these secondary lateral stabilizing
structures, a more conforming tibial polyethylene
component may be necessary to provide this sta-
bility (Fig. 11) (16).
Fig. 11 – Workflow for valgus soft tissue deformity.
Peroneal nerve release technique in valgus deformity
Acute correction of a valgus knee into a straight axis
arthroplasty knee may be associated with peroneal
nerve damage, especially in cases with additional
flexion contracture. The literature shows a signifi fi-
cant correlation between peroneal nerve pulsy and
the pre-operative degree of valgus deformity (17,
18). Asp and Rand reported about a recovery of

the nerve of only 50% (19). Proximally, the nerve
is thethered at the sacral plexus or the sciatic notch,
where the nerve can be compressed against the
ischium passing around the acetabulum. Distally,
the nerve goes around the fibular neck at a very lat-
eral position. More distally, the superficial
fi part con-
tinues in straight direction, while the deep portion
takes a sharp turn and passes under the interfas-
cial septum between lateral and anterior compart-
ments. These entrapment points pre-dispose to per-
oneal nerve injury. To prevent acute overtensioning
the nerve can be decompressed by partially open-
ing the peroneal tunnel at the fibular
fi neck and an
additional dissection of the intermuscular septum
(20). Fascial release is performed by a short oblique
skin incision, nerve identifification after opening the
superfi
ficial fascia and combined with a transverse
incision of the anterior compartment fascia.
Nerve decompression may be indicated in severe
valgus correction (>20°) combined with fl flexion
contracture.
References
1. Insall J, Ranawat CS, Scott WN, Walker P (2001) Total
condylar knee replacement: a preliminary report 1976.
Clin Orthop 388:3–6
2. Whiteside LA (2002) Soft tissue balancing: the knee. J
Arthroplasty 17(Suppl 1):23–27
3. Insall JN, Scuderi GR, Komistek RD, et al. (2002) Corre-
lation between condylar lift-off ff and femoral component
alignment. Clin Orthop 403:143–152
4. Sharkey PF, Hozack WJ, Rothman RH, et al. (2002) Why are
total knee arthroplasties failing today? Clin Orthop 404:7–13
5. Mulhall KJ, Ghomrawi HM, Scully S, et al. (2006) Current
etiologies and modes of failure in total knee arthroplasty
revision. Clin Orthop 446:45–50
The degenerative knee – surgical techniques: “gap balancing” 789
6. Claus A, Scharf HP (2007) “Ligament balancing” bei Var-
usgonarthrose. Orthopade 36:643–649
7. Insall J, Binazzi R, Scoudry M, Mestriner L (1985) Total
knee arthroplasty. Clin Orthop 192:13–22
8. Laskin RS (1995) Flexion space confifiguration in total knee
arthroplasty. J Arthroplasty 10:657–660
9. Bellemans J (2005) Achieving maximal fl flexion. In: Belle-
mans J, Ries MD, Victor J (eds) Total knee arthroplasty.
Springer, Berlin Heidelberg
10. Whiteside L, Kazuhiko S, Milhalko W (2000) Functional
medial ligament balancing in total knee arthroplasty. Clin
Orthop 380:45–57
11. Whiteside L (2004) Ligament balancing in total knee
arthroplasty. Springer, Berlin Heidelberg
12. Zalzal P, Papini M, Petruccelli D, et al. (2004) An In Vivo
biomechanical analysis of the soft tissue envelope of
osteoarthritic knees. J Arthroplasty 19:217–223
13. Aglietti P, Lup D, Cuomo P, Baldini A, De Luca L (2007)
Total knee arthroplasty using a pie-crusting technique for
valgus deformity. Clin Orthop Relat Res 464:73–77
14. Ranawat AS, Ranawat CS, Elkus M, et al. (2005) Total knee
arthroplasty for severe valgus deformity. J Bone Joint
Surg Am 87(Suppl 1):271–284
15. Neyret P, Verdonk P, Si Selmi TA (2008) Kniechirurgie
Urban & Fischer München Jena
16. Whiteside L, Milhalko W (2002) Surgical procedure for
flexion contracture and recurvatum in total knee arthro-
plasty. Clin Orthop 404:189–195
17. Horlocker TT, Cabanela ME, Wedel DJ (1994) Does post-
operative epidural analgesia increase the risk of peroneal
nerve palsy after total knee arthroplasty? Anesth Analg
79:495–500
18. Idusuyi OB, Morrey BF (1996) Peroneal nerve palsy after
total knee arthroplasty. Assessment of predisposing and
prognostic factors. J Bone Joint Surg Am 78:177–184
19. Asp JP, Rand JA (1990) Peroneal nerve pulsy after total
knee arthroplasty. Clin Orthop Relat Res 261:233–237
20. Paley D (2000) Principles of deformity correction.
Springer, Berlin Heidelberg
21. Wasielewski RC, Galat DD, Komistek RD (2004) An intra-
operative pressure-measuring device used in total knee
arthroplasties and its kinematic correlation. Clin Orthop
427:171–178

F. R. Orozco,
W. J. Hozack
Component orientation
and total knee arthroplasty
Introduction
P
roper component alignment during total
knee arthroplasty (TKA) is essential for
determining the early and long-term out-
comes of TKA. Incorrect alignment can lead to
abnormal wear, pre-mature mechanical loosening
of the components, instability, and patellofemoral
problems (1, 2)
Mechanical axial alignment
The mechanical axis of the lower extremity is
formed by a line that passes from the center of the
hip through the center of the knee into the cen-
ter of the ankle. The goal of TKA is to restore the
mechanical axis as close as possible to neutral. In
order to achieve this goal, the surgeon must create
a neutral mechanical axis at both the distal femur
and the proximal tibia (Fig. 1). There is some early
evidence that adequate alignment of TKA compo-
nents can be associated with faster rehabilitation
and even shorter hospital stay (3).
Fig. 1 – AP view of the knee demonstrating neutral mechanical axis at both
the distal femur and the proximal tibia.
Chapter 74
Femoral component alignment
Current instrumentation to establishing proper
varus or valgus orientation of the femoral com-
ponent can involve two diff fferent techniques:
intramedullary (IM) alignment and extramedul-
lary (EM) alignment.
Intramedullary alignment technique
The valgus cut at the distal femur is the diff
fference
between the anatomic and mechanical axis. Th The
femoral shaft is used as the anatomic reference.
To prepare the femur, the intercondylar notch is
exposed and the medullary canal of the femur is
entered approximately 1 cm above the origin of
the posterior cruciate ligament (PCL) and 2–3 mm
medial to the center of the intercondylar notch
(Fig. 2). A 5–6° valgus bushing instrumentation
is used and the distal femoral resection is made.
Careful attention to proper surgical technique is
mandatory since minor deviations in the insertion
point of IM instrumentation during TKA can result
in malalignment of several degrees. In a mathe-
matical model study, Nuño-Siebrecht et al. showed
that when using an IM technique, varus and val-
gus malalignment can be minimized with a proper
femoral entry point, and by increasing the IM rod
diameter and length used during primary TKA (4).
Fig. 2 – Proper entry site to the medullary canal approximately 1 cm above
the origin of the posterior cruciate ligament (PCL) and a 2–3 mm medial to
the center of the intercondylar notch.
792 Primary Total Knee Arthroplasty
This technique continues to be the most commonly
used during TKA to align the femoral component,
due to its simplicity, reproducibility, and reasonable
accuracy. Some of the concerns with its use is that
fat embolism, activation of coagulation, and bleed-
ing may occur from the penetration of the femoral
canal. A recent cadaveric study showed decreases
in femoral IM pressure of 86% proximally and 87%
distally when using a reamer/irrigator/aspirator
system (5).
Extramedullary alignment technique
Alignment guides can also be placed in reference to
external landmarks such as the anterior superior
iliac spine, center of the hip joint, and the center
of the ankle. The problem with these landmarks
is that they can be hard to identify and are less
reproducible (6). For this reason IM alignment
guides for the distal femoral resection of the femur
are more popular, and the preferred technique for
most surgeons. A recent study compared 100 con-
secutive patients undergoing primary TKA with
the use of either standard IM femoral instruments
(IM group) or a new extramedullary device (EM
group) that was calibrated based on templated data
obtained from a pre-operative full-limb weight-
bearing anteroposterior radiograph. Th The authors
reported no significant
fi diff
fferences in femoral com-
ponent coronal/axial alignment and concluded
that extramedullary reference with the addition of
careful pre-operative templating can be used dur-
ing TKA (7).
With the introduction of computer assisted sur-
gery (CAS) an extramedullary technique can be
used in a more accurate manner, still avoiding
violation of the femoral canal, and maintaining
proper alignment of the femur. Picard et al. per-
formed a prospective study of 57 consecutive navi-
gated TKAs, and found fewer outliers in regards to
coronal (100% of TKAs within +/−2°) and sagittal
Fig. 3 – Computer assisted surgery used to aid with the evaluation of the
femoral cuts.
(0% of TKAs with fixed
fi flexion greater than 5°)
alignment (8).
The technique uses bone surface landmarks that
are registered in the computer and special cutting
blocks held in place by small pins that allows fine
fi
tuning up to a degree to perform all the different
ff
femoral cuts required for a TKA. The surgeon can
perform the bone cuts and check each of them
with the aid of the computer (Fig. 3).
Tibial alignment
The tibial resection cut is made neutral to the tibial
axis (9). Current instrumentation to establishing
proper varus or valgus orientation of the tibial cut
can involve two diff
fferent techniques: IM alignment
and extramedullary alignment.
Intramedullary alignment technique
This technique is usually not used in primary TKA
due to the fact that tibial anatomic landmarks are
easy to determine and more reproducible. Also if
the tibia is bowed this technique can lead to poten-
tial inappropriate cuts (10). In revision surgery
there may be a better role for IM techniques since
tibia stems are used, and these stems can influence
fl
the tibial cut.
Extramedullary alignment technique
Extramedullary alignment of the tibia is more com-
monly used. TheTh anterior crest of the tibia is the
main landmark. The resection guide should be cen-
tered in the tibia plateau area in between the lateral
and medial cortices. Distally the main anatomic
landmark is the tibial crest, which is easily palpable
in most patients. Usually 3–5° of posterior sloped is
preferred (Fig. 4), but there is no consensus on an
Fig. 4 – Extramedullary tibial technique using the tibial crest as the main
anatomical landmark.

Fig. 5 – Extramedullary tibial technique using computer assisted surgery.
Fig. 7 – Distal aspect of the femur showing transepicondylar axis.
ideal anatomical reference or axis to determine the
posterior slope of the tibial plateau and the amount
of posterior slope necessary during TKA (11).
A prospective study in 350 patients undergoing
primary TKA assessed with long limb post-opera-
tive radiographs showed that extramedullary tibial
guides permit accurate cuts of the proximal end
of the tibia, and that tibial IM guides are not only
unnecessary but also potentially misleading (12).
With the use of CAS, as with the femur, an
extramedullary technique can be use for the
Component orientation and total knee arthroplasty 793
Fig. 6 – Distal aspect of the femur showing Whiteside’s line.
Fig. 8 – Distal aspect of the femur showing posterior condylar referencing
technique.
preparation of the tibia utilizing special cutting
guides that allowed the surgeon to precisely dial
the varus/valgus, depth, and slope of the tibial cut
(Fig. 5).
Rotational alignment
Femoral rotation
Correct femoral component rotation becomes very
important for adequate balancing of TKA as well
as varus/valgus stability. Th
This important area will
be discussed in detail in the next chapter. At least
four methods are available to be used to determine
femoral rotation. These include Whiteside's line
(Fig. 6), the transepicondylar axis (TEA) (Fig. 7),
posterior condyle referencing (Fig. 8), and rota-
tional alignment based on flexion gap symmetry
(Fig. 9). Our recommendation is to use all four
methods during surgery to better determine the
ideal femoral rotation.
794 Primary Total Knee Arthroplasty
Fig. 9 – Rotational alignment of the femur based on flexion gap symmetry.
Patellar tracking can also be inflfluenced by the rota-
tion of the femoral component. In a study of 60
patients undergoing TKA; the femoral component
was placed parallel to the epicondylar axis in 30
patients and the femoral component was placed in
3° external rotation to the posterior condylar axis
in 30 patients. The authors found that aligning the
femoral component parallel to the epicondylar axis
ficantly better patellar tracking (13).
lead to signifi
In a consecutive series of 100 patients undergoing
TKA at our institution, the accuracy of traditional
reference guides in determining the rotation of the
femoral component was compared with that of a
computerized navigation system. We showed that
although differences
ff between the three traditional
referencing methods were not statistically signifi- fi
cant, the possibility of finding an outlier leading
to excessive external or internal rotation of the
femoral component when using a fixed fi posterior
condyle reference guide mandates the use of other
referencing methods to avoid this error. Using
fixed posterior referencing, up to 17% of femoral
components would have diff ffered by more than
5° from the anatomic reference landmarks (TEA,
Whiteside's line). This degree of rotational mala-
lignment could lead to knee instability and early
failure (14).
Tibial rotation
Tibial rotation in TKA is usually determined by the
position of the tibial tubercle. The most commonly
used landmark is the junction between the medial
and center thirds of the tibial tubercle (15) (Fig. 10).
Proper tibial rotation is very important for ade-
quate patellar tracking. Excessive internal rotation
of the tibial component increases the risk of lateral
maltracking of the patella. Berger et al. compared
CT scans of 30 patients with isolated patellofemo-
ral complications after TKA against 20 patients
Fig. 10 – Tibial tubercle used as a landmark for proper orientation of the
tibial component.
with well-functioning TKA, and found that the
group with patellofemoral complications had exces-
sive combined tibial and femoral component inter-
nal rotation. Small amounts of combined internal
rotation (1–4°) correlated with lateral tracking and
patellar tilting. Moderate combined internal rota-
tion (3–8°) correlated with patellar subluxation.
Large amounts of combined internal rotational
(7–17°) correlated with early patellar dislocation
or late patellar prosthesis failure (16).
Excessive external rotation during TKA is uncom-
mon, but can also have a negative impact on patellar
tracking. In a cadaveric study, Nagamine et al. found
that externally malrotated tibial trays of more than
15° lead to medial shift of the patella (15).
Medial–lateral position
The medial–lateral position of the femoral and
tibial components should be as close as possible to
anatomic in the respective bones.
The femoral component should be placed to coin-
cide with the lateral margin to the femur, in order
to enhance patellar tracking. Overhang of either the
femoral or tibial components should be avoided,
since it can be a source of persistent dysfunction
and pain after TKA. Oversizing of the femoral and
or tibial components will cause overstuffi
ffing of the
knee joint with possible irritation of the capsule,
patellar tendon, and the medial and lateral collat-
eral ligaments (17) (Fig. 11).
Anterior–posterior position
Anterior–posterior position of the femoral and tib-
ial components should also be as close as possible
as anatomic in the respective bones.

Femoral component
The anterior height of the femur should be restored
during TKA. Increasing the anterior thickness will
lead to patellar problems and also will decrease
range of motion due to overstuffi
ffing of the joint.
The posterior femoral condylar off ffset should be
restored as well to insure midrange stability and
also to maximize flexion potential (18) (Fig. 12).
Fig. 11 – Trial tibial component demonstrating overhanging and the pos-
sible irritation of the capsule, patellar tendon, and the medial and lateral
collateral ligaments.
Fig. 12 – Lateral radiographs of the knee showing restoration of the poste-
rior femoral condyle offset.
Component orientation and total knee arthroplasty 795
Tibial component
As mentioned previously, attention should be
placed on avoiding any overhang of the component
which can lead to localized irritation and postop
pain.
Computer navigation alignment in total knee
arthroplasty
Newer techniques in TKA involve CAS. Anatomic
landmarks are input into the computer during
the surgical intervention and the computer then
shows the mechanical alignment and aids in the
proper cuts of the femur and tibia to obtain a neu-
tral mechanical alignment. Computer Navigation
may obviate the need to instrument the medullary
canal of the femur, with possible decrease in fat
embolism and bleeding.
Conclusions
The goal in TKA is to restore the mechanical axis to
neutral. In order to achieve this goal, the surgeon
must create a neutral mechanical axis at both the
distal femur and the proximal tibia.
Proper alignment of components is crucial for the
success of TKA and can even have an infl fluence in
early faster recovery.
Currently most surgeons use the technique of an
IM femoral guide and an extramedullary tibial
guides to obtain accurate cuts of the distal femur
and the proximal tibia.
Computer Navigation is an emerging tool that can
aid with the position of the components in TKA,
and could potentially decrease the number of out-
liers.
References
1. Incavo SJ, Wild JJ, Coughlin KM, Beynnon BD (2007)
Early revision for component malrotation in total knee
arthroplasty. Clin Orthop Relat Res 458:131–136
2. Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ
(1998) Flexion instability after primary posterior cruciate
retaining total knee arthroplasty. Clin Orthop Relat Res
(356):39–46
3. Longstaff
ff LM, Sloan K, Stamp N, et al. (2008) Good align-
ment after total knee arthroplasty leads to faster rehabili-
tation and better function. J Arthroplasty
4. Nuño-Siebrecht N, Tanzer M, Bobyn JD (2000) Potential
errors in axial alignment using intramedullary instru-
mentation for total knee arthroplasty. J Arthroplasty
15(2):228–230
5. Van Gorp CC, Falk JV, Kmiec SJ Jr, Siston RA (2009) TheTh
reamer/irrigator/aspirator reduces femoral canal pressure
796 Primary Total Knee Arthroplasty
in simulated TKA. Clin Orthop Relat Res 467(3):805–809
(Epub 19 April 2008)
6. Siegel JL, Shall LM (1991) Femoral instrumentation using
the anterosuperior iliac spine as a landmark in total knee
arthroplasty. An anatomic study. J Arthroplasty 6(4):317–
320
7. Baldini A, Adravanti P (2008) Less invasive TKA:
extramedullary femoral reference without naviga-
tion. Clin Orthop Relat Res 466(11):2694–2700 (Epub
19 August 2008)
8. Picard F, Deakin AH, Clarke JV, Dillon JM, Gregori A
(2007) Using navigation intraoperative measurements
narrows range of outcomes in TKA. Clin Orthop Relat Res
463:50–57
9. Hsu HP, Garg A, Walker PS, et al. (1989) Effect
ff of knee
component alignment on tibial load distribution with
clinical correlation. Clin Orthop 248:135
10. Jessup DE, Worland RL, Clelland C, Arredondo J (1997)
Restoration of limb alignment in total knee arthro-
plasty: evaluation and methods. J South Orthop Assoc
6(1):37–47
11. Yoo JH, Chang CB, Shin KS, et al. (2008) Anatomical ref-
erences to assess the posterior tibial slope in total knee
arthroplasty: a comparison of 5 anatomical axes. J Arthro-
plasty 23(4):586–592
12. Mason JB, Fehring TK, Estok R, et al. (2007) Meta-analy-
sis of alignment outcomes in computer-assisted total knee
arthroplasty surgery. J Arthroplasty 22(8):1097–1106
(Review)
13. Luring C, Perlick L, Bäthis H, et al. (2007) The effffect of
femoral component rotation on patellar tracking in total
knee arthroplasty. Orthopedics 30(11):965–967
14. Restrepo C, Hozack WJ, Orozco F, Parvizi J (2008) Accu-
racy of femoral rotational alignment in total knee arthro-
plasty using computer assisted navigation. Comput Aided
Surg 13(3):167–172
15. Nagamine R, Whiteside LA, White SE, et al. (1994) Patel-
lar tracking after total knee arthroplasty. Th The eff
ffect of
tibial tray malrotation and articular surface confi
figuration.
Clin Orthop 304:262
16. Berger RA, Crossett LS, Jacobs JJ, Rubash HE (1998) Mal-
rotation causing patellofemoral complications after total
knee arthroplasty. Clin Orthop Relat Res (356):144–153
17. Emerson RH Jr, Martinez J (2008) Men versus women:
does size matter in total knee arthroplasty? Clin Orthop
Relat Res 466(11):2706–2710
18. Clarke HD, Hentz JG (2008) Gender differences
ff in the
distal femur dimensions and variation patterns in rela-
tion to TKA component sizing. Clin Orthop Relat Res
466(11):2711–2716

M. Bonnin Rotation of components in total
knee arthroplasty
Introduction
T
he rotational positioning of the tibial and
femoral component in total knee arthro-
plasties (TKAs) affects
ff the functional result
and the development of tibiofemoral and patell-
ofemoral complications. No agreement exists con-
cerning the best intra-operative landmarks. Many
authors studied the rotational alignment of the
femoral component but few did for the tibial align-
ment.
Rotation of the femoral component
In the first and oldest method of positioning (1–3),
a symmetric posterior condylar resection was per-
formed parallel to the posterior condylar line (CL)
and the femoral component was positioned parallel
to this line. Initially this appeared to be a satisfac-
tory and logical option because it placed apparently
the femoral component in an anatomic position.
However, apparently anatomic positioning of the
femoral component was found to lead to a num-
ber of difficulties.
ffi Several studies have shown that
positioning in external rotation relative to the pos-
terior CL was an appropriate option.
Why external rotation of the femoral component?
During the last decades, authors emphasized sev-
eral justifi
fications in favor of applying few degrees
of external rotation to the femoral component.
Ligament balancing
In total knee replacement, tibial resection, which
is generally perpendicular to the mechanical axis
of the tibia (ATm), is not anatomic and necessar-
ily involves excessive resection on the lateral side.
(1, 2, 4–6) (Fig. 1A) This deviation from anatomy
is compensated in extension by femoral resec-
tion, which is perpendicular to the mechanical axis
of the femur (AFm), leading to excessive femoral
resection on the medial side (Fig. 1B). Th
This is not
Chapter 75
the case in flexion and there is no automatic cor-
rection by posterior femoral resection.
Thus, if resection in flexion is carried out parallel to the CL, with
symmetric resection of the posterior condyles, the result is a
trapezoidal space in flexion with a tight medial compartment and a
lax lateral compartment (3, 6) (Fig. 1).
A widely used solution is to release the medial col-
lateral ligament (MCL) in flexion, giving satisfac-
tory soft tissue balance in flexion.
fl In this option,
care must be taken to do a selective release of the
anterior fibers of the MCL – in order to release in
flexion but not in extension (7) – otherwise the
problem can merely be transferred to extension.
Insall (3) in the early 1980s advised asymmetric
posterior condylar resection, in external rotation
relative to the CL. He proposed carrying out pos-
terior condylar resection after tautening the liga-
ments in order to obtain a symmetric flexion gap
(Fig. 2). Th
This option provides a solution to the diffi
ffi-
culties of soft tissue balance in flexion
fl while retain-
ing the principle of tibial resection at 90° and being
adaptable to each case. It raises, however, the prob-
lem of adjusting this rotation since it depends on
the state of the ligaments (see below).
Hungerford, Kenna and Krakow (1, 2) advise leav-
ing a certain degree of varus in tibial resection in
order to set the tibial component in an anatomic
position. This alternative option brings up the
potential risks related to placing the tibial compo-
nent in varus.
The patellofemoral joint
Several authors during the 1980s and 1990s
stressed the frequency of patellofemoral compli-
cations after TKA in case of internal malrotation
of the femoral component (6, 8–12). TheTh inflfluence
of femoral rotation on patellofemoral kinematics
was further defifined in 1993 by in vitro studies by
Rhoads et al. (12) and Anouchi et al. (8). In 1995
Whiteside and Arima (13) and Arima et al. (14)
stressed the risk of incorrect rotational position-
ing of the femoral component in valgus knees
related to lateral condylar hypoplasia. Lastly, the in
vivo CT studies of Berger et al. (9) and Akagi et al.
798 Primary Total Knee Arthroplasty

Fig. 1 – The angle between the mechanical axis of the tibia (ATm) and the tibiofemoral joint line (tibial angle, AT) varies according to individual morphology.
In an individual with a normally aligned knee, where the mechanical axis of the leg passes through the center of the knee, the tibial angle is in varus with an
average of 3°. This gives an oblique joint line of 3°, the tibial varus being compensated by femoral valgus ((ATm = mechanical axis of the tibia) (A). Tibial resec-
tion perpendicular to the ATm leads to excessive lateral resection, which is compensated in extension by asymmetrical distal femoral resection (B). In flexion,
if posterior condylar resection is parallel to the posterior condylar line, the flexion space will be trapezoidal with a tight medial compartment and a lax lateral
compartment (C). The consequence can be a lateral laxity in flexion (D) or a too tight medial compartment requiring a medial collateral ligament release (E).

increasing degree of femoral internal rotation: 0.8°

in simple tilt, 1.8° on average in patellar sublux-
ation, 2.4° in dislocation, and 3.9° in loosening. For
Akagi et al. (15), placing the femoral component in
external rotation reduces the rate of lateral reti-
naculum release from 34 to 6%.

Fig. 2 – Tibial resection is perpendicular to the mechanical axis of the tibia. Pos-
terior condylar resection, performed after tautening the peripheral ligaments,
is parallel to tibial resection in order to obtain a symmetric flexion space.
(15) defi
fined and quantifified the risk of patellofem-
oral complications relative to femoral malrotation.
Berger et al. (9) considered that overall prosthetic
rotation (femoral and tibial) varies from 0 to 10°
external rotation in patients without patellofemo-
ral complications and from 1 to 17° internal rota-
tion in the group with complications. In addition,
the severity of the complication increases with the
Tibiofemoral kinematics
Hollister et al. (16), Churchill et al. (17), and Iwaki
and Pinskerova (18, 19) have observed through
anatomic studies, radiographic, MRI, and biome-
chanical studies that flexion/extension move-
ments of the knee may be resumed to rotation
occurring round two axes, one longitudinal paral-
lel to the tibial axis and the other transverse. TheTh
transverse axis is the same as the transepicondylar
axis for Hollister et al. (16), oblique by 2.9 ± 1.2°
for Churchill et al. (17) and these authors agreed to
assimilate the transverse axis of the knee with the
transepicondylar axis.
These studies naturally lead to the conclusion
that setting the femoral component parallel to
the transverse axis of flexion/extension of the
knee (the transepicondylar axis) should be ideal.

Moreover, Yoshioka et al. (20) and Stiehl (21, 22)
concur with this by showing that the TEA remains
perpendicular to the tibial and femoral mechanical
axes when the knee is fl
flexed.
Practical bony landmarks
We have thus seen that all these clinical, technical,
and biomechanical arguments are in favor of posi-
tioning the femoral component in slight external
rotation relative to the CL in total knee replace-
ment. The degree of rotation and the guides to be
used are still debatable. Several anatomic land-
marks can be used.
The transepicondylar axis
Anatomy
The epicondyles correspond to the zones of inser-
tion of the collateral ligaments of the knee.
The lateral epicondyle forms a prominence on the
lateral condyle on which the lateral collateral liga-
ment (LCL) inserts. It is bordered anteriorly by the
insertion groove of the popliteal tendon and supe-
riorly and posteriorly by part of the insertion of
the lateral gastrocnemius.
The medial epicondyle, which is larger, consists of
a horseshoe-shaped ridge with an inferior concav-
ity. The peripheral ridge corresponds to the zone
of insertion of the superficial
fi bundle of the medial
collateral ligament (MCL) and the central depres-
sion (sulcus), at the insertion of the deep bundle
of the MCL (23, 24) (Fig. 3). For Griffin
ffi et al. (24)
its diameter is 11.4 ± 1.4 mm and the depth of the
central sulcus is 1.2 ± 0.4 mm.
The transepicondylar axis (TEA) runs between the
Th
lateral and the medial epicondyle. Two types of
Fig. 3 – The medial epicondyle, which is larger, consists of a horseshoe-
shaped ridge with an inferior concavity (arrows). The peripheral ridge cor-
responds to the zone of insertion of the superficial bundle of the medial col-
lateral ligament (MCL) and the central depression (sulcus), at the insertion
of the deep bundle of the MCL.
Rotation of components in total knee arthroplasty 799
axis have been described depending on the land-
mark chosen at the level of the medial epicondyle
(9, 15, 20, 23) (Fig. 4):
The "clinical" TEA takes account of the most promi-
nent zone (most easily palpable) of the medial
epicondyle. This
Th is the anterior prominence seen
on CT scan or MRI at 90°. The angle between the
clinical TEA and the PCL forms the “condylar twist
angle” (CTA) (20).
The "surgical" TEA is based on the sulcus of the
medial epicondyle. The angle between the surgi-
cal TEA and the PCL forms the “posterior condylar
angle” (PCA) (23).
Some authors have compared these two axes (23, 28, 29). The angle
between them varies from 1.2 to 4.9°, the clinical TEA being rotated
more externally.
Clinical applications
Yoshioka emphasized the practical value of this
landmark for the first time in 1987 (20). He
showed that:
(1) The clinical TEA is a crucial landmark as it is per-
pendicular to the mechanical axes of the leg in fl flex-
ion and in extension, making it one of the reference
axes of the lower limb and (b) The angle between the
clinical TEA and the bicondylar line in flexion (con-
dylar twist angle) varies widely between individuals,
which makes the CL an unreliable landmark. Stiehl
in 1995 (21) confirmed
fi the findings of Yoshioka in
an in vitro study based on the clinical TEA.
These authors therefore advised placing the pros-
thesis in alignment with the mechanical axes of the
lower limb, that is, perpendicular to the tibiofemoral
mechanical axes in the frontal plane and parallel to
the transepicondylar axis in the horizontal plane.
Fig. 4 – The two transepicondylar axes (TEA). The surgical TEA (red line)
defining the posterior condylar angle (PCA) relative to the posterior condy-
lar line (blue line) and the clinical TEA (yellow line) defining the condylar
twist angle (CTA) relative to the posterior condylar line.
800 Primary Total Knee Arthroplasty
Berger et al. (23) in 1993 concurred with Yoshioka
but emphasized the diffi fficulty of locating the “clini-
cal TEA” during surgery. He noted considerable
intra-observer (1.5°) and above all inter-observer
(4°) variation in CTA measurement and described
the “surgical TEA” as easier to locate. He advised it
should be used to adjust femoral component rota-
tion, considering it of interest only in cases where
the CL cannot be used, in particular during revi-
sions. Griffin
ffi et al. (25) in 1998 using measure-
ments taken during surgery, showed that the PCA
varies considerably, with a mean of 3.7° but with
extremes ranging from 0 to 10°. He concluded that
it was difficult
ffi to select a fixed, universal angle rel-
ative to the PCL for all patients, and proposed that
the angle should be adjusted during the procedure
depending on the “surgical TEA” (Fig. 5).
Berger et al. (9) in 1998 introduced CT-scan local-
ization of TEA and emphasized its value for the
rotational alignment in TKA. However, even if the
medial epicondyle can easily be identifi fied in healthy
knees on CT scan (9) or MRI (24), this is not always
possible in arthritic knees because of flattening of
the medial epicondyle.(26, 27, 28) Akagi et al. (15,
26) described three types of epicondyle according
to the visibility of the central sulcus on CT scan:
type I clearly visible sulcus, type II sulcus recogniz-
able with diffi
fficulty, type III sulcus not visible.
The anteroposterior axis (Whiteside's trochlear line)
In 1992, Whiteside and McCarthy (29) described
their technique for unicompartmental knee arthro-
plasty, notably the technique of rotational posi-
tioning of the femoral component. An intra-med-
ullary stem is inserted at the top of the intercondylar
notch. The femoral component is aligned with the line
between this insertion point and the deepest part of
the trochlear groove with the knee in 90° flexion
fl . of 278 mm2 upon the medial epicondyle and 298
These authors called this line the anteroposterior axis
(APA) and showed that it was perpendicular to the
transverse axis of the knee and parallel to the tibial
axis. In 1995, Arima et al. (14) emphasized the inter-
A B
PCA = 3°
Fig. 5 – Great inter-individual variations can be observed in the value of the PCA or CTA. Here the PCA is measured at 3° (A), 5° (B), or −2° (C) (lateral epicon-
dyle = white arrow and medial epicondyle = white circle).
est of this axis in TKA: they showed that APA axis
was perpendicular to the “clinical TEA”, with a mean
internal rotation of 0.6° (mechanical measurement)
or 2.6° (radiographic measurement). Even if marked
individual variations were observed the authors rec-
ommend alignment of the prosthesis with the APA,
arguing that it is more easily identifi
fied at surgery
than the TEA and shows less variability.
Poilvache (30) using intra-op measurements found
a mean angle between the perpendicular to the APA
and the “clinical TEA” of 0.33° ± 2.44, with a gen-
der diff
fference, the APA being in 1.2°± 2.15 internal
rotation in men and in 0.41° ± 2.45 external rota-
tion in women. Akagi et al. (26), using preoperative
CT scan measurements of arthritic knees, showed
that the perpendicular to the APA is nearly always
parallel to the “clinical TEA” (angles of 0.5 ± 1.9,
0.2 ± 1.9 and 0.7 ± 1.8 in varus, normal and valgus
knees respectively).
Techniques for adjusting femoral rotation
Alignment with the transepicondylar axis
Principle: The posterior condylar cutting jig is rotated
in alignment with the TEA and resection is aligned
with this axis. Epicondyles can be located intra-op-
eratively or ideally with a pre-op CT-Scan (31).
Advantages: Ideal positioning from the kinematic
viewpoint as the prosthesis is in alignment with
the flexion/extension axis of the knee.
Disadvantages: (i) The medial epicondyle is diffi fficult
to locate both at surgery (14) and on preoperative
CT scan (28) making this measurement unreliable.
Stöckl et al. (32) confi
firmed recently signifi
ficant intra
and inter-observer variability: localization of epi-
condyles by four surgeons were located in an area
mm2 of the lateral. (ii) Deviation up to 4.6° between
“clinical” and “surgical” TEA has been described in
the literature without consensus about the more
appropriate axis to use (23, 26, 28). (iii) TheTh TEA
C
PCA = 5° PCA= -3°
 Rotation of components in total knee arthroplasty 801

is assimilated to the flexion/extension axis of the
knee by approximation only and so is theoretically
debatable (17, 19, 33). For Churchill, however, the
angle between these two axes is not significant
fi and
the most prominent points of the epicondyles are
close to the optimal flexion axis of the knee (0.2 mm
behind and 0.14 mm below on the medial side and
respectively 0.2 and 0.6 mm on the lateral side). For
Pinskerova, flexion/extension takes place along two
axes, of which the TEA is the best approximation.
Eckhoffff et al. (33) observed among 23 knees that
the mean diff fference between “clinical” TEA and
the flexion–extension axis was 4.6 ± 1.6° (range,
1.8–11.3°), which was signifi ficantly greater than 0°
( = 0.01). He concludes that alignment with TEA
(p
can potentially leads to ligament imbalance in TKA.
Fixed external rotation determined relative to the posterior
condylar line
Principle: The goal is to obtain an alignment of fem-
oral component with TEA. The posterior cut and
the implant are rotated externally relative to the
CL to a predetermined degree. In the literature, the
mean angle between the TEA and the CL has been
found to range from 0 to 6°, and this angle (gener-
ally 3°) is applied to the posterior condylar cutting
jig which is supported by the posterior condyles.
Advantages: This is a simple technique, which does
not have to be adapted to the various situations
encountered at surgery since rotation is deter-
mined by the ancillary system.
Disadvantages: (i) The
Th orientation of the TEA varies
greatly between individuals. It therefore seems dif-
ficult to choose arbitrarily a fixed angle relative to
the CL: an angle of 3° may be too much in certain
cases and inadequate in others (Fig. 5 and Table 1).
Akagi et al. (26) advises using a fixed
fi external rota-
tion angle of 6° in arthritic varus knees or knee
with normal axes, but recommends preoperative
CT scan measurement in markedly valgus knees.
(ii) There is an average difffference of about 3°
between the two TEA, which can be used, and this
may be as much as 4.9° (23). In fact, it is difficult
ffi to
know which line better reflects
fl the functional axis
of the knee.
Rotation adjusted to the flexion space
Principle: After orthogonal tibial cut, posterior
condylar resection is carried out parallel to the
plane of tibial resection, in 90° flflexion, after tens-
ing the collateral ligaments. This
Th technique recre-
ates a symmetric flexion space and thus promotes
soft tissue balance.
Advantages: A simple technique, which gives opti-
mal tibiofemoral stability in flflexion and avoids lat-
eral lift-off
ff in flexion, which can compromise func-
tional result and proprioception.
Disadvantages: (i) Alignment depends on the
state of the collateral ligaments and this may
lead to significant malrotation, notably in valgus
knees with medial laxity. Moreover, any medial
release carried out in extension in the first stage
influences the rotational alignment. Any ill-
judged release can be a cause of rotational mal-
position. This technique thus necessitates a dou-
ble check using fixed anatomic landmarks. (ii) If
there is marked constitutional tibial bone defor-
mity, particularly in varus knees, tibial resection
at 90° produces laxity by excessive resection on
the "healthy" side. This resection laxity, carried
over into flexion, leads to rotational malposition
(Fig. 6).
The tibial axis
Principle: As the mechanical axis of the tibia is per-
pendicular to the “clinical TEA” (20, 22) the principle
is to align posterior condylar resection with the per-
pendicular to the ATm, after distraction in flflexion.

Table 1 – Different values of the posterior condylar angle and condylar twist angle reported in the literature.
Authors Angle TEA/PCL (degrees; ± for SD) Reference
Yoshioka et al. (20) Males: 5.0 ± 1.8; females: 6.0 ± 2.4 CTA
Berger et al. (23) Males: 3.5 ± 1.2; females: 0.3 ± 1.2 PCA
Berger et al. (23) Males: 4.7 ± 3.5; females: 5.2 ± 4.1 CTA
Arima et al. (14) 4.4 ± 2.9 CTA
Poilvache et al. (30) 3.60 ± 2.0 CTA
Matsuda et al. (27) 6.03 ± 3.6 healthy knees; 6.0 ± 2.3varus knees CTA
Griffin
ffi et al. (25) 3.7 ± 2.2 PCA
Griffin
ffi et al. (24) 3.11 ± 1.7 PCA
Akagi et al. (26) 4.2 ± 2.1 PCA
Akagi et al. (26) 4 ± 1.4 varus knees; 8.8 ± 3.2 valgus knees CTA
Yoshino et al. (28) 3.0 ± 1.6 PCA
Yoshino et al.(28) 6.4 ± 1.6 CTA
PCA, posterior condylar angle; CTA, condylar twist angle.
802 Primary Total Knee Arthroplasty

A B
Fig. 6 – Critique of the technique based on the flexion space: if the medial collateral ligament (MCL) is lax, there is a risk that resection will be done in
internal rotation (A). In varus knees due to tibial bone deformity, laxity due to asymmetrical cutting is considerable and there is a risk of excessive external
rotation (B).

Advantages and disadvantages are the same as in
“Rotation adjusted to the flexion
fl space”.
The anteroposterior axis
Principle: The posterior condylar cutting jig is
rotated in alignment with the perpendicular to the
anteroposterior axis of Arima and Whiteside.
Advantages: (i) A simple technique, which can be
adapted to the patient's anatomy and is indepen-
dent of morphological abnormalities, in particular
in valgus knees. (ii) This line is easily identifi
fied at
surgery, and according to its advocates there is less
risk of error than when using the epicondyles as
landmarks. (iii) Technique giving alignment on the
TEA, as these two lines are practically perpendic-
ular in all studies of healthy knees except that of
Feinstein (34).
Disadvantages: (i) The deepest point of the tro-
chlear groove is sometimes difficult to locate in
knees with longstanding patellofemoral arthritis
or trochlear dysplasia (30). (ii) Even if the mean
angle between the APA and the TEA is close to
90°, this varies considerably between individu-
als. Systematic alignment with APA can then
potentially lead to mal-rotations relative to the
TEA.
Rotation adjusted to the bone resection.
When an orthogonal distal femoral cut is done,
the distal resection is asymmetric with a greater
resection on the medial side. For Yercan et al. (35)
and Bonnin et al. (31) the same asymmetry must
be applied to the posterior cut (Fig. 7). The
Th dis-
tal asymmetry is quantifified as the gap measured
between the distal lateral condyle and the distal
cutting guide. Th
This distance can be reported on
the posterior cut either by decreasing the pos-
terolateral cut of the same value (35), either by

Fig. 7 – Technique based on the “equivalent resection in flexion and extension”. In extension, the cutting guide is adjusted for an orthogonal cut. The cutting
guide is at the level of the medial distal condyle but is not in contact with the lateral condyle (A = anterior view, B = lateral view). The distance is measured
(white arrow). The same distance is applied with a metal block between posterior lateral condyle and posterior cutting guide (C). With this technique, exter-
nal rotation is applied exclusively through a decrease of lateral resection (see Fig. 8).

applying rotation using a statistical correspon-
dence (31).
Does computer assisted Surgery (CAS) solve the difficulties?
ffi
Using CAS, rotation of the femoral component can
be adjusted via an intra-operative localization of
the TEA, the APA, or both (32, 36, 37). It can be
also based on the balanced flexion space technique.
None of these techniques are specific of CAS and the limitations are
identical than with “conventional” surgery.
Yau, evaluating a non-image based CAS system
observed means errors of 8.8 mm in the localization
of the lateral epicondyle and 12 mm for the medial
epicondyle (36). Stöckl et al. (32) and Chauhan et al.
(37) reported better rotational alignment (in respect
with the TEA) but in their studies, comparison was
conducted between a fixed
fi 3° external rotation for
conventional surgery and a software calculation
based on TEA and APA for the CAS technique.
Rotation and level of resection
When the appropriate angle of rotation is deter-
mined, the amount of rotation can be obtained
either by decreasing the resection of the lateral
condyle, either by increasing the resection on the
medial condyle or both. In a valgus knee with a sig-
nificant
fi hypoplasia of the lateral condyle and/or a
medial laxity, the second technique increases the
risk of medial instability. The
Th first one is then prob-
ably more adapted. In a varus knee with a tight
medial compartment, the second technique is pre-
ferred (Fig. 8). It is then fundamental to know pre-
cisely how does the cutting-guides apply rotation.
Comparative studies and summing-up
Few studies have compared the precision and the
results of these various techniques.
Fig. 8 – Illustration of the different ways to apply external rotation to the
femoral component: In A, no external rotation is applied and the posterior
cut is symmetric on both condyles (gray zone = resected bone). In B, C and
D, the cut is parallel to the transepicondylar axis with an equivalent amount
of external rotation. In B, it is an extra-resection on the medial condyle,
combined with a decreased resection on the lateral side. In C, rotation is
applied exclusively through an extra resection of the medial condyle and in
D purely through a decrease of the resection on the lateral condyle. Conse-
quences on stability in flexion are not equivalent in these three situations
(see text).
Rotation of components in total knee arthroplasty 803
Olcott and Scott (38) compared four methods and
obtained better soft tissue balance by using the
transepicondylar axis as a landmark during sur-
gery. Stiehl and Cherveny (22), comparing two
techniques, obtained better alignment with the
TEA using the method based on the tibial axis.
Fehring (39) found that techniques based on the
fixed bony landmarks resulted in a trapezoidal
space in 44% of cases. He therefore recommended
that resection should be adapted to the fl flexion
space. Katz et al. (40) in an in vitro study of non-
arthritic knees emphasized the lack of precision in
intra-operative identification
fi of the TEA.
At the present time, there seems to be no perfect
technique for adjusting femoral component rota-
tion. Techniques using fixed
fi bone landmarks raise
the problem of recognition during surgery. Sys-
tematically adjusting rotation according to preop-
erative CT measurements raises the questions (i)
of the cost of the investigation, (ii) of the choice of
best axis and even more (iii) of the real kinematic
value of the TEA. It appears important to be always
able to use several landmark techniques in difficult
ffi
cases and not to be restricted to one single system.
Preoperative CT scan in at-risk cases should pre-
vent certain malpositions.
Rotation of tibial component
Goals
Correct positioning of the tibial component in
TKA requires satisfaction of two criteria simulta-
neously:
First, prosthetic coverage of the resected tibial
surface must be optimized to ensure uniform load
transfer and optimal implant fixation and stability.
(3, 41, 42) Although cortical coverage is not a goal
in TKA, it seems logical to obtain a sufficient
ffi cov-
erage of the resected surface. It is also important,
however, to avoid prosthetic overhang as this can
cause impingement against soft tissue: the medial
collateral ligament medially, and the popliteus
tendon posterolaterally. The
Th risk of posterolateral
impingement is further aggravated because the
proximal tibia is naturally asymmetric – the lateral
plateau generally having a smaller anteroposterior
dimension than the medial plateau.
Second, implant rotation must be meticulously
adjusted to ensure optimal knee kinematics and
patellar tracking (6, 9, 10, 11, 43): malrotation
of the tibial tray with respect to the femoral com-
ponent can lead to premature wear or breakage
of the polyethylene insert, in case of low con-
strained TKA, although mobile bearing implants
804 Primary Total Knee Arthroplasty
could reduce such effffects.(44, 45, 46) It can cause
impingement, stiffffness and walk abnormalities
in case of more constrained TKA. Rotation of the
tibial component therefore depends partly on the
orientation of the femoral component.
Internal malrotation of the tibial component is
a cause of patellar pain and instability. Excessive
external rotation can also be a source of patellar
maltracking (47)
Landmarks and techniques
Several landmarks can be used but it is important to keep in mind
that, even if one of them is routinely used, surgeons must often use
the others to check the final positioning.
Th
There is little or no consensus in the literature
about the ideal rotational alignment of the tibial
component in TKA (Table II):
– The Posterior Tibial Margin (PTM) is a widely
used reference axis for alignment of the tibial
component (1, 2, 4, 6). The baseplate is aligned
with the most posterior points of each tibial
plateau, after resection of the posterior osteo-
phytes. This technique is easy but it becomes
diffi
fficult in the presence of great ossifi
fications on
the posterior tibial surface. Rigorous resection
of ossifi
fications must be done. The validity of the
PTM is also controversial because it is internally
rotated relative to the TEA and the ATT axis (20,
48, 49, 50).
– Aligning the tibial tray parallel to the Trans Epi-
condylar Axis (TEA) is a logical choice if the femo-
ral component is already aligned to this axis. ThThis
can be achieved intra-operatively by aligning the
trial tibial tray with the Akagi axis. Based on a
CT scan study, this author described in 2004 a
new anteroposterior axis (48), which is the line
connecting the midposterior cruciate ligament
attachment to the medial border of the patellar
tendon, just before the level of its attachment on
the tibial tubercule. This axis is perpendicular to
the femoral TEA and then can be used as a land-
mark. It is important to note, however that the
reliability of preoperative CT projections of the
TEA onto the tibial plateau is uncertain because:
(1) external rotation of the tibia relative to the
femur is increased in athritic knees and (2) CT
scans are taken on non-weight bearing knees
(52). Moreover in case of advanced stage osteoar-
thritis, with severe coronal deformity and/or loss
of extension the reliability of this technique is
controversial. Aglietti, evaluating the accuracy of
the Akagi line on 100 pre-op CT scans, observed
that the mean angle between Akagi axis and the
perpendicular to TEA was 0.1 ± 3.3 in men and
0.0 ± 3.9 in women. However, he reported also
that the absolute value of this angle was greater
than 2° in 52% of the patients (51).
– Numerous authors prefer to align the tibial com-
ponent to the Anterior Tibial Tuberosity (ATT)
axis, notably referring to the medial margin of
the ATT (3), to its medial ⅓ (3, 48), or its cen-
ter (52). Thus, Barrack et al. (52) compared two
groups of TKA patients: a group with residual
anterior knee pain and a group without residual
pain. He observed that in the group with no pain,
the tibial component was aligned with the cen-
ter of ATT, whereas in the group suff ffering from
anterior pain the tibial component was rotated
internally by 6.2° relative to the ATT. This study
suggests that an alignment with the center of
the ATT could be benefi ficial for patellar track-
ing. However, systematic alignment of the tibial
component to the ATT center could induce error
in cases of patellofemoral dysplasia where its
position could be too lateral. Such alignment in
patellofemoral dysplasia patients allows patellar
realignment but can induce a mismatch relative
to the femoral component. Eckhoff ff et al. (10) and
Siston et al. (53) reported that alignment with
the tibial tubercule leads to more variabilities
than with other landmarks.
– In the “Self-adjusting”
g technique, the knee is mobi-
lized in flexion–extension after implantation of
the trial components with a “fl floating” insert on
the tibia. The insert aligns automatically with the
femoral component and the position is repro-
duced for the final implant. Huddleston et al. (54)
reported that using the self-adjusting technique,
the tibial plate aligns itself approximately 5.2 ±
5.0° externally relative to the medial margin of
the ATT. This corresponds to the junction of the
medial and middle third of the tibial tubercule.
However, a wide range of values was observed
from 10° internal rotation to 15° external rota-
tion and the author emphasize that in case of
systematic alignment to the tibial tubercule, 5%
of the patients may have a severe malrotation.
Ikeuchi et al. (55) observed also wide variations
in rotational alignment while using the self-
adjusting technique, with a range from 10 mm
medial to 9 mm lateral with respect to the medial
border of the ATT and recommend using fi fixed
landmarks rather than the self-adjusting tech-
nique.
– The Midsulcus line, described by Dalury in 2001, is
the line drawn 1 mm medial to the medial border
of the ATT and going through the midsulcus of
the tibial tibial spines (56). The
Th author obtained
with this technique the same positioning as with
the “self-adjustment” technique.
– Other authors recommended rotation relative to
distal reference axes of the foot or ankle (10, 48,
53), generally, the axis of the second metatarsal.
 Rotation of components in total knee arthroplasty 805

Table 2 – Different techniques for adjustment tibial rotation in TKA.

Landmark or technique
Tibial Tuberosity: medial border
or medial 1/3
Tibial Tuberosity: center
Posterior Tibial Margin
Transcondylar line of the tibia
Midsulcus of tibial spine
Malleolar axis or 2nd metatarsus
Akagi line
Trans Epicondylar Axis
Self adjustment
Disadvantages Advantages
Variability Easy to locate
Classic technique
Variability Easy to locate
Risk of external malrotation Good patellar tracking
Sizing diffi
fficulties due to tibial plateau asymetry
Diffi
fficult if osteophytes, severe bone loss or metaphyseal deformities Classic landmark
Risk of internal malrotation
Intra-operative localization difficult
ffi Good adaptation with tibia anatomy
Subjective definition
Variabilities due to the fact that antre landmark is the tibial tubercle Antre landmark easy to locate
Mid point of tibial spines sometimes difficult
ffi to locate in severe OA
Unreliable if extra-articular deformities or foot and ankle deformities Easy landmark
Prevents severe malrotations
Variations (Malrotation >2° in 50%) Easy
Accuracy of projection of TEA debatable Reliable
Needs a preop CT scan Adjusted for each patient
Accuracy of projection of TEA debatable
Prerequisite: good alignment of the femur Easy
Malrotation if femur malrotated Adapted to each patient
Necessity of adapted instrumentation

– The transverse axis of the tibia is the line joining
the most medial point of the medial plateau and
the most lateral point of the lateral plateau for
Siston et al. (53). Eckhoff
ff et al. (10) defines
fi this
line as “the imaginary bisector of the tibial pla-
teau to provide maximum coverage of the pla-
teau”. This technique has been considered by Sis-
ton and Yoshioka as the reference axis.
The use of mobile bearing tibial plates theoreti-
cally allows decoupling of bone coverage and rota-
tional alignment. Therefore,
Th if the metallic base
plate is aligned to the PTM to obtain optimum cov-
erage, the polyethylene liner can align automati-
cally to the position of the femoral component.
This ability of mobile bearing TKA to compensate
for tibial malrotation is shown to reduce femoral
stresses (46), but is not proven for prevention
of patellar tilt or subluxation (57, 58). ThThen, the
use of a mobile-bearing TKA does not authorize
to accept malrotation of the metallic base-plate.
Siston et al. (53) compared rotational alignment
of the tibia obtained with traditional techniques
and with navigation tools. He observed no ben-
efi
fice with navigation.
References
1. Hungerford QS, Kenna RV (1983) Preliminary experience
with a total knee prosthesis with porous coating used
without cement. Clin Orthop 176:95–107
2. Hungerford DS, Krackow KA (1985) Total joint arthro-
plasty of the knee. Clin Orthop 192:23–33
3. Insall JN (1984) Total knee replacement. In: Insall JN (ed)
Surgery of the knee. Churchill Livingstone, New York, pp
587–695
4. Greenberg RL, Kenna RV, Hungerford DS, Krackow KA
(1984) Instrumentation for total knee arthroplasty. In:
Hungerford DS, Krackow KA, Kenna RV (eds) Total knee
arthroplasty: a comprehensive approach. Williams and
Wilkins, Baltimore, pp 35–70
5. Moreland FR, Bassett LW, Hanker GJ (1987) Radiographic
analysis of the axial alignment of the lower extremity. J
Bone Joint Surg Am 69:745–749
6. Moreland FR (1988) Mechanism of failure in total knee
arthroplasty. Clin Orthop 226:49–64
7. Whiteside LA, Saeki K, Mihalko WM (2000) Functional med-
ical ligament balancing in total knee arthroplasty 380:45–57
8. Anouchi YS, Whiteside LA, Kaiser AD, Milliano MT (1993)
The eff ffects of axial rotational alignment of the femoral
component on knee stability and patellar tracking in total
knee arthroplasty demonstrated on autopsy specimens.
Clin Orthop 287:170–177
9. Berger RA, Crossett LS, Jacobs JJ, Rubash HE (1998) Mal-
rotation causing patellofemoral complications after total
knee arthroplasty. Clin Orthop 356:144–153
10. Eckhoff ff DG, Metzger RG, Vandewalle MV (1995) Malrota-
tion associated with implant alignment technique in total
knee arthroplasty. Clin Orthop 321:28–31
11. Figgie HE, Goldberg VM, Figgie MP, et al. (1989) TheTh eff
ffect
of alignment of the implant on fractures of the patella
after condylar total knee arthroplasty. J Bone Joint Surg
Am 71:1031–1039
12. Rhoads DD, Noble PC, Reuben JD, et al. (1990) The Th eff
ffect
of femoral component position on patellar tracking after
total knee arthroplasty. Clin Orthop 260:43–41
13. Whiteside LA, Arima J (1995) The anteroposterior axis for
femoral rotational alignment in valgus total knee arthro-
plasty. Clin Orthop 321:168–172
14. Arima J, Whiteside LA, McCarthy D, White SE (1995)
Femoral rotational alignment based on the antero-pos-
terior axis, in total knee arthroplasty in a valgus knee. A
technical note. J Bone Joint Surg Am 77:1331–1334
806 Primary Total Knee Arthroplasty
15. Akagi M, Matsusue Y, Mata T, et al. (1999) Effect
ff of rota-
tional alignment on patellar tracking in total knee arthop-
lasty. Clin Orthop 366:155–163
16. Hollister AM, Jatana S, Singh AK, et al. (1993) The
Th axes of
rotation of the knee. Clin Orthop 290:259–268
17. Churchill DL, Incavo SJ, Johnson CC, Beynnon BD (1998)
The transepicondylar axis approximates the optimal flex-
ion axis of the knee. Clin Orthop 356:111–118
18. Iwaki H, Pinskerova V, Freeman MA (2000) Tibiofemoral
movement 1: the shapes and relative movements of the
femur and tibia in the unloaded cadaver knee. J Bone
Joint Surg Br 82:1189–1195
19. Pinskerova V, Iwaki H, Freeman MAR (2001) The shapes
and relative movements of the femur and tibia in the
unloaded cadaveric knee: a study using MRI as an ana-
tomic tool. In: Insall JN, Scott WN (eds) Surgery of the
knee, 3rd edn. Churchill Livingstone, Philadelphia, pp
255–283
20. Yoshioka Y, Siu D, Cooke TDV (1987) The anatomy and
functional axes of the femur. J Bone Joint Surg Am
69:873–880
21. Stiehl JB, Abbott BD (1995) Morphology of the transepi-
condylar axis and its application in primary and revision
total knee arthroplasty. J Arthroplasty 10:785–789
22. Stiehl JB, Cherveny PM (1996) Femoral rotational align-
ment using the tibial shaft axis in total knee arthroplasty.
Clin Orthop 331:47–55
23. Berger RA, Rubash HE, Seel MJ, et al. (1993) Determin-
ing the rotational alignment of the femoral component
in total knee arthroplasty using the epicondylar axis. Clin
Orthop 286:40–47
24. Griffi
ffin FM, Math K, Scuderi GR, et al. (2000) Anatomy of
the epicondyles of the distal femur. MRI analysis of nor-
mal knees. J Arthroplasty 15:354–359
25. Griffi
ffin FM, Insall JN, Scuderi GR (1998) The posterior
condylar angle in osteoarthritic knees. J Arthroplasty
13:812–815
26. Akagi M, Yamashita E, Nakagawa T, et al. (2001) Relation-
ship between frontal knee alignment and reference axes in
the distal femur. Clin Orthop 388:147–156
27. Matsuda S, Matsuda H, Miyagi T, et al. (1998) Femoral
condyle geometry in the normal and varus knee. Clin
Orthop 349:183–188
28. Yoshino N, Takai S, Ohtsuki Y, Hirasawa Y (2001) Com-
puted tomography measurement of the surgical and clini-
cal transepicondylar axis of the distal femur in osteoar-
thritic knees. J Arthroplasty 16(4):493–497
29. Whiteside LA, McCarthy D (1992) Laboratory evaluation
of alignment and kinematics in a unicompartmental knee
arthroplasty inserted with intramedullary instrumenta-
tion. Clin Orthop 274:238–247
30. Poilvache PL, Insall JN, Scuderi GR, Font-Rodriguez DE
(1996) Rotational landmarks and sizing of the distal femur
in total knee arthroplasty. Clin Orthop 331:35–46
31. Bonnin M, Neyret P, Carillon Y, Chambat P (2006) Rota-
tion fémoral adaptée à la morphologie fémorale dans la
prothèse total du genou. In La prothèse du genou. Sau-
ramps Medical, Montpellier, France, pp 13–22, ISBN:
2-84023-479-3
32. Stöckl B, Nogler M, Rosiek R, et al. (2004) Navigation
improves accuracy of rotational alignment in total knee
arthroplasty. Clin Orthop Relat Res 426:180–186
33. Eckhoff ff D, Bach JM, Spitzer VM, et al. (2005) Three-
Th
dimensional mechanics, kinematics, and morphology of
the knee viewed in virtual reality. J Bone Joint Surg Am
87(Suppl 2): 71–80
34. Feinstein WK, Noble PC, Kamaric E Tullos HS (1996)
Anatomic alignement of the patellar groove. Clin Orthop
331:64-73
35. Yercan HS, Ait Si Selmi T, Sugun TS, Neyret PH (2005)
Tibiofemoral instability in primary total knee replace-
ment: a review, part 1: basic principles and classification.
fi
Knee 12:257–266
36. Yau WP, Leung A, Liu KG, et al. (2007) Interobserver and
intra-observer errors in obtaining visually selected ana-
tomical landmarks during registration process in non-
image-based navigation-assisted total knee arthroplasty.
J Arthroplasty 22(8):1150–1161
37. Chauhan SK, Scott RG, Breidahl W, Beaver RJ (2004) Com-
puter-assisted knee arthroplasty versus a conventional jig-
based technique. A randomised, prospective trial. J Bone
Joint Surg Br 86(3):372–377
38. Olcott CW, Scott RD (1999) Femoral component rotation
during total knee arthroplasty. Clin Orthop 367:39–42
39. Fehring TK (2000) Rotational malalignment of the femo-
ral component in total knee arthroplasty. Clin Orthop
380:72–79
40. Katz MA, Beck TD, Silber JS, et al. (2001) Determining
femoral rotational alignment in total knee arthroplasty. J
Arthroplasty 16:301–305
41. Incavo, SJ, Ronchetti, PJ, Howe, JG, Tranowski, JP (1994)
Tibial plateau coverage in total knee arthroplasty. Clin
Orthop Relat Res 299:81–85
42. Lemaire P, Pioletti DP, Meyer FM, et al. (1997) Tibial com-
ponent positioning in total knee arthroplasty: bone cover-
age and extensor apparatus alignment. Knee Surg Sports
Traumatol Arthrosc 5(4):251–257
43. Eckhoff ff DG, Piatt BE, Gnadinger CA, Blaschke RC (1995)
Assessing rotational alignment in total knee arthroplasty.
Clin Orthop 318:176–181
44. Wasielewski RC, Galante JO, Leighty RM, et al. (1994)
Wear patterns on retrieved polyethylene tibial inserts
and their relationship to technical considerations dur-
ing total knee arthroplasty. Clin Orthop Relat Res
299:31–43
45. Lewis P, Rorabeck CH, Bourne RB, Devane P (1994) Pos-
teromedial tibial polyethylene failure in total knee replace-
ments. Clin Orthop Relat Res 299:11–17
46. Matsuda S, White SE, Williams II VG, et al. (1998) Contact
stress analysis in meniscal bearing total knee arthroplasty.
J Arthroplasty 13(6):699–706
47. Nagamine R, Whiteside LA, White SE, et al. (1994) Patel-
lar tracking after total knee arthroplasty: the effectff of
tibial tray malrotation and articular surface confi
figuration.
Clin Orthop 304:262–271
48. Akagi M, Oh M, Nonaka T, et al. (2004) An anteroposterior
axis of the tibia for total knee arthroplasty. Clin Orthop
Relat Res Mar(420):213–219
49. Matsui, Y, Kadoya, Y, Uehara, K, et al. (2005) Rotational
deformity in varus osteoarthritis of the knee: analy-
sis with computed tomography. Clin Orthop Relat Res
Apr(433):147–151
50. Bonnin MP, Saff ffarini M, Mercier PE et al. (2010) Is the
Anterior Tibial Tuberosity a Reliable Rotational Land-
mark for the Tibial Component in Total Knee Arthro-
plasy? J Arthroplasty. 2010 May 7. [Epub ahead of print]
doi:10.1016/j.arth.2010.03.015
51. Aglietti P, Sensi L, Cuomo P, Ciardullo A (2008) Rotational
position of femoral and tibial components in TKA using
the femoral transepicondylar axis. Clin Orthop Relat Res
466:2751–2755
52. Barrack RL, Schrader T, Bertot AJ, et al. (2001) Compo-
nent rotation and anterior knee pain after total knee
arthroplasty. Clin Orthop Relat Res 392:46–55
53. Siston RA, Goodman SB, Patel JJ, et al. (2006) The high
variability of tibial rotational alignment in total knee
arthroplasty. Clin Orthop Relat Res 452:65–69
54. Huddleston JI, Scott RD, Wimberley DW (2005) Determi-
nation of neutral tibial rotational alignment in rotating
platform TKA. Clin Orthop Relat Res 440:101–106
55. Ikeuchi M, Yamanaka N, Okanoue Y, et al. (2007) Deter-
mining the rotational alignment of the tibial component

at total knee replacement. A comparison of two tech-
niques. J Bone Joint Surg Br 89(1):45–49
56. Dalury DF (2001) Observations of the proximal tibia in total
knee arthroplasty. Clin Orthop Relat Res 389:150–155
57. Aglietti P, Baldini A, Buzzi R, et al. (2005) Comparison
of mobile-bearing and fi fixed-bearing total knee arthro-
Rotation of components in total knee arthroplasty 807
plasty: a prospective randomized study. J Arthroplasty
20(2):145–153
58. Pagnano MW, Trousdale RT, Stuart MJ, et al. (2004)
Rotating platform knees did not improve patellar track-
ing: a prospective, randomized study of 240 primary total
knee arthroplasties. Clin Orthop Relat Res 428:221–227

S. Parratte,
A. Ashour,
Improving mobility
Y. Hémon,
J.-M. Aubaniac,
J.-N. Argenson
Background
A
chieving a complete pain relief and improv-
ing mobility are the two main goals after
total knee arthroplasty (TKA) first
fi to restore
patient function and second to ensure patient
satisfaction. Historically surgical techniques and
instrumentation in TKA are based on the pioneer-
ing innovation and thoughts of John Insall (1). Ini-
tially Insall believed that restoration of “normal”
anatomy was not often achieved and perhaps not
important to success (1). Evidence for this asser-
tion is that some of the early models of knee pros-
theses were often improperly implanted (1). If
many of these models failed, a surprising number
of these implants worked well with a very good
survivorship. As clinical experience increased,
surgical techniques improved and as well as TKA
designs which became more sophisticated, more
durable and more “natural” (1–4). Thus
Th in addition
to painless, high level of knee motion and high
level of function are expected (1–6). Some indi-
viduals require special consideration and the range
of motion is not only subject to inter-individual
variations and variations with age but also varies
with regards to cultural and racial factors in dif-
ferent geographic areas (7). ThThus the defi
finition of
high range of knee flexion may vary in the world:
more than 120° in Western countries, but more
than 150° in the rest of the world (7).
Mobility after TKA and particularly range of knee
flexion is related to three parameters: the patient
himself, the implant and last but not least, the
surgical management (2, 8–11). Th The patient char-
acteristics are determinant to consider motion
after TKA and factors such as obesity or osteoar-
thritis of the ipsilateral hip may limit motion after
TKA (2, 8–11). The implant characteristics are also
important (3, 4, 11, 12). The implant should safely
allow deep flexion without increasing the load on
the posterior aspect of the tibial insert or without
increasing the risk of dislocation in case of poster-
ostabilized implants (2, 8–11). The surgical tech-
nique should also be appropriate to achieve high
range of knee motion (2, 8–11). Finally the post-
operative management should include a perfect
Chapter 76
pain management to allow a pain-free early reha-
bilitation (13, 14). This step-by-step approach is a
multi-modal team work and this “team” includes
the patient, the surgeon, the anesthesiologist, and
the physiotherapist. If a proper surgical technique
remains the central part of the process to improve
range of knee motion, surgeons should also con-
sider with attention the pre-operative and the
post-operative steps of this multi-disciplinary con-
temporary approach in TKA.
We will provide guidelines for each of these steps,
particularly the surgical one and then briefl fly
report the results of our clinical experience using
this contemporary approach to achieve high range
of knee motion in TKA with a specifi fically designed
implant.
Pre-operative analysis
The first step of this approach remains a complete
pre-operative analysis including a careful clinical
and radiological exam of the patient lower extrem-
ities as well as an evaluation of the patient motiva-
tion toward the procedure. The goal of this analysis
is to identify all the factors, which could potentially
limit the post-operative range of knee motion.
The etiology of the knee arthritis should be iden-
tifi
fied and in case of rheumatoid arthritis or sys-
temic disease, the medical management of this
pathology should be appropriate. Patient history
and previous surgery on the lower extremities
should be known and their potential impact on
the post-operative range of motion evaluated.
The patient body mass index and the thigh cir-
cumference should be registered as the fat tissue
at the posterior aspect of the thigh may limit the
deep flexion (Fig. 1) (11). Flexion and extension
strength of the knee have to be evaluated. Pain or
deformation of the other joints including the feet
should be searched with attention as any associ-
ated trouble same limb may be a potential extrin-
sic factor of knee stiff ffness. All potential factors
of sepsis should be eliminated and the oro-dental
state should be perfect. Urinary and nasal sample
810 Primary Total Knee Arthroplasty

Fig. 2 – To reach deep flexion, the implant should allow an internal rotation
Fig. 1 – Fluoroscopic view of the flexion limitation related to the fat tissue of the tibia below the femur.
at the posterior aspect of the thigh.

should be systematically performed pre-opera-
tively to ensure the absence of contamination.
The mechanical axis of the lower limb should be
evaluated clinically as well as the stability of the
knee and the reducibility of the deformation in
case of marked varus or valgus. After an exhaus-
tive clinical exam, a complete radiological exam
is mandatory, including ML and AP view of the
knee, a full-limb radiograph, varus and valgus
stress, and sky-views radiography. Bony defor-
mations, osteophytes, the height of the patella,
and the alignment of the lower limb should be
carefully analyzed. This pre-operative analysis
should also include an evaluation of the patient
motivation toward the procedure. The patient
education concerning the post-operative rehabili-
tation program is an important step and the sur-
geon should ensure the patient adhesion toward
the procedure but also toward the rehabilitation
program.
mal knee kinematics and to improve range of knee
flexion, first to restore patient function and sec-
ond to minimize wear and improve survivorship
(2, 8). In a previous in vivo 3D-fl
fluorocopic study,
we demonstrated that this type of design can rep-
licate healthy knee motion and restore normal
knee kinematics (8). In another study, we com-
pared the in vivo kinematics of fixed and mobile
bearing of the same design, showing greater pos-
terior femoral rollback and greater weigh-bearing
flexion for mobile-bearing implants (17). Thus
surgeons aiming to improve range of knee motion
should consider these parameters when choosing
an implant.

Implant choice
Achieving deep knee fl flexion with standard TKA
may be limited and unsafe as reported in previ-
ous studies (2, 15, 16). To reach deep flexion,
fl the
implant should allow an internal rotation of the
tibia below the femur (Fig. 2) (2, 8, 11). To limit
potential drawbacks of deep flexion,
fl such as exces-
sive load on the tibial insert or a TKA dislocation
in case of posterostabilized implants, high-flex-fl
ion posterostabilized mobile bearing TKA have
been design (2, 8, 9). Specifi fic changes such as
an increased posterior offset
ff of the femoral con-
dyle, an anterior cut in the tibial insert to avoid
patellar tendon impingement and a greater size Fig. 3 – High-flexion posterostabilized mobile bearing TKA have an
of the posterostabilized cam to increase the jump increased posterior offset of the femoral condyle, an anterior cut in the
distance have been performed (2, 8) (Fig. 3). Th The tibial insert to avoid patellar tendon impingement and a greater size of the
goals of these implants are to provide more nor- posterostabilized cam to increase the jump distance and avoid dislocation.

Surgical key-points
Various surgical technique factors can lead to insuf-
ficient range of motion after TKA and classically
include: overstuffi
ffing of the patella, component
malposition or malrotation, flexion/extension gap
mismatch, joint line elevation, component sizing
errors, thigh posterior cruciate ligament in poste-
rior-conservative designs (18–25). These
Th technical
errors likely contribute to stiffness
ff in a subset of
patients and prevention of errors during the surgi-
cal procedure is essential.
Exposure and minimally invasive technique
Minimally invasive surgical (MIS) approaches are
now widely used in TKA (26). Using MIS technique
seems to allow a quicker recovery for the patient
due to less muscular damages and therefore may be
considered as a factor to achieve sooner a satisfying
range of knee motion (26). This
Th basis remains true
only if adequate technique and ancillaries, adapted
to MIS are used to allow a precise implant posi-
tioning through a limited approach (26). Indeed,
the main parameter to achieve high range of knee
motion remains the position of the implants and
the management of the extension and flexion fl
spaces: the so-called “gap balancing” (1, 27).
Gap balancing
During this step, bone cuts are made to implant
the prosthesis. As demonstrated initially by Insall,
when performing the bone cuts to insert the pros-
thesis, the surgeon should aim to create two bal-
anced spaces that the future prosthesis will fill (1,
27). Th
The first space is the extension gap defifined
when the knee is fully extended between the tib-
ial cut and the distal femoral cut (1, 27). The
Th sec-
ond space is the flexion gap defifined with the knee
flexed at 90° between the tibial cut and the poste-
rior femoral cut. The prosthesis should properly fill
the two spaces (1, 27). A space too tight may lead
to limited range of knee motion and a space too
loose may lead to instability after TKA (1, 27).
To properly fill this space, surgeon can control step
by step: the tibial bone cut (including the amount
of bone resection and the tibial slope), the distal
femoral bone cut, the size of the femoral implant,
the anterior and posterior femoral bone cuts, the
femoral implant rotation, and finally the thickness
of the polyethylene tibial insert. Technically, the
surgeon is commonly using the implant-dedicated
ancillaries to guide the cuts (1, 27).
The tibial bone cut can be done first. Using an
extra-medullary guide, the cut is done perpendicu-
Improving mobility 811
lar to the anatomical axis of the tibia. The
Th amount
of bone resection is done according to the cartilage
wear on the most aff ffected compartment. A cut too
high may tight the space both in fl flexion and in
extension (28). A cut too low on the tibia may lead
to a loose knee and the tibial implant will be fixed
fi
in a weaker bone (28). Tibial slope is also consid-
ered as a factor infl
fluencing post-operative flexion.
A slope lower than 0° may tight the flexion
fl space
and limits the post-operative flexion (11). A down-
slope around 6° leads to an average increase of 10°
of flexion (11). Therefore it is recommended to
perform a tibial cut with around 7° of tibial slope
(11). Contemporary ancillaries include this tibial
slope. Care must be taken to not exceed 7° which
may lead to anterior instability and cause fl flexion
instability (28).
The distal femoral cut is then considered. The goal
when performing the distal femoral cut is to cut
the amount of bone corresponding at the space
requested by the distal flange of the femoral
implant (1). After this cut, the gap in extension
is tested to verify the ability to fully extend the
leg on the tight. In case of pre-operative lack of
extension a greater amount of bone can be cut to
achieve full extension (1). The following step is to
determine the size of the femoral implant. Choos-
ing an oversized femoral implant may limit the
range of knee flexion and extension (1). Using an
anterior referencing system, the surgeon is also
going to check the anteroposterior placement of
the implant when performing the anterior and
the posterior cut (28). Positioning the femoral
implant too posterior will thigh the fl flexion space
and may create a notch on the anterior cortical
of the femur (29). During this step, the rotation
of the femoral implant should also be controlled
and an excess of external rotation may tight the
implant externally in flexion (29). Several refer-
ential can be used: the posterior condyles (3° of
external rotation relatively to the posterior con-
dyle), the whiteside line or the trans-epicondylar
axis (1). Once all the cut have been performed,
the range of motion can be tested using trial
implant and the adequate size of the tibial poly-
ethylene insert can be determined to obtain a
satisfying range of motion and a proper stability
of the knee (1).
Posterior space management: posterior recut and
osteophytes cleaning
Once, the tibial and femoral cuts are performed,
it is important to do a posterior recut on the pos-
terior aspect of the femoral condyles (4, 11). ThThis
will limit any bony impingement during very high
flexion against the tibial insert (Fig. 4) (4, 11). A
812 Primary Total Knee Arthroplasty

resection of all the posterior osteophytes and all Patellar tracking

soft-tissue remnants in the backside of the knee,
such as meniscal remnants or synovial tissue,
should also be performed during this step of the
procedure (Fig. 5) (4, 11). During this step, using
a lamina spreader is very convenient to open alter-
natively the medial aspect of the knee and then the
lateral one.
An improper patellar course may also limit the
range of knee motion. TheTh rotation of the femo-
ral implant is the main parameter and an excessive
internal rotation will cause lateral patellar tilt and
subluxation (4, 11). When a patellar resurfacing is
performed, the patellar cut should be symmetric
on the lateral and the medial aspect of the patella
and the final thickness of the patella should not
exceed the thickness of the original patella (4, 11).
Over-stuffi
ffing the patella will limit the knee flexion
(4, 11).

Post-operative management
To improve patient recovery after TKA, mini-
mally invasive approaches have been evaluated
and become more widely used in TKA. During
the same time, contemporary anesthesia proto-
cols have been developed to improve post-oper-
ative pain management (30). These
Th protocols are
multi-modal and include: low-dose opioids, local
Fig. 4 – Once, the tibial and femoral cuts are performed, it is important
anesthetic infi
filtration, peripheral nerve blocks,
to do a posterior recut on the posterior aspect of the femoral condyle. This
will limit any bony impingement during very high flexion against the tibial non-steroidal anti-infl
flammatory drugs, and cryo-
insert. therapy (30–32). A contemporary approach is to

A B

Fig. 5 – A resection of all the posterior osteophytes (B) and all soft-tissue rem-
nants in the backside of the knee, such as meniscal remnants or synovial tissue,
should also be performed during this step of the procedure. During this step,
using a lamina spreader is very convenient to open alternatively the medial
aspect of the knee (A) and then the lateral one (C).

use pre-operatively, peri-operatively, and post-
operatively various analgesic agents according to a
very precise schedule. ThThis concept is based on two
fundamental principal: first the additive or syner-
gistic eff
ffects of diff
fferent analgesics in order to use
smaller doses of each drug to achieve a sufficient
ffi
analgesia and second being pre-emptive. To be pre-
emptive (33) lead to reduce the central sensitiza-
tion that arises from noxious inputs experienced
throughout the entire peri-operative period and
not just from those occurring during the surgical
procedure (33). In practice, pre-emptive analgesia
involves the administration of analgesics prior to
painful stimuli. The goal is to stay ahead of the pain
to limit the total analgesia requirements for the
patients. Pain management problems after surgery
have been recognized as a patient specific fi cause of
stiff
ffness after TKA. Eff ffective pain management
improves patient satisfaction; decreases hospital
stays and allows early rehabilitation for a quicker
regain of range of knee motion. This pain manage-
ment approach associated with early rehabilitation
and careful patient education is a fundamental
point a contemporary approach in TKA (14).
Clinical results
We prospectively followed 516 primary high-flexion
fl
mobile-bearing posterostabilized TKA on 445 con-
secutive patients operated between 2001 and 2005
in the same institution by the same surgeon follow-
ing the previously mentioned pre-operative, peri-
operative, and post-operative protocol to improve
range of knee motion. The same cemented high-
flexion mobile-bearing posterostabilized TKA (LPS
Flex mobile-bearing) was used for all the cases. Th The
clinical evaluation was performed between Janu-
ary 2004 and February 2007 (with a minimum
follow-up of 2 years) by two independent observ-
ers (SP and AA) including the evaluation of patient
range of knee flexion
fl and the classical items to
complete the Knee Society score (34) At the same
time, patients were also asked to fill a specifi
fic survey
including the KOOS, (6, 35) the UCLA score (36, 37)
and specifi
fic questions concerning their recreational
or sportive activities. There were 299 women (67%)
and 146 men (33%) in the series (256 right knees
and 260 left knees). The procedure was bilateral for
70 patients (16%) and unilateral for 375 patients
(84%). The mean age of the patients at the time of
surgery was 71.6 ± 8 years (range, 22–96 years). The Th
mean body mass index of the patients was 28.3 ±
4.6 kg/m2 (range, 16–44 kg/m2). The etiology was
primary osteoarthritis for 474 knees (92%), rheu-
matoid arthritis for 11 knees (2%) and another
cause (post-traumatic, avascular osteonecrosis, sys-
Improving mobility 813
temic disease) for 31 knees (6%). The mean delay
before surgery was 39 ± 30 months. For 387 (75%),
the pre-operative alignment was in varus. In this
group the mean pre-operative alignment was 171.4
± 7º (range, 164–179º). For 129 (25%) knees, the
pre-operative alignment was in valgus. In this group
the mean pre-operative alignment was 188.4 ± 8º
(range, 181–202 º). Concerning the activity level at
the time of surgery, 173 (34%) patients were inac-
tive, 274 (54%) were limited at their activity of
the daily living, 46 (9%) were still engaged in labor
or sportive activities, and the activity level was
unknown for 14 (3%) patients. Some patients were
lost of follow-up or died before the fifinal evaluation,
thus we were able to analyze the objective and sub-
jective data for a total of 412 patients (483 knees).
Comparisons between pre-operative and post-op-
erative Knee Society Knee and Function scores (34)
at the time of the clinical evaluation (mean 3 years;
range, 2–4 years) showed a significant
fi improvement
in function and pain relief after TKA in our series.
Furthermore mean active knee flexion improved
from 117 ± 13º (range, 80–140º) pre-operatively to
128 ± 4º (range, 85–155º) at the time of the clini-
cal evaluation (p
( < 0.0001). The
Th mean KOOS values
at the time of the evaluation were: 82 ± 16 (range,
21–100) for the pain category, 80 ± 15 (range,
27–100) for the symptoms category, 79 ± 20 (range,
21–100) for the ADL category, 62 ± 32 (range,
0–100) for the sport category, and 71 ± 28 (range,
0–100) for the QOL category. The Th results of the
KOOS were signifi ficantly better in the group with a
flexion greater than 125° for all the categories of the
KOOS. In the series, 337 patients (82%) reported
to be involved in a sportive activity at the time of
the evaluation. The mean UCLA score was 6.9 ±1.6.
The delay reported by the patients before return-
ing to their sportive activity was 6 ± 4 months. Th The
more frequently practiced activities were walking or
hiking, gardening, swimming, exercising (including
cardio-training), cycling, and golfi fing. Among the
group of 337 patients involved in sportive activities,
86% reported to be at the same level (47 patients,
14%) or at a better level (243 patients; 72%) than
before surgery and 14% (47 patients) at a lower
level. Among the group of 337 patients involved
in sportive activities, 118 patients (35%) reported
to percept no knee related limitation during their
activities, 168 patients a slight limitation, and
51 patients (14%) a major limitation.
Conclusion
Our approach to improve ROM after TKA includes a
careful pre-operative analysis, an adapted implant
selection, a proper surgical technique and adapted
814 Primary Total Knee Arthroplasty
post-operative pain, and rehabilitation protocol.
During these steps, the surgeon will have to man-
age properly the three parameters which may
infl
fluence post-operative range of knee motion:
the patient himself, the implant, and the surgical
management. Using this approach, we were able
to obtain high range of knee motion, good patient
satisfaction, and a satisfying return to activities of
the daily living and even to the sportive activities.
Improving range of knee motion is challenging but
remains fundamental to fit with patient expecta-
tions toward their knee arthroplasty and obtain
patient satisfaction.
References
1. Vail TP, Lang JE (2006) Surgical techniques and instru-
mentation in total knee arthroplasty. In: Insall BJ, Scott
N, Insall WJ, Scott N, W. s. (eds) Surgery of the knee.
Churchill Livingstone Elsevier: Philadephia PA.
2. Argenson JN, Komistek RD, Mahfouz M, et al. (2004) A
high flexion total knee arthroplasty design replicates
healthy knee motion. Clin Orthop Relat Res 428:174–179
3. Bellemans J, Banks S, Victor J, et al. (2002) Fluoroscopic
analysis of the kinematics of deep fl flexion in total knee
arthroplasty. Inflfluence of posterior condylar off ffset. J
Bone Joint Surg Br 84(1):50–53
4. Victor J, Ries M, Bellemans J, et al. (2007) High-flexion,
fl
motion-guided total knee arthroplasty: who benefits fi the
most? Orthopedics 30(8 Suppl):77–79
5. Lingard EA, Sledge CB, Learmonth ID, Group KO (2006)
Patients expectations regarding total knee arthroplasty:
diff
fferences among the United States, United Kingdom,
and Australia. J Bone Joint Surg Am 88(6):1201–1207
6. Ornetti P, Parratte S, Gossec L, et al. (2008) Cross-cultural
adaptation and validation of the French version of the
Knee injury and Osteoarthritis Outcome Score (KOOS)
in knee osteoarthritis patients. Osteoarthritis Cartilage.
16(4):423–8.
7. Ahlberg A, Moussa M, Al-Nahdi M (1988) On geographi-
cal variations in the normal range of joint motion. Clin
Orthop Relat Res 234:229–231
8. Dennis D, Komistek R, Scuderi G, et al. (2001) In vivo
three-dimensional determination of kinematics for sub-
jects with a normal knee or a unicompartmental or total
knee replacement. J Bone Joint Surg Am 83-A(Suppl 2 Pt
2):104–115
9. Dennis DA, Komistek RD (2005) Kinematics of mobile-
bearing total knee arthroplasty. Instr Course Lect 54:207–
220
10. Dennis DA, Komistek RD, Mahfouz MR, et al. (2005)
Mobile-bearing total knee arthroplasty: do the polyethyl-
ene bearings rotate? Clin Orthop Relat Res 440:88–95
11. Dennis DA, Komistek RD, Scuderi GR, Zingde S (2007)
Factors aff
ffecting flexion after total knee arthroplasty. Clin
Orthop Relat Res 464:53–60
12. Victor J, Bellemans J (2006) Physiologic kinematics as a
concept for better flexion in TKA. Clin Orthop Relat Res
452:53–58
13. Horlocker TT, Hebl JR, Kinney MA, Cabanela ME (2002)
Opioid-free analgesia following total knee arthroplasty –
a multimodal approach using continuous lumbar plexus
(psoas compartment) block, acetaminophen, and ketoro-
lac. Reg Anesth Pain Med 27(1):105–108
14. Horlocker TT, Kopp SL, Pagnano MW, Hebl JR (2006)
Analgesia for total hip and knee arthroplasty: a multi-
modal pathway featuring peripheral nerve block. J Am
Acad Orthop Surg 14(3):126–135
15. Huang HT, Su JY, Wang GJ (2005) The early results of
high-fl
flex total knee arthroplasty: a minimum of 2 years of
follow-up. J Arthroplasty 20(5):674–679
16. Nagura T, Otani T, Suda Y, et al. (2005) Is high fl flexion
following total knee arthroplasty safe?: evaluation of
knee joint loads in the patients during maximal flexion.
fl J
Arthroplasty 20(5):647–651
17. Komistek RD, Argenson JN, Scuderi G, Mahfouz M (2006)
In vivo determination of knee kinematics into deep fl flex-
ion. 72nd Annual Meeting of the AAOS, Chicago
18. Babis GC, Trousdale RT, Pagnano MW, Morrey BF (2001)
Poor outcomes of isolated tibial insert exchange and arthrol-
ysis for the management of stiff ffness following total knee
arthroplasty. J Bone Joint Surg Am 83-A(10):1534–1536
19. Christensen CP, Crawford JJ, Olin MD, Vail TP (2002)
Revision of the stiff ff total knee arthroplasty. J Arthro-
plasty 17(4):409–415
20. De Beer J, Petruccelli D, Gandhi R, Winemaker M (2005)
Primary total knee arthroplasty in patients receiving work-
ers’ compensation benefi fits. Can J Surg 48(2):100–105
21. Haidukewych GJ, Jacofsky DJ, Pagnano MW, Trousdale
RT (2005) Functional results after revision of well-fixed fi
components for stiff ffness after primary total knee arthro-
plasty. J Arthroplasty 20(2):133–138
22. Keating EM, Ritter MA, Harty LD, et al. (2007) Manipula-
tion after total knee arthroplasty. J Bone Joint Surg Am
89(2):282–286
23. Keeney JA, Clohisy JC, Curry M, Maloney WJ (2005)
Revision total knee arthroplasty for restricted motion.
Clin Orthop Relat Res 440:135–140
24. Laskin RS, Beksac B (2004) Stiffness ff after total knee
arthroplasty. J Arthroplasty 19(4 Suppl 1):41–46
25. Mont MA, Seyler TM, Marulanda GA, et al. (2006) Surgi-
cal treatment and customized rehabilitation for stiff ff knee
arthroplasties. Clin Orthop Relat Res 446:193–200
26. Argenson JN, Parratte S, Flecher X (2005) Minimally inva-
sive total knee arthroplasty. Rev Chir Orthop Reparatrice
Appar Mot 91(S8):28–30
27. Insall JN, Binazzi R, Soudry M, Mestriner LA (1985) Total
knee arthroplasty. Clin Orthop Relat Res 192:13–22
28. Parratte S, Pagnano M (2008) Instability after TKA. J
Bone Joint Surg Am 90(1):184–194
29. Scuderi GR (2005) The Th stiffff total knee arthroplasty: cau-
sality and solution. J Arthroplasty 20(4 Suppl 2):23–26
30. Nuelle DG, Mann K (2007) Minimal incision protocols for
anesthesia, pain management, and physical therapy with
standard incisions in hip and knee arthroplasties: the
eff
ffect on early outcomes. J Arthroplasty 22(1):20–25
31. Liu SS, Wu CL (2007) The Th effffect of analgesic technique on
postoperative patient-reported outcomes including anal-
gesia: a systematic review. Anesth Analg 105(3):789–808
32. Pagnano MW, Hebl J, Horlocker T (2006) Assuring a pain-
less total hip arthroplasty: a multimodal approach empha-
sizing peripheral nerve blocks. J Arthroplasty 21(4 Suppl
1):80–84
33. Kissin I (1994) Preemptive analgesia: terminology and
clinical relevance. Anesth Analg 79(4):809–810
34. Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale
of the Knee Society clinical rating system. Clin Orthop
Relat Res 248:13–14
35. Roos EM, Lohmander LS (2003) The Knee injury and
Osteoarthritis Outcome Score (KOOS): from joint injury
to osteoarthritis. Health Qual Life Outcomes 1(1):64
36. Dahm DL, Barnes SA, Harrington JR, Berry DJ (2007)
Patient reported activity after revision total knee arthro-
plasty. J Arthroplasty 22(6 Suppl 2):106–110
37. Dahm DL, Barnes SA, Harrington JR, et al. (2008) Patient
reported activity level following total knee arthroplasty. J
Arthroplasty 23(3):401–7

E. J. Graham,
R. B. Bourne
Medical management before
and after TKA
Introduction
M
edical management of patients having
total knee arthroplasty (TKA) involves a
pre-operative assessment, pre-operative
optimization, and post-operative treatment. The Th
pre-operative assessment is aimed to identify med-
ical problems and determine risk profi file. Investiga-
tions are ordered specifific to the patient and their
medical history. Particular areas for concern are
the cardiac, respiratory, neurological, and urinary
systems. Pharmacotherapy in the peri-operative
period involves stopping or holding some regular
medications and prescribing prophylaxis against
infection and thromboembolism. The Th medical
management is often carried out by other physi-
cians, but it is important for the orthopedic sur-
geon to be aware of, and involved, in the process.
The aim of medical treatment is to reduce mor-
bidity and mortality. Mortality for TKA has been
reported to be 0.2–0.5%. Critical risk factors include
chronic renal impairment, congestive cardiac fail-
ure, chronic airway limitation, and advanced age.
In a study of 22,540 patients, 30 day mortality was
found to be 0.21% (1). Of those who died, 90% had
a history of pre-existing cardiac and/or respiratory
disease.
In the pre-admission clinic, the patient is inter-
viewed by members from the orthopedic, anes-
thetic and internal medicine teams. There is also
the opportunity for nursing, physiotherapy, occu-
pational therapy, and rehabilitation input. Pre-op-
erative tests are carried out. These tests are patient
specifi
fic (2).
A baseline hemoglobin is valuable as patients
undergoing TKA are likely to experience blood
loss. A white cell count is also useful as a base-
line. It is important to assess renal function with
urea, creatinine, and electrolytes on patients with
cardiac disease, hypertension, those on diuretics
and those over 50 years of age. A glucose level is
necessary for obese and diabetic patients. Bleed-
ing studies are indicated for those who have a
bleeding diathesis, chronic liver disease or mal-
nutrition. Electrocardiogram and chest x-ray are
recommended for those aged 50 or more, or with
Chapitre 77
ischemic heart disease, diabetes, hypertension or
respiratory illness.
Pre-operative Assessment:
1. Cardiac
2. Respiratory
3. Urinary
4. Neurological
5. Diabetes
6. Methotrexate
7. Steroids
Cardiac
The American Heart Association produces guide-
lines for peri-operative cardiovascular evaluation
for non-cardiac surgery (3). These
Th provide a frame-
work for considering cardiac risk, in non-cardiac
surgery, for a variety of patients. Th
This pre-operative
evaluation can then be used to give clearance for
surgery, to make recommendations on treatment
of cardiac problems over the peri-operative period
and provide a risk profi file to help make further
treatment decisions.
The history, physical examination, and electrocar-
diogram should focus on identifying potentially
serious cardiac disorders such as prior myocardial
infarction, heart failure, symptomatic arrhyth-
mia, and presence of a pacemaker. Clinical mark-
ers may be stratified
fi into major, intermediate, and
minor. Major markers are unstable coronary syn-
drome such as recent myocardial infarction, severe
angina, uncompensated heart failure, significantfi
arrhythmia, and severe valvular disease. Inter-
mediate factors are mild angina, remote infarct,
compensated failure, and diabetes. Minor factors
are non-specifific electrocardiogram changes, hyper-
tension, and some arrhythmias. Patients with
intermediate or minor markers with good exercise
tolerance can generally undergo intermediate risk
surgery (such as orthopedic) with little likelihood
of peri-operative death or infarction. Conversely
if exercise tolerance is poor, then these patients
should be considered for further testing.
Hypertension should be treated if the systolic pres-
sure is greater than 200, or the diastolic pressure is
816 Primary Total Knee Arthroplasty
greater than 110 mm Hg. Beta-blockers are helpful
in treating hypertension, particularly in high-risk
patients with known ischemic disease, age greater
than 70 years, diabetics, and those with renal fail-
ure or prior stroke. In this group they have been
shown to reduce mortality (4). Symptomatic
stenotic lesions are associated with high risk of
peri-operative heart failure and shock and should
be corrected prior to TKA.
It has been traditional to wait 6 months after
myocardial infarction before elective surgery. In
a study of 38,877 patients (5) it was found wait-
ing 6 months lowered mortality. Operating within
1 month of infarction is considered high risk and
before 6 months is intermediate.
Patients with mechanical valves on warfarin should
stop this 3–5 days prior to surgery and convert to
low molecular weight heparin (LMWH). Th The warfa-
rin can generally be recommenced on the post-op-
erative evening. Patients with non-valvular atrial
fibrillation who have not had an embolic stroke do
not generally need to convert to LMWH and may
simply go offff their warfarin for 3–5 days.
Respiratory
Pulmonary complications are often seen in the
peri-operative period. The common problems
seen are atelectasis, aspiration, pneumonia, and
pulmonary embolism. The best way to evaluate
patients for these problems is a history, physical,
and review of functional capacity. Patients, partic-
ularly those with chronic airway limitation should
not smoke for several weeks prior to surgery. Pre-
existing respiratory conditions should be treated
with bronchodilators and inhaled corticosteroids.
Post-operative physiotherapy focusing on cough-
ing, deep breathing, incentive spirometry, and
early mobilization is useful. Epidural and spinal
anesthesia is recommended for patients with sig-
nifi
ficant pulmonary disease.
Urinary
Peri-operative urinalysis is often recommended
for TKA. Current literature supports proceed-
ing with TKA in patients with bacteruria without
symptoms of urinary irritation or obstruction (6).
These patients are treated with an 8–10 day course
of oral antibiotic. Surgery should be delayed if pre-
operative evaluation reveals symptoms of obstruc-
tion or irritative symptoms. Retention has been
shown to increase the likelihood of urinary infec-
tion. Antibiotic treatment is warranted before
catheterization. Bacteremia occurs in 1–2% of
patients being catheterized and the same organ-
ism has been cultured from the urinary tract and
the prosthetic joint (7).
Neurological
Patients with prior cerebrovascular disease are at
a low risk for peri-operative event (approximately
1%). The degree of asymptomatic carotid artery
stenosis that may be left untreated is controversial
but is approximately 70%. A history of transient
ischemic attack may increase the risk of cerebro-
vascular event for 6 weeks.
Diabetes
Type 2 diabetes with a development of resistance
to insulin tends to occur in older overweight
patients. These patients may come to need TKA.
They require pre-operative assessment to deter-
mine diabetic complications aff ffecting coronary,
cerebral, and peripheral arteries. Oral hypoglyce-
mics may be withheld the day of surgery and blood
glucose is monitored. One regime is to then give
intravenous dextrose and a sliding scale of insulin.
For those on insulin they may have half of their
normal dose. For type 1 diabetics who are depen-
dent on insulin, they are similarly given a reduced
dose of insulin and are put on a sliding scale. Th
The
aim is to keep the blood sugar level stable in the
peri-operative period. It has been shown that
at glucose levels higher than 250 mg/dl there is
impaired phagocyte function.
Methotrexate
Methotrexate is a folate antagonist and a potent
cellular antimetabolite. It has been found by
some to be a predisposing factor for infection
around a prosthetic joint. Carpenter in 1996 stud-
ied patients for elective total joint arthroplasty
TJA (8). In group 1 of 19 patients there were no
infections, in comparison to the second group of
13 patients on methotrexate who had four infec-
tions. Kasdan in 1993 studied 15 patients on
methotrexate for rheumatoid arthritis undergoing
orthopedic surgery and found no post-operative
complications (9).
In a survey by Steuer (10) 200 orthopedic sur-
geons were questioned and almost half were con-
cerned methotrexate may increase peri-operative
infections and 17% recommended stopping the
drug pre-operatively and 12% post-operatively.
The majority of surgeons felt that national
guidelines and a large multi-center trial would be
required.

Perhala (11) looked at the 10 year follow up of
60 patients who underwent TJA and their sub-
sequent infection rate. The diff fference between
those who stopped methotrexate and those who
did not was not found to be signifi ficant. He sug-
gested treatment in the peri-operative period with
weekly low dose methotrexate does not increase
the risk of post-op infection or poor wound healing
in rheumatoid arthritis patients undergoing TJA.
Grennan in 2001 preformed a prospective random-
ized trial of 388 patients with rheumatoid arthri-
tis undergoing orthopedic surgery (12). Group A
ceased methotrexate 2 weeks pre-operatively until
2 weeks post-operatively. Signs of infection or sur-
gical complications were recorded. It was concluded
that methotrexate did not increase the complica-
tion rate in patients with rheumatoid arthritis who
underwent orthopedic surgery.
Steroid supplementation
Patients undergoing TKA have a significantfi stress
response. Patients receiving exogenous glucocorti-
coids such as prednisone may require supplemental
glucocorticoids to meet the physiological demands
of surgery. A study of 30 patients assessed stress
response to surgery by measuring cortisol urine
and blood levels (13). A 17-fold increase in cortisol
to creatinine clearance ratio for those undergoing
TKA was demonstrated.
The rationale for peri-operative steroid supplemen-
Th
tation is based on the suppression of the hypotha-
lamic-pituitary-adrenal axis that occurs with the
chronic use of exogenous steroids. Th This can result
in refractory hypotension and shock if the adre-
nal cortex fails to respond to the stress of surgery.
Friedman studied 19 glucocorticoid dependant
patients and showed no significant
fi increase in cor-
tisol to creatinine clearance ratio (14). Th
The absence
of a peri-operative rise in cortisol production does
not mean that such an increase would not be bene-
ficial. Additional studies, including a large random-
ized trial of patients taking endogenous corticos-
teroids, are warranted.
Peri-operative antibiotics
In the 1970s it was shown that antibiotic prophy-
laxis is more eff
ffective than placebo in preventing
infection in arthroplasty patients. Cephalosporins
are the drug of choice because of broad spectrum
coverage, low toxicity, and good tissue penetrance.
There is controversy regarding the duration of pro-
Th
phylaxis and many surgeons now use 24 h of a first
fi
generation cephalosporin such as cephazolin (15).
Medical management before and after TKA 817
It is recommended to wait at least 5 min between
administration of antibiotic and tourniquet infla-
fl
tion in order to achieve adequate tissue concentra-
tion (16).
Post-operative medical management
It is necessary to perform some post-operative
investigations. The full blood count is needed to
assess blood loss. For patients on warfarin the
coagulation profile
fi is checked. Those on LMWH
need to have platelet count checked. Glucose mon-
itoring is essential for diabetics. Electrolytes and
urea and creatinine are checked in patients with
renal impairment, diabetes and those on diuret-
ics. Part of the post-operative management is the
prophylaxis for deep vein thrombosis (DVT) and
infection.
DVT prophylaxis
Without prophylaxis the prevalence of DVT follow-
ing TKA may be as high as 84%. While this is con-
cerning, the most significant
fi concern is the inci-
dence of fatal pulmonary embolism (PE). Chemical
prophylaxis reduces the venographic prevalence of
DVT. It is unclear whether this results in a reduc-
tion in symptomatic PE. It is assumed that a reduc-
tion in venographic DVT rate will lead to reduction
in fatal PE. The use of thrombo-prophylaxis has
side eff
ffects and cost considerations.
Venous thromboembolic disease is the most sig-
nifi
ficant peri-operative threat to the life of patients
undergoing TKA. The rate of PE may be as high as
15% and the rate of fatal PE 1–3% without pro-
phylaxis. Routine prophylaxis has become the
standard of care since the recommendations of the
National Institute of Health Consensus Confer-
ence in 1986.
Risks of DVT
Virchow described conditions leading to thrombus
formation in 1856. The triad of vessel wall dam-
age, low blood flow, and a hypercoaguable state
are all present during knee replacement surgery:
stasis with decreased blood flow, immobility, and
tourniquet use. Vessel injury occurs during surgery
by compression in deep knee flexion when viewing
the tibial plateau. Similarly retraction and instru-
ment positioning may damage vessel wall cells and
induce formation of a blood clot.
818 Primary Total Knee Arthroplasty
Obesity has been described as a risk factor for
clot formation by some others and as not signifi- fi
cant by others (17). A prior history of thrombo-
embolic disease increases the risk for another
event after surgery approximately eightfold. A
hyper-coaguable state such as activated protein C
resistance, presence of lupus anticoagulant, defi-fi
ciency in protein C, and antithrombin 3 increases
the risk of venous thrombosis. A history of can-
cer increases the risk of thrombosis because of
increased procoagulant activity and reduced
fibrinolytic activity.
Factors such as age, history of ischemic heart
disease, congestive cardiac failure, smoking, and
hypertension are not as clearly linked to a throm-
bo-embolic events. Selective prophylaxis is difficult
ffi
as the at risk group is not clearly defined.
fi
Pathogenesis
Clot formation is by way of a cascade of reac-
tions resulting in conversion of thrombin from
prothrombin which initiates fibrin
fi formation.
Sharrock et al. found an increase in fibrinopep-
tide A, thrombin-anti thrombin 3 and D-Dimer
following surgery (17). Th These factors were not
defi
finitely correlated with DVT formation. It has
been established that activation of the clotting
cascade occurs during instrumentation of the
medullary canal in hip arthroplasty. It would be
logical to expect a similar process to occur in knee
replacement during distal femoral intramedullary
instrumentation.
Diagnosis
DVT is asymptomatic in the majority of cases. TheTh
classical signs of calf pain, swelling and a positive
Homan’s sign are an inaccurate diagnostic method.
Venography is the gold standard, but is invasive.
There can be local problems at the injection site,
hypersensitivity, and reaction and thrombus for-
mation secondary to the contrast agent. Doppler
is less expensive and non-invasive but is operator
dependant and lacks sensitivity (ranging from 40
to 80%). Radioactive imaging may also be used.
Pulmonary embolism (PE) may be diagnosed by
ventilation perfusion scanning. A high probability
scan indicates a PE, but only a minority of patients
with PE have a high probability scan. A low prob-
ability scan will incorrectly rule out a PE in 15%
of cases. The pulmonary angiogram is the best way
to diagnose PE but is not in general use due to its
invasive nature.
Significance
fi
Patients with a calf DVT have an increased risk of
PE (18). It is diffi
fficult to know if reducing the rate of
DVT would result in decreased mortality. DVTs may
vary in size and location. There
Th is diffi fficulty in deter-
mining the significance
fi of a clot, for instance calf
thrombi are twice as common in TKA as THA, but
PE is much less common in TKA. One study looking
at 5024 THA and TKA patients found a PE rate of
0.35% after THA and 0.05% after TKA (18). For-
merly the fatal PE rate without chemo prophylaxis
after TJA was 3–6% (19). A recent meta-analysis of
43,000 patients puts the rate at 0.12%. The Th fall in
PE rate may be due to improved surgical technique,
anesthesia, and accelerated rehabilitation.
Warfarin
Warfarin is the most common chemoprophylaxis
agent and has been used for the last two decades.
More than 50% of surgeons polled used it as their
first choice for prevention of thrombo-embolic
events (20) It has a high bioavailability and is rap-
idly absorbed from the gastrointestinal tract. It
inhibits vitamin K dependant factors including fac-
tor 2, 7, 9, 10 and protein C and S. Metabolic clear-
ance through the liver can be disrupted by other
drugs. The
Th major side eff ffect, as with the other
chemical agents to be discussed, is an incidence of
bleeding. The rate of bleeding has been described
in early studies as 8–12% (21). More recent studies
with reduced intensity anticoagulation with INR
2.0–2.5 have lower bleeding rates of 1–2%. Impe-
riale (22) compared aspirin, LMWH, and warfarin
and found a rate of important bleeding of 0.4% for
aspirin, 1.8% for LMWH, and 1.3% for warfarin.
On warfarin there has been shown to be a signifi- fi
cant reduction in rate of DVT to 35–55% and inci-
dence of proximal DVT of 2–14%. Those Th thrombi
that occur below the trifurcation of the deep calf
veins account for 80–90% of DVT and have less
immediate risk of embolization.
Low molecular weight heparin
LMWH such as enoxaparin and dalteparin inhibit
factor 10 of the clotting cascade. Le Clerc and
Spiro have both compared enoxaparin and war-
farin and found lower rates of DVT with enox-
aparin but higher bleeding rates (20, 23, 24). Th
The
bleeding rate has been described as 6–18% minor
and 1.3–2.1% for major (21). Major bleeding is
bleeding resulting in death, bleeding into a criti-

cal organ, requiring 2 unit transfusion or re-opera-
tion. There is a lower incidence of thrombocytope-
nia than after the use of unfractionated heparin
(25). A review of eight studies of LMWH in 1499
patients undergoing TKA found a rate of DVT of
31% which is a similar reduction to that seen with
the use of warfarin (20). The molecular weight of
these drugs is about 5000 daltons as opposed to
normal heparin with a weight of 15,000. They are
also less protein bound and so are more bioavail-
able and do not require monitoring. There
Th is how-
ever a need to teach self-injection techniques to
the patient. There has been an association of epi-
dural hematoma formation and the use of LMWH
which prompted the FDA to require drug compa-
nies which sell LMWHs to include this potential
complication in their product brochures.
Aspirin
Aspirin, or acetylsalicylic acid, inhibits thrombox-
ane by irreversibly binding cyclo-oxygenase result-
ing in inhibition of platelet aggregation. Platelet
turnover takes place in 8–10 days. Enthusiasm for
aspirin has waxed and waned. Th The NIH Consen-
sus found no justification
fi for effi
fficacy of aspirin.
The greatest attribute of aspirin is its safety and
recommendations for its use are based on lack of
bleeding complications and benefits fi in preven-
tion of arterial clotting. Although it is often used
for prophylaxis (30), it has not been determined
whether it is eff
ffective as a single agent.
Newer medications are available. Fondaparinux
is a factor 10 inhibitor given subcutaneously as a
single daily injection. It is a synthetic pentasaccha-
ride with a reported effi fficacy better than LMWH.
One trial looking at 362 TKA’s found a rate of DVT
of 12.5% and rate of proximal DVT 2.4% (26).
Another agent not yet FDA approved is ximelager-
tian a thrombin inhibitor. When compared to war-
farin it was found to be of greater effi fficacy (27).
Sequential compression devices (SCD)
Calf compression alters thrombus and plasma
activity thus modifying coagulation and fibrin-
fi
olytic pathways. Pneumatic compression devices
simulate physiologic pumps in the lower extremity.
They produce flow disturbance in the valve pockets
and increase release of endothelial derived relax-
ing factor which inhibits platelet aggregation. SCD
and aspirin reduce the prevalence of DVT after
TKA compared with aspirin alone. SCD have not
been shown to be more eff ffective than pharmaco-
Medical management before and after TKA 819
logical prophylaxis after TKA but may be useful in
combination with these agents.
A meta-analysis by Westrich (19) reviewed 23
studies and found rates of DVT of 53% with aspi-
rin, 45% with warfarin, 29% with LMWH. Consen-
sus statement in JAMA 1986 and Chest 2004 give
recommendations for DVT prophylaxis after TKA.
An argument has been put forth to use several dif-
ferent regimens including warfarin, LMWH, and
fondaparinux (28).
Antibiotic prophylaxis after TKA
Total joint implants have been shown to be sur-
rounded by an immune-incompetent fi fibro-infl
flam-
matory zone that may impair the body’s ability to
eliminate bacteria around the implant. A foreign
object always represents a possible site for infection.
The sites of prosthetic joints are at a potential risk
for infection by procedures that cause a transient
bacteremia. Dental procedures, endoscopy, and
cystoscopy are associated with a risk of bacteremia
and possible sequelae of periprosthetic infection.
The exact role of this transient bacteremia in caus-
ing infection is unclear as activity such as brushing
teeth and chewing gum has been shown to cause
transient bacteremia in 38 and 25% of subjects com-
pared to 40–91% of those having teeth extracted.
Dental procedures
Antibiotics are frequently prescribed in TKA
patients having dental procedures. Th This practice
is possibly due to interpretation of data regarding
late infection around prosthetic heart valves and
the concern of a similar process occurring around
prosthetic joints. In 1990 the Council of Dental
Therapeutics and the American Dental Association
noted there was insuffifficient data to support the
prophylactic use of antibiotics before dental proce-
dures in people who have a prosthetic joint.
The types of dental procedures for which antibi-
otics are recommended by the American Dental
Association are those that cause bleeding, such as
professional cleaning. They do not include adjust-
ment of orthodontic appliance, insertion of a fi fill-
ing above the gum line or injection of intraoral
local anesthetic.
The organism predominant in normal oral flora
and most commonly isolated from the blood after
a dental procedure is streptococcus viridans. This
Th
organism is involved in only 2% of late infec-
tions reported around a prosthetic joint. Pros-
thetic infections are most commonly caused by
820 Primary Total Knee Arthroplasty
staphylococcus aureus which is found in oral flora
fl
0.005% of the time and rarely found in the blood
after dental procedures.
The cost of prophylaxis was assessed by Jacob-
son in 1991 (29). He took 1 million hypothetical
patients and calculated the cost of no treatment
versus prophylaxis. In the untreated group 29.3%
developed an infection resulting in 1.93 deaths. In
the group with routine penicillin prophylaxis there
were 2.31 deaths and 400 cases of anaphylaxis at a
cost of 6.4 million dollars.
Some recommend prophylaxis for high-risk
patients. Patients at risk include those with rheu-
matoid arthritis, diabetes, immuno-suppression,
past history of infection, or a remote infection.
Hemophilia patients have a reported rate of late
infection of 9% which is considerably higher than
the generally reported rate of 0.3–1%. Other at
risk groups are those having revision surgery,
when a hinge is used and when major bone graft-
ing is used.
The agent recommended for prophylaxis is a first
generation cephalosporin such as cephalexin 2 g
orally. This will target the usual causal organism
namely staphylococcus and hemolytic streptococ-
cus. In cases of allergy to cephalosporins, 600 mg
clindamycin is recommended.
Targeting high-risk patients with a 1 day dose of
cephalexin improves cost effectiveness
ff while main-
taining a low risk of deaths (0.38 deaths per mil-
lion dental visits).
Nearly half of infections caused by hematogenous
spread occur in the first 2 years after the surgery,
prompting some to recommend prophylaxis for
this early period.
Non-dental procedures
The American Society of Colon and Rectal Surgeons
does not recommend prophylaxis to prevent pros-
thetic infections for colonoscopy or sigmoidos-
copy. The American Society for Gastrointestinal
Endoscopy does not recommend prophylaxis for
endoscopy. Urinalysis should be preformed prior
to cystoscopy and if positive then the specimen
should be cultured. The American Urological Soci-
ety recommends prophylaxis for at risk patients
such as immuno-suppressed, diabetic, rheumatoid
or for the first 2 years following surgery.
Conclusion
Pre-operatively patients need medical optimiza-
tion. History, examination, and routine tests pro-
vide information to determine risk profile.fi This
allows frank discussion with the patient to deter-
mine suitability to TKA. It also permits treat-
ment of specifi
fic cardiac, respiratory, and diabetic
problems. Post-operatively chemoprophylaxis for
prevention of DVT and infection is useful.
References
1. Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG (2001)
Thirty day mortality after total knee arthroplasty. JBJS
83:1157–1160
2. Smetana GW, Macpherson DS (2003) The case against rou-
tine preoperative laboratory testing. Med Clin North Am
87(1):7–40
3. Eagle KA, Berger PB, Calkins H, et al. (2002) ACC guideline
for perioperative cardiovascular evaluation for noncardiac
surgery. J Am Coll Cardiol 39:542
4. Auerbach AD, Goldman L (2002) Beta blockers and reduc-
tion of cardiac events in non cardiac surgery. JAMA
287:1435–1444
5. Tahran S, Moffi ffitt EA, Taylor WF, Giuliani ER (1972)
Myocardial infarction after general anaesthesia. JAMA
220:1451–1454
6. David TS, Tal DS, Vrahas MS (2000) Perioperative lower
urinary tract infections in patients undergoing total joint
arthroplasty. JAAOS 8(1):66–74
7. Redfern TR, Machin DG, Parsons KF, Owen R (1986) Uri-
nary retention in men after total hip arthroplasty. JBJS
68:1435–1438
8. Carpenter MT, West SG, Volgelgesang SA, Casey Jones
DE (1996) Postoperative joint infections in rheumatoid
arthritis patients on methotrexate therapy. Orthopedics
19(3):207–10
9. Kasdan ML, June L (1993) Postoperative results of rheu-
matoid arthritis patients on methotrexate at the time of
reconstructive surgery. Orthopedics 16(11):1233-35
10. Steuer A, Keat AC (1997) Perioperative use of methotrex-
ate. Br J Rheumatol 36:1009–1011
11. Perhala RS, Wilke WS, Clough JD, Segal AM (1991) Local
infectious complications in large joint replacement in
rheumatoid arthritis patients treated with methotrexate.
Arthritis Rheum 34(2):146-52
12. Grennan DM, Gray J, Loudon J, Fear S (2001) Methotrex-
ate and early postoperative complications in patients with
rheumatoid arthritis undergoing elective orthopaedic sur-
gery. Ann Rheum Dis 60:214–217
13. Leopold SS, Casnellie MT, Warme WJ, et al. (2003) Endog-
enous cortisol production in response to knee arthroscopy
and total knee arthroplasty. JBJS 85:2163–2167
14. Friedman RJ, Schiff ff CF, Bromberg JS (1995) Use of sup-
plemental steroids in patients having orthopaedic opera-
tions. JBJS 77:1801–1806
15. Mauerhan DR, Nelson CL, Smith DL, et al. (1994) Pro-
phylaxis against infection in total joint arthroplasty. JBJS
76:39–45
16. Friedman RJ, Friedrich LV, White RL, et al. (1990) Anti-
biotic prophylaxis and tourniquet inflation
fl in total knee
arthroplasty. Clin Orthop Relat Res 260:17-23
17. Sharrock NE, Hargett MJ, Urquhart B, et al. (1993) Factors
aff
ffecting deep vein thrombosis rate following total knee
arthroplasty. J Arthroplasty 8:133–139
18. Haas SB, Tribus CB, Insall JN, et al. (1992) The signifi fi-
cance of calf thrombi after total knee arthroplasty. JBJS
74B:799–802
19. Westrich GH, Haas SB, Mosca P, Peterson M (2000) Meta
analysis of thromboembolic prophylaxis after total knee
arthroplasty. JBJS 82B:795–800

20. Le Clerc JR, Geerts WH, Desjardin L, et al. (1996) Preven-
tion of venous thromboembolism after knee arthroplasty.
Ann Intern Med 124:619–626
21. Colwell CW, Collis DK, Paulson R, et al. (1999) Compari-
son of enoxaparin and warfarin prevention of venous
thromboembolic disease. JBJS 81:932–940
22. Imperiale TF, Speroff
ff T (1994) A metaanalysis of methods
to prevent venous thromboembolism following total knee
replacement. JAMA 271:1780–1785
23.Le Clerc JR, Gent M, Hirsh J (1998) The incidence of symp-
tomatic venous thromboembolism during and after pro-
phylaxis with enoxaparin. Arch Intern Med 158:873–878
24. Spiro TE, Fitzgerald RH, Trowbridge AA, et al. (1994)
Enoxaparin and warfarin for the prevention of venous
thromboembolic disease after elective knee replacement
surgery. Blood 246:970
25. Clagett GP, Anderson FA, Geerts W, et al. (1998) Preven-
tion of venous thromboembolism. Chest 114:531S–560S
Medical management before and after TKA 821
26. Turpie AG, Bauer KA, Eriksonn BI, Lassen MG (2002)
Fondaparinux vs enoxaparin for the prevention of venous
thromboembolism in major orthopedic surgery. Arch
Intern Med 162:1833–1840
27. Francis CW, Berkowitz SD, Comp PC, et al. (2003) Com-
parison of ximelagatran with warfarin for prevention of
venous thromboembolism after total knee replacement. N
Engl J Med 349:18
28. (1986) Prevention of venous thrombosis and pulmonary
embolism: NIH consensus development. JAMA (7)
29. Jacobson JJ, Schweitzer SO, Kowalski CJ (1991)
Chemoprophylaxis of prosthetic joint patients dur-
ing dental treatment. Oral Surg Oral Med Oral Pathol
72(2):167-177
30. Kim YH, Choi IY, Park MR, Cho JL (1998) Prophylaxis for
deep venous thrombosis with aspirin or low molecular
weight dextran . Int Orthop 22:6–10

B. Quelard, O. Rachet Rehabilitation protocol following
total knee arthroplasty
Introduction
K
nee replacement surgery has undergone a
rapid and signifi ficant growth over the past
three decades strongly supported by new
technologies and innovations, the development of
resistant biomaterials, a better understanding of
knee biomechanics combined with major improve-
ments in intra-operative management. The devel-
opment of prosthetic implants adapted to each ana-
tomical situation thus optimizes joint kinematics.
The number of knee implant surgeries performed
annually in France each year is in constant growth
and currently estimated at more than 50,000.
Degenerative changes in the knee joint resulting
from either primary or secondary osteoarthritis
are the main indication for knee arthroplasty. Th The
aff
ffected population is at risk due to its age (usu-
ally over 60 years) and the frequency of associated
comorbidities. Non-specifi fic post-operative com-
plications are frequently reported (59% accord-
ing to the study of Troussier), more or less severe
and varied, and may sometimes compromise the
functional outcome and even the vital prognosis.
Complications related to knee surgery affectff about
10% of the patients (Sharkey): infection, stiffness,
ff
algodystrophy and less commonly patellofemoral
or tibio-femoral instability pre-dominate. Preven-
tion and early detection of complications after
knee replacement are among the top priorities
during post-operative management.
The purpose of joint prosthetic replacement is to
provide pain relief, improve patients’ functional
abilities, and quality of life. To achieve these goals,
a proper rehabilitation protocol should be carried
out to promote satisfactory recovery of mobil-
ity and optimal active stability while taking into
account age and arthritis-related muscular and
neuromuscular changes, the severity and oldness
of pre-operative impairments, associated patholo-
gies and patient's expectations. Physiotherapy is
not highly technical but should perfectly adapt the
specifi
ficities of this population.
First, we will briefl
fly remind the muscular and neu-
romuscular changes resulting from the advanc-
ing age and progressive joint degeneration, and
Chapitre 78
then we will evoke their evolution after prosthesis
implantation as well as the occurrence of post-op-
erative complications. Therefore,
Th from these data,
we will detail the rehabilitation protocol.
Physiological muscular and neuromuscular
aging-related changes
Aging is associated with muscle atrophy (sarcope-
nia). The muscle mass accounts for approximately
45% of total body weight between 20 and 30 years
old but this rate declines to 27% by the age 70. This
Th
physiologic muscle atrophy mainly aff ffects type II
muscle fibers (fast-twitch) whose size and number
decreases with advancing age (1). Th The loss of con-
tractile tissue, replaced by a non-contractile con-
nective tissue, is responsible for the loss of muscle
strength (12–15% each decade from the age of
30) (2). At the same time, motor unit recruitment
is diminished which contributes to the slowing
down of maximum muscle contraction speed from
10% between the age of 20 and 60 years to 7%
between the age of 60 and 70 years (3). Th The num-
ber of mecano-receptors of the joint also decreases
which reduces proprioceptive ability (4). Loss of
muscle strength, reduction in muscle contraction
speed, and compromised proprioception have det-
rimental effffects on muscle control and balance
which spontaneously affectsff the level of activ-
ity (5). Therefore,
Th a vicious circle is established.
Muscle
atrophy
Decrease Loss of muscle
in activities strengh
Any pathology likely to decrease the level of activ-
ity (osteoarticular, pulmonary, heart, neurologi-
824 Primary Total Knee Arthroplasty
cal, infectious, or visual diseases …) will acceler-
ate the physiological muscle weakening. However
muscle atrophy may be reversed by adapted phys-
ical training.
A lower decrease in the eccentric strength has
been observed in comparison to the isometric
and concentric strength (6). Endurance activities
have little impact on muscle mass but improve
the muscle aerobic capacity and overall perfor-
mances. On the other hand, resistance training
encourages hypertrophy of the remaining type I
and II fibers, increases the muscle mass and mus-
cle recruitment thus improving the level of activi-
ties (7, 8).
Physiological muscular and neuromuscular
arthritis-related changes
Knee osteoarthritis is a progressive degeneration
of articular cartilage associated with osteosclero-
sis of the subchondral bone. Clinical symptoms
include mechanical pain, progressive functional
deficiency, and loss of the quadriceps muscle
strength responsible for a decrease in functional
abilities (9, 10). Quadriceps muscle strength in
patients with knee osteoarthritis is diminished
by 63% compared with that of healthy subjects,
and reveals a greater deficiency in eccentric
muscle activity than in isometric and concentric
activity (76 and 56%, respectively) (11). The loss
Destruction of articular surfaces
Loss of sensory
informations
Loss of Quadriceps
activation
Physiological
aging
Decrease in Quadriceps
Strengh
Muscle atrophy
of quadriceps muscle strength affects either the
arthritic knee and, to a lesser extent, the healthy
contralateral knee (12, 13). As demonstrated in
various studies, a decline in voluntary activation
of the quadriceps muscle contributes to muscle
deficiency (12, 15, 16, 17). This decrease in vol-
untary activation is attributable to the inhibition
of motor activity resulting from degenerative
lesions which lead to the degradation of sen-
sory information issued from the joint mecano-
receptors and therefore to the deterioration of
stimulation from motor neurons. Amyotrophy
induced by the limitations in daily activities as
well as pain do not appear to play a significant
role.
The quadriceps muscle activation and strength def-
icit, associated with mecano-receptors degenera-
tion, contribute to the alteration of proprioceptive
function evaluated through the ability of subjects
to correctly reposition the joint in a given angle or
to perceive a movement (4, 9, 11, 18).
The loss of muscle strength and alteration of
proprioceptive functions are correlated with
the decline in functional performance (9, 11).
Patients suffering from knee osteoarthritis
increase by 1.5 the time needed to achieve some
daily activities such as standing up from a chair
and walking (“Get up and Go” test) or stair climb-
ing and descending (11) compared with a con-
trol group of patients. The range of movement
needed to achieve such activities is significantly
impaired (19).
osteo-arthritis
Pain Loss of ROM
Decrease in activities
 Rehabilitation protocol following total knee arthroplasty 825

Healthy Osteoarthritic erative contractile force and 17% of its voluntary acti-
population (°) population (°) vation ability (13, 26, 27). These
Th defi ficits signifi
ficantly
Open-kinetic-chain flexion 135 105 decrease at 6 months (28). However, the maximal
Walking on flat floor 67 50 quadriceps muscle strength remains lower than that
of a control population of same age, even several years
5° slope ascent 64 48
after prosthesis implantation (12). Silva (29) reports
5° slope descent 72 53
a 30.7% decrease in the isometric quadriceps muscle
16.5 cm stair climbing 99 68 strength and a 32.2% decrease in the isometric ham-
16.5 cm stair descending 97 67 string muscle strength at 2 years post-operatively.
Sitting down on a low seat 102 77
Standing up from a low chair 105 80
Stepping over a bathtub 131 76 Proprioceptive ability
Getting out of a bathtub 138 77
Results vary according to the authors. Some authors
Gait analysis in osteoarthritic patients shows a longer believe arthroplasty will enhance perception of move-
phase of load transfer to the aff ffected leg, a shorter ment and joint position sense (30–32). According to
single support phase of the involved leg and a longer others, there is no significant
fi diff
fference in terms of
reception-stabilization phase of the healthy limb (20). proprioceptive ability between the implanted and
non-implanted knee (33, 34). For others, the thresh-
olds for motion detection and the rate of errors dur-
ing position tests are higher after arthroplasty (35).
A good knee ligament balance would contribute to
Evolution after knee arthroplasty the improvement in proprioceptive ability (34).

Articular aspect Functional outcomes

In the absence of any complication or technical
error, pre-operative moderate or severe extension
deficits
fi are always reduced post-operatively (21).
Flexion after TKA should vary from 100 to 130°
according to the authors. It is achieved within the
first post-operative year, then hardly varies. Pre-
fi
operative mobility is the first
fi predictive factor of
post-operative mobility (21, 22). However, accord-
ing to Rowe and Myles, 83% of the patients with
at least 90° of pre-operative knee flexion
fl show a
decrease in post-operative knee mobility whereas
those with a ≤ 90° of pre-operative knee fl flexion
improve mobility in 85% of the cases (23). Range of
movements required during daily activities follows
the same evolution: whatever the range of move-
ments used prior to surgery, all patients aim at the
same functional mobility sector at 2 years post-
operatively (23–25) the extent of which remains
lower by 26% than that of a control population.
Quality of life after TKA is signifi
ficantly correlated
to the recovery of functional range of movements.
Some surgical or medical-related factors may limit
the ROM recovery process: decrease in patellar
height, insuffi
fficient posterior osteophytes removal,
rotational disorders, over-sized implant, second-
ary algodystrophy…
The functional outcome after TKA is mainly corre-
lated with pre-operative functional status (36, 37),
quadriceps muscle strength (29, 38), and knee mobil-
ity (23). It also appears dependent from the patient’s
motivation (39–41). Even several years after prosthe-
sis implantation, TKA patients take more time than a
control group of patients in performing daily activi-
ties such as standing up from a seat or stair climbing
or descending (42). Fifty-two per cent of the patients
report a limited functional status compared to 22%
in the pilot group (32). Regarding gait pattern, the
diff
fferent phases appear more symmetrical but not
completely identical to that of the pilot group (43).
Pain, decreased functional mobility and alteration of
proprioceptive control contribute to a progressively
greater inactivity thus increasing atrophy and quad-
riceps muscle weakening in osteoarthritic patients.
While knee replacement surgery reduces pain, physi-
cal therapy should enhance passive and active knee
mobility and provide a better muscle control (vol-
untary muscle activation and maximum contractile
strength) to comply with the patient’s expectations.
TKA complications

Muscular aspect Non-specifific complications (44)

During the fi
first post-operative month, the quadri- Trombophlebitis (15.5–25%), urinary tract infec-
ceps muscle looses about 60% of its maximal pre-op- tions (10%), and skin necroses or wound dehis-
826 Primary Total Knee Arthroplasty
cences (2–12%) are the most commonly encoun-
tered non-specifi
fic complications following TKA.
Early specific
fi complications
Infection and algodystrophy are rare complications
(0.71% in the SooHoo study (45) and 1.3% in the
study of Kim (46)) but should be early diagnosed.
An adapted physical rehabilitation protocol should
be combined with the medical treatment.
ffness and pain are frequent complications
Stiff
which can be of diff fferent origin (implant over-siz-
ing, mispositioning of the prosthetic components,
insuffi
fficient release of the condylar shells, patellar
non-resurfacing, external patellofemoral conflict,fl
over thickening of the patellar button, bulky or
mispositioned tibial plate ...).
Secondary specific
fi complications
They include septic loosenings, primary aseptic
loosenings or secondary to misposition of the pros-
thesis, laxity-related instabilities, wear or osteoly-
sis, patellar Clunk syndroms, and disruption of the
extensor mechanism of the knee.
The rehabilitation protocol
The objectives
The recovery of joint mobility and stability is the
main objective of the rehabilitative protocol. Th
The
degree of recovery will depend on:
– The aetiologic diagnosis.
– The physiological age.
– Associated pathologies (cardiovascular, neuro-
logical …).
– The amount and duration of musculoskeletal
defi
ficits.
– Patient’s motivation.
The requirements
– Promote wound healing.
– Take account of associated gestures (anterior tib-
ial tubercle osteotomy, reaxation osteotomy …).
– Achieve rapid recovery of 90° of knee fl
flexion and
favor self-mobilizations.
– Control flexum.
– Improve quadriceps muscle function via a thor-
ough re-inforcement program while avoiding
excessive constrained forces exerted to the patel-
lofemoral joint.
– Global functional training should be initiated as
soon as possible.
The phases
The rehabilitation protocol is made of successive
phases, each one corresponding to specific
fi rehabil-
itative strategies, planned according to priorities.
Rehabilitation consists of four successive phases:
– D1–D10: Immediate post-operative rehabilita-
tion.
– D10–D30: Analytic and functional rehabilita-
tion.
– D30–D90: Readaptation.
– From D90: Rehabilitation focused on the persis-
tent defi
ficits.
The whole objectives should be achieved prior to
moving to the next phase.
D1–D10: Post-operative rehabilitation protocol
From the first post-operative day, priority is given to:
– Pain relief which requires the use of:
- the plexic block and morphine pump secondary
relieved by systematic intra-articular infiltra-
fi
tion analgesia associated with myorelant ther-
apy;
- cryotherapy several times a day by applying an
ice pack and taking care not to exceed 15–20 mn
of application on the same area for preservation
of cutaneous vascularization. Cold air cooling
and hyperbaric gaseous cryotherapy may also
be used after mobilizations. Cryotherapy has
a double interest: it has an analgesic effect
ff but
also displays anti-infl
flammatory properties.
– The prevention of locoregional complications
and particularly:
- Thromboembolic complications with systematic
use of anticoagulants associated with specific fi
measures taken to reduce venous stasis: lower
limbs placed in the declivitous position, elastic
splinting (band or compression stocking), and
active ankle mobilization.
- Cutaneous complications by avoiding any over-
compression bandage or prolonged ice applica-
tion. The presence of callus under weightbear-
ing areas (talus, sacrogluteal region) should be
assessed to prevent secondary infections.
– The prevention of general post-operative com-
plications correlated with comorbidity (diabetes,
heart, or renal failure decompensation...) and
systematic screening for infection (urinary, pul-
monary …).
During that period, the objectives of rehabilitation
should include:
– Prevention of peri-patellar adhesions by early
implementation of daily passive mobilization of
the patella, vertically then in the medio-lateral

direction, with the knee placed in maximum pos-
sible extension.
– Knee mobilization in flexion by progressively
increasing the range of motion to achieve 0°/90°.
Mobilizations are performed:
- Manually, in the pain-free range, with the
patient sitting at the edge of the bed. A decon-
tracturing massage is carried out prior to pas-
sive joint manipulations first (Fig. 1a and b)
then active exercises with assistance.
- Assisted by a slow speed arthromotor, 20 min
twice a day. Therefore, the patient can use
this device with complete confidence since
he manages the arthromotor remote con-
trol for stoppage or reversal of the mobiliza-
tion direction. It allows gentle and painless
manipulations.
During mobilization exercises, the quadriceps
muscle should relax when knee is placed in fl flex-
ion. Then, various postures performed on rubber
blocks of variable height are performed (Fig. 2) and
repeated several times a day during short periods
(about 20 min)
B
Fig. 1 – (a and b) Passive flexion mobilizations the day after surgery.
Rehabilitation protocol following total knee arthroplasty 827
– Recovery of passive extension. Early post-opera-
tive swelling and inflflammation may induce an
antalgic reflex
fl flexum managed with a tempo-
rary small comfort cushion placed under the
popliteal fossa. Removal of the cushion as soon
as possible appears suffi fficient to fully restore
extension. However, any excessive ligament
tension or pre-operative flexum might interfere
with proper restoration of 0° knee extension.
Flexum is managed with hamstring limbering
up exercises, passive ankle dorsifl flexion, gentle
passive knee extension (Fig. 3) combined with
extension postures.
– Activation of the quadriceps muscle which sider-
ation is almost constant, for active knee locking
recovery. This muscle activation requires:
- Rapid voluntary static contractions of vastus
muscles, also named «flflash» contractions, knee
in extension, patient in the sitting position to
obtain functional insuffifficiency of the rectus
femoris.
- Static contractions (Fig. 4) allowing patellar rise
and patellar tendon strain.
Fig. 2 – Flexion posture.
Fig. 3 – Passive mobilization in extension.
828 Primary Total Knee Arthroplasty

Fig. 4 – Static contraction of the quadriceps.

B
Th
These contractions should be repeated several
times a day. Vastus muscles electrical stimulation
and biofeedback will be implemented when knee
infl
flammation has decreased.
Locking in extension is usually obtained within
8–10 days in the absence of passive flexum.
fl
– Promote safe and independent ambulation using
a rollator walker first, then two parallel crutches
when proper balance has been achieved. Weight-
bearing is applied as tolerated. Progressively
increase the ambulation distance according to
the general state of the patient. From day 7, stair
climbing and descending is negotiated, stair by
stair, only using fl
flexion of the unaff
ffected leg.

D10–D30: Analytic and functional rehabilitation Fig. 5 – (a and b) Self-stretching of the hamstring muscles.
During that phase, the patient is either in com-
plete or partial hospitalization or discharged at
home. This will depend on the medical outcomes
(absence of locoregional or general complications),
the degree of independence, accessibility of the
patient’s house and socio-domestic environmental
factors. Diffi
fficulties in improving range of motion
should also be considered.
This second rehabilitation phase focuses on the func-
tional recovery of complete passive extension and
quadriceps muscle activity using open and closed
kinetic chain exercises.
Recovery of complete passive and active extension
is essential to achieve optimum prosthesis function.
Restoring the ability to perform normal walk will
depend on the absence of fl flexum. The recovery of the
quadriceps muscle control will provide knee stability. Fig. 6 – Posture in extension. The physiotherapist checks that the ham-
– Recovery of knee extension when there is genu string muscles are relaxed.
flexum requires:
fl
- Deep decontracturing massages of the poste- - Gentle extension postures repeated several
rior chain muscles. times a day associated with flash contrac-
- Hamstring self-stretching exercises through tions of the quadriceps muscle, the knee is
pelvic anteversion with the patient in the sit- left unsupported or placed over a soft cush-
ting position (Fig. 5a and b). ion (Fig. 6).
 Rehabilitation protocol following total knee arthroplasty 829

- Gentle and progressive passive knee extensions the patient being placed in the supine position
performed by the therapist (Fig. 7). with his contralateral lower limb in flexion
fl to
– In all cases, recovery of active extension requires: maintain pelvic stability (Fig. 13a and b).
- Continuing static contractions of the quadri- – Promote progressive static then dynamic full
ceps muscle while checking the vastus medialis weightbearing and independent ambulation. Nor-
muscle, the maximum patellar rise, the patel- mal gait recovery requires proper eccentric control
lar tendon strain and the absence of hamstring
contraction refl flex.
- Active exercises using the vastus muscles, in
open kinetic chain, within the last degrees of
dynamic concentric knee extension, the weight
of the leg being supported by an elastic band or
a spring (Fig. 8a and b).
- Vastus muscles electrical stimulation to facili-
tate muscle recruitment and biofeedback
which enhances patient’s eff ffort by assessing
the degree of vastus medialis muscle contrac-
tion.
The objectives of rehabilitation during that period:
– Increase the range of movements. Range of knee
flexion should progress regularly and reach a
minimum of 90° at day 30. If not, care should
be taken to investigate any mechanical problem, Fig. 7 – Manual passive mobilizations in extension.
eliminate any potential algodystrophy or small
sepsis and inform the surgeon. Various exercises
may be suggested: A
- After an arthromotor training session, passive
and activo-passive mobilizations are pursued
by therapist on short periods, while ensuring
quadriceps muscle relaxation during fl flexion and
using a manual lowering of the patella. These Th
mobilizations are performed with the patient
sitting over the edge of the table, then placed in
the lying position, with the hip in extension, the
leg off
ff the table. They will progressively become
active. In case of quadriceps muscle response,
hamstring activation using manual resistance
band exercises will help relax the quadriceps dur-
ing the hamstring strengthening program.
- With the patient in the supine position, the leg
is hung to provide assisted active triple flexion
fl B
and active mobilization of the quadriceps mus-
cle. At the end of the training session, mobiliza-
tion for increased range of motion will be per-
formed by the therapist to gain some degrees of
flexion (Fig. 9a and b).
- Skate board exercises should be implemented,
either for passive assisted knee flexion using
the unaff ffected contralateral lower limb (Fig.
10a and b) and active flexion using the ham-
string muscle (Fig. 11a and b).
- These exercises may be combined with passive
knee flexion self-mobilizations through active
ankle dorsi-flflexion (Fig. 12a and b).
– Restore hip extension, all the more defi ficitary
given the pre-operative genu flexum.
fl This objec- Fig. 8 – (a and b) Active mobilization using the quadriceps muscle, per-
tive requires hip extension postures associated formed in the last degrees of knee extension, the weight of the leg being
with flash contractions of the quadriceps muscle, supported by a spring.
830 Primary Total Knee Arthroplasty

A A

Fig. 9 – (a and b) Leg suspension for active assisted triple flexion strengthening.

Fig. 11 – (a and b) Skate board exercise for active strengthening in flexion.

Fig. 12 – (a and b) Self-mobilization in passive flexion by means of active

Fig. 10 – (a and b) Skate board exercise for passive strengthening in flexion. ankle dorsiflexion.
 Rehabilitation protocol following total knee arthroplasty 831

of pelvic translation via the gluteus medius mus-
cle, active knee-locking by the quadriceps muscle
in closed kinetic chain and the use of flexion dur-
ing the swing phase. The
Th first stage should be to
maintain monopodal balance with the knee locked
in extension via the quadriceps muscle. Various
exercises will help achieve these objectives:
- Static strengthening of quadriceps muscle, in the
standing position, with load progressively applied
using the “Pillow Squeeze" exercise (Fig. 14a–c).
- Posterior step exercise against resistance in
weightbearing conditions, using an elastic
band connected to a strap that passes behind
the popliteal fossa (Figs. 15a and b).
- Load transfer exercise through a progres-
sively increased external translation of the
pelvis relative to the affected knee until the
patient is able to full weight-bear without
compensating with the shoulder girdle or
pelvis (Fig. 16a andb).

A B
Fig. 13 – (a and b)Hip in extension associated with static contractions of the quadriceps muscle.

A B

Fig. 14 – (a–c) Static strengthening of the quadriceps muscle

in closed kinetic chain, with load progressively applied (``Pil-
C low squeezing’’ exercise).
832 Primary Total Knee Arthroplasty

Fig. 15 – (a and b) Weightbearing posterior step

A B exercise against resistance.

A B Fig. 16 – (a and b) Load transfer exercise.

A B Fig. 17 – (a and b) Active triple flexion.


- Active triple flexion using stairs of difffferent
heights, with initial manual assistance (Fig. 17a
and b).
- Bipodal antero-posterior and lateral knee stabil-
ity exercises using manual destabilizing thrusts
exerted on the pelvis. (Fig. 18).
- Treadmill exercises.
Independent ambulation using crutches is initi-
ated from day 21. In the absence of pain or gait
deviations, ambulation without canes is allowed
on a flat floor between day 30 and day 45. Out-
doors ambulation without crutches is performed
as soon as patient feels confifident enough.
– Gentle stair climbing and descending may be ini-
tiated if quadriceps muscle function and flexion
fl
are suffi
fficient (Fig. 19a and b).
D30–D90: Readaptation
This phase is performed at the therapist’s offi
ffice.
At that time, pain and inflammation
fl should have
Fig. 18 – Bipodal stability training.
A B
Rehabilitation protocol following total knee arthroplasty 833
decreased, active knee locking has been acquired,
flexion exceeds 100° and ambulation is safe and
independent. Rehabilitation will therefore focus on
sensory-motor reprogrammation with progressively
increased functional training. Besides global muscu-
lar strengthening, proprioceptive activities of pro-
gressively increased diffi
fficulty will improve the use
and control of the implanted lower limb to achieve
safe displacements while enhancing patient’s con-
fidence. The frequency, intensity and length of the
training exercises are adjusted according to the
knee reactivity These
Th exercises are based on:
– stepping over obstacles (Fig. 20a and b);
– lateral displacements (Fig. 21);
– slope ascent and descent (Fig. 22a–c);
– stair climbing and descending (Fig. 23);
– antero-posterior and latero-lateral balance on a
Castaing support (Fig. 24a and b);
– ambulation on irregular surfaces;
– kneeling (Fig. 25).
In the absence of any wound healing delay, aquatic
therapy will be initiated and include walking,
squatting, and pedalling exercises, the water act-
ing as a resistant and destabilizing element.
At the same time, analytic exercises will be contin-
ued and should focus on:
– Recovery of knee fl flexion with no limitations.
Flexion mobilization will also be performed with
the hip in extension to limber up the anterior
muscular chain and reduce the patellofemoral
strain. Stationary bike exercises with no resis-
tance should be initiated as soon as knee range
of motion has been recovered.
– Progressive strengthening of the hamstrings
starting with manual resistance first than using
elastic resistance bands.
– Triceps surae muscle strengthening exercises in
closed kinetic chain by standing up on the tiptoes
Fig. 19 – (a and b) Gentle single stair climbing and
descending.
834 Primary Total Knee Arthroplasty

A A

B
B
Fig. 20 – (a and b) Stepping over obstacles.

C
Fig. 22 – (a–c) Slope descent.

Fig. 21 – Lateral displacements.


Fig. 23 – Stair climbing.
A B
Fig. 24 – (a and b) Latero-lateral descending and antero-posterior balance
exercises using a Castaing platform.
starting with a bipodal (Fig. 26) then monopodal
weightbearing phase.
– Limbering up of the posterior muscular chain
and particularly the gastrocnemius muscle to
prevent genu flflexum.
– Quadriceps muscle strengthening in closed
kinetic chain within a 0°/60° angle
- Static strengthening of the quadriceps using
weight transfer movement in various flexionfl
angles, with the trunk held vertically.
- Dynamic concentric and eccentric exercises
by climbing and descending stairs of gradually
increasing height.
During that period, the patient should be able to
incorporate the knowledge from analytical and func-
tional rehabilitation in his daily activities and pro-
Rehabilitation protocol following total knee arthroplasty 835
Fig. 25 – Kneeling exercises.
Fig. 26 – Triceps strengthening.
gressively perform self-rehabilitation to ensure opti-
mal and long-term results. Care should be taken to
rest the knee and apply ice after each training session
while heavy loads and weight gain should be avoided.
The patient is allowed to drive from day 45.
From D90
Rehabilitation focuses on the remaining deficits fi
(quadriceps, hamstrings, gluteus…) to meet the
patient’s requirements. Physical activities such as
cycling, swimming, walking or gentle gymnastics
should be encouraged. Sports such as hiking, div-
ing, golf, sailing, cross-country skiing or hunting
might be considered.
Table 1 reports the priorities, objectives, and means
of the diff
fferent rehabilitation phases.
836 Primary Total Knee Arthroplasty

Table 1 – Rehabilitation phases.

Phase Priorities Objectives Means
– Manual passive patellar mobilizations in the A/P and sagittal
plane
Flexion
Post-operative – 0–90° mobility – Decontracturing massage of the quadriceps muscle
rehabilitation – Quadriceps and hamstring activation – Manual passive then active with aid mobilizations with
Pain relief
– Independent ambulation with crutches arthromotor, postures achieved by means of a rubber block
Wound healing
D0–D10 – Progressive stair climbing/descending Extension
with crutches – Triceps and hamstring limbering up
– Manual passive mobilizations, extension postures
– Static contractions of the vastus muscles
("flash" then continuous contractions)
Flexion
– Passive and active with assistance manual mobilizations
following mechanotherapy training session (if flexion ≤ 90°)
– Limbering up of anterior muscular chain
– Hold-relax hamstring contractions
– Hanging training, skate-board exercises
– 0–90° minimum mobility
Analytic and Extension
– Complete active extension
functional – Stretching up of posterior muscular chain
Complete passive – Quadriceps and hamstring
rehabilitation – Manual passive mobilizations, in extension
and active strengthening
– Quadriceps voluntary static contractions
extension – Independent ambulation on flat floor
D10–D30 + electrical stimulation + biofeedback
– Continuous stair climbing/descending
– Active contraction with concentric vastus muscle assistance,
with crutches and/or banister
in open kinetic chain, within the last degrees of extension
Independent ambulation
– Quadriceps contraction in closed kinetic chain within the last
degrees of extension and load transfer exercises
– Active triple flexion
– Treadmill walking

Continuing analytical training of previous phase

Readaptation – Manual flexion mobilizations + self-mobilizations
– Static and dynamic hamstring stretches against
D30–D90 – Maximum mobility + optimal mobility progressively increasing resistance
maintained during activities – Electrical stimulation + quadriceps muscle biofeedback
– Quadriceps and hamstring – Static and dynamic quadriceps contraction in closed kinetic
strengthening + global muscle chain 0°/60°
strengthening – Limbering up of anterior and posterior muscular chains
– Control of muscle activity and balance
Gradually increasing functional exercises
during destabilizing exercises
Sensori-motor – When good range of motion is achieved, stationary bike
reprogrammation exercises with no resistance
– When good wound healing is obtained, aquatic therapy
is initiated (pedalling, squatting, walking, lateral
displacements …)
– 5° slope and stairs ascent and descent
Self-rehabilitation – Proprioceptive activities are initiated
– Lateral displacements, steeplechase exercises
– Balance training using a Castaing platform
– Walking outdoors on irregular surfaces
…
Targeted
Resumption of physical activities
rehabilitation
Persistent deficits (cycling, swimming, hiking, golf, sailing, Analytical and functional exercises are adjusted to the deficits
hunting…)
From D90

Conclusion
Due to the major advances in prosthetic sur-
gery and the increasing functional requirements
inherent in the way of life, physical rehabilitation
should be continuously reaching out to provide the
patients with the best possible mobility and stabil-
ity while integrating the physiological age-related
changes and associated pathologies.
References
1. Lexell J (1995) Human aging, muscle mass and fi fiber com-
position. J Gerontol 50A:11–16
2. Stevens JE, Binder-Macleod S, Snyder-Mackler L (2001)
Characterization of the human quadriceps muscle in
active elders. Arch Phys Med Rehabil 82(7):973–978
3. Williams GN, Higgings MJ, Lewek MD (2002) Aging skel-
etal muscle: physiologic changes and the effect
ff of training.
Phys Ther 82(1):62–68
4. Pai YC, Rymer WZ, Chang RW, Sharma L (1997) Effect ff of
age and osteoarthritis on knee proprioception. Arthritis
Rheum 40(12):2260–2265
5. Hurley VM, Rees J, Newham DJ (1998) Quadriceps func-
tion, proprioceptive acuity and functional performance in
haelthy young, middle-aged an elderly subjects. Age Age-
ing 27:55–62
6. Hortobagyi T, Zheng D, Weidner M, et al (1995) Th The infl
flu-
ence of aging on muscle strength and muscle fi fiber char-
acteristics with special reference to eccentric strength
(abstract). J Geront A Biol Sci Med Sci 50(6):B399–B406
7. Kirkendall DT, Garrett WE Jr (1998) The Th eff ffects of
aging and training on skeletal muscle. Am J Sports Med
26(4):598–602
8. Häkkinen K, Kraemer WJ, Newton RU, Alen M (2001)
Changes in electromyographic activity, muscle fiber fi and
force production characteristics during heavy resistance/
power strength training in middle-aged and older men and
women. Acta Physiol Scand 171(1):51–62
9. Hurley MV, Scott DL, Rees J, Newham DJ (1997) Senso-
rimotor changes and functional performance in patients
with knee osteoarthritis. Ann Rheum Dis 56:641–648
10. Slemenda C, Brandt KD, Heilman DK, et al. (1997) Quad-
riceps weakness and osteoarthritis. Ann Intern Med
127:97–104
11. Hortobagyi T, Garry J, Holbert D, Devita P (2004) Aberra-
tions in the control of quadriceps muscle force in patients
with knee osteoarthritis. Arthritis Rheum 51:562–569
12. Berth A, Urbach D, Awiszus F (2002) Improvement of vol-
untary quadriceps muscle activation after TKA. Arch Phys
Med Rehabil 83(10):1432–1436
13. Stevens JE, Mizner RL, Snyder-Mackler L (2003) Quad-
riceps strength and volitional activation before and after
TKA for osteoarthritis. J Orthop Res 21(5):775–779
14. Mairet S, Maïsetti O, Rolland E, Portero P (2008) Altéra-
tions architecturales et neuromusculaires du muscle vas-
tus lateralis chez des patients atteints de gonarthrose uni-
latérale. Ann Readap Med Phys 24 Jan; 51(1):16–2
15. Becker R, Berth A, Nehring M, Awiszus F (2004) Neuro-
muscular quadriceps dysfunction prior to osteoarthritis of
the knee. J Orthop Res 22(4):768–773
16. Pap G, Machner A, Awiszus F (2004) Strength and volun-
tary activation of the quadriceps femoris muscle at dif-
ferent severities of osteoarthritic knee joint damage. J
Orthop Res 22(1):96–103
17. Hurley MV, Newham DJ (1993) The Th inflfluence of arthrog-
enous muscle inhibition on quadriceps rehabilitation of
Rehabilitation protocol following total knee arthroplasty 837
patients with early, unilateral osteoarthritic knees. Br J
Rheum 32:127–131
18. Sharma L, Pai YC, Holtkamp K, Rymer Wz (1997) Is knee
joint proprioception worse in the arthritic knee versus the
unaffffected knee in unilateral knee osteoarthritis? Arthri-
tis Rheum 40:1518–1525
19. Walker CR., Myles CM, Nutton RW, Rowe PJ (2001) Move-
ment of the knee in osteoarthritis. J Bone Joint Surg
83-B(2):195–198
20. Viton JM, Atlani L, Mesure S, et al. (1998) Modalités de
transfert du poids du corps chez le patient gonarthro-
sique. Rev Chir Orthop 84:705–711
21. Ritter MA, Harty LD, Davis KE, et al. (2003) Predict-
ing range of motion after TKA. J Bone Joint Surg
85-A(7):1278–1285
22. Gandhi R, de Beer J, Leone J, et al. (2006) Predictive risk
factors for stiff
ffknees in TKA. J Arthroplasty 21(1):46–52
23. Rowe PJ, Myles CM, Nutton RW (2005) The Th eff
ffect of total
knee arthroplasty on joint movement during functional
activities and joint range of motion with particular regard
to higher flexion users. J Orthop Surg 13(2):131–138
24. Myles CM, Rowe PJ, Walker CR, Nutton RW (2002) Knee
joint functional range of movement prior to and follow-
ing total knee arthroplasty measured using flexible
fl elec-
trogoniometry. Gait posture 16(1):46–54
25. Van der Linden ML, Rowe PJ, et al. (2007) Knee kinemat-
ics in functional activities seven years after TKA. Clin Bio-
mech 22(5):537–542
26. Mizner RL, Stevens JE, Snyder-Mackler L (2003) Voluntary
activation and decrease force production of the quadriceps
femoris muscle after TKA. Phys Ther 83(4):359–365
27. Mizner RL, Petterson SC, Stevens JE, et al. (2005) Early
quadriceps strength loss after TKA. The Th contribution of
muscle atrophy and failure of voluntary muscle activation.
J Bone Joint Surg Am 87(5):1047–1053
28. Gapeyeva H, Buht N, Peterson K, et al. (2007) Quadriceps
femoris muscle voluntary isometric force production and
relaxation characteristics before and 6 months after unila-
téral total knee arthroplasty in women. Knee Surg Sports
Traumatol Arthrosc 15(2):202–211
29. Silva M, Shepherd EF, Jackson WO, et al. (2003) Knee
strength after TKA. J Arthroplasty 18(5):605–611
30. Barrett D, Cobb AG, Bentley G (1991) Joint propriocep-
tion in normal, osteoarthrictic and replaced knees. J Bone
Joint Surg 73B(1):53–56
31. Warren PJ, Olanlokun TK, Cobb AG, Bentley G (1993) Pro-
prioception after knee arthroplasty. Clin Orthop Relat Res
297:182–187
32. Isaac SM, Barker KL, Danial IN, et al. (2007) Does arthro-
plasty type influence
fl knee joint proprioception? A lon-
gitudinal study comparing total and unicompartmental
arthroplasty. Knee 14(3):212–217
33. Ishii Y, Terajima K, Terajima S, et al. (1997) Comparison of
joint position sense after TKA. J Arthroplasty 12(5):541–
545
34. Wada M, Kawahara H, Shimada S, et al. (2002) Joint pro-
prioception before and after TKA. Clin Orthop 403:161–
167
35. Pap G, Meyer M, Weiler HT, et al. (2000) Proprioception
after TKA. Acta Orthop Scand 71(2):153–159
36. Jones CA, Voaklander DC, Suarez-Almazor M (2003) Deter-
minants of function after TKA. Phys Ther 83(8):696–706
37. Lingard EA, Katz JN, Wright EA, et al. (2004) Predicting
the outcome of TKA. J Bone Joint Surg 86-A(10):2179–
2186
38. Mizner RL, Petterson SC, Stevens JE et al. (2005) Quadri-
ceps strength and the time course of functional recovery
after TKA. J Orthop Sports Phys Ther 35(7):424–436
39. Noble PC, Gordon MJ, Weiss JM, et al. (2005) Does rotal
knee replacement restore normal knee function? Clin
Orthop 431:157–165
838 Primary Total Knee Arthroplasty
40. Mohamed NN, Liang MH, Cook EF, et al. (2002) The Th
importance of patient expectations in predicting func-
tional outcomes after total joint arthroplasty. J Rheuma-
tol 29(6):1273–1279
41. Weiss JM, Noble PC, Conditt MA, et al. (2002) What
functional activities are important to patients with knee
replacements? Clin Orthop Relat Res 404:172–188
42. Rossi MD, Hasson S, Kohia M, et al. (2006) Mobility and
perceived function after TKA. J Arthroplasty 21(1):6–12
43. Viton JM, Atlani L, Mesure S, et al. (1999) Influence
fl de
l’arthroplastie totale de genou sur les modalités de trans-
fert du poids du corps au cours du pas latéral. Rev Chir
Orthop 85:466–474
44. Troussier B, Rey S, Frappat D(2006) Suites opératoires
après arthroplastie du genou: etrude rétrospective à pro-
pos de 90 patients. Ann Readap Med Phys 49:640–646
45. SooHoo NF, Lieberman JR, Koo CY, Zingmond DS (2006)
Factors predicting complication rates following total knee
replacement. J Bone Joint Surg 88(3):480–485
46. Kim J, Nelson CL, Lotke PA (2004) Stiffness
ff after TKA.
Prevalence of the complication and outcomes of revision.
J Bone Joint Surg 86-A(7):1479–1484
The Patella in TKA

K. Corten,
S. J. MacDonald
Why I always resurface
the patella in TKA
Introduction
D
espite the undisputed success of total knee
arthroplasty (TKA), the patellofemoral
(PF) joint remains the Achilles heel and the
least predictable part of the procedure, leading to
new onset anterior knee pain (AKP) in 14–28% of
patients (1). Early implants were not designed for
patellar resurfacing and AKP occurred in 40–58%
along with other PF complications (2–8). This Th
prompted the development of tri-compartmen-
tal replacements that allowed for either patellar
resurfacing (RS) or non-resurfacing (NRS). How-
ever, initial complication rates of RS ranged from
4 to 50% and led to the concept of selective RS of
the patella in TKA (9–15). Currently, there is little
consensus about the best option, and the surgeon’s
preference remains the primary variable in the
decision-making process.
Controversy: to resurface or not?
Proponents for not resurfacing the patella argue
that newer femoral component designs are more
patella-friendly and that there will be minimal
need for patellar revision in the future. Other
surgeons argue that selective resurfacing of the
patella might be more appropriate (9–13, 15, 16).
However, patellar kinematics have been shown to
be more variable in TKA when compared to nor-
mal knees, leading to higher PF loads and progres-
sive cartilage degeneration (17–23). These
Th findings
provide a compelling argument in favor of patellar
RS. Proponents of RS argue that it leads to more
reproducible results, a lower incidence of AKP and
it pre-empts future concerns about the patellar
cartilage being the source of residual or new onset
AKP (11, 24–28).
In the final section of this chapter, the authors
have summarized the results of a meta-analysis
of the current literature on this topic in TKA
(Table 1). Randomized controlled trials (RCTs)
constitute the most reliable source of evidence
for the evaluation of the effi
fficacy of an interven-
Chapter 79
tion (29). However, confl flicting data from some
RCTs have led to the current controversy about
patellar resurfacing. First, diff ffering results were
infl
fluenced by variable methodologies with some-
times significant
fi flaws, variable follow-up times,
diff
fferent outcome tools, and diff fferent implant
designs. Most of the trials had relatively small
sample sizes and probably were underpowered
to detect significant
fi diff
fferences between the two
treatment options. Furthermore, and maybe most
importantly, none of the trials was controlled for
the indication to re-operate on the painful knee
replacement. Th This led to variable re-intervention
rates with often unpredictable results. The Th relative
ease to secondarily resurface the non-resurfaced
patella, thereby not always addressing the under-
lying cause of AKP, is an important confounding
factor in the decision-making process to treat the
patient with AKP. Finally, there is no consensus on
the term “anterior knee pain” and what it really
encompasses. Neither is there clear evidence
about its eff
ffect on patient satisfaction nor is there
consensus about the best outcome tools to evalu-
ate AKP.
Due to this lack of clear-cut data in the evidence-
based literature, patellar RS remains a rather
“philosophical” question for the surgeon who must
anticipate that some degree of AKP will occur in
one-fourth to one-third of patients undergoing
total knee replacement. Consequently, the deci-
sion is either to leave the patella unresurfaced and
expose the patient to a risk of secondary RS with
unpredictable results or, alternatively, to resurface
the patella routinely and accept a comparable inci-
dence of AKP for which revision options are more
limited and not routinely indicated. We prefer the
second option.
Basically, the question to resurface the patella or
not comes down to the willingness of the surgeon
to bear the possible consequences of either deci-
sion with a special emphasis on how persistent
AKP should be addressed. Therefore, the authors
have reviewed the balance of the pro’s and con’s
of either decision in four questions: (1) What is
the correlation between the resurfacing status of the
patella and anterior knee pain in TKA?, (2) What are
Table 1 – Overview of twelve prospective trials of which eleven were randomized. The number of patients that were enrolled and the number of patients that were followed at final follow-up are depicted. Initially, 1335 knees were
enrolled in all trials of which 1205 knees were followed at first follow-up report. In total 592 resurfaced and 635 non-resurfaced knees were followed at first follow-up report.
Author Type CR/PS Indic Pat component N Pat (N knees) N knees LRR (% knees) Author's conclusion
Enrolled Followed RS NRS RS NRS P
Consecutive series
Burnett '07 (RCT'92) [14] MG II CR OA Onlay, hat-shaped
Results 10 y (10–12) 32 (64) 20 (40) 20 20 30 20 NS No difference in bilateral TKA
842 Primary Total Knee Arthroplasty

Report of bilateral TKA

Barrack '01 [2]
Results 6 y (5–7) 67 (93) 47 46 No difference but signif more patients
with AKP than 3y earlier
Barrack '97 [4])
Results 2.5 y (2–4) 89 (121) 86 (118) 58 60 31 18 NS No difference
Burnett '04 (RCT '91) [15] AMK CR OA Dome-shaped
Results 10.8 y (10–12) 45 (50) 19 20 No difference but a trend towards better
results in NRS
Bourne '95 [11]
Results 2 y 90 (100) 83 (90) 42 48 24 10 na NRS lower (p<.03) KSS pain score but
higher revision rate
Kajino '97 (PT) [36] YS Excised RA na
Results 6.6 y (6–8) 26 (52) 26 26 More AKP and appearance of erosive
changes in NRS
Shoji '89 [68]
Results 2.7 y (2–4) 35 (70) 35 (70) 35 35 80 71 na No difference; in RA is best to do selective
RS
Non-consecutive series
Smith '08 (RCT '98) [69] Profix CR OA Inset, dome-shaped
Results 4.4 y (3–7) 164 (181) 142 (159) 73 86 20 17 na No difference
Campbell '06 (RCT'91) [16] MG II CR OA Onlay, hat-shaped
Results 10 y 100 (100) 58 (58) 30 28 57 54 na No difference
Author Type CR/PS Indic Pat component N Pat (N knees) N knees LRR (% knees) Author's conclusion
Enrolled Followed RS NRS RS NRS P
Non-consecutive series
Waters '03 (RCT '92) [74] PFC random OA/RA
Results 5.3 y (2–9) NA (503) 390 (474) 243 231 31 26 na RS better outcome; PCL-status and LRR
no influence on outcome
Wood '02 (RCT '92) [77] MG II CR OA Onlay, hat-shaped
Results 4 y (3–7) 201 (220) 180 (198) 92 128 na na na RS only superior in AKP and stair descent
Feller '96 (RCT '90) [25] PCA CR OA Dome-shaped
Results 3 y 40 (40) 38 (38) 19 19 0 0 NS NRS only superior in stair climb

Abbreviations:
AMK: Anatomical Modular Knee (Depuy)
CR: cruciate retaining
Indic: indication
LRR (% knees): percentage of total number of knees with a lateral retinacular release
MG II: Miller-Galante II (Zimmer)
N Pat (N knees): total number of patients (total number of knees)
OA: osteoarthritis
Pat component: patellar components, all PE and cemented
PCA: PCA Modular (Howmedica)
PFC: Press-Fit Condylar (J&J)
Profix: Profix (S&N)
PS: posterior substituting
RA: rheumatoid arthritis
YS: Yoshino-Shoji (Biomet)
Signif: significantly
na: not availabe
bilat.: bilateral
Why I always resurface the patella in TKA 843
844 Primary Total Knee Arthroplasty
the patellar complications if the patella is not resur-
faced?, (3) Are extensor mechanism complications
in resurfaced patellae different
ff from non-resurfaced
patellae?? and (4) What can we learn from the current
evidence based literature?. To conclude, the authors
try to answer the question that in our opinion
summarizes the whole chapter: Why should I not
resurface the patella?.
What is the correlation
between the resurfacing status of the patella
and anterior knee pain in TKA?
The etiology of AKP and PF complications follow-
ing TKA is multi-factorial with a complex interplay
of patient-related factors, surgical parameters and
implant design features.
Patient-related factors
PF complications have been found to be corre-
lated with numerous patient-related factors, but
these correlations were not consistent through-
out diff
fferent studies. From a report of the Swed-
ish Registry, women tend to have lower overall
knee scores and tend to be more satisfied fi with
the results of patellar RS than men (30). Heavier
patients had signifi ficantly poorer results in some
(28) but not all trials (1, 18, 27, 31, 32). Pre-op-
erative AKP has been reported to be present in
54% of patients but has not been found to be a
predictive factor for post-operative AKP, in either
resurfaced or non-resurfaced knees (1, 31, 33,
34). Similarly, patellar chondromalacia has not
been found to infl fluence the outcome scores (1,
18, 31, 33). Furthermore, there are no consis-
tent evidence-based data to support that age and
osteoporosis (patellar fracture), post-traumatic
arthritis, prior proximal tibial osteotomy (patella
infera), valgus deformity, and pre-operative patel-
lar (sub-) luxation are clearly correlated with more
PF complications (35).
In contradistinction to the abovementioned
parameters, infl flammatory arthritis has consis-
tently been reported as an absolute indication for
resurfacing of the patella. The remaining articu-
lar cartilage may provide an antigenic trigger for
persistent synovial infl flammation that may con-
tribute to peripatellar pain in patients with rheu-
matoid arthritis. Furthermore, the deterioration
of the patellar cartilage in rheumatoid arthritis
has been shown to be progressive, leading to less
favorable intermediate results in a consecutive
prospective series presented by Shoji and Kajino
(19, 22).
Surgical technique
A meticulous surgical technique will lead to more
reproducible results. The subvastus approach has
been suggested to lead to improved patellar track-
ing and subsequently to less lateral retinacular
releases in comparison to the standard medial
para-patellar approach (36, 37). More importantly,
correct component placement in the three planes,
maintenance of the joint line and preservation of
the patellar height have all been shown to lead to
improved patellar tracking and diminished patellar
complications (38–41). Lateral retinacular release
has been correlated to an increased number of PF
complications (42). This
Th was not confi firmed in our
meta-analysis. In seven RCTs, patellar resurfacing
led to an increased tendency to release the lateral
retinaculum without an increased rate of PF com-
plications in comparison to the non-resurfaced
groups (35% vs. 28% resp.) (Tables 1 and 2) (1,
18, 22, 27, 31, 33, 43). Several surgical factors are
critical to ensure a successful outcome with mini-
mal complications in RS. Patellar resection result-
ing in a thickness of less than 15 mm signifi ficantly
increases anterior patellar strain and should be
avoided (44). Lateral facet resection, fl flush with
the subchondral bone, is desirable to obtain equal
medial and lateral facet thicknesses and prevent
patellar tilt (45). The patellar clunk syndrome
can be minimized by recreating the native patel-
lar thickness and by positioning of the patellar
component just below the superior border of the
patella. This will avoid impingement of the quad-
riceps tendon on the femoral and patellar compo-
nent respectively.
Our preferred approach is to minimize bone resec-
tion, to restore the native patellar thickness and to
maximally preserve the blood supply. Th Therefore,
we use a one-peg, inset, dome-shaped all-polyeth-
ylene patellar component that is positioned in the
middle of the patella or slightly medialized and just
below the superior border of the patella. Th The cen-
tral dome design is less congruent, but more adap-
tive than the anatomic patellar component designs
that have increased shear stresses at the bone-com-
ponent interface (21, 46, 47). A lateral release is
very rarely indicated when central tracking cannot
be achieved and should be done at least 2 cm lat-
eral to the periphery of the patella in order to pro-
tect the superolateral geniculate artery (48). We do
not follow the “no thumb” rule that indicates that
the patella should have congruent tracking during
a full range of motion without additional medially
directed pressure on the patella with the thumb.
We feel that this will result in a lateral retinacular
release rate that is higher than required. Instead
the knee is taken through a range of motion assess-
ing patellar tracking. If there is lateral subluxation,

a towel clip clamp is placed in the tissue mimick-
ing closure of the medial arthrotomy. Once that
maneuver is performed the tracking is reassessed.
It would be very rare for the patella at the point to
still not be tracking centrally.
Implant design
Optimal implant design features signifi ficantly con-
tribute to improved patellar stability, less shear
stress, and less compressive forces. The contempo-
rary patella-friendly femoral component designs
have an anatomic, asymmetric trochlear groove
that is deep and broad and that extends far dis-
tally and posteriorly (49, 50). Every design has its
own features. Therefore, the results of every RCT
should be evaluated in the light of that specific fi
design and extrapolation to other designs should
be done cautiously. In one RCT of 474 knees,
retaining or substituting for the PCL did not have
a significant
fi infl
fluence on AKP, irrespective of the
patellar resurfacing status (27). Eleven of 13 RCTs
reviewed by the authors included only cruciate
retaining designs and only one was randomized
to cruciate substituting (Table 1). Therefore,
Th the
eff
ffect of cruciate substituting on PF complications
remains uncertain.
Anterior knee pain in TKA
AKP following TKA has been reported with an inci-
dence of 20–25% (Table 2) and its eff
ffect on patient
satisfaction is variable. Some authors have found
that AKP may not preclude overall patient satis-
faction [RCT10] while others found that patients
without AKP were 7.5 times more likely to be satis-
fied (1).
Due to the complex interplay of all the abovemen-
tioned variables, it remains very difficult
ffi to iden-
tify the resurfacing status of the patella as the
single reason for any residual or new onset AKP
following TKA. Moreover, the term “anterior knee
pain” has been suggested to encompass all post-
operative pain-related problems and there is no
clear consensus concerning the terminology, etiol-
ogy, and treatment for pain in the anterior part of
the knee. Consequently, post-operative AKP must
not be attributed to the PF articulation by default
(Table 3).
The incidence of AKP following TKA has been
Th
shown to be time related by some authors (1, 9, 30,
31, 33, 51) but not by others (17, 18). In the 6-year
period from 4 to 10 years following TKA, 31% of
Campbell’s (9) patients exhibited a trend toward
more pain and deterioration of their knee function
(Table 2). In a consecutive RCT series reported by
Why I always resurface the patella in TKA 845
Barrack (1, 31, 33), signifi ficantly more patients had
AKP at longer follow-up both in the RS and NRS
group. The authors found that post-operative AKP
was not related to pre-operative AKP. They also
found that most post-operative AKP actually was
of new onset and was unrelated to the resurfacing
status of the patella in the Miller-Galante II cruciate
retaining TKA (Zimmer) at 2.5, 6, and 10 years of
follow-up (1, 31, 33). ThisTh new-onset AKP was not
found in a consecutive RCT of the cruciate retain-
ing Anatomic Modular Knee (Depuy), reported by
Bourne and Burnett (17, 18) at 2, 7, and 11 years
of follow-up. In their 2-year follow-up series, NRS
led to signifi ficantly less pain and therefore signifi fi-
cantly improved Knee Society Clinical rating scores
in comparison to RS. At the 7-year follow-up series,
this significant
fi diff
fference between both groups
had disappeared. Unfortunately, AKP was not spe-
cifi
fically evaluated in the first follow-up series and
therefore the change or new onset of AKP between
the consecutive reports was not evaluated. In a
report from the Swedish Knee Arthroplasty reg-
ister, Robertsson (30) concluded that the satisfac-
tion of patients with RS lessened with time, which
was not found in the NRS group. To summarize,
these studies direct toward a “natural” evolution
of an increased incidence of AKP in TKA at longer
follow-up, both in RS and NRS patients. Th This evo-
lution makes it even more diffi fficult for the surgeon
to address the patellar cartilage as the single factor
in the painful TKA with a non-resurfaced patella.
Furthermore, no correlation between radiographic
findings of the extensor mechanism (e.g. patellar
tilting or sub-luxation) and AKP was found, leav-
ing radiographs to be less useful in the work-up of
the patient with AKP (18, 19).
Finally, secondary RS for AKP or revision of a patel-
lar component has been reported with unpredict-
able results and with high (57%) recurrence rates
of AKP (Table 4) (1, 31, 33). This is highly sugges-
tive that factors other than the resurfacing status
of the patella substantially impact the presence
of AKP in total knee replacements. Moreover, in
Bourne’s and Burnett’s series (17, 18) it was found
that none of the NRS knees that were pre-oper-
atively painful had pain at the 10-year follow-up
visit. Conversely, 50% of knees with RS that were
painful pre-operatively remained painful at the
10-year follow-up, indicating that pre-operative
AKP will not always be solved by RS the patella.
Both findings indicated that pre-operative AKP in
the osteoarthritic knee might have other than PF
causes.
In summary, residual or new onset post-operative
AKP is not uncommon and most likely to be time
dependent, patient related and design specific. fi This
makes it very diffi fficult for the surgeon to address
the resurfacing status of the patella as the most
Table 2 – The incidence of anterior knee pain is presented as the % of knees that were followed at the respective follow-up times. Satisfaction rates were not presented due to heterogeneity of satisfaction scores, only the calculated
P-values are presented. The preference for either the RS or NRS knee is presented as % of patients that were followed at the respective follow-up time. P-values in preference rates are presented.
PF Related Comp
Author Reop Any reason %(N) Isol Rev or Sec RS RS Related Complic Reop PF related Remarks
Rev
All RS NRS p RS NRS p Fract Loose Other RS NRS p RS NRS
Consecutive series
Burnett '07 9 (5) 11 (3) 7 (2) NS 0 7 (2) 0 4 (1) 0 4 (1) 7 (2) NS 0 0 Second and rev RS no relief AKP
Barrack '01 8 (10) na na 0 12 (7) 0 0 0 0 12 (7) 0 0 Second RS deterioration pain in 4 of 5 (80%) after 3y
Barrack '97 6 (7) na na 0 10 (6) 0 0 0 0 10 (6) 0 0 Second RS complete relief of AKP in 1 of 6 (17%)
Burnett '04 10 (9) 5 (2) 15 (7) NS 0 6 (3) NS 0 0 2 (1) 2 (1) 6 (3) NS 0 0 Second RS complete relief of AKP in 2 of 3 (66%)
846 Primary Total Knee Arthroplasty

Bourne '95 2 (2) 0 4 (2) 0 4 (2) 0 0 0 0 0 0 0 NRS higher revision rate

Kajino '97 1 (1) 0 3 (1) 0 0 0 0 0 0 3 (1) 0 0
Shoji '89 0 0 0 0 0 0 0 0 0 0 0 0
Non-consecutive series
Smith '08 6 (10) 6 (5) 5 (5) 0 0 0 0 0 1 (1) 1 (1) 0 0
Campbell '06 8 (8) 7 (4) 7 (4) 0 4 (2) 0 0 0 2 (1) 4 (2) 0 0 Second RS complete relief of AKP in 1 of 2 (50%)
Waters '03 6 (28)b na na 0 5 (11)a 0 0.4 (1)a 0 1 (3)a 5 (11)a 0 0 Second RS had complete relief of AKP in 10 of 11 (91%)
OA 0 0 0 NRS significantly more additional surgery (p= 0.0025)
RA 0 2 (1)a 0
Wood '02 13 (29) 13 (12) 13 (17) 2 (2) 9 (12) 1 (1) 3 (3) 0 10 (9) 12 (15) NS 0 0.7 (1) Second RS complete relief of AKP in 1 of 11 (9%)
Feller '96 5 (2) 10 (2) 0 0 0 0 0 0 10 (2) 0 0 0
Total subgroup (N) 97 na na 2 35 1 5 1 18 40 0 1
Total all (N) 97 37 7 58 1
% of knees 7.3% of 1335 2.8% of 1335 1.2% of 592 4.3% of 1335 0.01% of 1335 Second RS complete relief in 15 of 35 procedures (43%)

Legend and abbreviations:

%(N): all reoperations and complications are presented as % of enrolled number of knees in the trial unless stated otherwise (number of cases);
Isol Rev or Sec RS: isolated revision of RS or secondary revision to RS for AKP;
N: number;
PF Related Comp Rev: major component revisions done for patellofemoral related problems or AKP;
Reop Any reason: reoperation for any reason;
Reop PF related: all reoperations done related to the patellofemoral joint; isolated revision and secondary resurfacing are included;
RS Relat Compl: RS related complication;
second and rev RS: sondary RS and revision of RS.
a
% and N of evaluated knees and not of all enrolled knees because the exact N of enrolled knees was not known
b
Of 503 enrolled knees
 Why I always resurface the patella in TKA 847

Table 3 – Anterior knee pain following TKA can have numerous causes and an isolated revision of the patellar component for
should not be attributed to patellofemoral problems by default. the same indication. Registry studies suggest that
Intra- only 47% of these patients will have a satisfac-
Peripatellar Patellar Other
articular tory outcome leaving it to be a procedure with less
Non-resurfacing related predictable results than those with revisions of all
Femoral osteofytes TTendinitis Stress fracture Neuroma components (30, 54). Only 43% of secondary RS
Loose bodies Tendon rupture trauma CRPS procedures led to a complete relief of symptoms in
PCL laxity Plica syndrome Osteonecrosis Referred hip our meta-analysis (Table 2). In the follow-up series
pain of Barrack (1, 31), secondary RS was performed
Synovitis Patellar Sciatica in seven (12%) knees with initially some clinical
osteofytes improvement in six of seven (86%) patients. But
Component Cartilage AKP recurred in four of the five patients who were
issues: degeneration evaluated more than 5 years after the original pro-
Axial malrotation impingement: cedure. Ten per cent of Boyd’s patients who under-
Malposition On insert went secondary resurfacing for AKP continued to
Mismatch On femoral have pain and had a higher rate of skin slough,
notch infection, and decreased ROM (9). Other studies
Overhang have shown that 91% of patients had a complete
Snapping Maltracking: relief of AKP following secondary RS (27). Th The data
popliteus are thus conflflicting but most are generally not in
Aseptic Sub-luxation favour of secondary resurfacing. Lack of control for
loosening the indication to resurface the unresurfaced patella
Infection Dislocation is probably the most important methodological
Resurfacing related flaw that leads to these conflflicting results. Finally,
Patellar clunk Overstuffi
ffing Helmy (55) recently concluded from a predictive
syndrome model that only 31% of patients would benefit fi
"Meniscal from secondary RS. Furthermore, they concluded
tear" that those who did not benefi fit from the procedure
Aseptic actually had a quality of life that dropped to the
loosening level corresponding to the health state of patients
PCL: posterior cruciate ligament; CRPS: complex regional pain syndrome. with severe osteoarthritic pain according to the
McKnee modifi fied health utility index. Based on
this decision analysis, secondary RS of the patella
was not favored by the authors.
likely cause of the painful TKA. In our opinion, Fracture, dislocation, extensor disruption, and
leaving the patella unresurfaced can be either an osteonecrosis have all been reported without patel-
etiological or confounding factor of AKP, possibly lar RS but they have been reported with increased
leading to secondary resurfacing as an inadequate incidence as the practice of patellar RS increased
treatment of the unresurfaced knee with residual (2, 48, 56, 57).
or new onset AKP.

Are extensor mechanism complications

What are the patellar complications if the
patella is not resurfaced?
In total 41 of 635 non-resurfaced knees from our
meta-analysis (6.5%) had undergone a re-operation
for AKP or other PF complications (Table 4).
Secondary RS has been reported with high com-
plication rates and unpredictable results. If the
patella had not been resurfaced, this would appear
to expose the patient to a risk of secondary RS of
between 3 and 12% (1, 26, 52, 53). Thirty-fi five of
635 non-resurfaced knees (5.5%) that were fol-
lowed in the trials in our meta-analysis, had under-
gone secondary resurfacing for AKP. Whereas only
two of 592 resurfaced knees (0.3%) had undergone
in resurfaced patellae different
ff
from non-resurfaced patellae?
In total 18 of 592 (3%) resurfaced knees from our
meta-analysis had undergone a re-operation for
AKP or other PF complications (Table 4).
Resurfacing the patella is not always harmless and
has its possible hazards. Complications directly
attributable to patellar RS include component
wear, dissociation, loosening, and patellar clunk
syndrome. Initial revisions following patellar RS
have been reported with high complication rates
and have been attributed to non-optimal pros-
thetic designs and surgical techniques (48, 58).
These issues have been improved with the use of
Table 4 – The re-operation rates and absolute number of knees were presented as (1) revision for any reason, (2) isolated revision of the well-fixed patellar component or secondary resurfacing for AKP, (3) all re-operations related to
patellofemoral problems and (4) all component revisions for patellofemoral complications. The complications specifically related to the presence of the patellar component (fracture of the patella, loosening of the component and other
(avascular necrosis) were presented as well. The total numbers of knees with a re-operation or complication are presented per subgroup, as well as per section
Prognosticators
Author N knees Satis. AKP (% knees) Pain stairs/chairs (%) Preference (%) in bilat. TKA Remarks
of AKP
N
P RS NRS P RS NRS P RS NRS P Either
Pat
848 Primary Total Knee Arthroplasty

Consecutive series
Burnett '07 40 17 17 NS 20 37 22 NS 41

Barrack '01 93 NS 19 17 NS na na NS No found 24 21 29 na 50 New onset AKP in 28% RS and 14% NRS
Barrack '97 118 NS 7 13 NS na na NS No found 32 34 38 na 28 Pre-op AKP is not prognostic for post-op
AKP
Burnett '04
Results 10 y 39 NS 37 25 NS na na NS* No found 2 100 0 *NS: stair test was assessed instead
of only pain
Scores at 7 y 90 30 23 NS
Bourne '95
Results 2 y 90 * na na NS *KSS pain score less (P<.03) in NRS;
no AKP assessed
Kajino '97 0 35 31 26 na na na na

Shoji '89 * 35 23 29 na 48 *HSS pain score not different between

RS and NRS; no AKP assessed
Non-consecutive series
Smith '08 159 NS 30 21 NS FFC in RS; none in NRS

Campbell '06
Results 10 y 58 47 43 NS 51 69 NS No found

Results 8 y 29 33 NS 47 51 NS
Results 4 y 83 35 28 NS 24 29 NS
 Prognosticators
Author N knees Satis. AKP (% knees) Pain stairs/chairs (%) Preference (%) in bilat. TKA Remarks
of AKP
N
P RS NRS P RS NRS P RS NRS P Either
Pat
Waters '03 474 0.02* 5 25 <0.0001 No found 35 51 11 <0.001 37 *RS more satisfied; PS or CR not
different
OA 403 6 26 <0.0001
Non-consecutive series
RA 71 2 17 <0.0001
Wood '02 220 NS 16 31 0.016 17 25 NS Weight in NRS; none 13 na na na na NRS twice as likely to have AKP (p=
in RS 0.0028)

Feller '96 38 na na <0.05* *Patellar Score not different but signif

better stair climbing in NRS
Enis '90

Results 3y 20 45 15 NS 40
(3–5)
Results 1–3 y 22 46 0 <0.005 54

Average 20 25 22.9 44.6 18 42.57

Abbreviations:
N: number;
Satis: comparison of satisfaction rate between RS and NRS group with various satisfaction scores;
P: P-value;
NS: non-significant;
N Pat:number of patients;
Either: no preference for NRS or RS knee,
PS or CR: Posterior Substituting or Cruciate Retaining,
Signif: significant.
Why I always resurface the patella in TKA 849
850 Primary Total Knee Arthroplasty
all-polyethylene components but Berry and Rand
found that isolated revision of the patellar compo-
nent was fraught with a high rate (39%) of major
complications (59).
Patellar fractures
The prevalence of patellar fractures in TKA was
0.68% in a large series of 12.464 TKA from the
Mayo Clinic and was greater in men, resurfaced
patellae and in revision TKA (60). Risk factors for
patellar fracture directly related to RS are an exten-
sive bony resection and an inset patellar design.
Patient-related risk factors for fracture are obesity,
osteoporosis, high activity level, and a large range
of motion. One patient (0.2%) in our meta-anal-
ysis trials sustained a high-impact patellar frac-
ture. The healing potential of the patella does not
seem to be inflfluenced by patellar resurfacing (60)
but the most important consequence of a patellar
fracture is subsequent loosening of the component
(1–25%) (60, 61).
Soft tissue complications
The “patellar clunk syndrome” has been reported
with a prevalence of 3.5% in a series of 900 TKA
(14, 62). None of the trials in our meta-analysis
directly reported the incidence of the patellar
clunk syndrome. Resection of the fibrous
fi nodule
at the junction of the proximal patellar pole and
the quadriceps insertion site is usually success-
ful. AKP can also be caused by peripatellar fibrosis
fi
with crepitation and is more prevalent in femo-
ral component designs with a shallow trochlear
groove. Surgical treatment of the fibrosis
fi has been
reported with unreliable results (63).
Component failure
Loosening and wear of the patellar component can
be a cause of AKP and PF crepitation. Five compo-
nents (0.8%), of which four were onlay and hat-
shaped, were reported to be loose in the meta-anal-
ysis (Table 2). Although patellar component failure
rates have been decreased by improved compo-
nent designs, still 78% of the patellar components
were found to have wear at time of retrieval (64,
65). The radiographic findings of a loose patellar
component are surely not always obvious and the
diagnosis of a loose component as the cause for
the AKP can be challenging. Etiologic factors pre-
disposing to early patellar component failure are
fixation in defificient or osteonecrotic bone, mal-
tracking, asymmetric bone resection, an altered
joint line, osteolysis, obesity, a shallow trochlear
groove, and lateral retinacular release (64, 66). Th
The
results of revision of the loose patellar component
are less predictable and even poor in comparison
to revision of the painful well-fi
fixed component (1,
55, 67). The dome shaped all polyethylene patellar
component with good tracking and mild wear can
be retained during revision surgery (68).
Patellar pain
The above-mentioned complications can all pres-
ent with AKP and should be ruled out. Another
cause of AKP following patellar RS can be the unre-
surfaced lateral facet that can be treated success-
fully with resection. Residual flexion
fl contracture
has been found to be a risk factor for AKP in patel-
lar RS in one study (34) but not in others (Table
2). Patellar osteonecrosis is rare (0.05–2%) (11, 69)
and it remains unclear whether it is directly caused
by patellar RS. One patient (0.2%) from the series
in our meta-analysis had been reported with avas-
cular necrosis and subsequent fragmentation of
the patella (17, 18).
Revision of the patellar component
Well-fi
fixed and non-oxidized components can be
retained safely, even with manufacturing mis-
matches (68). Isolated revision of the patellar
component has been reported with high failure
and rerevision rates (67). Removing a well fixed
fi
but worn out patella should be done meticulously
in order to prevent the patella from fracturing.
The implant bed should only be roughened and
no further reaming should be done. Penetration
of the anterior cortex should by all means be pre-
vented since this signifi
ficantly weakens the patella.
A new patellar component can be safely cemented
in place. The problematic situation is the eroded,
thin, avascular patella with a loose component. In
this case, early loosening of a cemented revision
component is likely to occur (70) and impaction
grafting or trabecular metal can be used for these
situations (71, 72). AKP for an extended period of
time (1–2 years) can be anticipated after removal
of the component without revision.
Literature review
The authors conducted a literature review includ-
ing the reports of two National Joint Replacement
Registries, 13 RCT’s, and four recently published
meta-analyses presented in one of four major

Orthopaedic journals (The
Th American and British
volume of the Journal of Bone and Joint Surgery,
Clinical Orthopaedics and Related Research and
The Journal of Arthroplasty) (Tables 1, 2, and 4).
National Joint Replacement Registry data
The advantage of data derived from registries is
that the overall impact of one variable can be stud-
ied in a large cohort. The disadvantage is the lack
of detailed information regarding the variable of
interest.
Robertsson (30) reported an analysis of patient
satisfaction in 27,372 knees operated on between
1981 and 1995 from the Swedish Knee Arthroplasty
Register. Patients without resurfacing of the patella
were generally not as satisfied
fi as those with RS, irre-
spective if they had a TKA for osteoarthritis (19% of
NRS vs. 15% of RS were not satisfi fied) or rheumatoid
arthritis (15% of NRS vs. 12% of RS were not satis-
fied). The authors found a decrease in satisfaction in
the RS over time and concluded that the benefit fi of
patellar RS diminishes with time (30).
The 2008 Annual Report from the Australian
National Joint Replacement Registry (54) was
analyzed by the authors. Slightly more surgeons
did not resurface the patella, but the use of RS
increased over the last 2 years from 42% in 2005
to 45% in 2007. Patients with resurfaced patellae
(N
N = 70,968) had a signifi ficantly (p < 0.001) lower
risk for revision for any reason in comparison to
those with non-resurfaced patellae (N N = 93,796).
Revisions per 100 observed component years were
0.7 and 0.9 in the RS and NRS group, respectively.
Similarly, the cumulative percent revision rate
at 7 years was 3.8 and 4.7% in the RS and NRS
group, respectively. Secondary RS with or without
a polyethylene insert exchange represented the
vast majority (54%) of minor revisions. The 3-year
cumulative rerevision rate was slightly – but not
ficantly – higher in patients that had under-
signifi
gone a minor revision (15.8%) in comparison to
patients that underwent an all-component revi-
sion (12.5%). These
Th data confifirm previous conclu-
sions that secondary RS without major component
revision has less predictable results than all com-
ponent revisions for patients with residual knee
pain following TKA (1, 30, 55).
Randomized controlled trials
Thirteen prospective trials of which 11 were ran-
domized controlled were evaluated. Four papers
(1, 18, 19, 33) were consecutive follow-up reports
of three previously reported trials (17, 22, 31)
(Table 1).
Why I always resurface the patella in TKA 851
Outcome scores of osteoarthritic knees
The distinction between osteoarthritis and rheu-
matoid arthritis as the primary indication for TKA
is important since NRS in rheumatoid arthritis
has been reported with less predictable results
(19). If the results of all reports were included,
then a mean of 23% of resurfaced and 25% of non-
resurfaced knees had AKP at an average follow-up
time of 4.75 years (range, 2–10.8). With a maxi-
mum follow-up time of 10 years, the incidence
of AKP was by average 20 and 24% in the RS and
NRS group, respectively. The Th mean incidence of
AKP increased to 34 and 28%, respectively, if the
follow-up time was minimal 10 years. This Th find-
ing seems to be in concert with the conclusion of
Robertson that the benefi fit of patellar resurfacing
diminishes with time (30). The Th incidence of AKP
was signifi ficantly less in the resurfaced group in
two RCTs (including in total 694 knees) at a mean
of 4 (28) and 5.3 (27) years of follow-up. No signifi- fi
cant difffference between both groups was found in
the other trials (Table 2). The presence of AKP with
stair-climbing was compared between both groups
in six trials and was found to be signifificantly less in
the NRS group in one trial (24). Satisfaction rates
were presented in four trials and were found to be
ficantly better for RS in one trial but it was
signifi
unclear whether patients with rheumatoid arthri-
tis were also included in this evaluation (27). Total
Knee Society Clinical rating scores were reported
in seven trials and were not signifi ficantly diff
fferent
between RS and NRS groups. Range of motion was
evaluated in five trials and was not signifi ficantly
diff
fferent between both groups.
Outcome scores of patients with rheumatoid arthritis
Thirty-fi
five per cent of the knees without patel-
lar resurfacing had AKP in comparison to none of
the resurfaced knees at 6.6 years of follow-up (19,
22). Rheumatoid arthritis can therefore be consid-
ered as an absolute indication to resurface every
patella.
Bilateral TKA
Four prospective trials reported on the
patients’preference in bilateral TKA (22, 27, 31,
43). By average 45% of the patients preferred the
resurfaced side and only 18% the non-resurfaced
side (Table 2). In Barrack’s consecutive series,
there was a clear decrease in preference for the
non-resurfaced side from 38 to 22% over a fol-
low-up period from 2.5 to 10 years. Th The prefer-
ence for the resurfaced side remained stable over
the same follow-up period (34 and 37% resp.) (1,
31). Finally, Burnett’s minimal 10-year follow-up
report of these trials could not detect a signifi-fi
cant diff
fference in preference (33). In the series of
852 Primary Total Knee Arthroplasty
Waters (27) and Enis (43) it was unclear whether
patients with rheumatoid arthritis were included
in the evaluation of bilateral TKA. The patients in
both series had a high preference for the resurfaced
(51 and 45% resp.) over the non-resurfaced knee
(11 and 15% resp.) at a mean follow-up of 5.3 and
3.3 years, respectively. In a prospective series with
only rheumatoid arthritis patients reported by
Shoji (22), respectively 23 and 29% of patients had
a preference for the resurfaced and non-resurfaced
knee at a mean of 2.7 years of follow-up.
Complications
The overall re-operation rate of all enrolled patients
was 7.3% (Table 4). The overall PF-related re-oper-
ation rate was 3% in the resurfaced versus 6.5% in
the non-resurfaced knees. The average complica-
tion rate (fracture, loosening, and osteonecrosis)
directly attributed to patellar resurfacing was 1.2%
in 592 knees. Two additional knees had an isolated
revision of the patellar component. Th Thus in total
1.5% of the resurfaced knees (N N = 9) had a re-
operation directed toward the patella. Secondary
resurfacing procedures represented 85% of the PF
re-operations in the non-resurfaced group. Thus Th
in total 5.5% of the non-resurfaced knees (N N =
35) had a re-operation directed toward the patella.
Moreover, in total 1.5% of the resurfaced (N N = 9)
and 0.9% of the non-resurfaced knees (N N = 6) had
undergone a PF-related re-operation that was not
directed toward the patella. Th
This indicates that the
vast majority of re-operations were directed toward
the patella if the patella was not resurfaced. But it
also indicates that the PF-related operations would
be less in the non-resurfacing group if secondary
resurfacing would not be performed. Th There was no
correlation between pre-operative AKP or patel-
lar chondromalacia and the post-operative rate of
AKP or PF-related re-operations. Therefore
Th in our
opinion, these two guidelines that are generally
used for selective resurfacing are not supported by
evidence-based data.
Meta-analyses
Four comprehensive and recently published
meta-analyses using various methodologies were
reviewed (51, 55, 73, 74). Th Three of these meta-
analyses failed to show clear superiority of either
option but the authors considered resurfacing of
the patella to be a superior strategy with regard to
less frequent AKP and less need for re-operation
(51, 55, 73, 74). Parvizi (73) reported a meta-anal-
ysis of 14 RCTs. A lower relative risk of knee pain
after patellar RS was detected (p( < 0.00001) which
remained present after eradication of the influ-fl
ence of heterogeneity between diff fferent RCTs (p
= 0.01). Patients were more likely (p( < 0.0001) to
report better satisfaction with RS but this differ-
ff
ence in satisfaction disappeared after eradication
of the infl
fluence of heterogeneity. Furthermore,
there were no diff fferences in complication rates,
revisions or functional scores. Almost 9% of the
non-resurfaced knees had undergone a second-
ary resurfacing. No data on the outcome of these
procedures were provided. Nizard (74) concluded
from 15 prospective trials that the relative risks
for re-operation and AKP were in favor of RS (0.43
and 0.39, respectively) but that the follow-up
time in most studies was not long enough to draw
firm conclusions. In another analysis reported by
Pakos (51) it became clear that there was a time-
related benefi
fit of RS over NRS since only among
trials with at least 5 years of follow-up the odds
of re-operation were signifi ficantly smaller if the
patella had been resurfaced. They concluded that
one would need to resurface 15 patellae to pre-
vent one re-operation. Recently, Helmy (55) pre-
sented a predictive model based on seven RCTs.
The probability of having AKP in patients with RS
was 12% compared to 26% for NRS. In addition,
the probability of a PF-related re-operation was
2.8% in the resurfaced group whereas it was 7.2%
in non-resurfaced group. They also calculated that
the maximum achievable health utility following
a TKA could be achieved in 88% of the resurfaced
and in 74% of the non-resurfaced patients, indi-
cating that patellar RS leads to more reproducible
results. They concluded that RS remains the pref-
erable treatment of choice as long as the incidence
of AKP in resurfaced knees remains below 29% or
as long as the incidence of AKP in non-resurfaced
knees remains above 12%. Finally, they calculated
that resurfacing every patella would respectively
prevent one case of AKP and one re-operation for
every seven and 23 patients that would not have
been resurfaced (55).
Conclusion: “why should I not
resurface the patella?”
The primary goals of replacing the arthritic, painful
knee joint are to optimally improve the function-
ality of the patients with a minimal incidence of
residual knee pain. Both goals can reproducibly be
achieved either with or without resurfacing of the
patella. Most RCTs were not able to clearly indicate
a decreased incidence of AKP in knees where the
patella had been resurfaced. In our opinion, and
taking the results of several meta-analyses into
consideration, there is at least a trend toward a
decreased incidence of AKP if the patella had been
resurfaced. Taken together the data from 13 trials,

two Joint Replacement Registries, and four meta-
analyses, we conclude that prior to the 10-year fol-
low-up period, resurfacing of the patella leads to
more reproducible results regarding AKP. This Th find-
ing is even more substantiated by the high prefer-
ence for the resurfaced knee in patients with bilat-
eral TKA. The benefificial eff
ffect of resurfacing seems
to be diminished beyond 10 years of follow-up but
the results of only 138 patients from three trials
were available.
So why should we not resurface the patella? Pro-
ponents of non-resurfacing, or selective resurfac-
ing, argue the potential for a diminished risk of
extensor mechanism complications. Revising the
resurfaced patella can surely be very hazardous
and detrimental for the extensor mechanism. But
we believe that these risks are relative and are to
a certain extend controlled by meticulous surgi-
cal techniques. The risks are relative because they
should be evaluated in the light of the complica-
tion risks of the alternative, namely non-resurfac-
ing. In the evaluated trials, 50% fewer of the knees
with a resurfaced patella had undergone a re-op-
eration for PF-related problems in comparison to
non-resurfaced knees. Thus by not resurfacing the
patella the patient is exposed to an increased risk
of PF-related re-operations. Furthermore, without
clear indications for secondary resurfacing, four
times more patients underwent a re-intervention
that was directed toward the patellar bone. This Th
higher risk for a re-intervention can be taken away
by either resurfacing every patella or by evidence-
based indications for secondary resurfacing. As
long as the latter data are not available, we will
keep on resurfacing every patella at primary sur-
gery. Alternatively, one could decide to never con-
duct isolated secondary resurfacings. Th This can be
hard in the real world when the surgeon is faced
with the patient with a normal XR or an XR with
PF degenerative changes in a patient with a painful
total knee replacement.
There are some important shortcoming in the
present evidence-based literature. First, the vast
majority of trials started more than 15 years ago.
The surgical techniques and designs have dra-
matically evolved over time. Second, only one trial
randomized for posterior cruciate retaining or
substituting. The
Th finding that the results change
over 10 years of follow-up might be attributable
to increased posterior ligament laxity. Finally and
in our opinion most importantly, none of the tri-
als controlled for the indication of re-intervention.
The most important and most obvious diff
Th fference
between either resurfacing or not, is the re-oper-
ation rate directed toward the patella. The Th whole
controversy about the subject might disappear
once well-conducted RCTs with control for re-in-
tervention have been conducted. As long as these
Why I always resurface the patella in TKA 853
flaws are not eradicated in the evidence-based lit-
erature, we will continue to resurface every knee
since we believe that we can offffer a more reliable
and reproducible solution to our patients’painful
arthritic knee by resurfacing their patellae.
References
1. Barrack RL, Bertot AJ, Wolfe MW, et al. (2001) Patellar
resurfacing in total knee arthroplasty: a prospective, ran-
domized, double-blind study with five to seven years of
follow up. J Bone Joint Surg Am 83-A:1376–1381
2. Clayton ML, Thirupathi R (1982) Patellar complications
after total condylar arthroplasty. Clin Orthop 170:152–
155
3. Freeman MA, Samuelson KM, Elias SG, et al. (1989) The Th
patellofemoral joint in total knee prostheses: design con-
siderations. J Arthroplasty 4(Suppl): S69–S74
4. Insall J, Scott WN, Ranawat CS (1979) The total condy-
lar knee prosthesis. A report of two hundred and twenty
cases. J Bone Joint Surg Am 61:173–180
5. Insall J, Tria AJ, Scott WN (1979) The total condylar knee
prosthesis: the first 5 years. Clin Orthop 145:68–77
6. Insall JN, Ranawat CS, Aglietti P, Shine J (1976) A com-
parison of four models of total kneereplacement prosthe-
ses. J Bone Joint Surg Am 58:754–765
7. Mochizuki RM, Schurman DJ (1979) Patellar complica-
tions following total knee arthroplasty. J Bone Joint Surg
Am 61:879–883
8. Murray DG, Webster DA (1981) The Th variable-axis knee
prosthesis. Two-year follow-up study. J Bone Joint Surg
Am 63:687–694
9. Boyd AD Jr, Ewald FC, Thomas
Th WH, et al. (1993) Long-
term complications after total knee arthroplasty with or
without resurfacing of the patella. J Bone Joint Surg Am
75-A:674–681
10. Burnett RS, Bourne RB (2003) Indications for patellar
resurfacing in total knee arthroplasty. J Bone Jont Surg
Am 85:728–745
11. Keblish PA, Varma AK, Greenwald A (1994) Patellar resur-
facing or retention in total knee arthroplasty: a prospec-
tive study of patients with bilateral replacements. J Bone
Joint Surg Br 76:930–937
12. Kim BS, Reitman RD, Schai PA, Scott RD (1999) Selective
patellar nonresurfacing in total knee arthroplasty: 10 year
results. Clin Orthop 367:81–88
13. Levitsky KA, Harris WJ, McManus J, Scott RD (1993)
Total knee arthroplasty without patellar resurfacing.
Clinical outcomes and long-term followup evaluation. Clin
Orthop 286:116–121
14. Beight JL, Yao B, Hozack WJ, et al. (1994) The patellar
‘‘clunk’’ syndrome after posterior stabilized arthroplasty.
Clin Orthop 299:139–142
15. Vince KG, McPherson EJ (1992) The patella in total knee
arthroplasty. Orthop Clin North Am 23:675–686
16. Picetti GD, McGann WA, Welch RB (1990) The patellofem-
oral joint after total knee arthroplasty without patellar
resurfacing. J Bone Joint Surg Am 72:1379–1382
17. Bourne RB, Rorabeck CH, Vaz M, et al. (1995) Resurfac-
ing versus not resurfacing the patella during total knee
replacement. Clin Orthop 321:156–161
18. Burnett RS, Haydon CM, Rorabeck CH, Bourne RB (2004)
Patella resurfacing versus nonresurfacing in total knee
arthroplasty: results of a randomized controlled clinical
trial at a minimum of 10 years’followup. Clin Orthop Relat
Res 428:12–25
19. Kajino A, Yoshino S, Kameyama S, et al. (1997) Compari-
son of the results of bilateral total knee arthroplasty with
854 Primary Total Knee Arthroplasty
and without patellar replacement for rheumatoid arthri-
tis. A follow-up note. J Bone Joint Surg Am 79:570–574
20. Komistek RD, Dennis DA, Mabe A, Walker S (2000) An in
vivo determination of patellofemoral contact positions. J
Clin Biomech 15:29–36
21. Matsuda S, Ishinishi T, White SE, Whiteside LA (1997)
Patellofemoral joint after total knee arthroplasty: effect
ff
on contact area and contact stress. J Arthroplasty 12:790–
797
22. Shoji H, Yoshino S, Kajino A (1989) Patellar replacement
in bilateral total knee arthroplasty: a study of patients
who had rheumatoid arthritis and no gross deformity of
the patella. J Bone Joint Surg 71A:853–856
23. Stiehl JB, Komistek RD, Dennis DA, Keblish PA (2001)
Kinematics of the patellofemoral joint in total knee
arthroplasty. J Arthroplasty 16:707–714
24. Feller JA, Bartlett RJ, Lang DM (1996) Patellar resurfac-
ing versus retention in total knee arthroplasty. J Bone
Joint Surg Br 78-B:226–228
25. Insall JN, Tria AJ, Aglietti P (1980) Resurfacing of the
patella. J Bone Joint Surg Am 62:933–936
26. Ranawat CS (1986) The patellofemoral joint in total
condylar knee arthroplasty. Pros and cons based on
five-to ten-year follow-up observations. Clin Orthop
205:93–99
27. Waters TS, Bentley G (2003) Patellar resurfacing in total
knee arthroplasty: a prospective randomized study. J
Bone Joint Surg Am 85-A:212–217
28. Wood DJ, Smith AJ, Collopy D, et al. (2002) Patellar resur-
facing in total knee arthroplasty: a prospective, random-
ized trial. J Bone Joint Surg Am 84-A:187–193
29. Piantadosi S (1997) Clinical trials: a methodologic per-
spective. Wiley, New York
30. Robertsson O, Dunbar M, Pehrsson T, et al. (2000) Patient
satisfaction after knee arthroplasty: a report on 27,372
knees operated on between 1981 and 1995 in Sweden.
Acta Orthop Scand 71:262–267
31. Barrack RL, Wolfe MW, Waldman DA, et al. (1997) Resur-
facing of the patella in total knee arthroplasty: a prospec-
tive, randomized, double-blind study. J Bone Joint Surg
78A:1121–1131
32. Campbell DG, Duncan WW, Ashworth M, et al. (2006)
Patellar resurfacing in total knee replacement. J Bone
Joint Surg Br 88:734–739
33. Burnett RS, Boone JL, McCarthy KP, et al. (2007) A pro-
spective randomized clinical trial of patellar resurfacing
and nonresurfacing in bilateral TKA. Clin Orthop Relat
Res 464:65–72
34. Smith AJ, Wood DJ, Li MG (2008) Total knee replacement
with and without patellar resurfacing. J Bone Joint Surg
Br 90:43–49
35. Stern SH, Moeckel BH, Insall JN (1991) Total knee arthro-
plasty in valgus knees. Clin Orthop 273:5–8
36. Dalury DF, Jiranek WA (1999) A comparison of the mid-
vastus and paramedian approaches for total knee arthro-
plasty. J Arthroplasty 14:33–37
37. White RE, Allman JK, Trauger JA, Dales BH (1999) Clini-
cal comparison of midvastus and medial parapatellar sur-
gical approaches. Clin Orthop 367:117–122
38. Barrack RL, Schrader T, Bertot AJ, et al. (2001). Com-
ponent rotation and anterior knee pain after total knee
arthroplasty. Clin Orthop 392:46-55
39. Berger RA, Crossett LS, Jacobs JJ, Rubash HE (1998) Mal-
rotation causing patellofemoral complications after total
knee arthroplasty. Clin Orthop 356:144–153
40. Incavo SJ, Coughlin KM, Pappas C, Beynnn BD (2003)
Anatomic rotational relationships of the proximal tibia,
distal femur and patella. J Arthroplasty 18:643–648
41. Miller MC, Berger RA, Petrella AJ, et al. (2001) Optimizing
femoral component rotation in total knee arthroplasty.
Clin Orthop 382:38–45
42. Weber AB, Worland RL, Jessup DE, et al. (2003) The Th con-
sequences of lateral release in total knee replacements: a
review of over 1000 knees with follow-up between 5 and
11 years. Knee 10:187–191
43. Enis JE, Gardner R, Robledo MA et al. (1990) Comparison
of patellar resurfacing versus nonresurfacing in bilateral
total knee arthroplasty. Clin Orthop Relat Res 260:38-42
44. Reuben JD, McDonald L, Woodard PL, Hennington LJ
(1991) Effffect of patella thickness on patella strain fol-
lowing total knee replacement. J Arthroplasty 6:251–
258
45. Dennis DA (1997) Extensor mechanism problems in total
knee arthroplasty. Instr Course Lect 46:171–180
46. Barrack RL, Wolfe MW (2000) Patellar resurfacing in total
knee arthroplasty. J Am Acad Orthop Surg 8:75–82
47. Scuderi GR, Insall JN, Scott WN (1994) Patellofemoral
pain after total knee arthroplasty. J Am Acad Orthop Surg
2:239–246
48. Dennis DA (1995) Patellofemoral complications in total
knee arthroplasty. In: Kesser JR (editor) Orthopae-
dic knowledge update 5. Home study syllabus. Ameri-
can Academy of Orthopaedic Surgeons, Rosemont IL,
1995:283–289
49. Petersilge WJ, Oishi CS, Kaufman KR, et al. (1994) The Th
eff
ffect of trochlear design on patellofemoral shear and
compressive forces in total knee arthroplasty. Clin Orthop
309:124–130
50. Theis SM, Kitziger KJ, Lotke PS, Lotke PA (1996) Compo-
nent design affffecting patellofemoral complications after
total knee arthroplasty. Clin Orthop 326:183–187
51. Pakos EE, Ntzani EE, Trikalinos TA (2005) Patellar resur-
facing in total knee arthroplasty: a meta-analysis. J Bone
Joint Surg Am 87:1438–1445
52. Mayman D, Bourne RB, Rorabeck CH, et al. (2003) Resur-
facing versus not resurfacing the patella in total knee
arthroplasty: 8- to 10-year results. J Arthroplasty 18:541–
545
53. Muoneke HE, Khan AM, Giannikas KA, et al. (2003) Sec-
ondary resurfacing of the patella for persistent anterior
knee pain after primary knee arthroplasty. J Bone Joint
Surg Br 85-B:675–678
54. Association National Joint Replacement Registry. Annual
Report. AOA, Adelaide
55. Helmy N, Anglin C, Greidanus NV, Masri BA (2008) To
resurface or not to resurface the patella in total knee
arthroplasty. CORR 466:2775-2783
56. Dennis DA (1992) Patellofemoral complications in total
knee arthroplasty: a literature review. Am J Knee Surg
5:156–166
57. Healy WL, Wasilewski SA, Takei R, Oberlander M (1995)
Patellofemoral complications following total knee arthro-
plasty: correlation with implant design and patient risk
factors. J Arthroplasty 10:197–201
58. Holt GE, Dennis DA (2003) The role of patellar resurfacing
in total knee arthroplasty. Clin Orthop 416:76–83
59. Berry DJ, Rand JA (1993) Isolated patellar component
revision of total knee arthroplasty. Clin Orthop 286:110–
115
60. Ortiguera CJ, Berry DJ. Patellar fracture after total knee
arthroplasty. J Bone Joint Surg 84A:532–540, 2002
61. Grace JN, Rand JA (1988) Patellar instability after total
knee arthroplasty. Clin Orthop 237:184–189
62. Lucas TS, Deluca MD, Nazarian DG (1999) Arthroscopic
treatment of patellar clunk. Clin Orthop 367:226–
229
63. Markel DC, Luessenhop CP, Windsor RE, Sculco TA (1996)
Arthroscopic treatment of peripatellar fi fibrosis after total
knee arthroplsty. J Arthroplasty 11:293–291
64. Berend ME, Ritter MA, Keating EM, et al. (2001) The Th fail-
ure of all-polyethylene patellar components in total knee
arthroplasty. Clin Orthop 388:105–111

65. Collier JP, McNamara JL, Surprenant VA, et al. (1991). All-
polyethylene patellar components are not the answer. Clin
Orthop 273:198–203
66. Lonner JH, Lotke PA (1999) Aseptic complications after
total knee arthroplasty. J Am Acad Orthop Surg 7:311–
324
67. Leopold SS, Silverton CD, Barden RM, Rosenberg AG
(2003) Isolated revision of patellar component in total
knee arthroplasty. J Bone Joint Surg Am 85:41–47
68. Lonner JH, Mont MM, Sharkey PF, et al. (2003) Fate
of the unrevised all-polyethylene patellar component
in revision total knee arthroplasty. J Bone Joint Surg
85:56–59
69. Kelly M (2001) Patellofemoral complications following
total knee arthroplasty. Instr Course Lect 50:403–407
Why I always resurface the patella in TKA 855
70. Bayley JC, Scott RD, Ewald FC, Holmes GB (1988) Failure
of the metal-backed patella component after total knee
replacement. J Bone Joint Surg 70A:668–674
71. Rosenberg AG, Jacobs JJ, Saleh KJ, et al. (2003) The Th
Patella in Revision Total Knee Arthroplasty. J Bone Joint
Surg Am 85: S63–S70
72. Garcia RM, Kraay MJ, Conroy-Smith PA, Goldberg VM et
al. (2008) Management of the deficient
fi patella in revision
total knee arthroplasty. Clin Orthop 466:2790–2797
73. Newman JH, Shah NA, Karachalios T (2000) Should the
patella be resurfaced during total knee replacement? Knee
7:17–23
74. Nizard RS, Biau D, Porcher R, et al. (2005) A meta-analysis
of patellar replacement in total knee arthroplasty. Clin
Orthop Relat Res 432:196–203

A. J. Bigham,
J. L. Howard
Why I do not routinely resurface
the patella in TKA
Introduction
W
hether or not to resurface the patella in
total knee arthroplasty is a debate that
dates back to the early 1980s. It remains
unclear, even reviewing the most recent literature
in 2009, whether patellar resurfacing should be
done in every primary arthroplasty, only in selec-
tive cases, or whether it should not be done at all.
This chapter will discuss the historic perspective
for patellar resurfacing and discuss the recent lit-
erature that has infl
fluenced the current and future
direction of research surrounding patellar resur-
facing. It will highlight the difficulties
ffi that have
made this topic such a conundrum for orthopedic
surgeons and suggest that it is not necessary to
routinely resurface the patella.
Fig. 1 – (A and B) Patellar fracture with AVN following patellar
resurfacing.
Chapter 80
Historical notes
Historically, resurfacing the patella has come under
signifi
ficant scrutiny for a multitude of reasons. Ini-
tially in total knee arthroplasty, the patella was
never resurfaced. However, as patients began to
complain of anterior knee pain, the solution was
to resurface the patella in all cases (1–3). Through-
out the early and mid 1980s this was the standard
of practice. However, subsequent literature began
to highlight the complications of patellar resurfac-
ing including periprosthetic fracture, disruption
to the extensor mechanism, avascular necrosis,
patellar component loosening, and diffi fficulty with
revisions in these contexts (4–9) (Figs. 1 and 2).
This was the beginning of the debate surrounding
patellar resurfacing and formed the basis for the
initial research to determine which caused “less
harm”; to resurface the patella and assume those
associated risks or to not resurface and be faced
with anterior knee pain and the potential need for
revision surgery and secondary resurfacing.
Over time additional literature has amassed
designed to clarify variables related to the patellar
resurfacing controversy. This has included studies
addressing the cause of anterior knee pain (10–12),
the importance of component design both from a
patellar perspective (13) and femoral perspective
(14–16), the biomechanical nature of the patell-
ofemoral joint (17–23), and our ability to properly
assess pain and patient satisfaction with respect
to the patellofemoral joint (24–28). Despite this
increase in knowledge and understanding of these
Fig. 2 – Follow up radiograph on a total knee arthroplasty with a dis-
placed patellar component.
858 Primary Total Knee Arthroplasty
variables, many surgeons still debate whether or
not to routinely resurface the patella.
The cause of anterior knee pain
Anterior knee pain is universally discussed in stud-
ies addressing patellar resurfacing. Unfortunately,
research to date has not been able to adequately
defi
fine the pathologic cause of anterior knee pain.
Indeed, this pain, from a patient’s perspective, is any
pain that is centered around the patella. In fact the
source of the pain could be from the patella or any
of the surrounding structures. Certainly, resurfacing
either primarily or secondarily has not been shown
to consistently eliminate anterior knee pain indicat-
ing there are other factors contributing to anterior
knee pain beyond the status of the articular cartilage
(29–31). Due to this multi-factorial nature of ante-
rior knee pain, it has been difficult
ffi to defi
fine an out-
come measure to address the question of whether or
not to resurface the patella. Assessment tools such
as the International Knee Society Score (IKS), Visual
Analogue Pain Scores (VAS) during stair climbing or
rising from a chair, non-validated patella specific
fi pain
questionnaires, and overall patient satisfaction have
all been utilized in the past. None of these measures
evaluate the patellofemoral articulation in isolation,
and therefore variation in scores cannot be defini- fi
tively attributed to the status of the patellar surface.
Certainly if one makes the assumption that ante-
rior knee pain is caused solely by the patellofemoral
articulation, then a simple resurfacing in all patients
would be all that is required. Unfortunately, this has
not been demonstrated in the literature. Radio-
graphic changes before and after knee replacement
have not shown any correlation with anterior knee
pain following surgery (10, 32). Furthermore, com-
parison of the Outerbridge classification
fi of carti-
lage loss in the patellofemoral joint with anterior
knee pain following surgery has resulted only in a
weak correlation and no correlation to function of
the knee following arthroplasty (11). Therefore,
Th
simply addressing the cartilage in patellofemoral
reconstruction is inadequate to completely resolve
patient’s complaints of anterior knee pain.
Kinematics and soft tissue balancing
The patellofemoral joint has been described as the
“keystone” of the knee and therefore management
of the patellofemoral articulation effects
ff outcome
in total knee arthroplasty (33, 34). As total knee
arthroplasty techniques have continued to evolve
it has become clear that careful attention must be
paid to every aspect of joint kinematics to have an
optimal result. Attention to soft tissues balance
and repair of the tissue surrounding the patell-
ofemoral joint is as important as balancing of the
tibiofemoral joint. As it pertains to joint kinemat-
ics, the description of the knee as a simple hinge
joint is much too simple. Not only does this ignore
the normal external rotation that occurs through
the tibiofemoral articulation with normal ambu-
lation it also ignores the complex articulation of
the patellofemoral joint. Additionally, it ignores
the interdependence of the three joint surfaces
and the necessity of component placement at each
step to provide the best surgical outcome (35, 36).
The patella follows a curvilinear path as the knee
moves from extension into flexion and the contact
pressures experienced by this articulation are a
direct result of the balance of many integral com-
ponents. This path is controlled by a number of
soft tissue components as well as bony anatomy.
Included in these components are, balanced quad-
riceps musculature, the retinaculum, the patellar
tendon, the articulation with the trochlea includ-
ing the depth and length of the trochlea as well as
the shape of the femoral condyles and shape of the
patella (16, 17, 37–40). In fact, a study by Shih et
al. suggests that a significant
fi portion of anterior
knee pain may be secondary to maltracking (41)
The kinematics of the patellofemoral joint only
serve to magnify any complication as a result of
these components because approximately 3x the
patient’s body weight can be transferred through
this articulation with normal activities including
stair climbing and standing from a seated position
and up to 8x in deep knee bends (42). It is clear
that inadequately addressing this joint either from
component design or repair following arthroplasty
will only serve to cloud outcome measures.
It is well documented that proper balancing of the
tibiofemoral joint is required for successful out-
come from a total knee arthroplasty. Failure to do
so results in instability of the knee and adversely
eff
ffects ambulation and outcome. Less research and
emphasis has been directed to the balancing of
the patellofemoral joint. Historically this joint has
essentially been viewed as a pulley designed to pro-
vide knee extension. However, this is an oversim-
plifi
fied view. Failure to adequately address issues of
overstuffi
ffing, a possible need for a lateral retinacu-
lar release, failure to adequately repair the medial
arthrotomy or stretch of the medial arthrotomy
repair can all result in different
ff force vectors and
point loading that will lead to instability and pain
(17, 21, 37, 43–45). In much of the historical litera-
ture, the authors approach to these issues was not
clearly delineated. This
Th makes it diffi
fficult to extrap-
olate and base current practice on such data.
Evolution of surgical technique and implant design
over time has made much of the historic literature

dating back to the mid 1980s and early 1990s
essentially ungeneralizable to a discussion about
patella resurfacing today. Early total knee arthro-
plasty designs recreated a hinge style tibiofemoral
articulation and essentially ignored the patellofem-
oral joint. It is no great surprise than that patients
developed a significant
fi amount of anterior knee
pain. New femoral components have been coined
to be “native patella friendly” as they are designed
with changes to the lateral condyle; a widened lat-
eral flange, and a deepened, elongated and wid-
ened trochlear groove which all serve to decrease
contact stresses and aid in patellar engagement
throughout the joint range of motion (15, 23, 46).
These changes have improved upon the original
arthroplasty components by supporting the more
natural ergonomics of the knee and thus decreas-
ing the abnormal wear and contact stresses that
are hypothesized to have caused some aspect of
anterior knee pain seen in early studies (14, 19,
23, 47). In the same way, much of the discussion
surrounding complications of patella resurfacing
including the risks of AVN and component failure
dating from the mid 1980s is essentially irrelevant
as techniques have changed and awareness of the
complications has lead to increased care and atten-
tion when resurfacing (45). Any argument for or
against resurfacing must be derived from litera-
ture that takes into account the improvements in
component design and surgical technique.
The meta-analyses and before
Three meta-analyses were published in 2005 which
include over 21 difffferent articles (48–50Erreur !
Source du renvoi introuvable.). The Th conclusions
from the meta-analyses tended to show increased
rates of anterior knee pain and the need for re-
operation in patients with unresurfaced patel-
lae. However, a more careful review of the studies
considered in the meta-analyses suggests that the
results may not be generalizable to current practice.
In total, only seven articles were cited in all three
reviews (27, 31, 51–55). Three (27, 31, 51) of these
seven articles account for approximately 75% of the
total knee replacements with 782 knees analyzed
between them. We will focus on these three articles
as they account for the vast majority of total knee
replacements in the meta-analyses. Considering
the number of patients in these articles, conclusion
drawn from them will influence
fl the conclusions
that could be drawn from the meta-analyses.
The oldest of the three articles is that of Barrack
et al. in 2001 which includes 58 resurfaced and 60
knees treated with patelloplasty during replace-
ment with the Miller-Galante II total knee proth-
Why I do not routinely resurface the patella in TKA 859
esis. This randomized control trial was published
on 5–7-year follow-up and included 73 and 76% of
the patients respectively in the final analysis. Out-
come measures included IKS, anterior knee pain,
patient satisfaction, range of motion (ROM), and
re-operations. Seven of the non-resurfaced knees
were treated with revision for resurfacing repre-
senting a 12% revision rate. None of the initially
resurfaced knees were revised for anterior knee
pain. There was no noted diff fference in IKS, anterior
knee pain, patient satisfaction and ROM between
the two groups at time of final
fi follow-up.
Wood et al. in 2002 published on 128 non-resur-
faced and 92 resurfaced Miller-Galante II total knee
arthroplasties. This RCT had a mean follow-up of
48 months and included over 95% of the originally
enrolled patients in the final analysis. The authors
noted a significant
fi diff
fference in described and
localized anterior knee pain following surgery with
39 non-resurfaced patients (31%) and 15 resur-
faced patients (16%) describing these symptoms.
Interestingly, however, this significant
fi diff
fference
was not maintained with loading of the patel-
lofemoral joint during stair climbing in which 30
non-resurfaced patients (25%) and 14 resurfaced
patients (17%) reported anterior knee pain during
this exercise. No significant
fi diff
fference was noted
with the Knee society score or patient satisfaction
or with revision of the patellofemoral compart-
ment for any reason.
Most recently in 2003, Waters et al., published their
RCT on 231 non-resurfaced and 243 resurfaced
PFC prostheses with additional randomization for
cruciate sacrifi
ficing and sparing. They reported a
statistical significant
fi difffference in anterior knee
pain (25.1% vs. 5.3% respectively) and in patient
satisfaction. Additionally, the authors reported
a signifi
ficant diff
fference of 2.5 on the knee society
scores, which they deemed to be clinically relevant.
There was, however, no signifi ficant diff
fference in
functional outcome or ROM as determined using
knee society functional scores and post-operative
measurements.
These three articles represent the best of the RCTs
prior to the published meta-analyses. Unfortu-
nately, since these studies were initiated, newer
research has shown that the results are essen-
tially ungeneralizable to other knee prostheses.
The implants in the RCT’s have been shown to be
poor prosthetic choices to study the interaction
of a native patella in the patellofemoral joint. In
an article published in 2001, Tanzer noted using
cadavers that contact stresses varied signifi ficantly
depending on the femoral component (15). Of
note, the PFC prosthesis utilized by Waters had
a femoral notch that was “incompatible” with
the native patella at flexion angles >90°. At these
ranges there was impingement of the retropatel-
860 Primary Total Knee Arthroplasty
lar surface on the intracondylar notch resulting in
a marked indentation of the patella or dislocation
of the patella into the notch. This
Th was associated
with rapid changes in the contact areas on the
joint surface of the patella. Additionally this study
showed that all five components studied (Miller/
Galante II, Anatomic Modular Knee (AMK) Sys-
tem, Whiteside Ortholoc Modular, press-fi fit condy-
lar (PFC) and Insall-Burstein II) showed significant
fi
decreases in overall contact surface area resulting
in increases in contact stresses and point loading
as flexion angles increased.
Other research has also delineated that the pros-
thetic design has an effect
ff on patellofemoral pain
and outcomes. Whiteside compared the second
generation Ortholoc II to two newer generation
knees (Profixfi and Advantim) and noted that there
was signifi
ficantly less reported anterior knee pain
when climbing stairs, signifi ficantly higher IKS
scores and a signifificantly lower revision rate for PF
symptoms with the newer prostheses (46). Addi-
tionally, in the laboratory, Whiteside noted that
fix and Advantim demonstrated signifi
Profi ficantly
lower mean contact pressures and improved sur-
face contact than the Ortholoc II prosthesis at all
flexion angles greater than 60°. The newest pros-
thesis, Profifix, which had a deepened and widened
femoral notch and a wider lateral flange to support
the patella demonstrated no significant
fi diff
fference
in mean contact pressures and contact surface
when compared to the native knee. These early
reports have been substantiated by a more recent
report by Ma et al. in 2007 in which the conformity
of the patellofemoral joint in multiple prostheses
was measured (56). This study noted that the Low
Contact Stress prothesis, an anatomically designed
femoral component, had no significant fi diff
fference
in conformity during the native patella articula-
tion at all flexion angles. Conversely the older MG
II prosthesis demonstrated a signifi ficantly diff
fferent
conformity at all flexion angles measured.
These component design issues have defi finitely cast
a considerable shadow on any practice guidelines
drawn from the earlier RCTs and the subsequent
meta-analyses derived from them. Additionally,
orthopedic surgeons have begun to recognize the
importance of many surgical factors not addressed
in older literature (12). In 2001, Barrack et al.
noted that component malrotation, including both
the tibia and femoral components, is a significantfi
factor in development of anterior knee pain (35).
Work done by Miller et al. in 2001 suggested that
matching rotation utilizing the transepicondylar
axis improved not only tibiofemoral wear but also
wear associated with the PF joint (57). A biome-
chanical study done on seven cadaveric specimens,
by Armstrong et al. in 2003 (36) noted, even in
resurfaced knees, that femoral rotation signifi- fi
cantly effected
ff patellar tilt and patellar shift. In
general it was noted that any femoral component
malposition changed the spatial position of the
patellar component. Armstrong et al. concluded
that any femoral component malposition could
result in increased wear and component failure. In
an eff
ffort to compensate for femoral malrotation
using a rotating platform mobile bearing prosthe-
sis, Kessler et al., in 2008, concluded that although
this resolved any malposition with respect to the
tibiofemoral joint it failed to address the complexi-
ties associated with the patellofemoral joint as
they were not resolved due to rotation of the tibia
(58). They further suggested that improved meth-
odologies for determining accurate rotation of the
femoral component were needed. Unfortunately
only one RCT to date has commented on their
methodology for determining femoral component
rotation and thus the bulk of the results cannot be
properly interpreted with respect to this variable.
RCTs post-meta-analysis
Following 2005 when the meta-analyses were pub-
lished, there have been subsequent randomized tri-
als that have failed to show a significant
fi diff
fference
between resurfaced and unresurfaced patellae in
TKA (32, 59, 60). Burnett et al. in 2007 republished
the 10-year follow-up on a randomized cohort of
bilateral total knee replacements with clinical fol-
low-up of 20/37 patients. This study represents the
largest study in which bilateral knee replacements
have been used to study patellofemoral resurfac-
ing. This type of study permits side to side compar-
ison and serves to eliminate patient bias and allow
a comparison of compare resurfaced to non-resur-
faced patella. There
Th were no diff fferences with regard
to range of motion, Knee Society Clinical Rating
Score, satisfaction, revision rates, or anterior knee
pain. Thirty-seven per cent of patients preferred
the resurfaced knee, 22% the non-resurfaced knee,
and 41% had no preference. Two patients (7.4%) in
the non-resurfaced group and one patient (3.5%)
in the resurfaced group underwent revision for a
patellofemoral-related complication. Smith et al.
in 2008 published their 3-year follow-up on Pro-
fix knees. As discussed earlier the components in
this system have been shown to be native patella
friendly on kinematic studies. There
Th was no dif-
ference in re-operation rate, knee scores, patient
satisfaction, and functional outcomes comparing
patients with and without patellar resurfacing.
Finally, Campbell et al. (32) evaluated 100 consecu-
tive osteoarthritic patients randomized to undergo
total knee replacement using a Miller-Galante II
prosthesis. There were no signifi ficant diff
fferences

identifi
fied between resurfaced and unresurfaced
groups on Knee Society scores, WOMAC scores,
frequency of anterior knee pain, or the incidence
of patellar crepitus.
The downside of resurfacing
As was noted earlier, the primary indication to
avoid resurfacing is to eliminate the associated
complications. Such complications have included
periprosthetic fracture, extensor mechanism dis-
ruptions, avascular necrosis, component loosen-
ing, and the diffi
fficulty of revision given minimal
bone stock (4–9). More recent studies have sug-
gested that many of these complications were
secondary to surgical technique (45, 61, 62).
Some of the earlier complications may also have
been related to the prosthesis used; as suggest by
Kavolus et al. (63). Four large retrospective studies
have quantified
fi the risk of periprosthetic fracture;
one of the main complications that does not seem
to be solely l‡inked with surgical technique. Th The
risk of periprosthetic fracture according to these
studies seems to be between 0.12 and 3.8% of all
TKA (64–67). The largest of these utilizes the Mayo
Joint Registry and puts the risk of periprosthetic
fracture at 0.9% (67). Post-operatively risk of frac-
ture is commonly related to, but not limited to, a
variety of causes including trauma, the thickness
of the remaining patella, possible devasculariza-
tion of the patella during the original surgery, poor
bone quality and male gender (68). Although seem-
ingly small, the risks of periprosthetic fracture are
associated with signifi ficant morbidity as revision
has remained suboptimal even to the present day.
Treatment has varied from non-operative to patel-
lectomy, and those patients requiring surgery have
been faced with increased risk of infection and
surgical complications (65). For some surgeons,
these poor outcomes and diffi fficulty with revisions
have been a reason to avoid resurfacing altogether,
especially in light of more recent literature show-
ing equivalence of outcomes.
Selective resurfacing
In an attempt to defi fine a middle ground many
surgeons have supported a selective surfacing
approach (9, 69, 70). Although there is little evi-
dence that selective resurfacing yields any sub-
stantial benefifit it does, however, appear theoreti-
cally sound and gives the surgeon comfort given
ficant cartilage loss at the time of surgery. The
signifi
diffi
fficulty with selective resurfacing is determining
Why I do not routinely resurface the patella in TKA 861
when it is beneficial.
fi This requires the surgeon to
predict the subset of patients that will either have
signifi
ficant patella wear without a replacement or
are more prone to anterior knee pain. As noted ear-
lier, it is diffi
fficult if not impossible to truly deter-
mine or predict, at this point in time, the root
cause of anterior knee pain. Many recent studies
have unsuccessfully attempted to correlate carti-
lage wear (utilizing the Outerbridge classification
fi
at the time of surgery), prior anterior knee pain,
weight, height, lateral retinacular release, BMI,
ROM and gender with anterior knee pain post-op-
eratively (27, 31, 51, 71). Given the multi-factorial
nature of anterior knee pain and the inability to
demonstrate a predictable pre-operative determi-
nant, the ability to selectively resurface the patella
using an evidence-based practice remains elusive.
Although some authors advocate selective resur-
facing, since the decision to resurface versus not
resurface has not been delineated, there remain no
supported guidelines for such selection other than
professional opinion.
Conclusion
The decision to resurface the patella at the time of
total knee arthroplasty remains controversial. Mul-
tiple meta-analyses have been published to try to
come to a consensus by pooling data from previ-
ous studies. Unfortunately, the conclusions of these
meta-analyses have been heavily infl fluenced by a few
studies conducted using patellar unfriendly implants.
This limits the generalizability of the results to cur-
rent practice. More recent randomized trials have
failed to show a diff fference between patients with
resurfaced and unresurfaced patellae. Although the
complications of patella resurfacing are low given
improvements in technique, they cannot be entirely
eliminated and therefore represent a source of mor-
bidity for patients. Undoubtedly, further research is
warranted and techniques and implants continue to
evolve. However, based on current evidence using
contemporary surgical techniques and implant
designs, we do not advocate routine resurfacing of
the patella in total knee arthroplasty.
References
1. Insall JN, Ranawat CS, Aglietti P, Shine J (1976) A com-
parison of four models of total knee-replacement prosthe-
ses. J Bone Joint Surg Am 58(6):754–765
2. Ranawat CS, Insall J, Shine J (1976) Duo-condylar knee
arthroplasty: hospital for special surgery design. Clin
Orthop Relat Res 120:76–82
3. Levai JP, McLeod HC, Freeman MA (1983) Why not resur-
face the patella? J Bone Joint Surg Br 65(4):448–451
862 Primary Total Knee Arthroplasty
4. Scott RD, Turoffff N, Ewald FC (1982) Stress fracture of the
patella following duopatellar total knee arthroplasty with
patellar resurfacing. Clin Orthop Relat Res 170:147–151
5. Roff
ffman M, Hirsh DM, Mendes DG (1980) Fracture of the
resurfaced patella in total knee replacement. Clin Orthop
Relat Res 148:112–116
6. Ranawat CS (1986) The patellofemoral joint in total con-
dylar knee arthroplasty. pros and cons based on five- fi to
ten-year follow-up observations. Clin Orthop Relat Res
205:93–99
7. Lynch AF, Rorabeck CH, Bourne RB (1987) Extensor
mechanism complications following total knee arthro-
plasty. J Arthroplasty 2(2):135–140
8. Brick GW, Scott RD (1988) The patellofemoral compo-
nent of total knee arthroplasty. Clin Orthop Relat Res
231:163–178
9. Boyd AD, Ewald FC, Thomas
Th WH, et al. (1993) Long-
term complications after total knee arthroplasty with or
without resurfacing of the patella. J Bone Joint Surg Am
75(5):674–681
10. Han I, Chang CB, Choi J-A, et al. (2007) Is the degree of
osteophyte formation associated with the symptoms and
functions in the patellofemoral joint in patients undergo-
ing total knee arthroplasty? Knee Surg Sports Traumatol
Arthrosc 15(4):372–377
11. Han I, Chang CB, Lee S, et al. (2005) Correlation of the
condition of the patellar articular cartilage and patel-
lofemoral symptoms and function in osteoarthritic
patients undergoing total knee arthroplasty. J Bone Joint
Surg Br 87(8):1081–1084
12. McPherson EJ (2006) Patellar tracking in primary total
knee arthroplasty. Instr Course Lect 55:439–448
13. Lachiewicz PF (2004) Implant design and techniques
for patellar resurfacing in total knee arthroplasty. Instr
Course Lect 53:187–191
14. Matsuda S, Ishinishi T, Whiteside LA (2000) Contact
stresses with an unresurfaced patella in total knee arthro-
plasty: the eff
ffect of femoral component design. Orthope-
dics 23(3):213–218
15. Tanzer M, McLean CA, Laxer E, et al. (2001) Effect ff of
femoral component designs on the contact and tracking
characteristics of the unresurfaced patella in total knee
arthroplasty. Can J Surg 44(2):127–133
16. Aglietti P, Baldini A, Buzzi R, Indelli PF (2001) Patella
resurfacing in total knee replacement: functional evalu-
ation and complications. Knee Surg Sports Traumatol
Arthrosc 9(Suppl 1): S27–S33
17. Hsu HC, Luo ZP, Rand JA, An KN (1996) Influence fl of
patellar thickness on patellar tracking and patellofemo-
ral contact characteristics after total knee arthroplasty. J
Arthroplasty 11(1):69–80
18. Matsuda S, Ishinishi T, White SE, Whiteside LA (1997) Patel-
lofemoral joint after total knee arthroplasty: effect
ff on con-
tact area and contact stress. J Arthroplasty 12(7):790–797
19. Singerman R, Gabriel SM Maheshwer CB, Kennedy JW
(1999) Patellar contact forces with and without patel-
lar resurfacing in total knee arthroplasty. J Arthroplasty
14(5):603–609
20. Fuchs S, Schütte G, Witte H, Rosenbaum D (2000) Ret-
ropatellar contact characteristics in total knee arthro-
plasty with and without patellar resurfacing. Int Orthop
24(4):191–193
21. Walker PS (2001) Biomechanics of the patella in total
knee replacement. Knee Surg Sports Traumatol Arthrosc
9(Suppl 1): S3–S7
22. Stiehl JB, Komistek RD, Dennis DA, Keblish PA (2001)
Kinematics of the patellofemoral joint in total knee
arthroplasty. J Arthroplasty 16(6):706–714
23. Skwara A, Tibesku C, Ostermeier S, et al. (2008) Differ- ff
ences in patellofemoral contact stresses between mobile-
bearing and fixed-bearing total knee arthroplasties: a
dynamic in vitro measurement. Arch Orthop Trauma Surg
129(7):901–7
24. Pollo FE, Jackson RW, Koëter S, et al. (2000) Walking,
chair rising, and stair climbing after total knee arthro-
plasty: patellar resurfacing versus nonresurfacing. Am J
Knee Surg 13(2):103–108 (discussion 108–109)
25. Berti L, Benedetti MG, Ensini A, et al. (2006) Clinical
and biomechanical assessment of patella resurfacing in
total knee arthroplasty. Clin Biomech (Bristol, Avon)
21(6):610–616
26. Smith AJ, Lloyd DG, Wood DJ (2006) A kinematic and
kinetic analysis of walking after total knee arthroplasty
with and without patellar resurfacing. Clin Biomech (Bris-
tol, Avon) 21(4):379–386
27. Barrack RL, Bertot AJ, Wolfe MW, et al. (2001) Patellar
resurfacing in total knee arthroplasty: a prospective, ran-
domized, double-blind study with five to seven years of
follow-up. J Bone Joint Surg Am 83-A(9):1376–1381
28. van Hemert WLW, Senden R, Grimm B, et al. (2009) Patella
retention versus replacement in total knee arthroplasty;
functional and clinimetric aspects. Arch Orthop Trauma
Surg 129(2):259–265
29. Karnezis IA, Vossinakis IC, Rex C, et al. (2003) Second-
ary patellar resurfacing in total knee arthroplasty: results
of multivariate analysis in two case-matched groups. J
Arthroplasty 18(8):993–998
30. Muoneke HE, Khan AM, Giannikas KA, et al. (2003) Sec-
ondary resurfacing of the patella for persistent anterior
knee pain after primary knee arthroplasty. J Bone Joint
Surg Br 85(5):675–678
31. Wood DJ, Smith AJ, Collopy D, et al. (2002) Patellar resur-
facing in total knee arthroplasty: a prospective, random-
ized trial. J Bone Joint Surg Am 84-A(2):187–193
32. Campbell DG, Duncan WW, Ashworth M, et al. (2006)
Patellar resurfacing in total knee replacement: a ten-
year randomised prospective trial. J Bone Joint Surg Br
88(6):734–739
33. Barrack RL, Burak C (2001) Patella in total knee arthro-
plasty. Clin Orthop Relat Res 389(389):62–73
34. Rhee SJ, Haddad FS (2008) Patello-femoral joint in total
knee replacement. Current Orthopedics 22:132–138
35. Barrack RL, Schrader T, Bertot AJ, et al. (2001) Compo-
nent rotation and anterior knee pain after total knee
arthroplasty. Clin Orthop Relat Res 392:46–55
36. Armstrong AD, Brien HJC, Dunning CE, et al. (2003)
Patellar position after total knee arthroplasty: influ- fl
ence of femoral component malposition. J Arthroplasty
18(4):458–465
37. Lee G-C, Cushner GD, Scuderi GR, Insall JN (2004) Opti-
mizing patellofemoral tracking during total knee arthro-
plasty. J Knee Surg 17(3):144–149 (discussion 144–50)
38. Hofmann GO, Hagena FW (1987) Pathomechanics of the
femoropatellar joint following total knee arthroplasty.
Clin Orthop Relat Res 224:251–259
39. Dalury DF, Dennis DA (2003) Extensor mechanism
problems following total knee replacement. J Knee Surg
16(2):118–122
40. Barink M, Meijerink H, Verdonschot N, et al. (2007) Asym-
metrical total knee arthroplasty does not improve patella
tracking: a study without patella resurfacing. Knee Surg
Sports Traumatol Arthrosc 15(2):184–191
41. Shih H-N, Shih L-Y, Wong Y-C, Hsu RW-W (2004) Long-
term changes of the nonresurfaced patella after total knee
arthroplasty. J Bone Joint Surg Am 86-A(5):935–939
42. Dennis DA (1992) Patellofemoral complication in total knee
arthroplasty: a literature review. Am J Knee Surg 5:156–166
43. Hsu RW (2006) The management of the patella in total
knee arthroplasty. Chang Gung Med J 29(5):448–457
44. Komistek RD, Dennis DA, Mabe JA, Walker SA (2000) An
in vivo determination of patellofemoral contact positions.
Clin Biomech (Bristol, Avon) 15(1):29–36

45. Levai JP (2001) Technical aspects: the patellar side. Knee
Surg Sports Traumatol Arthrosc 9(Suppl 1): S19–S20
46. Whiteside LA, Nakamura T (2003) Effect ff of femoral com-
ponent design on unresurfaced patellas in knee arthro-
plasty. Clin Orthop Relat Res 410(410):189–198
47. Kulkarni SK, Freeman MA, Poal-Manresa JC, et al. (2001)
The patello-femoral joint in total knee arthroplasty: is the
design of the trochlea the critical factor? Knee Surg Sports
Traumatol Arthrosc 9(Suppl 1):S8–S12
48. Nizard RS, Biau D, Porcher R, et al. (2005) A meta-analysis
of patellar replacement in total knee arthroplasty. Clin
Orthop Relat Res 432:196–203
49. Parvizi J, Rapuri VR, Saleh KJ, et al. (2005) Failure to
resurface the patella during total knee arthroplasty may
result in more knee pain and secondary surgery. Clin
Orthop Relat Res 438:191–196
50. Pakos EE, Ntzani EE, Trikalinos TA (2005) Patellar resur-
facing in total knee arthroplasty: a meta-analysis. J Bone
Joint Surg Am 87(7):1438–1445
51. Waters TS, Bentley G (2003) Patellar resurfacing in total
knee arthroplasty: a prospective, randomized study. J
Bone Joint Surg Am 85-A(2):212–217
52. Newman JH, Shah NA, Karachalios T (2000) Should the
patella be resurfaced during total knee replacement?
Knee 7:17–23
53. Feller JA, Bartlett RJ, Lang DM (1996) Patellar resurfac-
ing versus retention in total knee arthroplasty. J Bone
Joint Surg Br 78(2):226–228
54. Partio E, Wirta J (1995) Comparison of patellar resur-
facing and nonresurfacing in total knee arthroplasty. J
Orthop Rheum 8:69–74
55. Schroeder-Boersch H, Scheller G, Fischer J, Jani L (1998)
Advantages of patellar resurfacing in total knee arthro-
plasty: two-year results of a prospective randomized
study. Arch Orthop Trauma Surg 117(1–2):73–78
56. Ma H-M, Lu Y-C, Kwok T-G, et al. (2007) The Th eff
ffect of the
design of the femoral component on the conformity of
the patellofemoral joint in total knee replacement. J Bone
Joint Surg Br 89(3):408–412
57. Miller MC, Berger RA, Petrella AJ, et al. (2001) Optimizing
femoral component rotation in total knee arthroplasty.
Clin Orthop Relat Res 392:38–45
Why I do not routinely resurface the patella in TKA 863
58. Kessler O, Patil O, Colwell CW, D’Lima DD (2008) The Th
eff
ffect of femoral component malrotation on patellar bio-
mechanics. J Biomech 41(16):3332–3339
59. Smith AJ, Wood DJ, Li M-G (2008) Total knee replacement
with and without patellar resurfacing: a prospective, ran-
domised trial using the profifix total knee system. J Bone
Joint Surg Br 90(1):43–49
60. Burnett RSJ, Boone JL, McCarthy KP, et al. (2007) A pro-
spective randomized clinical trial of patellar resurfacing
and nonresurfacing in bilateral tka. Clin Orthop Relat
Res 464:65–72
61. Bourne RB (1999) Fractures of the patella after total knee
replacement. Orthop Clin North Am 30(2):287–291
62. Kelly MA (2004) Extensor mechanism complications in
total knee arthroplasty. Instr Course Lect 53:193–199
63. Kavolus CH, Hummel MT, Barnett KP, Jennings JE (2008)
Comparison of the insall-burstein ii and nexgen legacy
total knee arthroplasty systems with respect to patella
complications. J Arthroplasty 23(6):822–825
64. Ortiguera CJ, Berry DJ (2002) Patellar fracture after total
knee arthroplasty. J Bone Joint Surg Am 84-A(4):532–540
65. Keating EM, Haas G, Meding JB (2003) Patella fracture
after post total knee replacements. Clin Orthop Relat
Res 416:93–97
66. Grace JN, Sim FH (1988) Fracture of the patella after total
knee arthroplasty. Clin Orthop Relat Res 230:168–175
67. Berry DJ. (1999) Epidemiology: hip and knee. Orthop Clin
North Am 30(2):183–190
68. Sheth NP, Pedowitz DI, Lonner JH (2007) Periprosthetic
patellar fractures. J Bone Joint Surg Am 89(10):2285–
2296
69. Bourne RB, Stephen R, Burnett J (2004) Th The conse-
quences of not resurfacing the patella. Clin Orthop Relat
Res 428:166–169
70. Kim BS, Reitman RD, Schai PA, Scott RD (1999) Selective
patellar nonresurfacing in total knee arthroplasty: 10 year
results. Clin Orthop Relat Res 367:81–88
71. Burnett RS, Haydon CM, Rorabeck CH, Bourne RB (2004)
Patella resurfacing versus nonresurfacing in total knee
arthroplasty: results of a randomized controlled clinical
trial at a minimum of 10 years' followup. Clin Orthop
Relat Res 428:12–25
Navigation in TKA

F. Picard,
A. Gregori,
Total knee replacement navigation:
A. Deakin
the diff
fferent techniques
Introduction
T
he first full navigated knee replacement on
patient was performed on January 21 1997
in Grenoble University hospital (1–3). Like
any innovative technology it took some time for
the professionals (both orthopedic companies
and surgeons) to perceive navigation as a techni-
cal advance in the field of orthopedics (4, 5). The
initial introduction of this technology and tech-
nique involved the so-called “innovators” (6). Next
the so-called “early users” became interested in the
concept of navigation or computer assisted sur-
gery and began shyly to sporadically try any sort of
navigation systems available at the time (Fig. 1).
By the end of the century only a few systems were
available (7). Two types of navigation systems
were in early stage of development: those using CT
imaging and those named CT free and also known
as non-image based systems. Orthopedic compa-
nies, including the major players, have now started
to invest in this new technology, generating some
competition in the field. Currently after years of
testing and trials most published studies show
signifi
ficant benefi
fits with navigation in total knee
replacement ranging from improving alignment (8,
9) reduced intra and post-operative bleeding (10)
or fat embolisms (11), enhanced teaching (12, 13),
and understanding of knee kinematics (14, 15).
Fig. 1 – Crossing the chasm between visionaries and pragmatists.
Chapter 81
However, most of these studies assessed non-image
based TKR navigation systems which are just a part
of a broader area in the field of computer aided sur-
gery including robotics, image based technology
and electronic equipments (16). Relative simplicity
and no requirement for imaging in the non-image
based technique facilitated its introduction among
orthopedic surgeons. Besides the concept of non-
image based techniques, “revisited technologies”
are under development such as lightweight robotic
systems (17) or 2D/3D imaging technology (18)
that will add new instruments in computer-assisted
orthopedic surgery. Nevertheless non-image based
navigation is still the most attractive technique for
orthopedic surgeons and undoubtedly the most
commonly used in the OR. In 2006/2007 a sur-
vey of members of the European Society of Sports
Traumatology Knee Surgery and Arthroscopy
(ESSKA) and the Swiss Orthopedic Society (SGO-
SSO) found that out of the 12% respondents, 202
(51.9%) reported that their center was equipped
with a navigation system, which was an image-free
based system for most (83.2%) and was primarily
used for total knee arthroplasty (61.4%) (12). Since
the beginning of this century diff fferent navigation
systems have been developed and used for diverse
type of implants and prosthesis. Notwithstanding
that the base concept of non-image based systems
comprises similar materials for diff fferent systems,
there are diff
fferent instrumentations, tracker fixa-
tion systems, software and many other details. In
this chapter we would like to describe the differ- ff
ent techniques currently in use and illustrate the
advantages and drawbacks of each system. We will
first review a short history of computer assisted
total knee replacement systems, then move to sys-
tems classifi
fication and finally explain the diff
fferent
computer assisted system techniques.
History
As mentioned above, the first non-image based
TKR navigation system was developed in Grenoble
(France) following a similar concept developed for
ACL reconstruction (19, 20) At the same time in
868 Primary Total Knee Arthroplasty

Buff
ffalo (NY, USA), K. Krackow and his team were to obtain a leg CT scan while it took 45 min back to
working on a similar concept using an Optoelec- the nineties for a poorer quality image). Optolec-
tronic camera to acquire intra-operative data so that tronic cameras are much lighter and more reliable
the surgeons could use it as a referencing system (for instance one of the first optoelectonic camera
to accurately place a knee implant (21). In the late used in orthopedics in the nineties was very heavy
nineties just three companies had access to this non- and cumbersome) (Fig. 2). Instead the new cam-
image based technology concept: Aesculap/BBraun® eras such as the Polaris™ (NDI, Waterloo, Canada),
(Tuttlingen, Germany), Praxim® (Grenoble, France) one of the most used in orthopedic is much lighter
and Stryker® (Kalamazoo, USA). However, the non- at just a few kilos, without compromising measure-
image based technique was not and is still not the ment quality. Computers are more and more pow-
only concept utilized in TKR navigation. Back in the erful and faster with impressive rapidly growing
early eighties, when the non-image concept emerged, memories (Fig. 3). The Th overall outcome of these
image based technology and robotics were dominat- systems has obviously been improved by each com-
ing the field of computer-assisted surgery (60). Com- ponent advance. New developments such as EM
panies like Curexo® Technology (Sacramento, USA) (Electromagnetic) tracking or hand-held robotic
who produced Robodoc®, the first ever computer tool image overlay will further augment the cur-
assisted system used in orthopedics, were reckoned rent computer aided instruments (36) (Fig. 4).
as the pioneer in the field of computer assisted joint
replacement. A few companies such as CASPAR®
(URS, Germany) took part in the design and devel-
opment of new tools for robotic aided joint surgery
(22). A tremendous eff ffort was achieved in develop-
ing this first active robot including intense collabo-
ration between scientists, engineers, and surgeons.
The first designed innovative ideas for registration,
the second developed new software and new devices Fig. 2 – (a) Optotrack® camera: heavy and cumbursome and (b) Polaris®:
and the last brought rationale and defined
fi the needs lightweight and stealth.
of these machines in surgery (23–25). Many techno-
logical problems needed solutions, such as match-
ing algorithms, 3D image reconstruction processes
and mechatronics masterpieces to control and oper-
ate the robot (26–29). Besides the active robotic
devices, other teams have concentrated their effortff
on other concepts such as semi-active controlled
forced robotic tools e.g., Davis and his team from
the Imperial College of London who developed the
ACROBOT® (30–32). Later on some of the robotic
tools were adapted to non-image based navigation
such as the Galileo® system (33). However, image
guided surgery was still the mainstream concept in
the early nineties and a few researchers supported
by companies initiated the use of medical imaging Fig. 3 – Moore’s law showing computer’s power prediction.
in TKR (34)For instance OrthoSOFT® (Zimmer,
Kalamazoo, USA) was one of the first companies to
obtain clearance from the FDA for an image-based
TKR navigation in 1999. BrainLAB® (Westchester,
USA) already famous in neuro-navigation jumped
into orthopedic navigation and successfully began
TKR navigation using pre-operative CT-scan imag-
ing. Another interesting concept arose called bone
morphing in which the intra-operative data are used
to fit a bone statistical model so that the surgeon
can orient the bone cuts according to a virtual model
representing the actual bone (35).
Technology improvement happened so fast that
every component of these computer-aided systems
benefifited from signifi
ficant changes. CT-scan imag-
ing is quicker and less invasive (it takes few minutes Fig. 4 – Robotic assistive prototype for bone cuts (36).

Classifification
According to our classifi fication (34) computer
assisted TKR surgery is divided into three catego-
ries:
To summarize and simplify: the active systems are
the active robots, the semi-active systems are the
controlled forced robot and the passive systems
are the navigation systems, but new advanced
technology modified
fi this simplistic view. A recent
review of today’s state of the art in surgical robot-
ics listed 159 robot systems with about 10 for
orthopedics, mainly for knee and hip replacement
(37) (Table 1).
Three different sources of data can be used to adjust
the surgical action of these systems: the medi-
cal images taken pre-operatively (pre-op. image
technology) the medical images taken intra-
operatively (intra-op. image) and finally the
intra-operative data collected during the surgi-
cal procedure (non image or image free or also
called CT free). The data is “fed” into the systems
computer and the software will process the data.
In the following paragraph we describe in detail
the different systems and highlight their charac-
teristics.
Table 1 – Computer assisted knee replacement classification.
Intra- Image free
Pre-op.
op. (non-image
image
image based)
Active system 9 8 8 ing on the manufacturer recommendations. For
Semi-active 9 8 9 instance the Navitrack System (OrthoSoft/Zim-
system
Passive 9 9 9 head (spacing 4.5 mm/increment 5 mm), 2 mm in
system
9Existing systems; 8Under development.
System description
CT Image based
CT Image based navigation includes three distinct
phases:
Pre-operative phase
Image guided navigation technology uses medi-
cal images to ultimately generate an accurate 3D
model of the femur, tibia and patella. Current
systems use CT scan images, no existing CAOS in
clinical use is yet based on MRI images, though
they can be used to create patient specifi
fic cutting
jigs. Ultrasound images have the potential to be
used more routinely. Th
The CT protocol relies on new
Total knee replacement navigation: the different techniques 869
CT spiral techniques that allow faster and better
image acquisition.
Most of the image-guided systems are now pinless
registration, meaning that no fiducial
fi markers are
fixed in the bone prior to the surgery which was a
routine procedure in the robotic assisted systems.
Several steps must be completed before taking CT
scan images in order to obtain high quality images.
Avoidance of metal, such as buttons or zippers,
must be removed from the leg region as they could
cause artifacts in the scan and advising the patient
not to move during the procedure, which is nowa-
days very fast usually being less than 2 min.
The patient is placed on the CT table in a supine
position and the patient is informed that he needs
to remain still during the CT scan. ThThe number of
slices ranges from 75 to 150.
Images must be continuous, under one exam
number and within the same series. Scouts must
be in a separate series from the images. TheTh tech-
nician acquires a scout image, which includes the
entire femur and tibia visualizing perfectly the hip
and the ankle joint. Then,
Th selected slices at 1 mm
spacing are taken in crucial areas (hip, knee, and
ankle joints). In metaphyseal areas the selected
slices are 1 mm thick and 5 mm spacing. In the
midshaft the slices are 1 mm thick with spacing
of 50 mm as this is a non-critical area. The field of
view should be as small as possible while ensuring
that the entire leg is within the field.
fi Other proto-
cols have been described in the literature depend-
mer) requires 3 mm slice thickness in the femoral
the knee area (spacing 2 mm/increment 2 mm)
and 3 mm in the ankle joint (spacing 3 mm/incre-
ment 4 mm). TheTh slice thickness is 100 mm within
the tibia and femur shafts (spacing 20 mm/incre-
ment 40 mm) (38).
The technician starts the scan and does not adjust
table height or field of view during the scan. At this
time the patient must not move at all. If patient
motion occurs at anytime during the scan, the pro-
cedure should be repeated.
After receiving the images from the CT scan com-
puter, each slice is then selected and analyzed on
the monitor screen in order to perform contour
acquisitions. Several algorithms have been imple-
mented to facilitate the process of contour acqui-
sitions. Automatic or semi-automatic edge recog-
nition software is now available to speed up the
process of 3D surface reconstruction and model
generation. Using this, each image is segmented
to obtain contours of the femur, tibia, and patella
geometry. The segmented image slices are then
interpolated between slices in order to generate a
full surface and 3D model of the bone geometry.
870 Primary Total Knee Arthroplasty
Once a three-dimensional bone model has been
built, 3D model and slices are downloaded in a
software program that can be utilized for planning.
Some systems also recommend defi fining land-
marks that will be digitized intra-operatively to
match the anatomy to the pre-op CT (Orthosoft).
This procedure depends on the type of intra-oper-
ative registration, either point registration need-
ing a pre-defi
finition of landmarks (usually 5 or 7 on
each bone) or a surface based registration avoiding
landmark acquisition.
Planning and Simulation
Conventional planning for TKR uses biplanar
radiographic images and templates. AP, lateral and
transversal views are immediately and interac-
tively accessible to fi
find the best fit and orientation
for femoral and tibial implants. This radiographic
planning can approximate implant position and
size. Computer assisted planning permits us to
simulate three-dimensional positioning of the
implant. Using a database of computer-assisted
implant models, the surgeon adjusts as acurably
as possible the implant in the patient’s model
(Fig. 5). A multitude of features are already avail-
able. Graphic software allows the surgeon to simu-
late cutting, drilling bones, moving implants, and
bones independently. As a result of this simulation,
the surgeon can observe the direct consequences
of the surgical procedure such as how much bone
should be ideally resected for placing the implants
and what the implant orientation is with respect
to the anatomical landmarks. Interactive software
enables the surgeon to move the bone and the joint
in order to appreciate the relationship between
implant and bone. In addition to this feature, the
computer can simulate the motion of the joint to
verify the proper placement of the implant. How-
ever today, no image guided TKR pre-operative
planner is yet able to use data based computer gait
Fig. 5 – CT pre-operative planning (KneeNav™).
modeling or surgical experience algorithms in rou-
tine practice.
Once the surgeon has optimized the plan and
placement of implant components, all relevant
parameters are stored for the image-guided proce-
dure. The data are then downloaded to a computer
in the OR for the intra-operative navigation.
Intra-operative phase
Several procedures exist to verify the quality of the
data transfer. Once the surgeon is satisfied
fi with the
simulation planning, the data are transferred to the
OR. The intra-operative set-up is organized with a
computer, an optoelectronic camera and LED or
passive trackers affixed
ffi on the femur and the tibia.
Surface or point registration is performed using
a pointer. The procedure then requires matching
of landmarks or surfaces based acquisition to the
pre-operative 3D CT model allowing the surgeon
to work on line with the patient’s specificfi three-
dimensional model and achieve his planned TKA
outcome. The rest of the procedure does not diff ffer
from any other computer-assisted technique. Th The
surgical instruments such as the resection guides
are equipped with LED or passive trackers and are
then used exactly as they are in the CT free proce-
dure.
Fluroscopy image based
Another procedure using fluoroscopy is available.
Medtronics® or Siemens® have been among the
first to develop this concept. Medtronic’s system
requires two dimension intra-operative images
after the surgical approach has been done. Th The
fluoroscopic–based navigation system is equipped
with LED tracking enabling exact localization of
the fluoroscope in all positions, a radio sensor
enables automatic acquisition of the pictures and
a calibration grid. Then the usual process of any
optolectronic navigation system is required includ-
ing bone tracker fixation and registration. Fluoro-
scopic images are acquired, activated and used for
navigation. After that the surgeon can work on
two-dimensional images overlaid with colored vir-
tual lines representing axis and level of cuts. ThThe
drawback of this technique is the need of flfluoros-
copy during joint replacement which is not a rou-
tine procedure. The joint centers are defi
fined with
two fluoro-views on which the surgeon defi fines the
centers that are recorded in the frame of reference
of the X-ray machine. For instance the hip center
is demarcated with views of AP and a 45° angle
whereas the knee and the ankle centers are defined
fi
with an AP and lateral X-ray (39–41). Th The other
disadvantage is the lack of a three-dimensional

Fig. 6 – CArm Fluoroscopy system (Siemens®).
view compared to the CT image based system. Sie-
mens have developed a rotating C Arm fluoroscope
fl
pivoting around the concerned joint and able to
reconstruct virtually a three-dimensional image
using the set of data collected during rotation very
similar to a CT procedure (Fig. 6). As a result these
intra-operative images are used in the same way to
those described above. Other systems are under
development such as the system described by May-
man et al. (42) regarding the Oxford Unicompart-
mental and the use of fluoroscopy.
Non-imaged based
Non-image based navigation is based on the con-
cept of using either kinematic or anatomic intra-
operative data. A series of relevant landmarks is
collected directly on the patient’s anatomy and is
process through a computer software that create
a frame of reference. Therefore any tracked instru-
ments are referred to the frame of reference so that
the surgeon can adjust cut alignments and implant
positions (see previous chapter). Three
Th basic com-
ponents are necessary for routine non-image navi-
gation systems: a computer, a localizer, and track-
ers. As a matter of fact these three components are
also part of the above-described systems.
Common platform of computer assisted knee
replacement
All these systems are made up of three funda-
mental components: a computer, a localizer, and
trackers.
Total knee replacement navigation: the different techniques 871
Fig. 7 – One of the first lightweight navigation systems in 1999 (Aesculap
system) including laptop, Polaris™ cameras and a central unit.
A computer
Each company selling or lending systems have cho-
sen their own computer provider. There is nothing
special with these computers except that some of
them need more memory to deal with three dimen-
sion medical images. For instance the computer
can include a UNIX workstation such as the O2
workstation (Fa Silicon Graphics Mountains View/
USA) that OrthoSoft uses in the Navitrack sys-
tem. In fact three types of computer are regularly
used: laptops, desktops, and integrated desktops.
Some companies use laptops in their systems such
as Stryker, Medtronics, and Aesculap in the past
(Fig. 7). The idea of using a laptop is to reduce the
overall size of the systems. Despite being attractive
there are some limitations in the laptop including
fragility and the small size of the monitor screen.
Most of the companies providing computer-as-
sisted systems have chosen to integrate a desktop
into a cart mounted on wheels holding one or two
arms supporting a monitor screen and a localizer.
A localizer
The most important characteristics of these cam-
eras are the bandwidth, the accuracy/precision,
and the working volume. There are two types of
cameras in regular use: Optical and electromag-
netic.
The optical camera used consists of two or three
single CCD (charged coupled device) cameras
observing the signals coming from the LEDs. Th The
main disadvantage is the camera field fi of view,
which limits the IR tracker’s visibility. Th
This draw-
back has been partially reduced with the fi fixation
of the camera on the OR ceiling like a standard sci-
alitic pendant allowing one to enlarge the fi field of
view. Several models of cameras are used in these
systems. One of the first was the Optotrack™ (NDI,
Waterloo, Canada). Since the nineties, this camera
has been broadly used in many sorts of computer-
assisted surgery such as maxillo-facial, neurosur-
872 Primary Total Knee Arthroplasty
gery, ENT, spine, and orthopedics. In orthopedics
Medivision® had originally developed an image
guided navigation system, so-called SurgiGATE™,
in order to initially navigate ACL reconstruction
and then later knee replacements. Th This camera was
one of the first used in this field and was extremely
accurate and precise but was very cumbersome
and expensive, which limited its distribution. New
optical tracking cameras were rapidly developed
and they were much smaller and cheaper. Again
Northern Digital® remained the leader in this field
fi
but has been followed up very closely by other
companies such as BrainLab® (already experienced
in computer assisted neurosurgery) and Stryker®
which had also developed its own tracking system
for navigation. The last made an optoelectronic
camera called Flashpoint 5000 with a large work-
ing volume and a wireless remote control capabil-
ity. Whichever company provides the camera they
have identical characteristics including a CCD
which identify active or passive trackers. Seven
items have to be considered when one wants to
judge camera performance:
• Size of measurement volume needed. The usual
field of view is a pyramidal volume covering
approximately 1.50 m. Some new theatre set-ups
have integrated the localizer mounting it directly
on the ceiling as a pendant. (Fig. 8) An optimal
distance is required to make sure the trackers are
constantly accurately seen with minimal error.
– Update rate required for measurements (the
bandwidth).
– Number and type of tools to be tracked including
accuracy and precision.
– Space restrictions and mounting location of sys-
tem. Most of the cameras have got a laser pointer
allowing rapid adjustment of the field
fi of view.
– Camera system protection. These Th cameras are
fragile and any bump can damage reliability and
accuracy so that software solutions have to be in
place for detecting any inaccuracy.
Fig. 8 – New integrated navigation systems (Stryker®) including a flash-
point camera and a monitor screen affi
ffixed on the theatre ceiling.
– Integration/compatibility with current system
trackers.
– Warm up time has to be minimum because it can
aff
ffect its reliability. Wide temperature operating
range is also an important question to ask the
provider making sure that temperature changes
will not aff
ffect measurement precision.
Electromagnetic tracking: Electromagnetic spa-
tial measurement systems check the location
of objects that are embedded with sensor coils.
When the object is placed inside controlled, vary-
ing magnetic fields, voltages are induced in the
sensor coils. These induced voltages are used by
the measurement system to calculate the position
and orientation of the object. As the magnetic
fields are of a low field strength and can safely
pass through human tissue, location measure-
ment of an object is possible without the line-of-
sight constraints of an optical spatial measure-
ment system. There are no line of sight and real
time measurement issues with the small sensor
coils but signifi ficantly the large local detector
needs to be used close to the sensors. Th The main
drawback remains the metal interference which
aff
ffects overall measurements.
So far there are no routinely used commercial sys-
tems with ultra sound and mechanical tracking
though ultra sound has been used for localizing
landmarks and facilitating building frames of ref-
erence (43).
DRB (dynamic reference base)
Despite sharing a similar structure the DRB has
diff
fferent features much like those off ffered in dif-
ferent cars! Whilst all cars have an identical basic
feature, each of them can off ffer specifi
fic charac-
teristics. The following paragraphs will highlight
these diff
fferences. Before going through the attri-
butes of each DRB system, it is important to note
that even though they share a similar basic archi-
tecture there is no international standard for soft-
ware or system build. International norms such
as FDA in the USA, CE in Europe or In-Country
Caretaker (ICC) in Japan still give no clear basic
recommendations to make sure these systems
have comparable features and guarantees offer- ff
ing similar results. However, recently the ASTM
(American Society for Testing and Material for
Standard) intends to unify requirements for these
types of systems. ASTM already recommend
standards in electronics, advanced materials and
instrumentation but only recently has a group of
experts developed some standards such as a phan-
tom to compare the system accuracy (Fig. 9). The Th
growing number of these systems is generating
more control and regulation that will undoubt-

Fig. 9 – Phantom used for accuracy and precision assessment of computer
assisted systems.
edly regiment computer assisted systems. For the
time being it is still difficult
ffi to understand the dif-
ferences between these systems when we look at
the hardware components and still more when we
look at the software.
In the following we will show the differences ff
between DRB and more particularly between
architectures. It is not intention to identify what
is best or what is worst because each individual
solution combined with different
ff materials in dif-
ferent environments can change accuracy (achiev-
ing a pre-determined result), precision (repeatabil-
ity), and obviously overall outcome. We will also
describe difffferences in terms of ergonomics and
practicability. Diff
fferent tracking systems are in
regular use: IR (infrared), EM (electro magnetic),
whilst US (ultra sound) is still in the evaluation
process.
Infrared tracking still remains the most commonly
utilized because of its reliability and ease of use.
Two types are described and used:
Active infrared LED tracking (Light Emitting
Diodes) (Fig. 10). A series of four or six diodes
are affi
ffixed into a rigid body (usually plastic) from
which a power cable comes out and is plugged to
the central unit that will alternatively illuminate
the LEDs in a given pattern which will be detected
by a camera system. A subsection of this is active
infra LED trackers which do not require external
wires for example as used in the Stryker naviga-
tion system. These trackers are battery powered
and flash in a fast sequence one after the other and
the emitted signals are read by a CCD camera. The Th
advantage of this is that there are no cables that
can get in the way and can get caught causing pos-
sible tracker movement. The two main drawbacks
Total knee replacement navigation: the different techniques 873
Fig. 10 – Cabled active tracking system.
Fig. 11 – Passive tracking system on a pointer.
of this tracking system are the battery costs and
the weight of the tracker that can cause motion
on its bone attachment and this can generate an
error.
Passive markers are refl flecting spheres with a
special surface coating (Fig. 11). Th These markers
are snapped onto a metallic frame with irregular
branches. Each tracker has to have a dissimilar
shape in order to be well recognized by the passive
fficient to acquire the exact loca-
IR camera. It is suffi
tion of at least three non-collinear points on each
object to locate the proper tracker. Additional cost
engendered by the disposable spheres and reduced
accuracy due to fat tissue or blood covering the
spheres are the two main disadvantages of this
technology. Advantages are preserved accuracy
and precision without any power cables in the way
facilitating overall tracker manipulation and oper-
ative ergonomics.
Electromagnetic tracking (EM) was developed since
the nineties and re-introduced in orthopedics by
Zimmer and Depuy (44). Like US tracking EM track-
ing do not rely on any direct line of sight. On the
other hand, metallic interferences and even non-
metallic objects can modify the electromagnetic
field causing deviation in measurement degrading
the overall accuracy of the systems (Fig. 12).
874 Primary Total Knee Arthroplasty

– Few pins maintained with a metallic armature

(Praxim®, Vicking™ Medtronic System).
– Mini plate with uni-cortical screws (OrthoPilot).
– Femoral clamp (Galileo) (62), OrthoPilot.
In 2004 a study from Marchant DC et al. showed
that all pins passing directly from anterior to
posterior 5 cm proximal to the femoral articular
cartilage (medial to lateral or lateral to medial)
62.5% of pins were within 5 mm of a major neu-
rovascular structure (47).
In 2008 another study showed that a release of the
fascia lata 1 cm either side of the screw placed in
the distal femur was the only alternative to avoid
Fig. 12 – New EM traking devices. either tracker movement or muscle damage (48).

Ultrasonic tracking is still not in use on a commer-

cial product despite some advantageous features
such as the unlimited field of view. However, this
technology is sensitive to temperature aff ffecting
the overall accuracy (45).
Mechanical tracking is used in some computer-
assisted systems such as the ACROBOT system
(London, UK), a controlled forced robot. Mechani-
cal sensors are used for landmark detection and
registration.
Diff
fferences between systems
These tracking rigid body systems are affi
ffixed either
on bone defi
fining the so-called dynamic reference
base (DRB) or on instruments allowing the sur-
geon to work in an established frame of reference.
Monitor screen touch/no touch
Most of the monitor screens in use are standard
flat computer monitor screens or the screen from
a laptop. Some of them are now integrated into
the ceiling and are already part of the normal sur-
gical room set-up. A few companies such as Brain-
Lab have chosen to commercialize touch screens
which have been used for some time in neuro
navigation. One of the issues was and still is the
monitor position in the theatre: too close to the
surgical site it could become a source of infection
unless covered with sterile plastic (which then
reduces the clarity of the display). If the monitor
is too far then the display is difficult
ffi to see and
is ergonomically inadequate because the surgeon
cannot reach the touch screen.

Tracking fifixation
The tracking markers need to be solidly inserted
into bones in order to form a DRB. ThThe camera fol-
lows in real time the trackers and consequently the
bone. Among the commercial products available
several type of fixation are used (Table 2):
– Bicortical Schanz pins (46).
– Cannulated screws (OrthoPilot™, Navitrack™,
Vector Vision™, Stryker Navigation™, Ampli-
tude™).
Sound/no sound
Sound has been used since the beginning of surgical
navigation. One of the first systems that has used
sound to help the surgeon when collecting land-
marks was the HipNav™ system, a CT based naviga-
tion system developed in Pittsburgh in the eighties
and nineties (49). Since then many manufacturers
have commercialized systems with a sound com-
mand that rings out each time the surgeon collects
relevant landmarks or when the computer has fin-
fi
ished computations and has displayed a solution.

Table 2 – Different tracker fixation systems.

Tracker fixation Advantages Disadvantages Systems in use
Pins Easy to use, minimally invasive Flexible – leading to movement +
Unicortical screws such as single-screw MIRA Easy to use, quick Invasive (muscle lesion, bone holes) +
system[4]
Bicortical screws Easy to use, stability Potential neuro-vascular damage +
Double-screw system such as MIRA system Intuitive Time consuming, needs to be mounted +
with the frame
Clamp Stability Invasive +
 Total knee replacement navigation: the different techniques 875

Pointer handle such as also routinely used with diathermy.

Diff
fferent sort of pointers are in use, but all of them
have a similar design including a tip, usually sharp
but sometimes with a spherical shape (ball nose).
The pointer may be pre-calibrated or not calibrated.
In the case of a pre-calibrated pointer orientation
and direction are immediately recognized when a
tracker is mounted on the assembly. In the case of
the non-calibrated pointer they have to be iden-
tifi
fied. Usually a calibration station receives the
pointer facing the camera to collect the position of
the tip of the pointer which will then follow in real
time wherever the pointer is. The extremity of the
pointer has to be robust and strong especially for
the pre-calibrated pointer to avoiding any discrep-
ancy between the real and virtual tip of the pointer.
The spherically shaped apex of the pointer is used
by circumducting the pointer on any chosen land-
mark and then the center of the sphere (<2 mm) is
the selected spot and is therefore recorded during
registration. The distal part of the pointer is made
of metal with various handle such as a pistol grip
(Stryker) or a stylus-shape handle. ThThis handle can
carry a trigger for recording a landmark during
registration. The last important part is the tracker
attachment off ffering a base for active or passive
trackers.
Some more innovative options have been brought
into computer guided knee navigation, such as the
touch screen already used in other domains (air-
plane self check-in!) or virtual mouse or keyboard
also developed in other sectors of industry (video
games!). Both novelties have some drawbacks in
orthopedic theatre and are listed below (Table 3).
Instrumentation
The concept of navigation has led to the require-
ment for new instrumentation. In fact two different
ff
ways have been chosen by orthopedic companies:
one was to adapt standard instrumentation to nav-
igation and the other one was to keep the standard
instrumentation with minor changes and to use a
tool that could fit onto any instruments and allow
any measurements. This tool is the so-called plate
probe and was developed and patented in the US in
the late 1990s. This instrument mimics a saw blade
and can be slid into any jig-slot guiding bone cuts.
In addition the same instrument equipped with a
tracker could be used to control actual resection
cuts by being laid flat on the bony surface after the
cut has been made (Fig. 13). ThThis tool is now used

Controller systems
Diff
fferent controller solutions have been developed
over the years. Originally every step of the pro-
gram was controlled by an engineer or technician.
These technical assistants were in theater piloting
the computer assisted system. The CT free naviga-
tion concept brought the idea of “autopilot” com-
puter aided surgery without any intra-operative
contribution by a technician. This basically meant
the surgeon was able to use the computer on his/
her own without any help. Th The controller principle
is similar to a computer mouse that enables the
user to move forward or backward through the
software menu. Most of the systems were inspired
from common orthopedic tools used daily in the
OR such as a footswitch pedal regularly used in
arthroscopic surgery or trigger-fi finger control on Fig. 13 – Plate probe flat on the actual tibial cut.
Table 3 – Different controller systems.
Controller Advantages Disadvantages
Foot switch pedal Usual set-up for surgeon used (diathermy, shavers Additional instrument with respect to usual standard
etc…) instrumentation
Virtual key board [54] Easy for young surgeon familiar with technology More diffi
fficult for senior surgeon not accustomed to technology

Digital controller(trigger Usual set-up for surgeon (diathermy, saw blade Manipulation sometimes difficult.
ffi
switch) etc…)
Touch screen Intuitive display Infection control risk
876 Primary Total Knee Arthroplasty

in almost all systems either as a key device used for such as the one from Anglin et al. have analyzed
all steps or a controlling tool (50) as checking tool. intra-operative patellar tracking and open a new
Most of the “company-followers” in the field fi of perspective in patella resurfacing navigation (52).
computer assisted orthopedic surgery have shyly Finally, a few companies are trying to integrate the
avoided significant
fi standard instrument modifi fica- computers outside the OR or hidden in cupboards.
tions for obvious cost implications and also to pre- These computers are linked to an integrated OR,
vent disrupting the surgeon’s known practice. Oth- the so called “Total Suite”, where the localizer
ers have opted for radical changes in instruments is affi
ffixed to the ceiling as the pendant operation
such as Galileo which is a completely new femoral lights. Many sorts of tools can be incorporated
mounted robotic tool. The Galileo robot consists of in this new OR such as X-rays, CT, and even MRI
a self oriented distal cutting guide mounted on a Scan (Fig. 15). Th
There is much competition between
frame which is affi ffixed on the distal femur. Using companies in order to attract customers to buy
non-image data calculated from intra-operative
landmarks and kinematic assessment the robotic
jig is adjusted until reaching the pre-determined
distal femur cut. Some others have made interme-
diate changes such as Stryker® or Depuy®. Their Th
instruments are very similar to standard instru-
ments on which a tracker attachment has been
added. Some others have completely revised their
instruments so that new jigs and new cutting guides
can receive a tracker (Amplitude®, Tornier®, Aescu-
lap®/BBraun…). A new line of jigs have appeared
going from fine tuning cutting guide orientation to
a five in one femoral guide that allow all the distal
femur cuts to be made at once. Most of these new
designed instruments are pre-calibrated allow-
ing their immediate intra-operative use without
disturbing the traditional way of setting them up.
Most of these new instruments rely on concepts
and principles developed over the years with stan-
dard instrumentations (61).
For the tibia the use of an extra-medullary guide
is still relevant as it can serve as a support for the
tibial cutting guide. However, when using navi-
gation the extra medullary jig uniquely plays the
role of guide support and does not help in guide
orientation. Studies have shown that navigation
improves alignment of the coronal and sagittal
tibia implant position. Th Therefore the extra med-
ullary guide is only used to support other jigs
and sometimes to “incorrectly” reassure novice
surgeons in navigation! (Fig. 14) Diff fferent types Fig. 14 – Standard instrumentation equipped with trackers.
of cutting guides have been developed over the
years, most of them derived from the standard
instruments on which a coupling system has been
placed to attach trackers. They then evolved to
adapted jigs more specifi fically designed for naviga-
tion with difffferent shapes. For instance a distal jig
enabling four or even fivefi cuts at a time. In 2008
Klima et al. showed that using specially designed
blocks was signifi ficantly quicker than non-specifi fic
instruments without compromising accuracy (2.9
mn vs. 6.4 mn p < 0.001) (51).
Regarding the patella there are no currently avail-
able systems in routine practice allowing assess-
ment of patellar tracking nor any patella guide for Fig. 15 – New OR suite including video system, MRI, navigation technol-
resurfacing when needed. However a few studies, ogy. (BrainLAB/Depuy).

complete OR surgical suites. Stryker, Siemens,
and Depuy have already demonstrated this kind of
set-up. Hospitals and surgeons are keen to refur-
bish their OR for reasonable deals and end up with
a brand new OR. On the other hand the companies
are keen to make deals with customers who will
then be linked with their products when they use
the OR suite.
Software
The software is the fundamental core of each sys-
tem and remains the intellectual property of each
company. It is not in our purpose to detail each
software which could be in itself an entire chapter.
Current trends in knee navigation
Improvements in medical imaging and robotic
seem to renew with computer assisted ortho-
pedic surgery which was forgotten for some
times because of the CT free navigation realism
and practicability. Both medical imaging and
robotic have benefited
fi from the recent advance-
ments allowing them to match more the surgical
demands such as friendliness none invasiveness
and reliability without missing cheapness which
must be taken in to account nowadays (53). How-
ever, there will be still some times before robotic
tools and image navigation systems become rou-
tine in the OR for TKR. Even diffi fficult knee revi-
sions have been performed using CT free naviga-
tion systems (54). It is also true that non-image
based knee navigation systems have showed a
great technical robustness and reliability to reach
the TKR aims such as alignment and soft tissue
management (55–59). CT free navigation has still
a lot of advantages and will remain undoubtedly
present in the OR especially for TKR and will ben-
efi
fit from new developments such as ultra sound
and force sensors which both will add features to
current assessment.
References
1. Delp SL, Stulberg SD, Davies B, et al. (1998) Computer assisted
knee replacement. Clin Orthop Relat Res 354:49–56
2. Picard F, Gregori A, Leitner F (2007) Computer assisted
total knee arthroplasty, Chapter 7. ProBUSINESS pub-
lisher Berlin, p 318
3. Saragaglia D, Picard F, Chaussard C, et al. (2001) Mise en
place des prothèses totales du genou assistées par ordina-
teur: comparaison avec la technique conventionelle. Rev
Chir Orthop 87:18–28
4. Lettl C, Hienerth C, Gemuenden HG (2008) Explor-
ing how lead users develop radical innovation: oppor-
Total knee replacement navigation: the different techniques 877
tunity recognition and exploitation in the field fi of
medical equipment technology. IEEE Trans Eng Manag
55(2):219–233
5. Lettl C. User involvement competence for radical innova-
tion (2007) J Eng Technol Manag 24(1–2):53–75
6. Hall GE, Loucks SF, Rutherford WL, Newlove BW (1975) Lev-
els of use of the innovation: a framework for analyzing inno-
vation adoption. Journal Teacher Education 26(1):52–56
7. Stulberg SD, Picard F, Saragaglia D (2000) Computer-
assisted total knee replacement arthroplasty. Oper Tech
Orthop 10(1):25–39
8. Bauwens K, Matthes G, Wich M et al. (2007) Navigated
total knee replacement. A meta-analysis. J Bone Joint
Surg 89(A):261–269
9. Mason JB, Fehring TK, Estok R, et al. (2007) Meta-analy-
ses of alignment outcomes in computer-assisted total knee
arthroplasty surgery. J Arthroplasty 22(8):1097–1106
10. Kalairajah Y, Simpson D, Cossey AJ, et al. (2005) Blood loss
after total knee replacement: eff ffects of computer-assisted
surgery. J Bone Joint Surg 87(B)(11):1480–1482
11. Church JS, Scadden JE, Gupta RR, et al. (2007) Embolic
phenomena during computer assisted and conventional
total knee replacement. J Bone Joint Surg 89(B)(4):481–
485
12. Friederich N, Verdonk R (2008) The use of computer-as-
sisted orthopedic surgery for total knee. Knee Surg Sports
Traumatol Arthrosc 16(6):536–543
13. Stulberg SD (2003) How accurate is current TKR instru-
mentation? Clin Orthop Relat Res 416:177–184
14. Picard F, Deakin AH, Clarke JV, et al. (2007) Using naviga-
tion intraoperative measurements narrows range of out-
comes in TKA. Clin Orthop Relat Res 463:50–57
15. Siston RA, Giori NJ, Goodman SB, Delp S (2006) Intra-
operative passive kinematics of osteoarthritic knees
before and after total knee arthroplasty. J Orthop Res
24(8):1607–1614
16. Stiehl JB (2007) Computer navigation in primary total
knee arthroplasty. Computer Navigation in Primary TKA.
J Knee Surg 20(2):158–64
17. Plaskos C, Cinquin P, Lavallée S, Hodgson AJ (2006) Prax-
iteles: a miniature bone-mounted robot for minimal access
total knee arthroplasty. Int J Med Robot Comput Assisted
Surg 1(4):67–79
18. Campana S, De Guise JA, Rillardon L, et al. (2007) Lumbar
intervertebral disc mobility: effffect of disc degradation and
of geometry. Eur J Orthop Surg Traumatol 17(6):533–541
19. Dessenne V, Lavallée S, Julliard R, et al. (1995) Computer
assisted knee anterior cruciate ligament reconstruction:
first clinical tests. CVRMed, pp 476–480
20. Leitner F, Picard F, Minfelde R, et al. (1997) Computer-
assisted knee surgical total replacement. CVRMed-MR-
CAS’97, vol 1205. pp 629–638
21. Krackow K, Bayers-Th Thering M, Phillips MJ, et al. (1999)
A new technique for determining proper mechanical axis
alignment during TKA. Orthopedics22:698–702
22. Siebert W, Mai S, Kober R, Heeckt PF (2004) Total knee
replacement: robotic assistive technique. In: DiGioia AM,
Jaramaz B, Picard F, NolteL-P (eds) Computer and robotic
assisted knee and hip surgery. Oxford University Press.
Uk, pp 127–138
23. Bauer A (2004) Total hip replacement. Robotic assisted
technique. In: DiGioia A, Jaramaz B, Picard F, Nolte LP
(eds) Computer and robotic assisted knee and hip surgery,
Chapter 9. Oxford University Press. Uk, pp 83–95
24. Taylor RH, Lavallée S, Burdea GS, Mösges R (eds) Comput-
er-integrated surgery technology and clinical applications.
MIT Press Cambridge, MA USA, 1995
25. Taylor RH (2004) Medical robots hardware components.
In: DiGioia AM, Jaramaz B, Picard F, Nolte L-P (eds) Com-
puter and robotic assisted knee and hip surgery, Oxford
University Press. UK, Chapter 5. pp 54–59
878 Primary Total Knee Arthroplasty
26. Lavallee S (1995) Registration for computer integrated
surgery: methodology, state of the art. Computer inte-
grated surgery, technology and clinical applications. MIT
Press Cambridge, MAUSA, pp 77–98
27. Simon DA, Lavallee D (1998) Medical imaging and regis-
tration in computer assisted surgery. Clin Orthop Relat
Res 354:17–27
28. Taylor RH (2004) Robotic systems for orthopaedic surgery.
In: DiGioia AM, Jaramaz B, Picard F, Nolte L-P (eds) Com-
puter and robotic assisted knee and hip surgery, Oxford
University, Press. Uk, Chapter 7. pp 67–78
29. Vannier M, Totty W, Stevens W (1985) Musculoskeletal
applications of three dimensional surface reconstructions.
Orthop Clin North Am 16(3):543–555
30. Davies BL, Ho SC, Hibberd RD (1994) Th The use of force con-
trol in robot assisted knee surgery. A. Digioia, T. Kanadi,
R. Taylor (eds) MRCAS’94 Pittsburgh, USA, vol 2, Session
VI. Pittsburgh, PA, September, 22–24, pp 258–262
31. Kienzle TC, Stulberg SD, Peshkin M, et al. (1996) A comput-
er-assisted total knee replacement surgical system using a
calibrated robot. Orthopaedics. In: Taylor RH, Lavallée S,
Bundea GS, Mösges R (eds) Computer integrated surgery.
MIT Press, Cambridge Massachusetts, pp 409–416
32. Matsen FA, Garbini JL, Sidles JA, et al. (1993) Robotic assis-
tance in orthopaedic surgery. A proof of principle using distal
femoral arthroplasty. Clin Orthop Relat Res 296:178–186
33. Ritschl P, Machacek F, Fuiko R, et al. (2004) The Th Galileo
system for implantation of total knee arthroplasty. An
intergrated solution comprising navigation, robotics and
robot-assisted ligament balancing. In: Stiehl JB, Koner-
mann WH, Haaker RG (eds) Navigation and robotic in
total joint and spine surgery. Navigation and robotics in
total joints and spine surgery, Chapter 39. Springer Berlin,
pp 281–286
34. Picard F, Moody J, DiGioia A, et al. (2004) Classification.
fi
In: DiGioia AM, Jaramaz B, Picard F, Nolte L-P (eds) Com-
puter and robotic assisted knee and hip surgery, Chap-
ter 4. Oxford University Press. Uk, pp 43–48
35. Fleute M, Lavallee S, Julliard R (1999) Incorporating a
statiscally-based shape model into a system for computer-
assisted anterior cruciate ligament surgery. Medical image
analysis, vol 3. Oxford University Press London, pp 209–222
36. Devos T, Martin P, Picard F (2005) A handheld computer-
controlled tool for total knee replacement. In: Langlotz F,
Davies BL, Schlenska D (eds) Proceeding CAOS. Interna-
tional Helsinki ProBUSINESS, Berlin
37. Pott PP, Scharf HP, Schwarz LR (2005) Today’s state of the
art in surgical robotics. Comput Aided Surg 10(2):101–132
38. Mattes T, Puhl W (2004) Navigation in TKA with the navi-
track system. In: Stiehl JB, Konermann WH, Haaker RG
(eds) Navigation and robotic in total joint and spine sur-
gery, Chapter 41. Springer, p 295
39. Foley KT, Simon DA, Rampersaud YR (2001) Virtual fl fluo-
roscopy: computer-assisted fluoroscopic navigation. Spine
26(4), 347–351
40. Rampersaud YR, Foley DA, et al. (2001) Radiation expo-
sure to the spine surgeon during fluoroscopically assisted
pedicle screw insertion. Spine 25(20):2637–2645
41. Victor J, Hoste D (2004) Image-based computer-assisted
total knee arthroplasty leads to lower variability in coro-
nal alignment. Clin Orthop 428:131–139
42. Mayman DJ, Rudan J, Watson D, Ellis R (2004) Computer
enhanced insertion of the Oxford unicompartmental
arthroplasty: a fluoroguide technique. Comput Aided Surg
9(3):81–85
43. Parratte S, Argenson JN (2007) Validation and usefulness
of a computer-assisted cup-positioning system in total hip
arthroplasty. A prospective, randomized, controlled study.
J Bone Joint Surg Am 89:494–499
44. Graydon AJ, Malak S, Anderson IA, Pitto RP (2009) Evalu-
ation of accuracy of an electromagnetic computer-assisted
navigation system in total knee arthroplasty. Int Orthop
33(4):975-9
45. Moulder C, Sati M, Wentkowski MV, Nolte LP (2003) A
Transcutaneous bone digitizer for minimally invasive reg-
istration in orthopedics: a real time focused ultrasound
beam approach. Comput Aided Surg 8:120–128
46. Konermann WH, Kistner S (2004) CT-free navigation
including soft-tissue alancing: LCS-TKA and vector vision
systems. In: Stiehl JB, Konermann WH, Haaker RG (eds)
Navigation and robotic in total joint and spine surgery,
Chapter 36. Springer, Berlin, pp 254–265
47. Marchant DC, Rimmington DP, Nusem I, Crawford RW
(2004) Safe femoral pin placement in knee navigation sur-
gery: a cadaver study. Comput Aided Surg 9(6):257–260
48. Board TN, Kendoff ff D, Citak M, et al. (2008) Soft tissue
dissection in placement of reference markers during com-
puter aided total hip arthroplasty. Comput Aided Surg
13(4):218–224
49. Jaramaz B, DiGioia AM (2004) Total hip replacement.
Navigation technique. In: DiGioia AM, Jaramaz B, Picard
F, Nolte L-P, (eds) Computer and robotic assisted knee and
hip surgery, Chapter 109, pp 97–112
50. Restripo C, Hozack WJ, Orozco F, Parvizi J (2008) Accu-
racy of femoral rotational alignment in total knee arthro-
plasty using computer assisted navigation. Comput Aided
Surg 13(3):167–172
51. Klima S, Zeh A, Josten C (2008) Comparaison of opera-
tive time and accuracy using conventional fixed fi naviga-
tion cutting blocks and adjustable Pivotal™ cutting blocks.
Comput Aided Surg 13(4):225–232
52. Anglin C, Ho KCT, Briard JL, et al. (2008) In vivo patellar
kinematics during total knee arthroplasty. Comput Aided
Surg 13(6):377–391
53. Otake Y, Suzuki N, Hattori A, et al. (2007) System for
intraoperative evaluation of soft tissue generated forces
during total hip replacement by measurement of the pres-
sure distribution in artifi ficial joints. Comput Aided Surg
12(1):53–59
54. Massin P, Boyer P, Pernin J, Jeanrot C (2008) Navigated
revision knee arthroplasty using a system designed for
primary surgery. Comput Aided Surg 13(4):179–187
55. Jenny JY, Boeri C, Picard F, Leitner F (2004) Reproduc-
ibility of intra-operative measurement of the mechanical
axes of the lower limb during total knee replacement with
a non-image based navigation system. Comput Aided Surg
9(4):161–165
56. Marchant DC, Rimmington DP, Crawford RW, et al. (2005)
An algorithm for locating the center of the ankle in knee
navigation. Comput Aided Surg 10(1):45–49
57. Marin F, Mannel H, Claes L, Durselen L (2003) Accurate
determination of a joint rotation center based on the
minimal amplitude point method. Comput Aided Surg
8:30–34
58. Martelli S, Zaffffagnini S, Bignozzi S, et al. (2007) Descrip-
tion and validation of a system for intra operative evalua-
tion of knee laxity. Comput Aided Surg 12(3):181–188
59. Stindel E, Gil D, Briard JL, et al. (2005) Detection of the
center of the hip joint in computer assisted surgery: an
evaluation study of the Surgertics algorithm. Comput
Aided Surg 10(3):133–139
60. Kienzle TC III,, Stulbergg SD,, Peshkin MA, et al. (1993) An
integrated CAD-robotics system for total knee replace-
ment surgery. Proc. IEEE Int. Conf. Robotics and Automa-
tisation (1):889–894
61. Strauss JM, Rüther S. (2004) Navigation and soft-tissue
balancing of LCS total knee arthroplasty. In: Stiehl JB,
Konermann WH, Haaker RG (eds) Navigation and robotic
in total joint and spine surgery, Chapter 37. Springer Ber-
lin, pp 266–273
62. Glossop ND (2009) Advantages of optical compared with
electromagnetic tracking. J Bone Joint Sung Am 91:23–28

P. Deprez, J. Victor Why using navigation in total knee
arthroplasty?
Introduction
T
otal knee arthroplasty (TKA) is a predictable
and reliable surgical procedure.
Correct positioning of the components
together with a stable, balanced joint are key fac-
tors in the success. Component malposition can
cause pain (1), limited range of motion (2), insta-
bility (3), polyethylene wear, and loosening of the
implant (4, 5). In the earlier days of TKA, much
attention was given to the correction of limb align-
ment as the detrimental eff ffects of remaining mala-
lignment were obvious and well documented, both
clinically (6–14) and biomechanically (15–17).
With the improvement in surgical training and bet-
ter instrumentation systems, correct positioning
of the components evolved to a routine procedure.
Over the last decade, alignment issues received less
attention in the orthopaedic literature, but mala-
lignment remains a threat to the patient undergo-
ing TKA.
A round table and multi-center evaluation of the
French orthopedic community concluded that 31%
of the patients with major pre-operative coronal
malalignment had a deviation of the mechanical
axis of more than 5° post-operatively (18).
Jeff
ffery et al. (19) noted satisfactory post-operative
coronal alignment (mechanical axis deviation of
less than 3°) in 2/3rd of their total knee arthro-
plasties. In 1/3rd of the operated knees, greater
mechanical axis deviation in the coronal plane was
found. These knees had a mechanical loosening
rate of 24% at 8 years, as opposed to 3% mechani-
cal loosening for normally aligned knees.
Sharkey et al. (5) showed that malalignment and
malposition of components play a significant
fi role in
the failure mechanism of modern knee prostheses.
The recent interest in minimally invasive surgery
(MIS) has further accentuated this issue. Surgeons
undergo pressure from peers, industry and patients
to follow this new trend (20). TheTh reduction of the
surgical exposure limits the ability of the surgeon
to find the usual anatomic landmarks that are used
for component positioning. It is clear that MIS is
associated with an increased risk of surgical error,
even in the hands of experienced surgeons.
Chapter 82
Computer assisted surgery (CAS) was developed
before the big wave of MIS hit the orthopaedic
community. Two mainstream technologies pre-
vailed: imageless CAS and image-based CAS, the
latter being most often combined with fluoroscopy
in total knee surgery. CAS in theory could improve
positioning, alignment, balance and prosthesis
survival. From the beginning, navigation was also
considered as an excellent teaching instrument
because it provides intra-operative feedback which
was not available before. Nowadays, most naviga-
tion systems document knee alignment data in
three planes, component positioning and maximal
flexion and extension values. Also medial and lat-
eral joint opening can be measured. With naviga-
tion the exact level of the joint line can be deter-
mined and maintained. A major advantage is the
intra-operative possibility to simulate bonecuts
and implant position, before any action is under-
taken (21) (Fig. 1). The
Th obtained data can be used
for improving surgical accuracy but also for further
development and improvement of implants and
kinematics.
An abundance of literature on computer assisted
knee arthroplasty surgery has been published
in the last years. This chapter will give an over-
view on the published radiographic and clinical
results.
Fig. 1 – The most obvious advantage for the surgeon is the possibility to
plan and predict component position before any surgical cut is made.
880 Primary Total Knee Arthroplasty
Alignment and soft tissue balance in CAS-TKA
It’s evident that the goals for alignment are the
same as for conventional TKA. Using navigation,
the surgeon can measure intra-operatively and
adjust untill optimal results have been achieved
(Fig. 1). Consequently this should lead to more
accurate bonecuts and soft tissue releases with
improved alignment and stability. Th The published
results for each separate plane are discussed.
Coronal alignment
It is widely accepted that deviation of the mechani-
cal axis of the limb of more than 3° from the neu-
tral is associated with reduced longevity of the
implant (19, 22). However, there is very little
direct evidence to support this. On the contrary,
a recent study from Pagnano et al. concluded
that malaligned knees do not necessarely lead to
worse survival (23). It seems that 3° is an arbitrary
threshold and there is no reason to believe that it
represents a defi finitive value for the acceptability
of alignment. It is more likely that any deviation
from neutral will reduce longevity in a proportional
eff
ffect. Errors in tibial and femoral alignment of
more than 3° occur in at least 10% of TKA’s using
mechanical alignment systems (24, 25).
There is however until today no complete consen-
Th
sus whether component positioning and mechani-
cal alignment signifi ficantly improves with the use
of navigation.
Improved coronal (and sagittal) alignment with nav-
igation was found in a randomized controlled study
by the senior author of this chapter (19). Ninety-
seven total knee arthroplasties were performed;
49 with fluoroscopy-based navigation, the others
with conventional methods. For the mechanical
axis in the coronal plane, in the computer assisted
group all knees (N N = 49) scored within 0–2° on the
post-operative X-ray. In the conventional group
(N = 48), 73.5% of the knees fell within 0–2°, and
(N
26.5% within 3–4°. No knees had a mechanical axis
deviation of more than 4°. The diff fference in vari-
ance between the CAS and the conventional groups
was signifificant. Results were less variable in the
group with navigation. Th These conclusions were con-
firmed in other studies and recently meta-analyses
on the subject. TheTh first meta-analysis was pub-
lished by Bäthis et al. (26). They analyzed 13 com-
parative studies. In all studies CAS was compared
with conventional TKA surgery. In the CAS Group,
93.9% (863/919) of the prostheses were implanted
within the safe zone (±3° from neutral alignment)
( < 0.0001). The
(p Th diff fferences between the groups
were statistically significant
fi in 11 of the 13 studies.
Bauwens et al. (27) performed another meta-analy-
sis of 33 studies (11 randomized trials) comparing
navigated with conventional knee arthroplasties.
The mechanical alignment was not signifi ficant dif-
ferent between the navigated and conventional
surgery group (weighted mean difference, ff 0.2°;
95% confi fidence interval, -0.2 to 0.5°). Patients
managed with navigated surgery had a lower risk
of malalignment at critical thresholds of >3° (risk
ratio, 0.79; 95% confi fidence interval, 0.71–0.87)
and >2° (risk ratio, 0.76; 95% confidence
fi interval,
0.71–0.82). These
Th authors therefore concluded that
navigated knee replacements provided only few
advantages over conventional surgery on the basis
of radiographic end points. Th These findings were
later corrected in an other meta-analysis by Mason
et al. (28). They remarked that analytic errors were
made by Bauwens et al. Although their results were
based on almost the same studies, they had other
conclusions: computer-assisted navigation in TKA
off
ffers a signifi
ficant (p < 0.05) improvement in both
the accuracy and reproducibility of prosthetic com-
ponent orientation for all alignment outcomes at
±3° from neutral when compared with conventional
knee techniques, with the exception of sagittal
femoral alignment and tibial slope, which did not
reach statistical signifi
ficance. Although therefore at
least two meta-analyses showed superior (coronal)
alignment results with navigation, there is still a lot
of controverse, even in the most recently published
papers (29).
Sagittal alignment
The optimal prosthetic alignment in the sagittal
plane is unknown. Femoral and tibial mechanical
axes are the usual references. In most cases a tibial
slope of 3–5° is aimed for. The impact of sagittal
malalignment has not been studied extensively.
However, sagittal instability does occur and has
been associated with an excessive tibial slope. Since
variations in tibial slope produce alterations in
the flexion and extension gaps, the complications
of sagittal malalignment are probably the conse-
quences of flexion–extension mismatch (22).
Matziolis and others found that computer-assisted
implantation of total knee replacements improved
the sagittal alignment of the femoral component
but not of the tibial component (27, 28, 30). Minoda
et al. investigated the sagital alignment of computer
assisted TKA and concluded that the use of diff ffer-
ent reference points on the distal femoral condyle
resulted in diff
fferences of as much as 3° alignment in
the sagittal plane (31). Although the optimal pros-
thetic alignment for TKA in the sagittal plane is not
known, surgeons and technicians using navigation
systems should be aware of this difference
ff and the
risk of hyper-extension between the femoral and

tibial components as a result, which might lead to
anterior post-cam impingement (32, 33).
Rotational alignment
Adequate rotational positioning of the femoral
component is important for patellar tracking and
flexion stability. Anatomic referencing is sometimes
fl
diffi
fficult and inadequate. In the surgical strategy of
independent femoral and tibial cuts, the ideal fem-
oral component rotation is parallel to the surgical
axis of Berger, from the medial femoral sulcus to
the lateral epicondyle (=transepicondylar axis + 2
°) (34). Victor et al. confi
firmed the surgical transepi-
condylar axis as the correct theoretical reference
line and stressed the variability of the trochlear AP
axis (Whiteside's line). The smallest variability was
found for the posterior condylar axis (35, 36).
Excessive internal rotation leads to abnormal
patellar tracking and flexion instability. Some
studies show that internal rotation greater than 3°
may lead to early failure (37). Sikorski found that
mismatch of the femoral and tibial components in
rotation is the most important factor leading to
early prosthesis failure (before 10 years) compared
to late failure (after 10 years) (22).
In a prospective randomized study Stockl et al.
found superior results for rotation of the femoral
component when navigation was compared to con-
ventional techniques (38). They used a peroperative
referencing for the transepicondylar axis. Jerosh et
al. and Jenny et al. stressed the weak peroperative
reproducibility of the transepicondylar axis (39,
40). Michaut et al. also stated that determination
of the transepicondylar axis with navigation is not
reliable (37). They propose a pre-operative CT-scan
for better determination of the transepicondylar
axis. In their study satisfactory femoral rotation
(parallel with the Berger axis ±2°) was obtained in
77% for femoral component rotation compared to
44% when using conventional ancillary (22).
Soft tissue balance
Even with perfect bone cuts and component posi-
tioning, TKA will fail when soft tissue balanc-
ing is inadequate. Unfortunatelly, it is today still
not clear what the surgeon should aim for. Th There
is little evidence to show that there is a quantita-
tive relationship between soft tissue balance and
outcome, partly because evaluation of “balance” is
totally subjective (37).
It is generally accepted that the surgeon should
aim for “some” medial-lateral laxity, but only few
numerical data are currently available to guide the
surgeon. Vandamme et al. (41) published a cadav-
Why using navigation in total knee arthroplasty? 881
eric study which provides the knee surgeon with the
“normal” values for knee laxity obtained with a fl flu-
oroscopy-based latest-generation spatial navigation
system. Average medial joint-line opening on valgus
stress was 2.6 mm at 0°, 5.1 mm at 30°, and 7.1 mm
at 90° of flexion. The average lateral joint-line open-
ing on varus stress was 3.1 mm at 0°, 5.9 mm at 30°,
and 8.1 mm at 90° of flexion. The average anterior-
posterior laxity was 3.9 mm at 0°, 9.2 mm at 30°,
and 7.7 mm at 90° of flexion. Mean rotational lax-
ity increased from 14° in extension to 34° at 30° of
flexion and to 36° at 90° of flexion. When the goal
of TKA is to restore the natural anatomy as closely
as possible, then the orthopaedic surgeon should
aim for these laxity values. But this was a cadaver
study in non-artritic knees, and after TKA laxity
requirements may have changed because cruciate
ligaments have been resected. Additional work is
therefore necessary to validate these findings.
There have been few reports about soft tissue balance
assessment with navigation system in vivo (42, 43).
Stulberg et al. reported that the average total pre-
operative medial-lateral laxity of arthritic knees as
measured using a navigation system was pre-opera-
tive 10.3° and post-operative 3.9°(43). Saragaglia et
al. reported that 41 (45.5%) of 90 cases were intra-
operatively overcorrectable and 20 cases were reduc-
ible to a neutral axis (44). The accuracy of soft tissue
balance assessment using navigation was reported
and clarifified in a recent publication by Matsumoto et
al. (45). They performed 30 TKA’s with a CT-free navi-
gation and tensor system which was able to measure
the angle between the femoral cut and the tibial cut
(in degrees) and also the joint component gap. Intra-
operative measurements were in flexion and exten-
sion and with the patella everted and reduced. With
the patella everted, their measurements resulted in
a mean joint component gap imbalance of 8.8 mm
and a mean varus ligament balance of 1.3° between 0
and 90° of knee flexion. With a reduced PF joint how-
ever, the joint component gap imbalance dropped
to 5.4 mm and the mean varus ligament balance
between 0° and 90° of flexion dropped to 4.2°. With
an everted patella, knee stability is mainly aff
fforded by
the medial and lateral collateral ligaments and gives
an unphysiological minimum running distance of the
extensor mechanism. This condition may cause less
anterior and laterally shifted tension, thereby leading
to a larger component gap and a slight varus ligament
balance at 90° of flexion.
fl They conclude therefore
that it is better to assess ligament balancing with the
patella reduced.
Navigation and minimal invasive surgery
With the reduction of the surgical exposure in MIS,
anatomical landmarks are harder to locate. Espe-
882 Primary Total Knee Arthroplasty
cially the lateral tibial plateau, the posterior part
of the femoral condyles and the epicondyles can-
not be located as accurately with MIS than with a
conventional exposure. In imageless systems, loca-
tion of these reference points is mandatory and is
a main determinant for the accuracy of the proce-
dure (46). One can imagine that accuracy of image-
less CAS systems will decrease if used in combina-
tion with MIS. Image-based systems have the great
advantage that reference points can be chosen or
controlled on X-ray images. Th This additional infor-
mation can be extremely valuable in combination
with a radical reduction of the exposure. As far as
we know, all published studies where MIS and CAS-
TKA were combined, used an imageless navigation
system. Chandrasekaran et a lpublished a study of
30 total knee arthroplasties performed with MIS
and imageless computer assistance (47). With CAS
and MIS the accuracy of component alignment
was maintained despite the minimally invasive
approach. Biasca et al. found that imageless com-
puter navigation in TKA preserved accurate coro-
nal, sagittal, and rotational components alignment
even with a minimally invasive approach (32, 48).
In a prospectine randomized study of 90 cases
where three groups were compared (conventional
TKA, MIS TKA, and CAS MIS TKA), mechanical leg
axis was signifificantly better in the CAS MIS Group
compared to both other groups. At any time point
there was no clinical significant
fi diff
fference (49). It
seems that a minimal invasive approach combined
with navigation can be associated with comparable
alignment results compared with conventional
techniques, even using an imageless system.
Clinical results after computer assited total knee
arthroplasty
Although literature is not clear, most authors
report better alignment and less outliers using
navigation in TKA. Since alignment is essential for
good function and survival of the total knee pros-
thesis, one could expect improved clinical results
as well. There is however evidence in the literature
that this is not the case, at least in the short-term
follow-up (26, 27, 29, 32, 50–52).
But also midterm follow-up does not seem to sug-
gest a clinical diff
fference. In a retrospective study
Molfetta et al. found no statistical diff
fference in clini-
cal outcome between TKA with or without naviga-
tion at 5 years (53). In their study only varus knees
with a pre-operative deformity of less than 15° were
included. As far as we know there are no studies
available with more than 10 year follow-up.
With respect to the clinical outcome after MIS, Lüring
et al. (49) performed a prospective randomized
study and compared three groups; TKP placed in the
conventional manner, with MIS, and MIS combined
with navigation. They found no statistically signifi fi-
cant difffference in early rehabilitation between MIS
and the conventional approach. Seon and Song (54)
used the less-invasive (LIS) minimidvastus approach
in combination with CAS and compared with con-
ventional (CON) TKA. They demonstrated better
pain scores, shorter time to achieve 90° flexion
fl and
straight leg raise, and a smaller extension lag during
the very early post-operative period. However, there
were no diff fferences between the groups at 2 weeks
post-operatively. Navigation-assisted LIS-TKA had
fewer prosthetic alignment outliers than CON-TKA
but did not eliminate outliers.
Finally, computer navigation may avoid the poten-
tial problem of fat and marrow embolization seen
with intra-medullary instruments. Some reports
mention less blood loss and a decreased pulmo-
nary complication risk (50, 55).
In view however of the absence of proven clinical
benefifit, the question can be asked if one should
abandon computer assistance in primary TKA and
use it only in diffi
fficult cases with disturbed anatomy
or in revision cases? We may not forget what navi-
gation has learned us already. The Th data collected
from navigating knees helped, and will continue
to help us, to critically evaluate what we are doing
and will determine better what works and what
does not work. There are still a lot of questions in
TKA that are not answered and where navigation
can help us to fi find the answer. Better understand-
ing of kinematics for example will hopefully give us
an answer why some operated knees do not “feel
normal” to the patient. It is clear that the succes
of TKA depends not only on the alignment alone.
Instability, often representing a failure to correct
a deformity or balance the fl flexion and extension
spaces at the time of the index arthroplasty, can
lead to implant failure. In some studies, 30–35% of
patients underwent revision TKA (5, 11, 56).
In a prospective, controlled, multi-center study
in 13 European orthopaedic centers Jenny et al.
compared diff fferences between experienced ortho-
paedic surgeons and beginners in performing com-
puter assisted TKA (57). They found no diff fference
between both groups, except for operating time
which was signifi ficantly longer in the beginners
group. However, this increase in operating time
disappeared after 30 implantations. So, they con-
cluded that the system's learning curve levels off ff
at that point. Given the high accuracy of implan-
tation when using their navigation system they
believe this learning curve to be acceptably low.
Most studies reported longer operation time when
using navigation. Extra time varies between a few
minutes and half an hour. Some well experienced
surgeons report after multiple procedures even

shorter total operation time when using naviga-
tion compared with conventional means.
Novak et al.(58) analyzed the cost-effectiveness
ff of
computer assisted TKA. They concluded the cost-ef-
fectiveness of CAS to be very sensitive to the incre-
mental cost of the navigation equipment, the incre-
mental benefi fit of computer-assisted surgery over
mechanical guides in terms of implant alignment,
and the impact of implant malalignment on implant
survival and revision rates. Additional studies exam-
ining the long-term outcomes of TKA with regard to
implant alignment will further determine cost-effec-
ff
tiveness. If the costs associated with this technology
would decrease and the accuracy of computer-guided
implant alignment would improve, CAS would have
the potential to become a cost-saving technology
while at the same time improving patient outcomes.
Complications related to navigation are limited.
Femoral fractures have been described through pin
tract sites. Intra-operative quadriceps entrapment
and post-operative scarring can be avoided using
smaller pins. Infection rate in TKA is similar with
or without navigation.
What are the challenges for the next future? New
data will allow us to understand better knee and
implant kinematics. Current concepts in soft tissue
balancing have to be reinvestigated, evaluated, and
adjusted to obtain optimal clinical outcome. If long-
term follow-up shows clinically better results with
navigation then consequently computer assistance
should become widespread. If we want navigation be
used even in low practice, we will need further evolu-
tion of the equipment. The ideal navigation system
must have useful tools, give correct measurement,
and have no learning curve. Extra operation time
should be minimal. Additional costs must be lim-
ited. Recently, electromagnetic navigation was intro-
duced instead of infrared-systems. The advantage of
the Electromagnetic (EM) navigation system is that
no line-of-sight issues are present. However, special
iron-free instruments are required. More studies are
required to assess accuracy of this new technology.
References
1. Hofmann S, et al. (2003) Rotational malalignment of the
components may cause chronic pain or early failure in
total knee arthroplasty. Orthopade 32(6):469–476
2. Bellemans J, et al. (2002) Fluoroscopic analysis of the
kinematics of deep flexion in total knee arthroplasty.
Infl
fluence of posterior condylar off
ffset. J Bone Joint Surg
Br 84(1):50–53
3. Kumar PJ, et al. (1997) Severe malalignment and soft-tis-
sue imbalance in total knee arthroplasty. American J Knee
Surg10(1):36–41
4. Gibbs AN, et al. (1979) A comparison of the Freeman-
Swanson (ICLH) and Walldius prostheses in total knee
replacement. J Bone Joint Surg Br 61:358
5. Sharkey PF, et al. (2002) Why are total knee arthroplasties
failing today? Clin Orthop 404:7–13
Why using navigation in total knee arthroplasty? 883
6. Agglietti P, et al. (1988) Posteriorly stabilised total condy-
lar knee replacement: three to eight years follow-up on 85
knees. J Bone Joint Surg Br 70:211–216
7. Bargren JH, et al. (1983) Alignment in total knee arthro-
plasty. Clin Orthop 173:178–183
8. Hamilton LR (1982) UCI total knee replacement: a fol-
low-up study. J Bone Joint Surg Am 64:740–744
9. Insall JI, et al. (1979) The total condylar knee prosthesis:
a report on two hundred and twenty cases. J Bone Joint
Surg Am 61:173–180
10. Laskin RS (1990) Total condylar knee replacement in
patients who have rheumatoid arthritis: a ten year fol-
low-up study.J Bone Joint Surg Am 72:529–535
11. Lotke PA, et al. (1977) Inflfluence of positioning of prosthesis
in total knee replacement. J Bone Joint Surg Am 59:77–79
12. Ritter MA, et al. (1994) Postoperative alignment of total
knee replacement. Clin Orthop 299:153–156
13. Tew M, et al. (1985) Tibiofemoral alignment and the results
of knee replacement. J Bone Joint Surg Br 67:551–556
14. Windsor RE, et al. (1989) Mechanisms of failure of the
femoral and tibial components in total knee arthroplasty.
Clin Orthop 248:15–19
15. Bartel DL, et al. ((1982) Performance of the tibial component
in total knee replacement. J Bone Joint Surg Am 64:1026
16. Green GV, et al. (2002) The
Th effffects of varus tibial alignment
on proximal tibial surface strain in total knee arthroplasty.
J Arthroplasty 17:1033–1039
17. Hsu HP, et al. (1989) Eff ffect of knee component alignment
on tibial load distribution with clinical correlation. Clin
Orthop 248:135–144
18. Brilhaut J, et al. (2003) Les Annales Orthopédiques de
l’Ouest. Prothèse Totale de Genou et grandes déviations
axiales 35:253–288
19. Jeff
ffery RS, et al. (1991) Coronal alignment after total knee
replacement. J Bone Joint Surg Br 73:709–714
20. Callaghan JJ(2005) Internet Promotion of MIS and CAOS
in TKA by Members of the Knee Society. Presented at the
Knee Society Interim Meeting, NY, NY
21. Mayman DJ (2008) Computer navigation for total knee
arthroplasty: a current perspective. Tech Knee Surg
7(3):138–143
22. Sikorski JM (2008) Alignment in total knee replacement.
J Bone Joint Surg Br 90(9):1121–1127
23. Pagnano MW, Trousdale RT, Berry DJ, Parratte S. (2008)
The mechanical axis may be the wrong target in computer-
assisted TKA #203. Presented at the American Academy of
Orthopaedic Surgeons 75th Annual Meeting. March 5–9
24. Amiot LP, Poulin F (2004) Computed tomography-based
navigation for hip, knee, and spine surgery. Clin Orthop
Relat Res 77
25. Bäthis H, Perlick L, Tingart M, et al. (2004) CT-free com-
puter-assisted total knee arthroplasty versus the conven-
tional technique: radiographic results of 100 cases. Ortho-
pedics 27:476
26. Bäthis H, Shafi fizadeh S, Paffffrath T, et al. (2006) Are com-
puter assisted total knee replacements more accurately
placed? A meta-analysis of comparative studies. Ortho-
pade 35(10):1056–1065
27. Bauwens K, Matthes G, Wich M, et al. (2007) Navigated
total knee replacement. A meta-analysis. J Bone Joint
Surg Am 89(2):261–269
28. Mason JB, Fehring TK, Estok R, et al. (2007) Meta-analy-
sis of alignment outcomes in computer-assisted total knee
arthroplasty surgery. J Arthroplasty 22(8):1097–1106
29. Kim YH, Kim JS, Choi Y, Kwon OR (2009) Computer-as-
sisted surgical navigation does not improve the alignment
and orientation of the components in total knee arthro-
plasty. J Bone Joint Surg Am 91(1):14–19
30. Matziolis G, Krocker D, Weiss U, et al. (2007) A prospec-
tive, randomized study of computer-assisted and conven-
tional total knee arthroplasty. Three-dimensional
Th evalua-
884 Primary Total Knee Arthroplasty
tion of implant alignment and rotation. J Bone Joint Surg
Am 89(2):236–243
31. Minoda Y, Kobayashi A, Iwaki H, et al. (2008) tka sagit-
tal alignment with navigation systems and conventional
techniques vary only a few degrees. Clin Orthop Relat Res
32. Biasca N, Wirth S, Bungartz M (2009) Mechanical accu-
racy of navigated minimally invasive total knee arthro-
plasty (MIS TKA). Knee 16(1):22–29
33. Verborgt
b O
O, Victor J (200
(2004)) Post impingement in posterior sta-
bilised total knee arthroplasty. Acta Orthop Belg 70(1):46–50
34. Berger RA, Rubash HE, Seel MJ (1993) Determining the
rotational alignment of the femoral component in total
knee arthroplasty using the epicondylar axis. Clin Orthop
186:40–47
35. Victor J, Van Doninck D, Labey L, et al. (2009) A common
reference frame for describing rotation of the distal femur.
J Bone Joint Surg Br (in press)
36. Victor J, Van Doninck D, Labey L, et al. (2009) How precise
can bony landmarks be determined on a CT-scan of the
knee? Knee (in press)
37. Michaut
h M, Beaufi fils P, Galaud B, et al. (2008) Rotational
alignment of femoral component with computed-assisted
surgery (CAS) during total knee arthroplasty Rev Chir
Orthop Reparatrice Appar Mot 94(6):580–584
38. Stockl B, Nogler M, Rosiek R, et al. (2004) Navigation
Improves Accuracy of Rotational Alignment in Total. Knee
Arthroplasty. Clin Orthop 426:180–186
39. Jenny JY, Boeri C (2004) Low reproducibility of the intra-
operative measurement of the transepicondylar axis during
total knee replacement. Acta Orthop Scand 75(1):74–77
40. Jerosch J, Peuker E, Philipps B, Filler T (2002) Interindi-
vidual reproducibility in perioperative rotational aligne-
ment of femoral components in knee prosthetic surgery
using the transepicondylar axis. Knee Surg Sports Trau-
matol Arthrosc 10:194–197
41. Vandamme G, et al. ((2005) What should the surgeon aim
for when performing computer-assisted knee arthro-
plasty? J Bone Joint Surg87A:52–58
42. Saragaglia D, et al. (2001) Computer assisted knee arthro-
plasty: comparison with a conventional procedure. Results
of 50 cases in a prospective randomized study. Rev Chir
Orthop Reparatrice Appar Mot 87:18–28
43. Stulberg SD, et al. (2002) Computer-assisted navigation in
total knee replacement: results of an initial experience in
thirty-fi
five patients. J Bone Joint Surg Am 84:90–98
44. Saragaglia D, Chaussard C, Rubens-Duval B (2006) Navi-
gation as a predictor of soft tissue release during 90 cases
of computer-assisted total knee arthroplasty, Orthopedics
29(10 Suppl): S137
45. Matsumoto T, Muratsu H, Tsumura N, et al. (2008) Soft tis-
sue balance measurement in posterior-stabilized total knee
arthroplasty with a navigation system. J Arthroplasty
46. Fuiko R, Kotten B, Zettl R, Ritschl P (2004) The accuracy
of palpation from orientation points for the navigated
implantation of knee prostheses. Orthopäde 33(3):338–
343
47. Chandrasekaran S, Molnar RB. Minimally invasive image-
less computer-navigated knee Ssrgery: initial results. J
Arthroplasty 23 :441–445
48. Mizu-Uchi H, Matsuda S, Miura H, et al. (2008) Three-di-
Th
mensional analysis of computed tomography-based naviga-
tion system for total knee arthroplasty the accuracy of com-
puted tomography-based navigation system. Arthroplasty
49. Lüring C, Beckmann J, Haiböck P, et al. (2008) Minimal inva-
sive and computer assisted total knee replacement compared
with the conventional technique: a prospective, randomised
trial. Knee Surg Sports Traumatol Arthrosc 16(10):928–934
50. Chauhan SK, Scott RG, Breidahl W, Beaver RJ (2004) Com-
puter assisted knee arthroplasty versus a conventional jig-
based technique. J Bone Joint Surg 86-B:372–377
51. Ensini A, Catani F, Leardini A, et al. (2007) Alignments
and clinical results in conventional and navigated total
knee arthroplasty. Clin Orthop Relat Res 457:156–162
52. Victor J, et al. (2004) Computer assisted surgery: image-based
computer-assisted total knee arthroplasty leads to lower vari-
ability in coronal alignment. Clin Orthop 428:131–139
53. Molfetta L, Caldo D (2008) Computer navigation versus con-
ventional implantation for varus knee total arthroplasty: a
case-control study at 5 years follow-up. Knee 15(2):75–79
54. Seon JK, Song EK (2006) Navigation-assisted less inva-
sive total knee arthroplasty compared with conventional
total knee arthroplasty: a randomized prospective trail. J.
Arthroplasty 21(6):777–782
55. Kalairajah Y, Simpson D, Cossey AJ, et al. (2005) Blood loss
after total knee replacement: eff ffects of computer-assisted
surgery. J Bone Joint Surg Br 87(11):1480–1482
56. Nabeyama R, Matsuda S, Miura H, et al. ((2004) The accu-
racy of image-guided knee replacement based on CT. J
Bone Joint Surg Br 6:366–371
57. Jenny
J JY,
JY Miehlke
M hlk RK, RK Giurea
G A (2008) Learning curve in
navigated total knee replacement. A multi-centre study com-
paring experienced and beginner centres. Knee 15(2):80–84
58. Novak EJ, Silverstein MD, Bozic KJ (2007) The cost-ef-
fectiveness of computer-assisted navigation in total knee
arthroplasty. J Bone Joint Surg Am 89(11):2389–2397
59. Bäthis H, Perlick L, Tingart M, et al. (2004) Alignment
in total knee arthroplasty. A comparison of computer
assisted surgery with the conventional technique. J Bone
Joint Surg 86-B:982–987
60. Bäthis H, Perlick L, Tingart M, et al. (2004) Radiological
results of image-based and non-image-based computer
assisted total knee arthroplasty. Int Orthop 28(2):87–90
61. Catani F, Biasca N, Ensini A, et al. ((2008) Alignment devia-
tion between bone resection and final fi implant position-
ing in computer-navigated total knee arthroplasty. J Bone
Joint Surg Am 90(4):765–771
62. Jenny JY, et al. (2001) Computer-assisted implantation of
a total knee arthroplasty: a case-controlled study in com-
parison with classical instrumentation. Rev Chir Orthop
Reparatrice Appar Mot 87(7):645–652
63. Jessup DE. et al. (1997) Restoration of limb alignment in
total knee arthroplasty: evaluation and methods. J South-
ern Orthop. Ass 6(1):37–47
64. Kalairajah Y, Cossey AJ, Verrall GM, et al. (2006) Are sys-
temic emboli reduced in computer assisted knee surgery? A
prospective, randomized, clinical trial. J Bone Joint Surg Br
88:198–202. Erratum in: J Bone Joint Surg Br 2006; 88:140
65. Kim YH, Kim JS, Hong KS, et al. (2008) Prevalence of Fat
Embolism After Total Knee Arthroplasty Performed with
or without Computer Navigation. J. Bone Joint Surg. Am
90:123–128
66. Laskin RS, Beksaç B (2006) Computer-assisted Naviga-
tion in TKA. Where we are and where we are going. Clin
Orthop Relat Res 452:127–131
67. Mielke RK, et al. (2001) Navigation in knee endoprosthe-
sis implantation - Preliminary experience and prospective
comparative study in comparison with conventional tech-
nique. Z Orthop Ihre Grenzgeb 139(2):109–116
68. Moreland JR, et al. Radiographic analysis of the axial
alignment of the lower extremity. J Bone Joint Surg Am
1987; 69:745–749
69. Sparmann M, et al. (2003) Positioning of total knee arthro-
plasty with and without navigation support. A prospective,
randomised study. J Bone Joint Surg Br 85(6):830–835
70. Victor J, et al. (1994) Femoral intramedullary instrumen-
tation in total knee arthroplasty: the role of pre-operative
X-ray analysis. TheTh Knee 1:123–125
71. Yaff
ffe MA, Koo SS, Stulberg SD (2008) Radiographic and
navigation measurements of TKA limb alignment do not
correlate. Clin Orthop Relat Res 466(11):2736–2744
Results in Primary TKA

M. Dunbar,
S. Sripada,
Results and function of total knee
R. Kjar
arthroplasty
Introduction
T
otal knee arthroplasty (TKA) has been dem-
onstrated to be a successful surgical interven-
tion for the treatment of end-stage debilitat-
ing arthritis of the knee (1). However, TKA has been
shown to be less successful than total hip arthro-
plasty and there are numerous factors that have
been identifified in the literature that can have a neg-
ative impact on function and results of TKA (2).
Based on previous documented success of the pro-
cedure, in general, as well as changing indications
for the surgery and an ageing population, the inci-
dence of TKA has been projected to increase by
more than 650% by the year 2030 in the United
States (3). Similar increases are likely in other juris-
dictions. TKA, as a procedure is being translated to
a younger, heavier, and more active population,
not necessarily with the requisite improvement
in prosthetic design and technique. As such, it is
important to have an in depth understanding of the
results of TKA and the factors that aff ffect outcomes
to allow for optimal surgical decision-making.
Historical background
The first published report on endoprosthetic knee
arthroplasty is often attributed to Gluck in 1890
(4). Gluck employed endoprostheses made of
ivory for the treatment of knee joints destroyed
by tuberculosis. At the time, the only alternatives
to this “radical” intervention were amputation,
arthrodesis, interpositional arthroplasty, or benign
neglect. Gluck’s surgical interventions were initially
deemed successful, mostly because the alternatives
to the prosthesis were so dismal. Still, Gluck later
cautioned about the use of this prosthesis because
of continued problems with infection. Th This note
of caution represented the first report on the out-
comes after endoprosthetic knee arthroplasty.
With the continued development of modern
anesthesia, aseptic technique and antibiotic pro-
phylaxis, the modern era of endoprosthetic knee
arthroplasty began. In 1954, Shiers reported a case
Chapter 83
study of two patients using a stainless steel hinged
prosthesis (5). In one patient, heterotopic ossifica-
fi
tion limited the results, but the other was deemed
to be successful. Shiers considered the operation
a success because the patient was painless, could
walk without a stick, and could ascend and descend
stairs. Walldius reported encouraging results of
endoprosthetic knee arthroplasty using a cobalt–
chromium hinged prosthesis (6).
Gunston, the originator of an endoprosthesis con-
sisting of individual stainless steel semicircular
runners articulating with separate high density
polyethylene runners cemented to the tibia (The Th
Polycentric Knee), reported on the results of 22
knee arthroplasties in 20 patients (7). With 2 years
follow-up, Gunston reported on the radiographic
results as well as pre- and post-operative pain, flex-
fl
ion, and lateral instability. This assessment began
to resemble some of the current outcome tools
used to assess knee arthroplasty.
In the early 1970s Swanson and Freeman designed
an unlinked duocondylar prosthesis with a metal-
on-polyethylene articulation that was cemented to
the bone (8). In 1972, the prosthesis was modifiedfi
to include a patellar component that articulated
with the femoral component as well as a stemmed
tibial component. This prosthesis was referred to
as the Total Condylar Knee (9). Current knee pros-
theses can directly derive their lineage from these
prostheses and represent variations of the basic
concepts introduced.
The importance of the advances in prosthetic design
relates directly to the fact that the threshold for
endoprosthetic knee arthroplasty had moved from
that of a salvage operation performed in extreme
cases, to an intervention designed to improve the
quality of life in patients who might otherwise
cope without the intervention. Hence, judging the
results of the intervention may relate more to sub-
tler improvements in quality of life, including relief
of pain and improvement in function. Furthermore,
current prostheses have all benefited
fi from the tech-
nological learning curve in the design of prostheses,
and modern prostheses can be expected to survive
in situ, barring infection, for at least a decade, or
perhaps 2 decades, with relative certainty. Th
The net
888 Primary Total Knee Arthroplasty
eff
ffect of the homogeneity of current prostheses
(with respect to stable and lasting designs) has been
for an emerging emphasis on somehow quantifying
subtler outcomes after knee arthroplasty.
Conceptually, the development of TKA has occurred
in two phases following an asymptotic curve. Phase
1 innovation saw rapid changes in design occupying
the steep uptake of the asymptotic curve. In Phase
2, more recent and subtle changes in the evolution
of TKA can be conceptualized as occupying the fl flat
portion of the asymptotic curve (Fig. 1). Subse-
quently, assessing differences
ff in patient outcome
regarding the assessment of the function of new
implants has become more problematic.
Assessing function and results (outcomes)
Numerous methods have been used to assess the
function and results post TKA. Each method has
associated strengths and limitations that should be
considered in the context of the specifi
fic question
trying to be answered when assessing outcome.
The paradox of arthroplasty outcomes
The impact of a medical/surgical intervention can
be assessed using the metric of the standard effect
ff
Fig. 1 – Asymptotic curve used to conceptualize the development of total knee arthroplasty. Phase 1 represents the rapid evolution and radical change in
design seen with the introduction of new technologies. Phase 2 represents the current state of total knee arthroplasty evolution with much more subtle
changes being introduced with time.
size (SES). This
Th is a well-described statistical met-
ric that is calculated by subtracting the post-op-
erative metric of interest from the pre-operative
metric and dividing by the standard deviation of
the post-operative metric (10). Standardized val-
ues can be assigned to assess the impact, with a
SES of <0.4 considered small, 0.4–0.6 medium,
and >0.6 considered large (11). TKA has been
shown to have a SES in the magnitude of 2.0 (12).
This represents a profound and rapid change in
health status for the patient that confounds the
ability of clinician/researcher to determine subtle
diff
fferences in Phase 2 innovations. In essence
the eff
ffect of the intervention in general acts as a
source of noise in the post-operative assessment
period.
Objective outcome questionnaires
In 1976, Insall et al. introduced a surgeon derived
outcome score for knee arthroplasty that incorpo-
rated various parameters including technical out-
comes related to the procedure (e.g., alignment,
range of motion, etc.) and subjective patient fac-
tors such as pain (13). This questionnaire has come
to be known as the Hospital for Special Surgery
Knee Score (HSS). In 1989, Insall et al. developed
a second surgeon derived score, which incorpo-
rated similar parameters. Th This score has come to

be known as the Knee Society's Clinical and Func-
tional Scoring System (KSS) (14). The Th HSS and
KSS have been used fairly extensively in outcome
studies on knee arthroplasty. Unfortunately, and
despite their continued popularity, the HSS and
KSS scores have never been fully validated using
formal psychometric validation procedures. Fur-
thermore, these questionnaires have been found
to be exceedingly unreliable, leading some authors
to conclude that these scoring systems should not
be used (15, 16).
Subjective outcome questionnaires
In 1947, the World Health Organization defined fi
health as follows: “Health is not only the absence
of infi
firmity and disease but also a state of physical,
mental, and social well-being.” Th This defifinition re-
introduced the concept that the mind and body are
in fact one, and the “well being” of the mind and
body combined represents health. Subsequently,
the measurement of health moved from simply
defi
fining the success of a procedure by defi fining its
eff
ffect on infi firmity and disease, to the more ambi-
tious approach of defi fining what effffect the inter-
vention had on physical, mental, and social well
being. By this defi finition, it was no longer adequate
to defi fine the outcome of TKA by simply stating
what the range of motion was or what the impact
was on mobility. Instead, a more comprehensive
metrics were needed.
Partly in an eff ffort to avoid the surgeon bias asso-
ciated with objective outcomes, other disease/site
specifific questionnaires emerged that were relevant
to knee arthroplasty. In the 1980s the Lequesne
Index of Severity for the Knee (ISK) and the West-
ern Ontario and MacMaster Universities Osteoar-
thritis Index (WOMAC) were introduced (17, 18).
The Oxford-12 Item Knee Score (Oxford-12) was
later developed and released in 1998 to be used
specififically with knee arthroplasty patients (12).
Unlike the HSS and KSS, these questionnaires do
not rely on surgeon input and all have been well
validated. The WOMAC and Oxford-12 are the
most common disease and joint specific fi question-
naires, respectively, used in the assessment of
function and results post TKA.
General health questionnaires have also been
applied to assess the function and results of TKA,
the most popular of which are the 12-Item Short-
Form Health Survey (SF-12) and the 36-Item
Short-Form Health Survey (SF-36) (19, 20). Gen-
eral health questionnaires have utility in that they
allow for examination of domains of outcomes
sometimes outside of the scope of the disease and
joint specifific questionnaires, and also because they
allow for comparison of outcomes across dissimilar
Results and function of total knee arthroplasty 889
medical/surgical procedures. This
Th has allowed for
the important literature that demonstrates highly
favorable ratios of improvement in quality of life
for health care expenditures, as compared to other
procedures (21).
Subjective outcome questionnaires consistently
demonstrate good pain relief after TKA. However,
functional improvement after TKA has been less
consistently improved. In a large study on over
8000 patients with the same type of TKA pros-
thesis, 98% had improvement in pain scores while
37% reported limited functional improvement (1).
This is a sobering result and should result in refl
flec-
tion on why better results cannot be obtained
more consistently with functional outcome post
TKA.
Satisfaction as an outcome
Patient satisfaction post TKA is a relevant out-
come metric as, by definition,
fi it is patient specifi
fic
in that it allows for the patient to consciously or
subconsciously factor in a multitude of factors
when assessing their own outcome. Many of these
factors would not necessarily be contained within
the domains of other subjective outcome ques-
tionnaires. Results of patient satisfaction post
TKA are remarkably consistent from country to
country, with approximately one in five fi patients
being dissatisfi fied with their TKA at 1 year or
greater post surgery (22–24) Although consis-
tent from study to study, the fact that one in fi five
patients post TKA is not satisfi fied is another hum-
bling result and indicates that significant
fi research
is still required regarding patient selection and
expectations as well as prosthetic design and
surgical technique. Satisfaction rates post TKA
are lower than for total hip arthroplasty (THA)
and subsequently the highly consistent favorable
results of THA cannot necessarily be translated to
TKA(2).
In a large study of patient satisfaction after TKA
from the Swedish Knee Arthroplasty Registry, sat-
isfaction post TKA was most highly correlated with
improvement in pain and secondarily to improve-
ment in function. (24, 25) In the same study,
the pre-operative diagnosis leading to TKA had a
significant
fi eff
ffect on satisfaction rates post TKA.
Patients with long standing disease, such as rheu-
matoid or osteoarthritis had signifi ficantly higher
percentages of satisfi fied patients as compared to
patients with rapid onset of disease, such as post-
traumatic osteoarthritis or osteonecrosis (Fig. 2).
The authors imply that patients with long stand-
ing disease compare their surgical outcome to a
diseased state while patients with rapid onset dis-
ease more often compare their outcome to that of
a normal disease state. Patient psychology plays a
large role in the results of TKA.
890 Primary Total Knee Arthroplasty
Fig. 2 – The proportional distribution of patient satisfaction after total knee
arthroplasty as stratified by pre-operative diagnosis (red – dissatisfied, pink
– uncertain, blue – satisfied, and green – very satisfied). Patients with rapid
onset of disease, such as osteonecrosis and significantly less satisfied than
patients with chronic, long-standing disease, such as rheumatoid arthritis.
Reproduced with permission from Ref. (24).
In a latter study from the Ontario Joint Replace-
ment Registry, odds ratios were calculated for fac-
tors associated with dissatisfaction after TKA (23).
The highest odds ratio was for failure to meet pre-
operative expectations (10.7x), followed by a low
1 year WOMAC score (2.5x), a low pre-operative
WOMAC pain score while at rest (2.4x), and com-
plication requiring hospital admission (1.9x).
Satisfaction is a nebulous concept in that patient’s
self-reports of satisfaction do not correlate strongly
with other subjective outcome metrics that measure
pain and function, such as the WOMAC or Oxford-12.
For example, patients can self report a poor score
for the Oxford-12 but still be very satisfied fi with
the procedure, and conversely can report excellent
Oxford-12 scores but still be very satisfi
fied (25).
National Registry Data – revision as an outcome
The Swedish Knee Arthroplasty Registry (SKAR)
was established in 1975 and has been prospectively
collecting data on essentially all TKAs in Sweden
since that time (26) (www.ort.lu.se/knee/). Th The
SKAR represents the fi first national health care
quality register. Since that time, numerous other
nations have established their own national arthro-
plasty registries, including Norway, Denmark,
England, Canada, and Australia. Today, the SKAR
is somewhat unique because of its completeness
and length of follow-up. In essence, the database
represents a nation’s experience with knee arthro-
plasty since its modern inception. Th
The eff
ffect of the
longevity and completeness of follow-up, facili-
tated with the use of a national personal number,
has aff
fforded eff
ffectual observations regarding vari-
ous aspects of knee arthroplasty (27–30).
In 1982 Tew et al. (31) described a method of sur-
vival analysis for knee arthroplasty that made it
possible to estimate the annual failure rate and
the cumulative 10-year revision rate. This
Th meth-
odology has been used by arthroplasty registries
to produce survival curves for various prostheses,
techniques, etc, using revision as an endpoint. Of
particular importance is the fact that the SKAR can
demonstrate continuous reduction in the cumula-
tive revision rate over successive 5-year periods,
likely as a result of continuous quality improve-
ment feedback loop through dissemination of out-
come data (Fig. 3). The
Th cumulative revision rate at
10 years in Sweden is now less than 5% (32).
Variable aff
ffecting revision rates
Patient age at time of surgery has been clearly
shown to have a significant
fi impact on revision
rates in both the Swedish and Australian registries
(32, 33). The 8-year cumulative revision rate in
Australia for TKA is 11.3% for patients less than 55
years of age, 6.8% for patients aged 55–64, 4.7% for
patients aged 65–74, and 2.7% for patients older
than 75. The diff
fference in cumulative revision rates
by age cohort is similar and significant
fi in Sweden.
Fig. 3 – Decreasing cumulative revision rates over time in Sweden for total
knee arthroplasty. Reproduced with permission from Ref. (32).

Gender has also been shown to have an effect
ff on
cumulative revision rates in Sweden and Australia,
with men having higher revision rates than women
(5.5% for males versus 4.6% for females in Austra-
lia) (32, 33).
Limits of revision as an outcome
Revision status has particular merits as an outcome
metric as it is relatively easy to define
fi and the inci-
dence of revision is defifinite. The SKAR has defi
fined
revision as the addition, removal, or exchange of an
endoprosthetic component, including amputation
(34). Revision status within the SKAR has been
demonstrated to be accurate (35). While defi finitive,
revision status is a relatively blunt metric and is
generally non-representative of the functional per-
formance, degree of pain relief, and overall patient
satisfaction after knee arthroplasty. Furthermore,
diff
fferent surgeons have diff fferent thresholds for
performing revisions and not all patients requiring
revision surgery undergo the procedure because of
co-existing medical problems, personal wishes, etc.
Revision status yields data on the small minority
of operations that fail and tells us nothing of the
status of the majority of patients who have not
come to revision. Revision rates, while important,
are not a panacea of outcomes.
Discrepancy in results between registries and single
center series
Numerous reports in the literature from single cen-
ters with high volume academic arthroplasty sur-
geons, often involved in the design of the prosthesis
in question, frequently report excellent outcomes of
10–15 year survival of TKA of approximately 95%
(36–38). National arthroplasty registries, refl
flecting
an entire nations experience, fail to demonstrate
these superlative results (32, 33). Th
There is subse-
quently a degree of disconnect between published
results and Registry outcomes for the average sur-
geon, underlying an intrinsic value of the registries
to represent the plurality of surgeon’s experiences.
Range of motion as an outcome metric
Range of motion is a compelling outcome metric
in that it is reliable and objective. TKA, on average
results in a signifificant improvement in range of
motion compared to the pre-operative status. Inter-
estingly, the most reliable predictor of post-operative
range of motion is pre-operative range of motion.
Patients with low flexion pre-operatively (<100°)
Results and function of total knee arthroplasty 891
were more likely to gain flexion,
fl whereas those with
high flexion pre-operatively (>120°) were most likely
to maintain or lose flexion post-operatively (39).
Other factors aff
ffecting function and results
Obesity
The eff
ffect of obesity on patient outcomes after TKA
is somewhat controversial. It appears that TKA
results in significant
fi improvement in knee flex-
ion, knee function scores, physical function, and
relief of pain for patients regardless of weight (40).
Interestingly, obese patients, on average, do not
lose weight after TKA (40). More problematic out-
comes, including increased complication rate and
decreased survivorship have been associated with
morbid obesity (BMI > 40) (41, 42). The Th eff
ffect of
obesity on outcomes is a highly germane issue given
the increasing rates of obesity. In a study on 54,406
TKA patients from the Canadian Joint Replace-
ment Registry, obesity was found to be a significant
fi
risk factor for the need for TKA. In reference to a
BMI less than 25, there was a 3.2x-increased risk of
TKA for patients with a BMI 25-29.9, an 8.5x risk
for BMI between 30 and 34.9, an 18.7x risk for BMI
between 35 and 39.9, and a staggering increased
risk of TKA of 32.7x for patients with a BMI greater
than 40 (43). Currently, 87% of all patients receiv-
ing TKA in Canada are obese or overweight.
Co-morbidity
Patient co-morbidities have also been shown to influ-
fl
ence negatively the outcome as measured by subjec-
tive outcome questionnaire. Patients with poorer
pre-morbid disposition, as assessed by co-morbid-
ity, do not gain the same absolute post-operative
pain relief and restoration of function as patients
with better pre-morbid disposition, although their
net gains were similar for pain and larger for func-
tion (28). Co-morbidity can have a significant
fi eff
ffect
on a patient’s perception of the result of the TKA,
even when other factors are accounted for (44). As
such, it is important to consider co-morbidity in the
assessment of function and results post TKA.
Implant alignment and gait
Overall mechanical alignment post TKA appears to
have an eff
ffect on overall survivorship, especially
when alignment is outside the “safe zone” of plus
or minus 3° from a neutral axis (37, 45). Computer
892 Primary Total Knee Arthroplasty
assisted TKA has been shown through numer-
ous studies to reduce the outliers with respect to
mechanical axis (46–48). Whether or not this leads
to an improvement in function or survivorship has
yet to be determined. It is difficult
ffi to determine
this partly because of the large standard effect
ff
size for TKA, as mentioned above and also because
long-term studies will be required to assess survi-
vorship.
Pre-operative gait, an assessment of functional
alignment and load distribution has been shown
to have a signifificant impact on RSA migration
patterns of the tibial component post TKA (49,
50). In this case, RSA acts as a surrogate marker
of increased risk for failure secondary to asepti-
cally loosening. This dynamic aspect of alignment
is sometimes consider in an informal sense by the
treating surgeon, but is hard to characterize with-
out a formal gait laboratory, which is not practi-
cal for the average surgeon. Still, the RSA results
are compelling and it is likely that dynamic load-
ing will be better incorporated as a pre-operative
assessment metric in the future.
Fixation
Long-term data from the Swedish Knee Arthro-
plasty Registry show that historically uncemented
components, typically on the tibial side, have a
signifi
ficantly higher revision rate than cemented
components (32). As such, few components in
that country are used without cement. How-
ever, patients receiving TKA are now heavier and
younger, on average, than previous cohorts (32,
33). Given the higher cumulative revision rates for
young patients, there is an impetus for innovation.
A recent radiostereometric analysis (RSA) study on
an uncemented porous metal knee implant shows
promising results for these implants. Long-term
outcomes will be required to defi finitively answer
whether these prostheses will live up to the prom-
ising short term RSA results (51).
Implant design
There are numerous design considerations that
have been promoted as potentially improving
function and results. These include mobile bearing
tibial inserts, gender specifi
fic knees, and high flex-
ion articulations. Unfortunately, a clear advantage
for any of these alternative concepts has not been
demonstrated with respect to improved function
or survivorship (39, 52–54). Th This should not be
surprising, again considering the large standard
eff
ffect size of TKA and the fact that we are operat-
ing in Phase 2 of the development curve for TKA.
Conclusions
TKA has proven to be reliable and successful,
enjoying good longevity and reasonable satisfac-
tion. However, there is still considerable room for
improvement, especially considering function and
satisfaction. TKA has not yet enjoyed the overall
excellent results associated with THA. As a pro-
found increase in the incidence of TKA has been
projected, especially in younger, heavier, and more
active patients, it is imperative that factors nega-
tively impacting the function and results of TKA be
researched in a rigorous and earnest fashion.
References
1. Franklin PD, Li W, Ayers DC (2008) The Th Chitranjan Rana-
wat Award: functional outcome after total knee replace-
ment varies with patient attributes. Clin Orthop Relat Res
466(11):2597–2604
2. Bourne RB, Chesworth B, Davis A, et al. (2009) Compar-
ing patient outcomes after THA and TKA: is there a differ-
ff
ence? Clin Orthop Relat Res 468(2):542–546
3. McClung CD, Zahiri CA, Higa JK, et al. (2000) Relation-
ship between body mass index and activity in hip or knee
arthroplasty patients. J Orthop Res 18(1):35–39
4. Gluck T (1890) Die Invaginationsmethode der Osteo- und
Arthro-plastick. Berl Klin Wschr 19(732)
5. Shiers LG (1954) Arthroplasty of the knee. Preliminary
report of new method. J Bone Joint Surg Br 36:553–
560
6. Walldius B (1996) Arthroplasty of the knee using an endo-
prosthesis (classical article). Clin Orthop 331:4–10
7. Gunston FH (1971) Polycentric knee arthroplasty. Pros-
thetic simulation of normal knee movement. J Bone Joint
Surg Br 53(2):272–277
8. Freeman MA, Levack B (1986) British contribution to
knee arthroplasty. Clin Orthop 210:69–79
9. Insall J, Scott WN, Ranawat CS (1979) The total condy-
lar knee prosthesis. A report of two hundred and twenty
cases. J Bone Joint Surg Am 61(2):173–180
10. Kazis LE, Anderson JJ, Meenan RF (1989) Effect ff sizes
for interpreting changes in health status. Med Care 27(3
Suppl):S178–S189
11. Meenan RF, Kazis LE, Anthony JM, Wallin BA, et al. (1991)
The clinical and health status of patients with recent-
onset rheumatoid arthritis. Arthritis Rheum 34(6):761–
765
12. Dawson J, Fitzpatrick R, Murray D, Carr A, et al. (1998)
Questionnaire on the perceptions of patients about total
knee replacement. J Bone Joint Surg Br 80(1):63–69
13. Insall JN, Ranawat CS, Aglietti P, Shine J, et al. (1976)
A comparison of four models of total knee-replacement
prostheses. J Bone Joint Surg Am 58(6):754–765
14. Insall JN, et al. (1989) Rationale of the knee society clini-
cal rating system. Clin Orthop Relat Res (248):13–14
15. Konig A, et al. (1997) The need for a dual rating system
total knee arthroplasty (in process citation). Clin Orthop
(345):161–167
16. Ryd L, Karrholm J, Ahlvin P (1997) Knee scoring systems
in gonarthrosis. Evaluation of interobserver variability
and the envelope of bias. Score Assessment Group (see
comments). Acta Orthop Scand 68(1):41–45
17. Bellamy N (1989) Pain assessment in osteoarthritis:
experience with the WOMAC osteoarthritis index. Semin
Arthritis Rheum 18(4 Suppl 2):14–17

18. Lequesne MG, et al. (1988) Indexes of severity for osteoar-
thritis of the hip and knee. Validation – value in compari-
son with other assessment tests [published errata appear
in Scand J Rheumatol Suppl 73:1 and Scand J Rheumatol
1988; 17(3): following 241]. Scand J Rheumatol Suppl
1987; 65:85–89
19. Ware J Jr, Kosinski M, Keller SD (1996) A 12-item short-
form health survey: construction of scales and preliminary
tests of reliability and validity. Med Care 34(3):220–233
20. Ware JE Jr, Sherbourne CD (1992) Th The MOS 36-item
short-form health survey (SF-36). I. Conceptual frame-
work and item selection. Med Care 30(6):473–483
21. Laupacis A, Bourne R, Rorabeck C, et al. (1993) TheTh eff
ffect
of elective total hip replacement on health-related quality
of life. J Bone Joint Surg Am 75(11):1619–1626
22. Anderson JG, Wixson RL, Tsai D, et al. (1996) Functional
outcome and patient satisfaction in total knee patients
over the age of 75. J Arthroplasty 11(7):831–840
23. Bourne RB, Chesworth BM, Davis AM, et al. (2010) Patient
satisfaction after total knee arthroplasty: who is satisfied
fi
and who is not? Clin Orthop Relat Res 468(1):57-63
24. Robertsson O, Dunbar M, Pehrsson T, et al. (2000) Patient
satisfaction after knee arthroplasty: a report on 27,372
knees operated on between 1981 and 1995 in Sweden.
Acta Orthop Scand 71(3):262–267
25. Robertsson O, Dunbar MJ (2001) Patient satisfaction
compared with general health and disease-specific fi ques-
tionnaires in knee arthroplasty patients. J Arthroplasty
16(4):476–482
26. Robertsson O, Lewold S, Knutson K, Lidgren L, et al. (2000)
The Swedish knee arthroplasty project. Acta Orthop Scand
71(1):7–18
27. Bengston S, Knutson K, Lidgren L (1989) Treatment of
infected knee arthroplasty. Clin Orthop 245:173–178
28. Dunbar MJ (2001) Subjective outcomes after knee arthro-
plasty. Acta Orthop Scand Suppl 72(301):1–63
29. Knutson K, Hovelius L, Lindstrand A, Lidgren L, et al.
(1984) Arthrodesis after failed knee arthroplasty. A
nationwide multicenter investigation of 91 cases. Clin
Orthop 191:202–211
30. Robertsson O (2000) The Swedish knee arthroplasty regis-
ter: validity and outcome. Thesis,
Th Lund
31. Tew M, Waugh W (1982) Estimating the survival time of
knee replacement. J Bone Joint Surg Br 64(5):579–582
32. Annual report 2008 – The Swedish knee arthroplasty reg-
ister (2008) Lund University Hospital, Lund, Sweden
33. Australian Orthopaedic Association, National Joint Replace-
ment Registry Annual Report (2009) Sydney, Australia
34. Robertsson O, Dunbar MJ, Knutson K, et al. (1999) The Th
Swedish knee arthroplasty register. 25 years experience.
Bull Hosp Jt Dis 58(3):133–138
35. Robertsson O, Dunbar M, Knutson K, et al. (1999) Vali-
dation of the Swedish knee arthroplasty register: a postal
survey regarding 30,376 knees operated on between 1975
and 1995. Acta Orthop Scand 70(5):467–472
36. Cloutier JM, Sabouret P, Deghrar A (1999) Total knee
arthroplasty with retention of both cruciate ligaments. A
nine to eleven-year follow-up study. J Bone Joint Surg Am
81(5):697–702
37. Rasquinha VJ, Ranawat CS, Cervieri CL, Rodriguez JA, et
al. (2006) The press-fifit condylar modular total knee sys-
tem with a posterior cruciate-substituting design. A con-
cise follow-up of a previous report. J Bone Joint Surg Am
88(5):1006–1010
Results and function of total knee arthroplasty 893
38. Wright RJ, Sledge CB, Poss R, et al. (2004) Patient-re-
ported outcome and survivorship after Kinemax total knee
arthroplasty. J Bone Joint Surg Am 86-A(11):2464–2470
39. McCalden RW, MacDonald SJ, Charron KD, et al. (2010)
The role of polyethylene design on postoperative TKA
flexion: an analysis of 1534 Cases. Clin Orthop Relat Res
468(1):108-114
40. Unver B, et al. (2009) Eff ffects of total knee arthroplasty
on body weight and functional outcome. J Phys Th Ther Sci
21(2):201–206
41. Bordini B, Stea S, Cremonini S, et al. (2009) Relationship
between obesity and early failure of total knee prostheses.
Bmc Musculoskelet Disord 10:29
42. Dewan A, Bertolusso R, Karastinos A, et al. (2009)
Implant durability and knee function after total knee
arthroplasty in the morbidly obese patient. J Arthroplasty
24(6):89–94
43. Bourne RN (2007) Role of obesity on the risk for
total hip or knee arthroplasty. Clin Orthop Relat Res
465(4):188
44. Dunbar MJ, Robertsson O, Ryd L (2004) What's all that
noise? The eff
ffect of co-morbidity on health outcome ques-
tionnaire results after knee arthroplasty. Acta Orthop
Scand 75(2):119–126
45. Pagnano MW, Hanssen AD (2001) Varus tibial joint line
obliquity: a potential cause of femoral component malro-
tation. Clin Orthop Relat Res 392:68–74
46. Lützner J, Krummenauer F, Wolf C, et al. (2008) Com-
puter-assisted and conventional total knee replacement:
a comparative, prospective, randomised study with
radiological and CT evaluation. J Bone Joint Surg Br
90(8):1039–1044
47. Mihalko WM, KrackowKA (2006) Differences ff between
extramedullary, intramedullary, and computer-aided
surgery tibial alignment techniques for total knee arthro-
plasty. J Knee Surg 19(1):33–36
48. Pang CH, Chan WL, Yen CH, et al. (2009) Comparison of
total knee arthroplasty using computer-assisted naviga-
tion versus conventional guiding systems: a prospective
study. J Orthop Surg (Hong Kong) 17(2):170–173
49. Hilding MB, Lanshammar H, Ryd L (1996) Knee joint load-
ing and tibial component loosening. RSA and gait analysis
in 45 osteoarthritic patients before and after TKA. J Bone
Joint Surg Br 78(1):66–73
50. Hilding MB, Ryd L, Toksvig-Larsen S, et al. (1999)
Gait aff
ffects tibial component fixation. J Arthroplasty
14(5):589–593
51. Dunbar MJ, Wilson DA, Hennigar AW, et al. (2009) Fixa-
tion of a trabecular metal knee arthroplasty component.
A prospective randomized study. J Bone Joint Surg Am
91(7):1578–1586
52. MacDonald SJ, Charron KD, Bourne RB, et al. (2008) The Th
John Insall Award: gender-specificfi total knee replacement:
prospectively collected clinical outcomes. Clin Orthop
Relat Res 466(11):2612–2616
53. McCalden RW, MacDonald SJ, Bourne RB, Marr JT, et al.
(2009) A randomized controlled trial comparing “high-
flex” vs. “standard” posterior cruciate substituting poly-
ethylene tibial inserts in total knee arthroplasty. J Arthro-
plasty 24(6 Suppl):33–38
54. Pagnano MW, Trousdale RT, Stuart MJ, et al. (2004) Rotat-
ing platform knees did not improve patellar tracking: a
prospective, randomized study of 240 primary total knee
arthroplasties. Clin Orthop Relat Res 428:221–227
Difficulties in Primary TKA

J. Vanlauwe,
H. Vandenneucker,
TKA in the stiff
ff knee
J. Bellemans
Introduction
T
he stiff
ff knee as a candidate for total knee
arthroplasty is generally defined
fi as a knee
with a range of motion (ROM) of less than
50°. This can be very debilitating for the patient
since such limited ROM is not functional in daily
life (1). Full extension for example is mandatory
for optimal knee functionality. Walking velocity
and ability are decreased if full extension cannot
be reached (2). Flexion of at least 70° is needed for
normal ambulation in swing phase, whereas 90° is
necessary for stair descending and 110° is a mini-
mum for cycling (1). Stiffness
ff can be the conse-
quence of long standing disease with development
of an extension contracture, a flexion
fl contracture
or patella baja (3). All these entities have their
respective origins and have to be treated accord-
ingly. The surgical approach to a stiff ff knee can
be very challenging due to a number of technical
hurdles, such as a diffi
fficult eversion of the patella
that may lead to severe damage to the extensor
apparatus.
Several techniques have been presented to facilitate
the surgical access to the knee and prevent damage
to the patellar tendon. In some cases this can be
achieved in a relatively harmless way, for example
A B
Fig. 1 – (a and b) Ankylosing osteoarthritis with severe stiffness (0–20°
active range of motion) Pre-operative to total knee arthroplasty.
Chapter 84
by performing a lateral patellar release, in others a
complicated and risky procedure such as a V-Y turn
down of the quadriceps tendon may be required.
This last is however only seldom or even never per-
formed nowadays, since newer techniques such as
the quadriceps snip, the modifified quadriceps snip,
tibial tubercle osteotomy, epicondylar osteotomy,
and the femoral peel techniques have been popu-
larized (4–7).
In case adequate exposure cannot be achieved, cor-
rect component position, limb alignment, and soft
tissue balancing may not be achievable.
In long standing stiff ffness or ankylosis, disuse
osteoporosis frequently occurs, which may further
jeopardize ligament attachment strength and may
bring the knee at risk for ligament avulsion on
attempted flexion (Fig. 1).
When dealing with a stiff ff or ankylosed knee, it
is therefore of utmost importance to use a total
knee system that can tackle the above-described
problems. In case of severe osteoporosis and the
risk for ligament failure, the availability of a con-
strained implant should be considered.
Surgical approach
We routinely install the patient with a tourniquet
around the thigh, a foot support halfway the calf
and a side support at the level of the tourniquet
to keep the knee in flexion
fl once this is obtained
(Table 1). The knee is approached through an
Table I – Surgical approach in the stiff knee: consecutive steps applied by
the authors.
1. Anteromedial incision extending well proximal into quadriceps tendon.
2. Reconstitution of suprapatellar poach and mediolateral gutters.
3. Resection of all scar tissue surrounding deep part of quadriceps and
patellar tendon.
4. Introduction of one or two pins into patellar tendon.
5. Progressive and repeated flexion stretches of quadriceps expansion.
6. Consider lateral retinacular release.
7. Consider rectus snip.
8. Consider tibial tubercle osteotomy.
898 Primary Total Knee Arthroplasty

anteromedial access that goes high up in the proxi-

mal extension of the quadriceps. A deep subfascial
plane of dissection is key in preventing skin prob-
lems. When multiple scars are present the most
lateral should be preferred, since the vascular sup-
ply is pre-dominantly originating from the medial
side.
Next, the suprapatellar poach is reconstituted and
the medial and lateral gutters are re-established
by resecting all fibrotic
fi scar tissue. The proximal
tibia is exposed by subperiosteal dissection of the Fig. 2 – The four components of an isolated extension contracture: 1. adhe-
medial capsular sleeve around the midcoronal sions between patella and trochlea, 2. obliteration of the suprapatellar
plane of the tibia until the semimebranosus reces- poach, 3. scarification of the vastus intermedius, and 4. shortening of rectus
femoris muscle [7].
sus is reached. It is important to spend enough
time in removing all fi fibrotic scar tissue around
the deep part of the quadriceps expansion, patel-
lar tendon, and peripatellar retinaculum in order Extension contracture
to reconstitute the suppleness of the surround-
Specifific causes for isolated extension contracture
ing soft tissues. The lack of tissue flexibility is the
have been reported in literature (3, 13, 14). Ana-
most important cause for a difficultffi access to the
tomically there are four major components to con-
stiff
ff knee. Reducing the thickness of the capsule
sider (15) (Fig. 2):
to normal proportions can dramatically increase
–Shortening of the medial and lateral retinacula of
the flexibility of the tissues and may even increase
the patella and obliteration of the gutters.
the functional length of the patellar tendon in case
–Obliteration of the suprapatellar poach due to
of a patella baja situation. Protecting the patellar
scarring and adhesions between patella and ante-
tendon insertion by one or two pins obliquely
rior femur.
inserted into the tuberosity is a useful safety mea-
–Fibrosis and adhesion of the vastus intermedius
sure to prevent the patellar tendon to peel off ff from
muscle to the anterior femur and Rectus femoris.
the tuberosity.
–Shortening of the rectus femoris muscle itself.
Everting the patella is not always necessary to
Each of these should be addressed consecutively
adequately expose the knee, and usually a simple
during surgery.
dislocation may suffi ffice. If necessary, it may even
Apart from the above-mentioned steps in gain-
become possible to evert the patella at a later stage
ing exposure to the knee, additional manoeuvres
during the procedure due to gradual stress relax-
may be necessary to fully expose femur and tibiain
ation. In case there is still too much tension in the order to be able to adequately position and align
extensor apparatus for adequate exposure after the prosthetic components.
the previously described manoeuvres, a lateral In case the intra-articular release of the suprapa-
retinacular patellar release could be considered in tellar poach and gutters is not suffi fficient (Steps 1
order to facilitate patellar eversion. Th This however and 2), one should extend the incision proximally
has the disadvantage that the patella may become in order to resect or release the fibrotic vastus
devascularized. As the next step a rectus snip can intermedius muscle (Step 3). In some rare cases it
be performed by making an obliquely directed inci- may even be necessary to release the insertion of
sion into the quadriceps tendon, at an angle of the rectus femoris muscle off ff the anterior inferior
30–45° in a proximal–lateral direction (4, 8, 9). As iliac spine (Step 4). (15–19).
an alternative a tubercle osteotomy can be consid-
ered, especially in situations where shortening of
the patellar tendon is present, such as in patella
baja. Flexion contracture
In such case the insertion of the tendon can be
shifted proximally as much as 2 cm by using a lon- Flexion contractures are classifi
fied as mild when less
ger osteotomy. In case of extreme bone loss in the than 15°, moderate when between 15 and 30°, and
proximal tibia or in thin patients with skin at risk, severe when more than 30°. We have previously
a tubercle osteotomy is, however, better avoided published our algorithm and results in a series of
due to the risks for skin problems or inadequate 863 patients with flexion
fl contracture. Seven hun-
fixation of the tuberosity (10–12). When applying dred ninty-four knees had a mild, 95 a moderate,
the above-mentioned principles, the authors have and 35 a severe flexion contracture pre-operatively.
experienced that the use of a V-Y turn down can be Our algorithm consists of four steps that should be
avoided, even in the most severe cases. performed sequentially:
 TKA in the stiff knee 899

–Step 1 consists of meticulous resection of 10° and two patients were left with 10 and 15° at
osteofytes around femur and tibia, adequate liga- 2 years.
ment balancing and proximalization of the femur We have found that using this algorithm each
with 2 mm (Fig. 3). patient with a flexion
fl contracture can be addressed
–In Step 2 the posterior capsule and gastrocne- adequately.
mius muscles are released from the femur using a
rongeur or a curved chisel. If necessary transverse
section of the posterior capsule of the knee is per-
formed, avoiding damaging the popliteal vessels The specifific situations of patella baja
(Fig. 4). –Step 3 is performed in case full extension
is not yet achieved after Steps 1 and 2, and consists Patella baja is most often seen in conjunction with
of a further proximalization of the femur with an quadriceps tendon rupture, flaccid
fl neuromuscular
additional 2–4 mm (Fig. 5). –Step 4 is performed in disease (CP or polio), achondroplasia, and post-op-
case full extension is not yet achieved after Steps 1, eratively after high tibial osteotomy or total knee
2, and 3, and consists of trans-section of the ham- arthroplasty (20, 21) (Fig. 6).
string tendons. It is not very clear whether one can avoid the
In the group with a mild contracture all but development of patella baja in TKA using a gen-
seven patients reached full extension after Step 1 tle surgical technique when opening the knee,
(716 knees) and Step 2 (78 knees). The remaining together with limited resection of the fat pad,
seven had less than 5° residual flexion contrac- and trying to avoid proximalization of the joint
ture. In the group with moderate contractures,
81 patients reached full extension after Step 1
(54 cases), Step 2 (29 cases), Step 3 (11 cases), and
Step 4 (1 case). Thirteen patients did not reach full
extension (less than 5° contracture left at 2 years)
and patient was left with 7°. In the severe group 29
patients reached full flexion after Step 1 (9 cases),
Step 2 (8 cases), Step 3 (10 cases), and Step 4
(8 cases). Four patients were left between 5 and

Fig. 5 – Step 3 includes further proximalization of the distal femoral cut.

Fig. 3 – When performing TKA in the patient with a flexion contracture,

Step 1 should be to perform meticulous resection of all posterior osteo-
phytes.

Fig. 6 – Severe patella baja after HTO with shortening and adherence of the
Fig. 4 – In Step 2 the posterior capsule is released. patellar tendon to the proximal tibia.
900 Primary Total Knee Arthroplasty
line, combined with early post-operative ROM
exercises (22).
Failure to address patella baja while performing
TKA may lead to decreased ROM, decreased patel-
lofemoral lever arm, extensor lag, impingement of
the patella against the tibial polyethylene or tibial
plate, anterior knee pain, increased energy expen-
diture, and rupture of the patellar or quadriceps
tendons.
Treatment of patella baja depends on determining
the cause and distinguishing between patella baja and
pseudo-patella baja. Potential corrective measures
include re-establishing the joint line by using distal
femoral augments when necessary, tibial tubercle
osteotomy with proximalization, surgical lengthen-
ing of the patellar tendon by adhesiolysis and even
Z-lengthening, removal of recessing the anterior
portion of the tibial polyethylene, and placement of
the patellar implant in a cephalad position.
References
1. Bae DK, Yoon KH, Kim HS, Song SJ (2005) Total knee
arthroplasty in stiff
ff knees after previous infection. J Bone
Joint Surg Br 87(3):333–336
2. Perry J, Antonelli D, Ford W (1975) Analysis of knee-joint
forces during flexed-knee stance. J Bone Joint Surg Am
57(7):961–967
3. Rajgopal A, Ahuja N, Dolai B (2005) Total knee arthro-
plasty in stiffff and ankylosed knees. J Arthroplasty
20(5):585–590
4. Barrack RL (1999) Specialized surgical exposure for revi-
sion total knee: quadriceps snip and patellar turndown.
Instr Course Lect 48:149–152
5. Barrack RL (2001) Evolution of the rotating hinge for
complex total knee arthroplasty. Clin Orthop Relat Res
392:292–299
6. Masri BA, Campbell DG, Garbuz DS, Duncan CP (1998)
Seven specialized exposures for revision hip and knee
replacement. Orthop Clin North Am 29(2):229–240
7. Younger AS, Duncan CP, Masri BA (1998) Surgical expo-
sures in revision total knee arthroplasty. J Am Acad
Orthop Surg 6(1):55–64
8. Arsht SJ, Scuderi GR (2003) The quadriceps snip for expos-
ing the stiff
ff knee. J Knee Surg 16(1):55–57
9. Garvin KL, Scuderi G, Insall JN (1995) Evolution of the
quadriceps snip. Clin Orthop Relat Res 321:131–137
10. Clarke HD (2003) Tibial tubercle osteotomy. J Knee Surg
16(1):58–61
11. Whiteside LA (1995) Exposure in difficult ffi total knee
arthroplasty using tibial tubercle osteotomy. Clin Orthop
Relat Res 321:32–35
12. Whiteside LA, Ohl MD (1990) Tibial tubercle osteotomy
for exposure of the diffi
fficult total knee arthroplasty. Clin
Orthop Relat Res 260:6–9
13. Aglietti P, Windsor RE, Buzzi R, Insall JN (1989) Arthro-
plasty for the stiff
ff or ankylosed knee. J Arthroplasty
4(1):1–5
14. Kelly MA, Clarke HD (2003) Stiff ffness and ankylosis in
primary total knee arthroplasty. Clin Orthop Relat Res
416:68–73
15. Bellemans J, Steenwerckx A, Brabants K, et al. (1996) The
Th
Judet quadricepsplasty: a retrospective analysis of 16
cases. Acta Orthop Belg 62(2):79–82
16. Ali AM, Villafuerte J, Hashmi M, Saleh M (2003) Judet's
quadricepsplasty, surgical technique, and results in limb
reconstruction. Clin Orthop Relat Res 415:214–220
17. Daoud H, O'Farrell T, Cruess RL (1982) Quadricepsplasty.
The Judet technique and results of six cases. J Bone Joint
Surg Br 64(2):194–197
18. Judet R, Judet J, Lagrange J (1956) Une technique de
libération de l'appareil extenseur dans les raideurs du
genou. Mém Acad Chir 82:944–947
19. Rose RE (2005) Judet quadricepsplasty for extension con-
tracture of the knee. West Indian Med J 54(4):238–241
20. Chonko DJ, Lombardi AV Jr, Berend KR (2004) Patella
baja and total knee arthroplasty (TKA): etiology, diag-
nosis, and management. Surg Technol Int 12:231–
238
21. Maeno S, Kondo M, Niki Y, Matsumoto H (2006)
Patellar impingement against the tibial component
after total knee arthroplasty. Clin Orthop Relat Res
452:265–269
22. Verborgt O, Victor J (2004) Post impingement in poste-
rior stabilised total knee arthroplasty Acta Orthop Belg
70(1):46–50
23. Bellemans J, Vandenneucker H, Victor J, Vanlauwe J
(2006) Flexion contracture in total knee arthroplasty. Clin
Orthop Relat Res 452:78–82
24. Caton J, Deschamps G, Chambat P, et al. (1982) Patella
infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice
Appar Mot 68(5):317–325
25. Dejour D, Levigne C, Dejour H (1995) Postoperative
low patella. Treatment by lengthening of the patel-
lar tendon. Rev Chir Orthop Reparatrice Appar Mot
81(4):286–295
 Chapter 85

R. Zayni, M. Bonnin The lateral approach in the valgus

knee

Defifinition History

E
ven if the lateral approach is less common
than the medial approach in the daily prac-
tice of knee surgeons, this option has several
advantages for TKA in valgus knees: the vascular-
ization of the patella is preserved as well as the
infra-patellar branch of the saphenous nerve (1).
Lateral release and ligament balancing are easier in
severe valgus knees than with a medial approach.
The Medial Collateral Ligament is always preserved
during the approach and the extensive release of
the lateral patellar retinaculum can be useful in
case of subluxated patella.
Moreover, in diffi
fficult cases, an osteotomy of the
tibial tuberosity can be done. It provides an excel-
lent view of all compartments of the knee and a
proximal or distal extension of the approach can be
done easily at any moment during the procedure
(2–5).
The disadvantages of the lateral approach are due
to increased technical diffi
fficulties: a longer skin inci-
sion is required compared with medial approach,
an osteotomy of the Anterior Tibial Tuberosity
(ATT) is generally necessary in case of stiff ff knee
and visualization of medial tibial plateau is limited
compared with medial approach.
The first descriptions of lateral approaches for the
knee were described in the 1950’s but were lim-
ited to traumatology, removal of bone fragments
or lateral meniscectomy (6–8). Th The real develop-
ment of lateral approach in TKA is more recent
and has been promoted by Muller (9) and the Swiss
school in Europe and then by Keblish (10) in USA.
These authors emphasized the advantages of this
approach in the valgus knee: the direct approach in
the concavity of the deformity simplifies
fi the cor-
rection of the valgus and the ligament balancing
and also improves patellar tracking.
Despite these early descriptions, the lateral
approach has been used infrequently and most
knee surgeons are unfamiliar with this approach,
even if many authors reported its interest in the
valgus knee compared with the medial approach.
Indications and contraindications
The decision weather to use a medial or a lateral
approach in a valgus knee depends on many fac-
tors (11): The origin of the valgus, the mediolateral

Table 1 – Results of the lateral approach in the litterature.

Author Year Number of knees Follow-up Results
Keblish (11) 1991 79 2 years More aesthetic
Objectively superior results
Approach of choice" for fixed valgus deformity in TKA
Lootvoet (14) 1997 90 32 months Significant amelioration in function score, knee score and
radiological results
Achieve joint stability with good mobility and a neutral
mechanical axis in total knee arthroplasty
Fiddian (15) 1998 Technique description Technique Safe and may give a better outcome than that through the
description medial capsule
Burki (16) 1999 61 1 year Complications are rare.
No patellar necrosis occurred
Tsai (17) 2001 525 1 year No complications
Good Clinical and radiologic results
Zhou(18) 2007 10 19.6 months Effective way to correct the deformity
Boyer (19) 2008 63 7 years Good outcomes
902 Primary Total Knee Arthroplasty
stability, the situation of the patella, the history of
the knee, the age of the patient, and finally the sur-
geon’s experience. Decision in our center is based
on the algorithm in Table 1. A lateral approach is
preferred in case of medial laxity, of femoral defor-
mity and in case of moderate (<10°) tibial defor-
mity. A subluxation of the patella is also in favor of
a lateral approach.
Indications for lateral approach in multi-operated
knees are more limited, especially in case of stiff- ff
ness or patella baja, because it often requires an
osteomy of the tibial tuberosity. This
Th approach is
then used only in case of necessity (i.e., previsible
metal block on the lateral tibial plateau after tibial
plateau fracture, revision lateral UKA with bone
loss…).
Pre-operative planning
Pre-operatively it is important to check the condi-
tion of the skin overlying the knee, the presence of
prior knee incisions, stability of the patella, and the
vascular status of the limb. In case of stiff ff knees,
multi-operated knees or obesity, we generally pre-
fer doing a medial approach. In these situations, if
a lateral approach is decided, the surgeon must be
aware that an osteotomy of the tibial tubercle will
probably be necessary.
Prior to surgery, we obtain weight-bearing XR of
the knee to evaluate the patient for arthritis and
lower extremity deformity. Each patient has a long
standing XR, an AP and lateral view centered on
the knee and a standing AP with the knee fl flexed at
30° to improve visualization of the lateral compart-
ment’s wear. Axial views of the patellae with the
knee flexed at 30° are also systematic. This series
of radiographs are eff ffective in detecting arthritis
in each compartment of the knee and assist with
surgical planning. In case of patella baja, if the
indication of lateral approach is maintained, an
osteotomy of the tibial tubercule will be planned.
Stress XR can also be useful in the valgus knee to
assess the reductibility of the deformity.
In valgus knees, we perform systematically a
pre-op CT-scan in order to analyze the orientation
of the trans-epicondylar axis. The posterior condy-
lar angle, measured between the posterior condy-
lar line and the surgical trans-epicondylar axis, will
be reported on our cutting block in order to obtain
an appropriate rotational alignment of the femoral
component.
Pre-operative templating is performed for each
patient and does not diff ffer based on the approach.
Templating the implant size and the location and
orientation of the bone cuts on the radiographs
facilitate intra-operative effi
fficiency.
Surgical technique
The patient is positioned in the supine position
without leg holder or bump beneath the drapes
to hold the knee. This gives the surgeon the abil-
ity to change the position of the knee easily and
frequently throughout the surgery. A tourniquet is
placed on the proximal thigh and the knee is ster-
ilely prepped and draped.
We will describe here the conventional Keblish lat-
eral approach, performed without osteotomy of
the tibial tuberosity, which is, in our experience,
rarely necessary for primary TKA, even in case of
severe valgus deformity.
Conversly, with a lateral approach, an osteotomy of
the tibial tuberosity is nearly always necessary in
case of multi-operated knee, especially if such an
osteotomy has been previously done, in case of revi-
sion and in case of patella baja. In such cases were
diffi
fficulties are foreseeable, the osteotomy must be
bone immediately during the approach in order to
avoid any lesion of the patellar tendon. A large and
comfortable approach of the knee joint is then pos-
sible without any risk for the extensor apparatus.
We will describe a typical lateral approach done
for a lateral OA with a severe valgus deformity. A
medial laxity is observed on the monopodal weight-
bearing AP XR (Fig. 1). The valgus deformity is due
(1) to the bone deformity (valgus deformity of the
femur), (2) to the wear with bone loss on the lat-
eral tibial plateau, and (3) to the medial laxity.
On the pre-op CT-scan, we can observe a hypopla-
sia of the lateral condyle in the axial plane with a
posterior condylar angle of 6° (Fig. 2).
Skin incision is done longitudinally on the midline
or lateral 2–4 cm from the lateral border of the
patella. The skin incision is straight and not curved
as mentioned on many books. A curved incision
increases the risks of skin problems. Fascia super-
ficialis is then incised at the same level as skin inci-
sion and dissection is conducted in the pre-patellar
bursa. A lateral flap is then progressively retracted.
The dissection must be done deep with respect with
the fascia superfi ficialis (Fig. 3). Fascia Lata, Quadri-
ceps tendon and distal fibers
fi of the Vastus Lateralis
are then identifi fied. Distally, Patellar tendon, and
lateral patellar retinaculum are also visualized.
Deep incision is done on a symmetric way as for
a medial para-patellar approach: it begins at the
junction between Vastus Lateralis and Quadriceps
tendon, 5 cm proximal to the superior border of
the patella. Distally, the lateral patellar retinacu-
lum is incised and incision follows the lateral bor-
der of the patellar tendon until the tibial tuberos-
ity (Fig. 4). If a more extensive approach of the
femur has been planned (for hardware removal,
femoral osteotomy, or Quadriceps release), a sub-

vastus lateralis approach can also be done with
this approach. In that case, the incision can be
extended proximally until the hip without dif-
ficulties. Careful hemostasia must be done. An
osteotomy of the tibial tuberosity must generally
be done in such cases (In Fig. 5 such an approach
has been done in a patient with a malunion of a
femur fracture. A lateral extended approach has
been done for TKA with Quadriceps release and
distal femoral osteotomy). The osteotomy is done
from lateral to medial side, taking care to pre-
serve medial periosteal attachments of the tibial
tubercle. The bone cut must be 5–6 cm long.
A retractor is then carefully positioned behind the
patellar tendon and the fat-pad is gently dissected
from the deep side of the tendon. The fat-pad must
be kept attached to the lateral capsule and to the
Fascia-Lata in order to preserve its vasculariza-
Fig. 1 – Lateral OA with medial laxity.
Fig. 3 – Mid line skin incision with lateral approach.
The lateral approach in the valgus knee 903
tion. Lateral capsule and the fat-pad are then pro-
gressively detached from the Gerdy’s tubercle in
continuity with the Anterior Tibialis muscle. Th These
three structures are detached from anterior to pos-
terior until the posterolateral corner of the lateral
tibial plateau (Fig. 6A).
The patella is gently everted on the medial side of
the knee, taking care not to damage patellar tendon
insertion. A retractor grasps the patella dislocated
while the knee is extended and the knee is then
progressively flexed
fl at 90°. If the patella cannot be
everted at this step the proximal incision on the
Quadriceps tendon must be checked: almost 5 cm
proximal to the superior border of the patella is
generally required. If necessary, this incision can be
extended proximally. Removal of exuberant patellar
and/or femoral osteophytes are often necessary at
that step. If the patella cannot be everted or if the
Fig. 2 – The Trans Epicondylar axis is externaly rotated by 6°.
Fig. 4 – Lateral arthrotomy with preservation of the fat-pad.
904 Primary Total Knee Arthroplasty
tension on patellar tendon exposes to avulsion, a
Quadriceps snip from lateral to proximal (Keblish)
can be done or an osteotomy of the tibial tuberos-
ity can be done (author’s preferred option).
At that step, all the posterolateral structures are
then easily visualized: popliteus muscle, Lateral
Collateral Ligament and lateral meniscus (Fig. 6B).
Posterior border of the tibial plateaus is then pro-
gressively released (here a Postero-Stabilized TKA
will be implanted) and a Z-retractor gently translates
the tibia anteriorly. Posterior osteophytes are then
removed. A second retractor is placed on the medial
border of the medial tibial plateau, which is then
progressively exposed. We cut the tibia first but any
technique can be used with this approach, depend-
ing on surgeon’s choice. Tibial cut must be done only
when a good visualization of the medial tibial pla-
teau is obtained (Fig. 7). If not, measurement of the
level of resection and alignment can be misjuged.
After removal of the resected tibia, femoral cutting
guide is then inserted. Here the posterior cut is
done first (Fig. 8). In case of valgus deformity, the
rotation of the femoral component must be metic-
Fig. 5 – Osteotomy of the tibial tuberosity in a stiff knee.
Fig. 7 – Exposure of the medial plateau and tibial cut.
ulously adjusted according to the pre-operative
planning. The Transepicondylar axis is externally
rotated in respect with the Posterior Condylar
Line, but there is also frequently a medial collateral
laxity. Here the asymetry is obtained exclusively by
decreasing the posterolateral resection (see chapter
rotation). Balancing in flexion
fl is checked and a spe-
cial attention is paid to removal of posterior osteo-
phytes, especially in case of loss of extension.
The distal cut of the femur is done with the usual
technique, orthogonal to the mechanical axis of the
femur. However, in case of long-standing valgus,
generally due to bony deformity, a residual valgus
of few degrees may be tolerated as it facilitates liga-
ment balancing and improves the cosmetic result.
Here, (Fig. 9) the distal resection is very asymet-
ric due to hypoplasia of the lateral condyle. Bal-
ancing in flexion and extension is then checked
with appropriate spacers. With this direct lateral
approach, a stable gap balancing both in fl flexion
and in extension is usually accomplished. In case
of imbalance or loss of extension, an additional lat-
eral release can be done. Three techniques can be
Fig. 6 – Lateral release and medial eversion of the patella.
Fig. 8 – Posterior condyle cut.
 The lateral approach in the valgus knee 905

Fig. 10 – Implantation of components.

Fig. 9 – Distal resection of the femur.

considered: distal LCL release on the fibular head

(11, 12), progressive release of LCL and popliteus
tendon on the lateral epicondyle (author’s pre-
ferred method) or lateral sliding osteotomy of the
lateral epicondyle (13).
Rotational alignment of the tibial component can
be misjuged due to internal rotation of the tibia
(Fig. 10). Authors recommend checking alignment
with more than one landmark (i.e., ATT and bimal-
leolar axis) in order to avoid any malrotation.
After implantation the diff fferent layers are closed
with the knee flexed at 90°. Lateral closure can be
diffi
fficult if the valgus deformity was severe. Patellar
retinaculum is not closed and only the synovium
is sutured on the lateral border of the patella. Dis-
tally, the lateral gap is filled
fi with the preserved fat-
pad, which is sutured to the lateral border of the
patellar tendon (Fig. 11).
Rehabilitation has no specifi ficity. Physiotherapy
begins the morning following surgery and fl flex-
ion is authorized as tolerated. Full weight bear-
ing is authorized immediately. Two crutches are
used during the first days and are progressively
abandoned. In case of OTT, a brace is used for 4–6
weeks with authorization of full weight bearing
and flexion is limited at 90° for 6 weeks.
Pearls and pitfalls
Diffi
fficulties of ligament balancing in the valgus
knee depend on the etiology of the deformity. In
most cases, the origin of the deformity is on the
femur (lateral condyle hypoplasia). The deformity
is then mostly intra-articular and the correction is
quite easy to obtain. Bone resection on the distal
and posterior lateral condyle can be very limited
and in some severe cases bone blocks can be neces-
sary. Care must be paid to the rotational alignment
of the femur.
Fig. 11 – Lateral closure with the fat-pad.
In case of tibial deformity (constitutional or due to a
previous HTO), the problem is extra-articular. Cor-
rection requires a very asymmetric bone cut and lig-
ament balancing is therefore challenging (see chap-
ter TKA after failed HTO). In case of distension of
the MCL, bone resection must be decreased on the
tibial side (-2 to -4 mm). Some authors recommend
reattachment of the MCL in these situations ( ) but
in these a constrained TKA in the operating room.
In valgus knees, the size of the tibial component can
be diffi
fficult to determine due to the asymmetry of
the tibial plateaus: the AP dimension of the lateral
plateau is generally much smaller than the one of
the medial plateau. A posterolateral overhang can
create an impingement with the popliteus tendon.
Stabilizing the patella can be very challenging in the
valgus knee. Rotational alignment of both compo-
nents is then of fundamental importance and, to
our opinion, must be planned pre-operatively via
a CT-scan. Moreover it must be noted that using
a lateral approach is helpful to avoid any internal
malrotation of the tibial component.
Result
Few articles had treated the issue of the lateral
approach for total knee replacement. All pub-
906 Primary Total Knee Arthroplasty
lished series prove the safety and the good results
of this approach. Keblish (10) in 1991 evaluated
the outcome of the lateral approach in 79 cases
(2-year of follow-up). For this author, clinical
experience had proven this approach to be more
aesthetic with objectively superior results. Scores
have been good or excellent in 94.3% of cases.
He recommended the lateral approach as the
"approach of choice" for fixed valgus deformity
in TKA. Same satisfaction was found by Lootvoet
et al. (14). In his retrospective study of 90 total
knee arthroplasties performed through a lat-
eral approach in knees with a valgus deformity,
he found a significant
fi amelioration in function
score, knee score, and radiological results. Loot-
voet concluded that a strict operative technique
using a lateral approach in severe valgus knee
deformity can make it possible to reproducibly
achieve joint stability with good mobility and
a neutral mechanical axis in total knee arthro-
plasty.
Fiddian et al. (15) considers this approach safe and
may give a better outcome than that through the
medial capsule for the replacement of valgus knees.
Burki et al. (16), in 1991 published a prospective
study of 51 patients (61 cases) with primary total
knee arthroplasty performed with lateral approach
and osteotomy of the tibial tubercle (1 year of
follow-up). No post-operative tibial fractures, no
delayed unions, and no non-unions at the site of
the osteotomy were reported. No patellar necrosis
occurred. The results were good or excellent in 88%
of his patients. Complications related to technique
as hematoma and compartment syndrome were
rarely reported. Tsai et al. (17) agrees with Fiddian
and Burki that this new technique is safe and even,
he goes farther in considering that lateral approach,
in valgus deformity, may give better outcomes. He
studied 475 primary total knee arthroplasties in
344 patients and 50 revision TKAs in 39 patients
performed with lateral approach without ligament
release and found no complications such as disrup-
tion of patellar blood supply and knee instability,
more frequently observed in the medial approach
with ligament release. Clinical and radiologic out-
comes were found satisfying. Same, in a recent
study about the lateral parapatellar approach of
total knee arthroplasty (8 patients/10 knees with
severe valgus osteoarthritis knee), Zhou et al. (18)
found that for TKR with moderate to severe fixed fi
valgus knee, lateral approach is an effffective way to
correct the deformity.
Finally, in 2008, Boyer et al. (19) (reported also
good outcomes of a series of 63 knee replacements
performed with lateral appr(oach at a mean fol-
low-up of 7 years.
Thus, we find that all published studies agree that
lateral approach for total knee replacement in val-
gus deformity may be a logical and well-justified
fi
choice.
References
1. Horner G, Dellon AL (1994) Innervation of the human
knee joint and implications for surgery. Clin Orthop Relat
Res 301:221–226
2. Arnold MP, Friederich NF, Widmer H, et al. (1999) Lat-
eral approach to the knee combined with an osteotomy
of the tibial tuberosity. Its use for total knee replacement.
Orthop Traumatol 7(3):212–220
3. Mertl P, Jarde O, Blejwas D, et al. (1992) L’abord latéral
du genou avec relèvement de la tubérosité tibiale pour la
chirurgie prothétique. Rev Chir Orthop 78:264–268
4. Whiteside LA, Ohl MD (1990) Tibial tubercle osteotomy
for exposure of the diffi
fficult total knee arthroplasty. Clin
Orthop. 260:6–9
5. Wolffff MA, Hungerford DS, Krackow KA (1989) Osteot-
omy of the tibial tubercle during total knee replacement. J
Bone Joint Surg Br 71(A):847–852
6. Abbott LC, Carpenter WF (1945) Surgical approaches to
the knee joint. J Bone Joint Surg Br 27(A):277–310
7. Kaplan EB (1957) Surgical approach to the lateral (per-
oneal) side of the knee joint. Surg Gynecol Obstet
104:346–356
8. Lange M (1951) In: Bergmann J (ed) Orthopädisch-chiru-
rgische Operationslehre. München, pp 660–664
9. Müller W (1982) Das Knie. Form, Funktion und liga-
mentäre Wiederherstellungschirurgie. Berlin Heidelberg,
New York
10. Keblish PA (1991) The lateral approach to the valgus knee.
Surgical technique and analysis of 53 cases with over two
year follow-up evaluation. Clin Orthop 271:52–62
11. Keblish P, Sthiel J (2003) Valgus deformity in TKA: the
direct lateral approach. Tech Knee Surg 2(4):250–266
12. Buechel FF (1990) A sequential three-step lateral release
for correcting fixed valgus knee deformities during total
knee arthroplasty. Clin Orthop 260:170–175
13. Brilhault J, Lautman S, Favard L (2002) Lateral femoral
sliding osteotomy lateral release in total knee arthro-
plasty for a fixed valgus deformity. J Bone Joint Surg Br
84:1131–1137
14. Lootvoet L, Blouard E, Himmer O, et al. (1997) Complete
knee prosthesis in severe genu valgum. Retrospective
review of 90 knees surgically treated through the anterio-
external approach. Acta Orthop Belg 63(4):278–286
15. Fiddian NJ, Blakeway C, Kumar A (1998) Replacement
arthroplasty of the valgus knee. A modified fi lateral capsu-
lar approach with repositioning of vastus lateralis. J Bone
Joint Surg Br 80(5):859–861
16. Burki H, Von Knoch M, Heiss C, et al. (1999) Lateral approach
with osteotomy of the tibial tubercle in primary total knee
arthroplasty. Clin Orthop Relat Res 362:156–161
17. Tsai CL, Chen CH, Liu TK (2001) Lateral approach without
ligament release in total knee arthroplasty: new concepts
in the surgical technique. Artif Organs 25(8):638–643
18. Zhou DG, Zhang B, Kou BL, et al. (2007) Total knee
arthroplasty by lateral parapatellar approach for valgus
knee. 87(27):1885–1889
19. Boyer P, Boublil D, Magrino B, et al. (2008) Total knee
replacement in the fixed valgus deformity using a lateral
approach: role of the automatic iliotibial band release for a
successful balancing. Int Orthop 33(6):1577-83.
 Chapter 86

J. Brilhault,
P. Burdin
TKA in the severe valgus knee:
lateral epicondyle sliding osteotomy
technique

Defifinition femur is of abnormal shape, the flflexion axis of the

knee is then oblique toward the mechanical axis of

W
hen performing a total knee arthroplasty the femur and the malalignment is irreducible. In
(TKA), orthopedic surgeons have three these specifi
fic cases positioning the femoral com-
tasks: limb alignment, knee balancing, and ponent perpendicular to the mechanical axis of the
extensor mechanism balancing (and alignment as femur does not induce the matching of the pros-
well). Overall alignment with horizontal joint line thesis flexion axis to the flexion axis of the knee
is obtained with bone resections perpendicular
to the mechanical axis of the femur and the tibia.
In well aligned and varus knees (from tibia vara)
the flexion axis of the knee is perpendicular to the
mechanical axis of the femur (Fig. 1). When per-
forming the distal femoral resection perpendicular
to the mechanical axis of the femur, the fl
flexion axis
of the femoral prosthesis automatically matches
the flexion axis of the knee joint (Fig. 2). In val-
gus knees, malalignment of the knee may be due
to constitutional deformity of the femur or wear
of the lateral compartment. When valgus is due to
wear, femoral shape is normal and malalignment
is reducible. Positioning the femoral component
perpendicular to the mechanical axis of the femur
induces matching of the flexion
fl axis of the pros-
thesis to the flexion axis of the knee joint (Fig. 3).
When valgus is due to femoral deformity, the
Fig. 1 – Flexion axis in varus knees from tibia vara.

Fig. 2 – Matching of the flexion axis of the femoral prosthesis with the Fig. 3 – Matching of the flexion axis of the femoral prosthesis with the flex-
flexion axis of the knee due to adequate femoral bone resection in varus ion axis of the knee due to adequate femoral bone resection in valgus knees
knees from tibia vara. from lateral wear.
908 Primary Total Knee Arthroplasty
Fig. 4 – Mismatch of the flexion axis of the femoral prosthesis with the
flexion axis of the knee due to femoral deformity.
Fig. 5 – Adequate distal femoral bone resection perpendicular to the
mechanical axis inducing trapezoidal tibio-femoral gap.
Fig. 6 – Distal sliding of the epicondylar osteotomy allowing matching
of the isometric lateral formation with the flexion axis of the knee arthro-
plasty.
joint (Fig. 4). Once the distal femoral resection is
performed perpendicular to the mechanicals axis,
the tibio-femoral (TF) gap is of trapezoidal shape
(Fig. 5). Knee balancing is then required for which
we proposed a sliding osteotomy of the lateral epi-
condyle. It allows the TF gap to be rectangular and
the limb malalignment to be corrected. It tilts the
flexion axis of the knee joint toward the flexion axis
of the femoral component that will allow matching
of the isometric lateral formation with the fl flexion
axis of the knee arthroplasty (Fig. 6). Most of all,
this technique respects lateral collateral ligament
and popliteus tendon insertion preserving the lat-
eral compartment stability both in extension and
flexion.
Indications and contraindications
The lateral epicondyle sliding osteotomy is indi-
cated in case of fixed valgus knee from femo-
ral origin in which the flexion
fl axis of the knee is
oblique toward the mechanical axis of the femur.
Contraindications are valgus knees from tibial ori-
gins as in overcorrected high tibial osteotomy. In
these cases, flexion
fl axis of the knee is in normal
position. Balancing the knee using lateral epicon-
dyle sliding osteotomy would result in an oblique
flexion axis of the knee regarding to the prosthetic
joint line (Fig. 7).
Surgical technique
Pre-operative planning
Recommended pre-operative X-rays are: an A/P
knee joint single-leg stance X-ray; a long-leg X-ray
with weight on both legs; a lateral X-ray in 90° of
flexion and a skyline view of the patella in 30° of
flexion. Long-leg X-rays help plotting the mechani-
cal and anatomical axes of the lower limb. The Th
femoral angle (difference
ff between mechanical and
anatomical femoral axes) is determined. It deter-
mines the distal femoral bone resection.
Positioning of the patient
The patient is placed in supine position, knee 90°
flexed. A supporting roll on the table and a lateral
support is useful to facilitate extension and flexion
fl
of the knee. A knee positioner could be alterna-
tively used.
 TKA in the severe valgus knee: lateral epicondyle sliding osteotomy technique 909

Fig. 7 – Oblique flexion axis induced by

sliding osteotomy of the lateral epicondyle
in valgus knee from tibia valga.

Approach
We advocate an antero-lateral approach. It address
directly the shortened soft tissues located on the
lateral part of the knee. It allows a simultaneous
lateral release of the patella required by the lat-
eralized extensor mechanism of the valgus knee.
The meniscal-capsular-fat-pad flap is everted on
the lateral inferior geniculate artery according to
Keblish (1). This
Th flap has to be performed carefully
since it will be required to close the antero-lateral
soft tissue defect induced by limb and extensor
mechanism alignment restoration. This Th approach
sometimes requires an additional anterior tibial
tubercle step cut osteotomy for adequate exposure
(Fig. 8). Anterior tibialis muscle and iliotibial band
are elevated subperiosteally. Anterior and posterior Fig. 8 – Antero-lateral approach with dissected fat pad flap, lateral release
cruciate ligament are systematically resected since of the patella, elevation of the ilio-tibial band and additional anterior tibial
they could restrain correction of the deformity. tubercle osteotomy.

Bone resection
Principal bone resections are performed in refer-
ence to the mechanicals axis for their orientations.
Thickness of the bone resection equals the thickness
of the implant on the intact medial compartment in
order to preserve the original level of the joint line.
Both Whiteside line and epicondylar axis are used for
rotational references (2,3). Once correct bony align-
ment is achieved, if the tibio-femoral gap is of trap-
ezoidal shape, lateral epicondyle sliding osteotomy is
required to correct the ligament imbalance (Fig. 5).

Fig. 9 – Anterior cut of the lateral epicondyle osteotomy.

Lateral epicondyle osteotomy
Osteotomy is performed using a thin oscillat-
ing power saw. Anterior cut is performed fi
first at
the distal part of the anterior chamber, parallel
to the anterior femoral resection plane (Fig. 9).
Medial cut is then performed. It is perpendicular
to the distal femoral resection plane and should
910 Primary Total Knee Arthroplasty
Fig. 10 – Medial cut of the lateral epicondyle osteotomy; thickness is
related to condyle size as well as bone quality.
Fig. 12 – Mobilization of the lateral epicondyle by capsulotomy from the midline to the bone block along the proximal border of the popliteus tendon.
be at least 5 mm thick (Fig. 10). The
Th thickness will
depend of the size of the lateral femoral condyle
and the size of the cruciate-substituting box in
order not to weak the proximal part of the lateral
femoral condyle. It usually corresponds to ¼ of
the distal femoral condyle thickness. The
Th last cut
is proximal. It is performed on the lateral cortex
at the proximal level of the posterior condyle bone
resection (Fig. 11). These
Th cuts separate a bone
block that includes both insertions of the lateral
collateral ligament and the popliteus tendon.
Mobilization of the bone block is completed by a
capsulotomy along the proximal border of popli-
teus tendon from the bone block to the midline
(Fig. 12). This capsular release prevents any flex-
ion contracture once limb alignment is achieved.
Appropriate ligament balancing with sliding
of the osteotomy
Correct ligament balance is assessed using spacer
blocks to achieve rectangular tibio-femoral gap both
in flexion and extension. Sliding of the lateral epi-
Fig. 11 – Proximal cut of the lateral epicondyle osteotomy will detach the
bone block.
condyle osteotomy is automatically adjusted in fl flex-
ion and extension with the appropriate spacer. If
the femoral bone resections were performed neutral
to the posterior condyle the bone block would only
slides distally (Fig. 13). If the femoral bone resections
were performed in slight external rotation toward
the posterior condyles, the bone block would then
slides distal and posterior as well (Fig. 14). Fixation of
the osteotomy is recommended with two K-wires to
check ligaments tension and knee stability (Fig. 15).
Fixation of the osteotomy
Two to three 3.5 mm screws are usually used for
final fixation of the osteotomy (Fig. 16). Screws
length corresponds to the thickness of the lat-
eral condyle. Care must be taken not to interfere
with the cruciate-substituting box. One might
want to augment fixation material upon bone
quality. Prominent bone is trimmed to accom-
modate the trial femoral component (Fig. 17).
In our experience this has never threatened the
 TKA in the severe valgus knee: lateral epicondyle sliding osteotomy technique 911

Fig. 13 – Automatic sliding of the

osteotomy with the spacer block;
isolated distal sliding due to femo-
ral resection in neutral rotation.

Fig. 14 – Automatic sliding of the

osteotomy with the spacer block;
simultaneous distal and posterior
sliding due to femoral resection in
external rotation

Fig. 15 – Pinning of the osteotomy with two K-wire recommended when Fig. 17 – Trimming of the distal prominent part of the osteotomy one fixed
checking ligament balance and knee stability. to accommodate the trial femoral prosthesis.

Fig. 16 – Usual fixation of the

osteotomy with two 3.5 mm screws.
912 Primary Total Knee Arthroplasty

insertions of neither lateral collateral ligament

nor popliteus tendon. Cementation of the final
femoral component will complete the fixation of
the osteotomy.

Rest of the procedure

The rest of the procedure is performed as usual.
Appropriate rotation of the tibial component as
well as thickness of the polyethylene is determined
with trial component. A lateral soft tissue gap
results from the patellar tendon self adjustment.
This gap must be respected and filled tension free
with the lateral composite flap dissected during the
approach (Fig. 18). The
Th flap is tailored according to
Keblish. Skin closure over a drain is performed in
Fig. 18 – Closure requires use of the fat pad flap.
a routine fashion.

Fig. 19 – Example of TKA on a valgus

knee performed through a lateral
approach with a sliding osteotomy of
the lateral epicondyle.

Fig. 20 – Sliding osteotomy of the lateral epicon-

dyle fixed with two 4.5 mm screws on an ultra
congruent stabilized TKA.
 TKA in the severe valgus knee: lateral epicondyle sliding osteotomy technique 913
Post-operative care
A compressive dressing with a splint is applied for
3 days. Rehabilitation is performed as usual with
no restriction with full weight bearing.
Outcomes and complications
We published our first 13 cases in 2002 (2). All
knees were stable with good mechanical align-
ment (Fig. 19). We encountered a single pseudar-
throsis of the osteotomy once at the beginning
of our experience. Re-operation was performed
because of pain (but not because of instabil-
ity). Bony fusion was achieved with good out-
come. Care must therefore be taken to achieve
stable fixation of the osteotomy. In case of weak
osteopenic bone we recommend to increase the
thickness of the bone block. Th
This is easier when
using a deep dish ultra congruent TKA without
post-cam cruciate-substituting box in witch thick
osteotomy with large 4.5 mm screws fixation
fi can
be performed (Fig. 20).
Reference
1. Keblish PA (1991) The lateral approach to the valgus knee:
surgical technique and analysis of 53 cases with over two-
year follow-up evaluation. Clin Orthop 271:52
2. Whiteside LA, Arima J (1995) The anteroposterior axis for
femoral rotational alignment in valgus total knee arthro-
plasty. Clin Orthop 321:168
3. Stiehl JB, Abbott BD (1995) Morphology of the transepi-
condylar axis and its application in primary and revision
total knee arthroplasty. J Arthroplasty 6:785
4. Brilhault J, Lautman S, Favard L, Burdin P (2002) The
lateral femoral sliding osteotomy. J Bone Joint Surg
84-B:1126

Y. Catonné, E. Sariali,
F. Khiami, B. Tillie
Total knee replacement in patients
with severe varus deformity
Introduction
T
he knee varus deformity is the most frequent
frontal malalignment in patients undergoing
total knee arthroplasty (TKA). This deformity
may generate technical diffifficulties when trying to
restore simultaneously an HKA angle of 180° and a
good ligament balancing.
These technical problems depend on the type of
deformity, which should be analyzed meticulously
beforehand. This deformity includes three compo-
nents which may be isolated or combined together:
the bony deformity, the osteochondral wear, and the
laxity.
The bony deformity may be constitutional or post-
Th
traumatic and exists before the knee destruction by
osteo-arthritis. If this extra-articular deformity is
severe, it makes the ligament balancing difficult
ffi to
achieve, and an osteotomy may be required before-
hand or at the time of the knee replacement surgery.
The medial compartment’s wear, which may be purely
Th
chondral or osteochondral, increases the varus defor-
mity and is the direct consequence of osteo-arthri-
tis. A severe medial wear may generate technical
problems for knee reconstruction especially for the
medial tibial plateau.
The ligament laxity on the convex side appears sec-
ondarily and increases the dynamic deformity in
the standing position when loaded. ThisTh lateral lax-
ity is more often caused by the soft tissue retrac-
tion on the concave side (medial ligament, posteri-
or-medial capsule) rather than to a real stretching
of the lateral structures which appears only in
the advanced cases. This ligament laxity has to be
taken into account for the ligament balancing, and
if this balance is not achievable constrained pros-
theses should be used.
The literature review shows that it seems diffi fficult
to restore a normal knee alignment in the case of
severe varus deformity, as a residual varus gener-
ally persists (1). A meticulous pre-operative analy-
sis of the deformity has to be achieved in order to
propose optimized technical solutions adapted to
the varus type (2), and which take into account the
varus size and the site where the extra-articular
deformity is located (3).
Chapter 87
Analysis of the deformity
and pre-operative planning
A three-dimensional analysis of the alignment
should be carried out before surgery in order to
assess the amount of intra-articular and extra-
articular deformity.
The wear and the laxity correspond to the intra-
articular varus which is generally reducible during
the clinical examination. Contrary, the bony varus
cannot be corrected clinically when performing a
valgus stress test.
The radiological assessment of severe varus deformi-
ties includes standard X-rays and sometimes a CT-
scan in order to detect associated torsional abnor-
malities and a sagittal malalignment.
Anterior–posterior and lateral X-rays of the knee are
performed in the standing unipodal position. Fur-
thermore, four other X-rays are used: an anterior
shüss radiographic view, a sunrise view to analyze
the femoro-patellar joint and finally an anterior
view made during a valgus/varus stress test.
The authors always perform an anterior–posterior
long-standing X-ray (hip–knee–ankle fi film): the
limitations and the precision of this examination
have to be considered. A lateral pangonogram in
the standing position may be useful to detect a
knee-flflexion contracture.
The deformity analysis has to be performed in the
three dimensions: frontal (coronal), sagittal, and
axial.
Frontal deformity
The frontal deformity is assessed on the anteri-
or–posterior pangonogram using the HKA angle
determined by the mechanical axis of both the
femur and the tibia. When measured on the medial
side of the knee, this HKA angle is less than 180° in
the case of a varus and it is above 180° in the case
of a valgus deformity.
The bony deformity is determined using the
mechanical angle of both the femur and the tibia.
The Femoral Mechanical Angle (FMA) is formed
between the mechanical axis of the femur and the
bicondylar line: the normal value is 92 ± 2°.
916 Primary Total Knee Arthroplasty
The Tibial Mechanical Angle (TMA) is measured
between the mechanical axis of the tibia and the
line tangent to the tibial plateau before the wear
occurred, which is approximated by using the line
tangent to the non-worn plateau. Th The normal value
is 88° ± 2°. These angles are increased in the case of
a valgus deformity and they are decreased in the
case of a varus deformity.
The intra-articular deformity corresponds to the
combination of the wear and the ligaments lax-
ity. It can be measured as the difference
ff between
the maximal deformity obtained during the val-
gus–varus stress tests and the bony deformity as
defi
fined beforehand.
Sagittal deformity (knee-flexion
fl contracture: flessum,
genu recurvatum)
The sagittal deformity may also combine both an
extra-articular and an intra-articular component.
The bony deformity may be assessed on the sagit-
tal view by measuring the angle between the meta-
physeal axis and the diaphyseal axis.
The tibial slope is the angle measured between the
two following lines: the tangent to the tibial pla-
teau and the tibial diaphyseal axis (or the posterior
Fig. 1 – Classification of the varus deformities. Type 1: varus secondary to wear. No ligamentous insuffi
with ligamentous insuffifficiency. No bone deformity. Type 3: wear associated with intra-osseous deformity. No ligamentous insuffi
ated with ligamentous insuffi fficiency and bone deformity.
tibial cortical). In the case of a bony fl
flessum, the
tibial slope is increased. This situation is especially
encountered in some post-traumatic mal-union or
following osteotomies.
Axial deformity
An axial deformity may be associated to the
varus. These rotationnal abnormalities are usually
assessed with a CT-scan using three-dimensional
reconstructions.
The EOS system, developed by Georges Charpak,
seems to be an attractive alternative option for the
analysis of the malalignment of the lower limb and
especially in the case of a mal-union. This system
is based on a low-radiation system, which is used
to achieve two simultaneous orthogonal X-rays of
the whole skeleton. Afterwards, a library of bones
shape is used to fifind the volumes which fit to the
bones of the patient, by applying a progressive dis-
tortion algorithm. This
Th technique allows 3D recon-
structions using a lower radiation dose (100–1000
fold less). The most attractive advantage is the pos-
sibility of performing X-rays in functional positions
such as the standing position for the static analy-
sis of the lower limbs. It permits also to achieve a
fficiency. No bone deformity. Type 2: wear associated
ffisancy. Type 4: wear associ-

global static analysis of the patient (spine, pelvis,
hips, knees, ankles). However, this technique does
not investigate the bone density and its accuracy
has still to be investigated.
Using this pre-operative analysis methodology, the
deformity may be graded into four types (Fig. 1):
– Type 1 Varus: The deformity is purely intra-ar-
ticular, due to the medial wear and there is no
associated lateral ligament laxity.
– Type 2 Varus: The medial compartment wear is
associated to a lateral ligament laxity.
– Type 3 Varus: There is a bony extra-articular
deformity, associated to the medial wear. How-
ever, there is no combined lateral ligament lax-
ity.
– Type 4 Varus: This type combines the types 3 and
4: a medial compartment wear, associated to a
lateral ligament laxity and a bony extra-articular
deformity.
Surgical technique for TKA in varus deformity
Some surgical techniques (surgical approach, strat-
egy of bone loss reconstruction) are valid for all
types of varus deformities. However, some specific
fi
techniques are required according to the grade.
The surgical approach
The surgical exposure depends on the surgeon’s
preference. The anteromedial approach with
patella lateral dislocation seems well adapted for
TKA in the case of varus deformity whatever the
grade. This approach allows achieving an excellent
exposure as well as a medial ligament release and a
reconstruction of the medial plateau.
The skin incision may be purely anterior or antero-
medial. The capsule is incised anteromedially and
the patella is dislocated laterally by performing
either an eversion or simply a subluxation of the
patella.
The lateral skin incision may be proposed in two
specifi
fic situations: Firstly, in the case of a previ-
ous lateral approach, in order to avoid skin necro-
sis due to a poor blood supply. Secondly, in obese
patients, the skin is incised laterally; afterwards a
usual parapatellar approach is performed
An osteotomy of the anterior tibial tubercle may
be performed in the case of a severe knee stiff- ff
ness which renders the patella difficult
ffi to dislocate
especially in the presence of a patella baja (4). Th
The
authors perform a tibial tubercle osteotomy when-
ever the patellar tendon is excessively tensed. This
Th
osteotomy has to detach a long and thick bone
fragment in order to enhance bone fusion.
Total knee replacement in patients with severe varus deformity 917
Bone loss of the medial compartment
The surgical technique depends essentially on the
deformity type which includes: the importance of
medial compartment wear, the ligament laxity, and
the bony deformity.
The bone loss of the medial compartment due to
the wear may generate technical difficulties
ffi in
the severe varus, whatever the deformity type.
These problems depend on two factors: the loca-
tion of the defect (epiphyseal or metaphyseal) and
whether this defect is contained or not.
The reconstruction of the medial plateau is dif-
ficult each time the theoretical cut level on the
normal contro-lateral plateau (equal to the height
of the tibial prosthetic component) passes above
the worn tibial plateau. The use of a cement wedge
does not seem to be an adequate technique: two
solutions may be used, either a screwed autogenic
graft (using a cut bone fragment) or a metallic
wedge fixed under the tibial plate (modular aug-
mentation of the tibial implant). This
Th later tech-
nique is the most widely preferred solution in the
case of a non-contained bone loss because of the
high risk of graft osteolysis and non-union which
are reported in up to 15% of cases (5).
The bone graft is preferred in the case of a con-
tained bone loss, as the bony frame remains, insur-
ing consequently a good mechanical support for
the prosthetic implant. An autogenic bone graft
(provided by the bone cut) is preferred, rather than
an allograft because of its biologic properties.
The prosthetis type
A standard prosthesis (semi-constrained, with a
short stem) may be used in many cases of varus
deformity. The posterior cruciate ligament (PCL)
may be preserved or not according to the surgeon
habits. However, the authors advise not to main-
tain the PCL if an important release is required
because this ligament restricts the release of the
medial structures
A long stem is required if a modular tibial wedge is
used or if a constrained implant such as a CCK type
(Constrained Condylar Knee) or a rotating hinge
prosthesis is implanted.
The authors think that a constrained prosthesis is
required only in the case of an important ligament
insuffi
ffisancy. A bone loss, even if it is severe, does
not require the use of a constrained prosthesis,
unless a ligament laxity is associated.
We decide eventually to use CCK implants during
the surgical procedure, if a small ligament laxity
remains when testing the knee stability after the
trial implants have been implanted, especially if
the laxity is found in the fl
flexed position. The use
918 Primary Total Knee Arthroplasty
of a rotating hinge prosthesis is required only
in the case of a severe defificiency of a collateral
ligament, this choice is the more often made pre-
operatively.
Surgical strategy according to the varus grade
Varus type 1
In this grade, the varus is due to the wear. There
Th
is neither a ligamentous laxity nor a bony defor-
mity. The medial wear may generate a laxity which
is however reducible.
The fill with the prosthetic volume is enough to
correct the misalignment and to make the laxity
disappear. The surgical technique is standard and
depends on the surgeon habits: dependant or inde-
pendent cut sequence, starting with the tibial cut
or the femoral cut.
In those cases, it is not mandatory to perform
a release of the medial soft tissues. The medial
approach consists only in removing the medial
osteophyte by detaching the superficial
fi bundle of
the medial collateral ligament (MCL), but the deep
part of this ligament has to be respected as well as
the posteromedial capsule.
Afterwards, the importance of the medial plateau
wear has to be assessed: this wear generally pre-
dominates at the posterior part of the plateau
In this grade of varus, the most frequently used
type of prosthesis is a standard semi-constrained
total prosthesis: the posterior cruciate ligament
may be maintained according to the surgeon con-
victions. It is not mandatory to use a constrained
prosthesis because the ligamentous wrap is normal.
In the case of a non-contained defect and the use
of a metallic wedge, long stems, including an off-ff
set if required, have to be added without implant-
ing a more constrained prosthesis.
Varus type 2
In this grade, there is a lateral collateral ligament
(LCL) stretching or a medial collateral ligament
(MCL) retraction associated to the medial wear.
Once the bone cuts have been performed, there
is an asymmetrical trapezoidal joint space which
generates a ligament unbalancing. To solve this
problem, there are three technical solutions. Th The
first one is to perform a medial soft tissue release,
fi
the second one is to retighten the lateral side and
the final solution is to use a constrained prosthesis
without ligament balancing.
Release of the medial soft tissue
The ligament balancing is performed once the tib-
ial cut, or all the cuts have been achieved. Once a
minimal orthogonal tibial cut has been performed,
the ligament balancing is done progressively. The Th
importance of the medial release depends on the
severity of the soft-tissue retraction or the lateral
laxity (6, 7).
A subperiosteal release is performed detaching
the superfificial bundle of the medial collateral liga-
ment, and in the case of a severe retraction the
semi-membranous tendon and the posteromedial
capsule may have to be released.
The timing of the release sequence varies accord-
ing to the authors. Insall et al. (8) proposed to
perform successively, from forward to backward,
a subperiosteal detachment of the superficial fi
bundle of the MCL, then the deep MCL bundle
and the hamstring tendons and finally the poster-
omedial capsule and rarely the semi-membranous
tendon.
This technique of release from forward to backward
is also preferred by Hungerford (1) and Krackow
(9) who propose to release the MCL superficial fi
bundle, but they detach the posteromedial capsule
and the semi-membranous tendon only in the case
of a knee-fl
flexion contracture.
On the contrary, Dejour (10) performs the release
from backward to forward, by detaching first fi the
semi-membranous then the capsule and finally the
MCL superfi ficial bundle. Two anatomic details have
to be kept in mind while performing the release.
Firstly, the superficial
fi MCL bundle is attached on
the tibia 8–10 cm under the joint line and this dis-
tance varies according to the knee size. Secondly,
the anterior fibers of this bundle are relaxed dur-
ing knee-extension and tensed during knee-flex- fl
ion, contrary to the posterior fibers.
fi These biome-
chanical properties have to be taken into account
to adapt the release technique.
The cadaveric studies of Matsueda (11) concerning
normal knees, showed that a release of the whole
medial structures are required on a minimal height
of 8 cm in order to obtain an angular correction of
7.7° during extension and 10.9° during flexion.
fl The
correction increases to 9.5 and 15.1° if the MCL is
released on the femoral condyle, and it reaches
15.3° and 20° if the posterior cruciate ligament is
removed. However, the gain in the femoro-tibial
space seems low of about 3 mm in extension if the
release is performed on 8 cm height and it reaches
6 mm if the PCL is cut.
Engh et al. (12) proposed as an alternative option
to the release: a medial epicondylar osteotomy.
Retighten the lateral structures
In the case of a severe lateral laxity, some authors
proposed to retighten the lateral collateral liga-
ment, either by performing a fibular
fi head osteot-
 Total knee replacement in patients with severe varus deformity 919

omy and transposition or by transposing the LCL Type 3 varus

insertion. However, these techniques are rarely In this grade, there is a bony deformity without a
used because of the risk of the knee stiffness.
ff ligament stretching.

Which type of prosthesis? Which surgical technique?

In this type of varus, it may be technically pos-
sible, to use PCL preserving prosthesis, and some
authors (13) always manage to do. However, the
ligament balancing is more difficult
ffi to achieve
when preserving the PCL. Indeed, Dejour et al.
showed that the PCL limits the valgus after the
MCL and the ACL
Some authors proposed to perform a PCL release,
but it makes more sense to use a posterostabilized
prosthesis. Th
The PCL sacrifi
fice will induce an open-
ing of the femoro-tibial space which will require a
higher tibial insert and consequently a patella low-
ering.
If the ligament balancing is correctly achieved, a
semi-constrained prosthesis may be implanted.
Otherwise, if an asymmetric space remains despite
the release, a more constrained prosthesis has to
be used, either a CCK type or a rotating hinge pros-
thesis (Fig. 2).
The more frequent problem corresponds to the con-
stitutional tibial varus deformity. Specificfi technical
diffi
fficulties are generated by this extra-articular defor-
mity. Indeed, if the same TKA principles are used, per-
forming the bone cuts perpendicular to the mechani-
cal axis will generate the following consequences:
– a laxity on the lateral convex side because the lat-
eral bone cut will be much more important than
the medial side.
– a major medial release is required, inducing conse-
quently modification
fi of the MCL tibial insertion.
– A thicker implant is necessary, inducing a lower-
ing of the patella.
Wolff ff and Hungerford (3) showed that the con-
sequences of a 20° varus due to an extra-articular
tibial or femoral deformity vary according to its
location relatively to the knee joint. Indeed, if the
deformity is located at the supra-condylar zone,
a triangular bone resection of 18° was required,

A B

Fig. 2 – A case of Rheumatoid arthritis in a 59-year-old man is presented. It corresponds

to a type 2 varus with severe bone destruction. The deformity is reducible and there is no
bone deviation. A reconstruction using a wedge and a graft was performed. A CCK pros-
thesis was implanted. Good clinical outcomes were achieved at 8 years follow-up.
920 Primary Total Knee Arthroplasty
A B
Fig. 3 – Post-traumatic mal union in a 60-years-old patient. Type 3 varus (a)
and (b): pre-operative X-rays. There was an indication of an opening wedge
tibial osteotomy and TKR in a one stage surgical procedure. © and (d): Once
tibial osteotomy has been performed, a metallic wedge with a temporary
staple are implanted. (e) Post-operative X-rays (2 years follow-up)
inducing consequently a ligament lengthening of
24 mm. While, a deformity located far from the
knee (1/10th distal part) required only a bone
angular resection of 2° corresponding to a liga-
ment lengthening of only 2.6 mm.
Practically, the authors admit that a bone deformity
of less than 10° may be corrected with a conventional
technique combining a bone cut perpendicular to the
mechanical axis and a medial release (Fig. 3). Above
10° of bone deformity (8° according to some authors),
an osteotomy may be proposed, either before the knee
replacement or during the same surgical procedure.
If a valgus osteotomy is planned, a medial tibial
opening wedge technique may be performed at the
time of the total knee replacement. Long stems
should be used and off ff-set stems may be required.
According to the stability, a supplementary osteo-
synthesis may be necessary.
One stage surgical procedure
combining tibial osteotomy and TKA
There are two main technical solutions for per-
forming a one stage surgical procedure combining
a tibial osteotomy and TKA. The osteotomy may be
performed after the prosthesis implantation: this
technique requires the use of a tibial implant with
studs or a short rod and an osteosynthesis using
a plate or staples (14). Otherwise, the osteotomy
is performed beforehand, and then the prosthe-
sis is implanted using the normal ancillary (15).
The authors prefer this second technical solution
which requires using a long stem, and sometimes a
supplementary osteosynthesis.
In the case of a genu varum due to an extra artic-
ular tibial deformity, the authors perform a tibial
medial opening-wedge osteotomy (Fig. 4). Once
the usual approach and the femoral preparation
are performed, a pin is implanted on the medial
side of the tibial metaphysis and it is directed
toward the head of the fibula. The osteotomy is
carried out with a saw and a bone chisel. After-
wards, a metallic wedge is implanted along the
osteotomy plane in order to achieve the medial
opening. The wedge height is planned pre-oper-
atively in order to achieve the required angular
correction. A temporary staple is used to stabi-
lize the osteotomy during the tibial preparation
which is performed with an intra-medullary
ancillary.
Afterwards, a posterostabilized prosthesis, includ-
ing a long stem with an offset,
ff is implanted. The
metallic wedge is replaced with a bone graft pro-
vided by the bone cuts. If the long stem does not
ensure a good stabilization, an osteosynthesis is
added using a plate or a staple.
If the deformity is located on the femoral side,
ligament balancing is a diffifficult challenge: after
femoral and tibial cuts, the gap is asymetical only
in flexion and not in extension. The realization of a
symetrical gap in flexion
fl should lead to instaure an
internal rotation in the femoral component and a
patellar maltracking.
In the case of important femoral varus deformity
we prefer to perform a lateral substraction osteot-
omy during the same surgical procedure using the
same technical principles described above.
Which prosthesis type?
If the extra-articular deformity is less than 8 or
10°, and the release insures a good ligament bal-
 Total knee replacement in patients with severe varus deformity 921

A B

C D

Fig. 4 – A case of a 78-year-old woman with a bilateral genu varum is

shown. On the left side, there was a severe lateral laxity. This is case of a
type 2 varus with a total insuffi
fficiency of the lateral collateral ligament. Indi-
cation of a rotatory hinge prosthesis.

ance, then a posterostabilized prosthesis with PCL is usually used. The

Th stem is never cemented; the
removal should be used. In the case of an associ- cement is only seated under the plateau. It is not
ated osteotomy, the PCL may be preserved accord- mandatory to use a constrained prosthesis because
ing to the surgeon habits. A long stem prosthesis the ligaments are normal.
922 Primary Total Knee Arthroplasty
A B
Fig. 5 – Major lateral laxity corrected with a constrained TKA.
Type 4 varus
This grade combines an exta-articular deformity
and a ligament stretching.
Like the grade 3, a varus deformity of less than 10°
may be compensated by a medial release. The Th com-
bination of an extra-articular deformity and a lat-
eral ligament laxity may theoretically require per-
forming an osteotomy in order to correct the bone
varus and a medial release to enhance the ligament
balancing. Practically, the varus grade 4 often justi-
fies the use of a constrained prosthesis.
If the spaces in flexion
fl and in extension are not
balanced, a constrained prosthesis should be used,
either a constrained posterostabilized prosthesis
with a long lug, or rotating hinge prostheses with
long stems (Fig. 5)
Conclusion
Severe varus deformities require an adapted treat-
ment according to the varus grade. A meticulous pre-
operative analysis of the bone deformity, the wear
and the ligament defificiencies is mandatory. A modu-
lar medial wedge may be required in the presence of
a severe wear. In the case of a bone deformity, a liga-
ment balancing using a release may be performed
up to 8–10°. Above this threshold, an osteotomy is
required, using either a one-stage or a two-stage sur-
gical procedure. The prostheses type depends essen-
tially on the ligament balance. Constrained total
knee prostheses are indicated in presence of severe
ligament defi
ficiencies and in elderly people.
References
1. Teeny SM, Krackow KA, Hungerford DS, Jones M (1991)
Primary total knee arthroplasty in patients with severe
varus deformity. Clin Orthop 273:19–31
2. Mullaji A, Padmanabhan V, Jindal G (2005) Total Knee
Arthroplasty for profound varus deformity. Technique
and radiological results in 173 knees with varus of more
than 20°. J Arthroplasty 20:550–61
3. Wolf AM, Hungerford DS, Pepe CL (1990) Th The eff
ffect of
extraarticular varus and valgus deformity on total knee
arthroplasty. Clin Orthop 271:35–51
4. Nayak N, Bourne RB, Rorabeck CH, et al. (1995) Tech-
niques of exposure for the stiff ff total knee. Knee 2(4):
189–194
5. Laskin RS (1989) Total knee arthroplasty in the presence
of large bony defects of tibia and marked knee instability.
Clin Orthop 248:66–70
6. Huten D (2002) Libérations ligamentaires dans le genu
varum. Prothèses totales de genou. Cahiers d’enseignement
de la SOFCOT n°81.Elsevier Ed, pp 84–101
7. Vince GK (2001) Soft tissue releases for the varus knee.
Techniques in knee surgery. Lippincott Williams & Wilkins
Ed, Philadelphia, pp 231–244
8. Insall JN (1984) Surgical approaches to the knee. In: Insall
JN (ed) Surgery of the knee. Churchill Livingstone, New
York, USA, pp 41–54
9. Krackov KA (1990) Varus deformity In: Krackov KA (ed)
The Technique of total knee arthroplasty. The CV Mosby
company, Saint Louis, pp 317–340
10. Dejour H, Dejour D Technique d’implantation des pro-
thèses totales de genou. Encycl Med Chir, Elsevier Paris,
Techniques chirurgicales- Orthopédie-Traumatologie, pp
44–850,18
11. Matsueda M, Gengerke TR, Murphy M, et al. (1999) Soft
tissue release in total knee arthroplasty: Cadaver study
using knees without deformities Clin Orthop Relat Res.
366:264-7.
12. Engh GA, Ammeen D (1999) Results of total knee arthro-
plasty with medial epicondylar osteotomy to correct varus
deformity. Clin Orthop 367:141
13. Laskin RS (1996) Total knee replacement with posterior
cruciate ligament retension in patient with a fixed
fi varus
deformity. Clin Orthop 331:29–34
14. Lerat JL, Godenèche A, De Polignac T (2004) Prothèse
totale de genou associée à une désostéotomie: technique
de l’ostéotomie après la mise en place de la prothèse. Rev
Chir Orthop 90:381–383
15. Zanone X, Aït si Selmi T, Neyret P (1999) Prothèse totale
et ostéotomie tibiale de correction simultanées pour
gonarthrose sur genu varum excessif constitutionnel. Rev
Chir Orthop 85:749–756

M. Bonnin, R. Zayni Total knee arthroplasty after failed
high tibial osteotomy
Introduction
W
hen total knee arthroplasty (TKA) is
performed following a failed high tibial
osteotomy (HTO), the surgeon must con-
front several diffifficulties: the tibial metaphysis is
deformed, former cutaneous incisions complicate
the surgical approach, peripheral ligaments are
sometimes weakened, the patella may be low and
the knee is often stiff ff (Table 1).
Technical diffi
fficulties depend on the type of osteot-
omy carried out (closing or opening wedge), on the
reason for failure (hypercorrection, deformity recur-
rence or a simple evolution of cartilaginous lesions)
and on the location of deformities (intra or extra-
articular). Surgical planning must, therefore, be rig-
orous as the diffi
fficulties must be anticipated and the
strategy determined before the intervention.
Analysis of the difficulties
ffi
The skin
Former incisions constitute varying diffi fficulty
according to their number and localization. Verti-
cal approaches must be differentiated
ff from hori-
zontal approaches.
– Vertical approaches: When they are near to the
median line it is preferable to use them again or
to extend them. It is therefore possible to per-
form a medial or lateral arthrotomy on request
by a subaponeurotic detachment if necessary.
This is usually possible for anterolateral incisions
which just need to be extended proximally. On
the other hand medial incisions are often more
posterior and more diffi fficult to use again. The
rule is to never create reversed pedicle cutaneous
flaps, where the isthmus is open distally and to
avoid narrow flaps or parallel incisions.
– Horizontal approach: Horizontal, lateral, or medial
approaches create less problems. The Th chosen
approach for the prothesis can be used. An ante-
rior medial incision crosses the horizontal scar at
Chapter 88
a right angle creating an upper pedicle wide flap
fl
with good vitality.
Hardware removal
The removal of the hardware osteotomy material, if
it is still in place, can be done either during former
surgery, a few weeks before TKA, or during the same
surgery. Undergoing the ablation of the material
beforehand has the inconvenience of exposing the
patient to two anaesthetics, two surgeries and two
hospitilizations. On the other hand the advantage
is being able to take a bacteriological sample from
the first operative site (1) and to limit detachments
if the surgical approaches are different.
ff The other
advantage is to enable the reduction of the incision
during the implantation of the prosthesis and to
avoid the risk of hematoma at the site of the mate-
rial ablation. Two operations are necessary when
there is a concern regarding infection. It also can
be preferable when the approach to be used is dif-
ferent to the approach for the prosthesis, or when
the material is particularly voluminous or that its
extraction looks diffi fficult. When the material is not
voluminous, its extraction is simple by a scarcely
enlarged incision or a small contraincision and its
ablation can be carried out at the same time.
Bone deformity
Tibial deformity can be exclusively extra-articular,
linked to the Osteotomy or intra-articular due to
the bone wear of the tibial plateau of one of the
two tibiofemoral compartments. The Th intra-articu-
lar deformity is easily corrected by the prosthesis
and sometimes necessitates metallic holds. The
extra-articular deformity is more complex to cor-
rect and follows the rules and principles of surgery
in case of vicious consolidation after fractures.
Varus deformity
– When the deformity is secondary to an impaction
of the osteotomy area, which is the most fequent
case, it is purely extra-articular. The
Th correction is
 fficulties in TKA after failed HTO.
Table 1 – Sources of diffi
Situation
Previous incisions Vertical antero-medial
Vertical antero lateral
Vertical but distal/joint-
Difficulties Technical precautions
Risk of skin necrosis in case of parallel incisions – Re-use the previous skin incision
– Medial arthrotomy
– OTT if: patella baja, stiff knee, previous OTT or if planned simultaneous HTO
– Re-use the previous skin incision
– Medial arthrotomy after prepatellar dissection if no previous OTT or if no patella baja
– Lateral arthrotomy with OTT if: patella baja, stiff knee, previous OTT or planned HTO
Risk of necrosis only if distal crossing with acute angle – Re-use the distal part
924 Primary Total Knee Arthroplasty

line – Do a separate incision with min. 2 cm between incisions

Hardware to be removed
Ligaments
Extra-articular deformities
Intra-articular deformities
Patella
OTT, osteotomy of tibial tuberosity; MCL, medial collateral ligament; HTO, high tibial osteotomy.
– Do not cross incisions distally with acute angle
– Re-use if hardware to remove
Vertical but far from Impossible to re-use the incision – Mid-line incision
midline – Re-use previous incision only for hardware removal
Horizontal Risk of skin necrosis if oblique crossing – Cross skin at 90°
– Re-use for hardware removal
Removal simultaneously – Staged surgery only if high risk of infection (biopsy and germ analysis): previous
infection, poor skin, associated pathology…
Closing wedge MCL a priorii intact
Lateral retraction possible
Opening wedge MCL can be weak (particularly anterior fibers)  potential medial – Careful approach on the medial side
laxity (particularly in flexion) – Check stability in extension AND in flexion just before cutting bone (tibia and femur)
– Limited resections
– Check stability in flexion before deciding rotation of femoral component
– Re-fixation of MCL
– Consider Constrained TKA
Valgus Asymmetric cut on tibia can create a medial laxity if severe deformity – Adapted level of resection on tibia
– Lateral wedge can be necessary
– Lateral release
– Correction via re-osteotomy (Previous/simultaneous)
– Consider Constrained TKA in older patients
Varus Asymmetric cut on tibia can require excessive MCL release – Simultaneous osteotomy in case of severe varus (opening wedge easier)
Increased Tibial slope Excessive anterior bone resection – Level of cut adapted
Insuffi
fficient posterior bone resection
Valgus or varus Wear and/or initial hypocorrection – Metal blocks and long stem if severe deformity
Baja or fixed Approach difficult
ffi – Osteotomy of the tibial tubercle (OTT)
Risk of residual patella baja

made either by an asymmetrical tibial cut or by
simultaneously carrying out a high tibial valgisa-
tion osteotomy if there is a severe deformity.
– When the tibial deformity is exclusively due
to bone wear on the medial tibial plateau, it is
intra-articular and can easily be corrected by the
prosthesis. In the case of major wear it may be
necessary to correct the defect with the help of
a medial metallic block. Here the difficulties
ffi are
not linked to the deformity itself but to local con-
ditions (Patella baja, stiff
ff knee…).
Correction by primary TKA
The option of primary TKA is often possible. The
tibial cut is hence asymmetrical with a large lateral
resection. A medial ligament release must be carried
out whose consequences are the same in extension
and in flexion, which facilitates ligamentary balanc-
ing. It is difficult
ffi to determine the limit of correc-
tion by a prosthesis on its own: 10 mm of release
for Insall (2), 10° of global deformity for Dejour and
Deschamps (3) and 20° for Hungerford and Lennox
(4). Beyond this limit of correction, it is preferable to
correct the deformity by an associated tibial osteot-
omy ideally carried out simultaneously (Fig. 1).
Correction by TKA and simultaneous osteotomy
Technically the approach is anteromedial, and the
osteotomy is done above the anterior tibial tuber-
osity. It is carried out after having dislocated the
patella laterally and the tibia anteriorly. The
Th level of
the osteotomy must be distal and horizantal enough
so as not to interfere with the tibial cut which will
be carried out later. The most simple option is to
carry out an opening wedge HTO (5). The opening is
carried out progressively, after putting a tibial guide
in place – which can be intra or extramedullary –
A B
Fig. 1 – Failure of a closing wedge HTO (A). The origin of the varus deformity is mostly extra-articular. The tibial slope is 0°, with
no patella Baja. Correction of the deformity with the prosthesis would necessitate a significantly asymmetric cut. A PS TKA was
implanted with a simultaneous corrective Opening-wedge HTO (B). A long stem was used, the gap was filled with autograft
(obtained from bone resections) and complementary fixation was obtained with two staples.
Total knee arthroplasty after failed high tibial osteotomy 925
so that the tibial plateaus are horizontal in relation
to the axis of the tibial guide. This
Th manœuvre is all
the more easy if a intramedullary guide is used. It is
temporarily fixed (plate with unicortical screws or
staples) and the tibial cut for TKA can be made. At
the end of the intervention, an extended tibial stem
ensures the fixation, and bridges the site of osteot-
omy and the area is filled with the help of autografts
taken from bone sections. Some prefer to implant
the prosthesis at the beginning of the operation
without correcting the deformity and then carry
out the osteotomy at the end of the intervention
after implantation of the defi finitive components.
This option is technically more delicate and means a
tibial base without a keel must be used (6).
In the case of a particular septic risk it is preferable
to carry out a two-step operation (Fig. 2).
Valgus deformity
A valgus deformity is generally linked to an even-
tual hypercorrection associated to wear of the lat-
eral tibial plateau. These
Th deformities are the most
diffi
fficult to correct.
Correction by primary TKA
A correction in the prosthesis means that a very
asymmetrical tibial cut must be made which leads
to two types of problem (Figs. 3, 4):
– The risk of creating a ``resection laxity'': The oblique-
ness of the joint space in relation to the tibial axis
falsifi
fies the calculation of the level of the cut which
can become excessive, leading to resection laxity.
This can be particularly pejorative if this is added
to pre-existing ligamentary lesions. The Th level of
the bone cut must be meticulously adjusted mak-
ing sure that the level of cut is measured on the
926 Primary Total Knee Arthroplasty

Fig. 2 – Multi-operated knee with previous patello-femoral prosthesis, Opening Wedge HTO and infection successfully treated. The previous skin incisions
were longitudinal on the medial side and the quality of the skin was poor (A). A two-step surgery was done with firstly a closing wedge HTO (note the
osteotomy of the tibialtuberosity and the mid-diaphysisosteotomy of the fibula) with multiple bacteriological analysis. A TKA was implanted one year after
the osteotomy (B).

A B

Fig. 3 – Overcorrected HTO with lateral OA following a Closing Wedge HTO performed with an osteotomy of the tibial tubercle. The valgus is mostly extra-
articular, a lateral longitudinal approach had been used for HTO (A). The lateral skin incision was used for TKA, an osteotomy of the tibialtuberosity was done.
Correction of the valgus was obtained with asymmetric tibial cut. Lateral release was done firstly on the ilio-tibial band, which was desinserted from Gerdy’s
tubercle and then the popliteus tendon and the LCL were released subperiostely from lateral epicondyle (B).

A B

Fig. 4 – Overcorrected HTO with lateral OA following a Closing Wedge

HTO. The tibial deformity is severe and the patient is 85 years old (A).
Correction was obtained with a rotating hinge TKA.

medial border of the medial tibial plateau and not
at the bottom of the cupula (Fig. 5).
– Excessive lateral lengthening: In the case of a large
deformity, the lateral cut can come close to the
lateral tibial plateau and necessitate the use of
a lateral tibial metal block. Th This leads to a lat-
eral lengthening which can be worsen if a thick
polyethylene is neccessary due to residual medial
laxity. This
Th lateral ``reconstruction'' imposes car-
rying out a sometimes aggressive lateral release.
The hierarchy of ligamentary release movements
depends on the approach used.
If a medial approach has been used, the release may
interest the Fascia-lata which is either desinserted
at the Gerdy, either released by ``Pie-Crusting'', the
Lateral Collateral Ligament (LCL) and the tendon
of the popliteus muscle. These
Th can be released sub-
periosteally or by carrying out an osteotomy of the
lateral epicondyle which can be re-attached at the
end of the intervention. Burdin and Brilhaut per-
form a real osteotomy of the lateral condyle with a
more distal attachment with two screws. This pro-
cedure carried out indiff fferently whether medially
or laterally is however logical only in the case of
valgus deformity of a femoral origin (7).
The chronology of release movements varies
depending on the authors: some like Insall (2) start
with the LCL-popliteus muscle to the femur. Others
like Krackow (8, 9) and Hungerford (10) prefer to
start by desinsertion of the Fascia-Lata at the level
of Gerdy’s tubercle, maintaining its continuity with
the tibial aponeurosis. For Whiteside (11), if lateral
retraction exists in flexion and extension which is
normally the case, the LCL and the popliteus muscle
should be released, then the ilio-tibial band and the
posterior capsule. If the retraction only exists in
extension, he only releases the ilio-tibial band. If the
retraction only exists in flexion, he only releases the
LCL and more rarely the popliteus muscle.
If a lateral approach (12, 13) has been used, part
of the release is done through the approach due to
the desinsertion of the Fascia Lata from the Gerdy’s
tubercle and of the release of the lateral tibial plateau.
In this context, a lateral approach often necessitates
an osteotomy of the anterior tibial tuberosity.
Fig. 5 – Same patient as in Fig. 3. In case of severe tibial deformity, the level of
cut must be meticulously measured. If measurement is referred to the middle
part of the tibial plateau (A), the “real” resection, measured on the medial
border of the medial tibial plateau is much greater. It can be calculated with
a mathematical formula (B). It is important then to measure intraoperatively
the level of cut on the medial border of the medial tibial plateau (C).
Total knee arthroplasty after failed high tibial osteotomy 927
Whatever approach used, this lateral ``recon-
struction'' determines the limit of the correction
because if it is excessive, ligament balancing is dif-
ficult to obtain both in flexion and extension, a
patella Baja appears and peroneal nerve palsy due
to stretching can appear (3–4% for Krackow and
Holtgrewe (8) and Ranawat et al. (14)). Intra-ar-
ticular correction of a metaphyseal malalignment
of 10° requires, for a 10 cm tibia width, a 15 mm
asymmetry of the cut (15). Likewise when the tibia
valgus is more than 10–15°, the correction of the
deformity with the prosthesis presents a certain
number of inconveniences and it is preferable to
envisage other options such as a constrained pros-
thesis in elderly patients (Fig. 4) or to associate a
corrective osteotomy to the prosthesis.
Correction by TKA and tibial osteotomy
A corrective osteotomy enables an extra articular
deformity to be corrected and then insertion of the
TKA is therefore close to the installation of a pri-
mary prosthesis as regards ligament balance. TheTh
simplest technique is to carry out a medial closing
wedge HTO which enables the patella to be raised.
This option leads to a shortening of the limb (9)
and some prefer a curviplanar osteotomy (16). As
for an opening wedge HTO, this will run the risk of
lesion by stretching the peroneal nerve.
Modifications of the tibial slope
A tibial osteotomy regularly leads to modifications
fi
of the tibial slope. Closing Wedge HTO is more
than often the origin of a decrease in slope whereas
Opening Wedge HTO is frequently the origin of an
increase in tibial slope. Certain technical precau-
tions (17–19) enable the increase in slope to be
limited in the OWHTO. However most series show
an increase in the tibial slope in opening wedge
osteotomies (20, 21) (Fig. 6).
A decrease in the tibial slope does not increase the
diffi
fficulties during the implantation of a TKA as
long as it remains positive. Inversely, an increased
slope creates diffi
fficulties in ligament balancing, it is
all the more diffi
fficult if an orthogonal cut prosthesis
is used in the sagittal plane. Bone removal is then
more signifificant anteriorly than posteriorly which
is the source of diff ffculties in ligament balance: if
the cut is referred to the mid portion of the pla-
teau, the thickness of the prosthetic tibial plateau
will be excessive posteriorly, source of excessive
constraints and stiff ffness in flexion and insuffi
fficient
anteriorly, source of laxity in extension (Fig. 7). Th The
choice of the level of cut must be adapted according
to the situation: in the case of a knee that is limited
in extension (flflexum deformity), it is preferable to
increase the anterior tibial resection (level of cut
referred to the posterior part of the tibial plateau).
Otherwise it is preferable that the cut is referred
928 Primary Total Knee Arthroplasty
Fig. 6 – Lateral OA following an Opening Wedge HTO. The tibial slope is
increased and there is a patella baja.
to the mid portion of the plateau or even to the
anterior part of the plateau, a posterior condylar
cut can be envisaged at the end of the intervention
if the knee is too stiff
ff in flexion.
Troubles in rotation
Possible rotatory problems created by the osteot-
omy are stituated above the anterior tibial tuber-
osity and are generally moderate. Partial correction
can be made by adapting the rotatory positioning
of the prosthetic tibial part but the margin of cor-
rection is limited as the tibial rotation must be in
line with that of the femoral part.
An osteotomy of the anterior tibial tuberosity can
correct an excessive lateralization due to external
rotation but it does not correct external rotation
of the foot.
The translation
A residual tibial, mediolateral, or anteroposterior
translation can be the source of diffi
fficulty particularly if
long tibial keels are used. Th
This diffi
fficulty was estimated
at 15% of cases for Neyret et al. (22) and may require
custom made prostheses, in order to avoid conflict fl
between the tibial cortex and tibial stem (Fig. 8).
The ligaments
In Opening wedge osteotomies, the superficial
fi bundle
of the Medial Collateral Ligament must be either cut
or desinserted in order to signifi
ficantly decrease pres-
Fig. 7 – Determination of the optimal level of cut is difficult
ffi in case of increased
tibial slope. If the cut is referred to the mid portion of the plateau (left), the
resection is excessive anteriorly (possible cause of instability in extension) and
insuffi
fficient posteriorly (cause of stiffness in flexion). If the cut is referred to the
posterior part of the tibial plateau (right), the level is appropriate for flexion
but resection is exaggerated anteriorly, source of severe instability.
Fig. 8 – In case of translation of the epi-
physis, an impingement can occur between
tibial cortex and tibial stem (Courtesy from
R Badet and P Neyret).
sure on the medial compartment (23). During TKA, if
a medial approach is used, there is a high risk to desin-
sert remaining fibres of the Medial Collateral Liga-
ment. In a stiff
ff knee it is diffi
fficult to approach the joint
cavity without releasing the medial side of the tibial
metaphysis and this release may lead to major medial
laxity straightaway. It is necessary to check stability
in the frontal plane in extension and flexion, fl once
the incision has been made and before cutting any
bone. The discovery of medial laxity at this early stage
means that the tibial resection must be decreased
(laxity in flexion
fl and extension) and/or the posterior
condylar cuts adapted (no external femoral rotation).
This risk of ``iatrogenic'' laxity justifi
fies the presence of
a constrained prosthesis in the operating theatre.
Valgisation osteotomy by lateral closing wedge
HTO may be accompanied by a mobilization of the
head of the fibula upwards, slackening the Lateral
Collateral Ligament. This is particularly the case

when a fibular osteotomy is not associated with a
tibial osteotomy (simple desinsertion of the supe-
rior peroneotibial articulation).
The patella
The appearance of a patella baja is possible follow-
ing valgisation osteotomy. It is rare following Clos-
ing wedge HTO osteotomies but not exceptional
following Opening wedge HTO (20, 24, 25) and
can be found in 80% of cases for Windsor et al.
(1). In case of patella baja means an osteotomy of
the anterior tibial tuberosity must be considered,
which makes the surgical approach easier and leads
to the possibility of raising the patella at the end of
the intervention.
The stiff
ffness of the knee
The existence of articular stiffffness in flexion or
extension makes surgical difficulties
ffi worse but
technical consequences are not specific.
fi
A limitation of extension requires in chronological
order: a posterior arthrolysis with release of the
posterior condylar capsule, an additional tibial cut
of 2 mm, an additional distal femoral cut of 2 mm
and in certain exceptional cases a desinsertion of
the gastrocnemius, or even a lengthening of ham-
string tendons.
A severe limitation of knee flexion creates a prob-
lem during the articular approach. Th The patellar
eversion can be diffi
fficult even sometimes impos-
sible and an osteotomy of the anterior tibial tuber-
osity or a ``Quadriceps Snip'' are often necessary.
After patellar eversion, residual limitation offlex-
ffl
Fig. 9 – Strategy for TKA following failed HTO.
Total knee arthroplasty after failed high tibial osteotomy 929
ion is due to intra-articular causes. The ablation of
osteophytes and of intra-articular fi fibrosis often
improve the situation.
If flexion remains limited after reposition of the
extensor apparatus, it may be necessary to either
raise the patella (fixation
fi of the anterior tibial
tuberosity in a more proximal position) or, for cer-
tain cases lengthen the extensor apparatus.
Bone quality
Following opening wedge osteotomy using bone
substitutes, bone quality can be mediocre. It is
therefore preferable to bridge the area occupied by
the substitution material with a long stem and to
replace this material with an autologous graft pre-
pared with bone cuts.
Strategy
The technical stategy depends on various fac-
tors which are often associated: former incisions,
skin condition, presence of material, importance
of deformity, type of osteotomy, type of defor-
mity, height of patella, risk of infection, and age
of patient.
The principle is summarized in Fig. 9.
Results
The issue of whether a previous HTO has any poten-
tial adverse eff
ffect on a subsequent TKA remains
930 Primary Total Knee Arthroplasty

a matter of controversy (Table 2). Some authors
report inferior results in patients who have under-
gone previous HTO (1, 26, 27) while others report
similar results (28–32). A systematic review, done
by Van Raaij et al. (33) in July 2009 of 458 articles
had suggested that the osteotomy does not com-
promise subsequent knee arthroplasty: no signifi- fi
cant diff
fferences between primary TKA and TKA
after osteotomy were found for range of motion,
clinical scores and rate of revisions after a median
follow-up of 5 years.
For Amendola et al. (28) previous osteotomy does
not seem to affffect the global outcome even if range
of motion appears to be decreased and inclination
of the tibial plateau may be altered.
Meding et al. (34), in a comparative study of thir-
ty-nine patients who had undergone bilateral TKA
demonstrated that the clinical and radiographic
results for knees with and without a previous
proximal tibial osteotomy were not substantially
different
ff after a mean duration of follow-up of 8.7
years.
For Bae et al. (35), a meticulous surgical technique
can produce satisfactory results in TKA after HTO,
considering the correction of the deformity, Joint
Line Height and the amount of the tibial bone
resection.
Kazakos et al. (36) comparing two groups of TKA
(primary versus following failed HTO) reported no
difference
ff for post-operative knee scores, ligament
releases, blood loss, thromboembolic or neurologic
complications and infection rates. However, surgi-
cal time was longer, patellar subluxation, patella
baja and impingement between the tibial stem and
the lateral tibial cortex were more frequent in the
case of previous HTO. Knee alignment, stability
and ROM were also found with no statistically sig-
nifi
ficant diff
fference.
For Van Raaij et al. (37), TKA after HTO is tech-
nically more demanding than primary TKA, but
clinical outcomes were almost identical with HSS,
KSS, and WOMAC scores being not signifi ficantly
diff
fferent. However, arthroplasty conversion was
more diffifficult after lateral closing wedge proce-
dures. This was also concluded by Whitehead in his
controlled cadaveric study (38).
Haslam et al. (39) studied forty patients with 51
knee arthroplasties after HTO and compared them
with a matched group of patients with primary
knee arthroplasties, at an average FU of 12.6 years.
The overall HSS scores showed no signifi ficant dif-
ference but there were more patients in the osteot-
omy group with a poor result, ROM was reduced
and the rate of re-operation was higher.
For Karabatsos et al. (40) functional outcomes
in TKA in patients with a previous HTO tended
to be inferior but the diff fferences were not sig-
nifi
ficant. Longer operative times, more diffifficulties
with patellar eversion and an increased number of
lateral releases were reported in TKA post-HTO.
Results were worse for pain, function, and stiff- ff
ness categories for the WOMAC score in the post-
HTO group, but the results did not reach statisti-
cal significance.
fi A previous HTO does not aff ffect

Table 2 – Results of TKA after failed HTO in the literature.

Authors Year No. of TKA Follow-up Results/primary TKA
Bae et al. (35) 2009 16 Not mentioned No difference
Kazakos et al. (36) 2008 38 4.5 years No difference
Van Raaij et al. (37) 2007 12 3.7 years Technically more demanding, but clinical outcome identical
Haslam et al. (39) 2007 51 12.6 years No significant difference but reduced ROM and more revisions
Parvizi et al. (45) 2004 166 15.1 years Factors of bad prognosis: weight, age, gender, and limb malalignment
Rozkydal and Pink (42) 2003 50 5.4 years Similar outcomes. Increased risk of Patella Infera
Madan et al. (43) 2003 29 7.5 years Technically more demanding. Results inferior than after primary TKA
Karabatsos et al. (40) 2002 20 5 years Poorer functional results (but no statistical significance)
Noda et al. (41) 2000 28 25 months Poorer results
Meding et al. (34) 2000 95 8.6 years No difference
Haddad and Bentley 2000 50 5 years Overall outcome remains good to excellent
(44)
Gill et al. (46) 1995 30 3.8 years Results of TKA after failed HTO >than after failed UKA
Mont et al. (27) 1994 73 73 months Risk factors of bad results: (1) workmen's compensation patient, (2)
history of RSD after HTO, (3) early onset (less than one year) or no
period of relief of pain after HTO, (4) multiple surgeries before HTO,
and (5) an occupation as a labourer
Neyret et al. (22) 1992 38 3 years Poorer results for walking distance and flexion angle

Amendola et al. (28) 1989 41 37 months Global outcome identical but decreased ROM
Staheli et al. (31) 1987 35 29 months No difference

the general health of patients after TKA, as there
was no difffference between the two groups in SF-36
scores.
Noda et al. (41) evaluated the outcomes of 23
patients and found that when TKA is done after
HTO, various technical problems may influence fl
the outcome, such as correction of the soft tissue
imbalance, in addition to diffi fficulties with patel-
lar eversion and exposure of the proximal part of
the tibia. The
Th clinical results of TKA after HTO are
found to be slightly inferior to those of primary
TKA, probably because of technical problems.
Meding et al. (34) in reviewing a series of 39 bilat-
eral total knee arthroplasties at an average of 8.7
years found that knee scores and radiographic
results of primary versus post-HTO TKAs were
similar. However more knees were painfree in the
primary TKA group but this difference ff was not
found to be signifificant. Knee alignment and stabil-
ity, femoral and tibial component alignment, and
range of motion also were found to be similar in
both groups.
Rozkydal and Pink (42) compared a group of 50
patients who had primary TKA versus 50 follow-
ing a previous HTO. He found that the outcomes of
TKA, as assessed by functional scores, were similar
in the two groups. Th This condition had some eff ffect
on the development of a patella infera but only to
a mild degree.
Madan et al. (43) studied retrospectively a total of
29 cases of post-osteotomy knee arthroplasties.
Average follow-up was 7.5 years with an average
interval between osteotomy and knee arthroplasty
of 4.7 years. He reports signifi ficant balancing prob-
lems and inferior results.
Haddad and Bentley (44) compared 50 consecutive
TKA after failed HTO to an age and sex-matched
group of 50 primary TKA, with a minimum fol-
low-up of 5 years. Surgery in the osteotomy group
took on average 23 min longer, and there was a
decrease of 8° flexion post-operatively but without
an associated diff fference in knee scores. Patellar
subluxation was also seen more frequently. Th There
was no difference
ff in the revision rate at an aver-
age follow-up of >6.2 years. Although there are
signifi
ficant technical diffi
fficulties and subtle clinical
differences,
ff the overall outcome remains good to
excellent in most cases.
Mont et al. (27) reviewed the results of 73 TKA in
67 patients after a HTO at an average follow-up
period of 73 months. Only 64% of the patients had
good to excellent results in the post-HTO group,
compared with 89% in a primary-TKA group. In
addition, their study showed that some factors
may worsen outcome. These factors included (1)
workmen's compensation patient, (2) history of
flex sympathetic dystrophy after HTO, (3) early
refl
onset (less than one year) or no period of relief of
Total knee arthroplasty after failed high tibial osteotomy 931
pain after HTO, (4) multiple surgeries before HTO,
and (7) an occupation as a laborer. Other risk fac-
tors were described and discussed by Parvizi et al.
(45), who reviewed a cohort of 118 patients and
166 knees. Male gender, increased weight, young
age at the time of TKA, coronal laxity, and pre-op-
erative limb malalignment were identified fi as risk
factors for early failure and loosening.
Neyret et al. (22) compared the functional results of
38 TKA following an HTO (mean of 8.5 years after
osteotomy) with a group of 208 patients with pri-
mary TKA. ln the post-osteotomy group the results
were worse in respect to the walking distance and
flexion angle. The GUEPAR and HSS score were
found very similar but rate of revision, especially
for arthrolysis, was increased after osteotomy.
Windsor et al. (1) reviewed patients with 45
cemented total condylar total knee replacements
with an average followup of 55 months. Although
they had good or excellent results, in 80% of the
patients in the study, the authors concluded that
total knee replacement after HTO had results simi-
lar to those after TKA, with inferior results com-
pared with primary total knee replacement.
Interestingly, Gill et al. (46), in his retrospective
matched-pair analysis reports better results (KS
Score) for TKA following failed HTO than failed
UKA. However, the results confirm fi that revisions
after unicondylar arthroplasty and HTO are both
technically demanding.
References
1. Windsor RE, Insall JN, Vince KG (1988) Technical consid-
erations of total knee arthroplasty after proximal tibial
osteotomy. J Bone Joint Surg 70A:547–555
2. Insall JN (1984) Surgery of the knee. Churchill Living-
stone, New York
3. Dejour H, Deschamps G. Technique opératoire de la pro-
thèse totale à glissement du genou, vol 35. Paris: Expan-
sion Scientifi
fique Française; 1989.
4. Hungerford DS, Lennox DW (1984) Fixed valgus defor-
mity. In: Hungerford DS, Krackow K and Kenna R (eds)
Total knee arthroplasty – a comprehensive approach. Wil-
liams & Wilkins, Baltimore, pp 167–178
5. Zanone X, Aït Si Selmi T, Neyret P (1999) KneeArth-
roplasty and simultaneoushigh tibial osteotomy, for
osteoarthritis and severecongenital tibia varumdeformity.
RevChirOrthop 85:749–756
6. Lerat JL, Godenèche A, Moyen B, et al. (2008) Total knee
replacement in the valgus knee. In: Bonnin M, Chambat P
(eds) Osteoarthritis of the knee. Springer, Paris pp 285–314
7. Brilhault J, Lautman S, Favard L, et al. (2002) Lateral fem-
oral sliding osteotomy lateral release in total kneearthro-
plasty for a fixed valgus deformity. J Bone Joint Surg Br
84(8):1131–1137
8. Krackow K, Holtgrewe JL (1990) Experience with a new
technique for managing severely overcorrected valgus high
tibialosteotomy at total knee arthroplasty. ClinOrthop
258:213–224
9. Krackow KA, Jones MM, Teeny SM, et al. (1991) Pri-
mary total knee arthroplasty in patients with fixed valgus
deformity. ClinOrthop 273:9–18
932 Primary Total Knee Arthroplasty
10. Krackow MM, Antonaides S, Krackow KA, Hungerford
DS (1994) Total knee arthroplasty after failed high tibi-
alosteotomy: a comparaison with a matched group. Clin
Orthop Relat Res 299:125–130
11. Whiteside LA (1993) Correction of ligament and bone
defects in total arthroplasty of the severely valgus knee.
ClinOrthop 288:234–245
12. Keblish PA (1991) The lateral approach to the valgus knee:
surgical technique and analysis of 53 cases with over two-
year follow-up evaluation. ClinOrthop 271:52–62
13. Lootvoet L, Blouard E, Himmer O, et al. (1997) Complete
knee prosthesis in severe genu valgum. Retrospective
review of 90 knees surgically treated through the anterio-
external approach. Acta Orthop Belg 63(4):278–286
14. Ranawat CS, Rose HA, Rich DS (1984) Total condylar
knee arthroplasty for valgus and combined valgus fl flexion
deformity of the knee. In: JA M (ed) Intructional course
lectures. CV Masby, St Louis pp 412–416
15. Wolffff AM, Hungerford DS, Pepe CL (1991) The eff ffect of
extra articularvarus and valgus deformity on total knee
arthroplasty. ClinOrthop 271:35–51
16. Cameron HU, Park US (1996) Total knee replacement fol-
lowing high tibialosteotomy and unicompartimental knee.
Orthop Research 19:807–808
17. Hernigou P, Medevielle D, Debeyre J, et al. (1987) Proximal
tibial osteotomy for osteoarthritis with varus deformity.
A ten to thirteen-year follow-up study. J Bone Joint Surg
Am 69(3):332–354
18. Marti CB, Wachtl SW, Gautier E, et al. (2004) Accuracy of
frontal and sagittal plane correction in open-wedge high
tibial osteotomy. Arthroscopy 20(4):366–372
19. Song EK, Seon JK, Park SJ (2007) How to avoid unin-
tended increase of posterior slope in navigation-assisted
open-wedge high tibial osteotomy. Orthopedics 30(10
Suppl):127–131
20. Brouwer RW, Bierma-Zeinstra SM, Van Koeveringe AJ, et al.
(2005) Patellar height and the inclination of the tibial pla-
teau after high tibial osteotomy. The
Th open versus the closed-
wedge technique. J Bone Joint Surg Br 87(9):1227–1232
21. El-Azab H, Halawa A, Anetzberger H, et al. (2008) The Th
eff
ffect of closed- and open-wedge high tibial osteotomy
on tibial slope: a retrospective radiological review of 120
cases. J Bone Joint Surg Br 90(9):1193–1197
22. Neyret P, Deroche P, Deschamps G, et al. (1992) Prothèse
totale du genou après ostéotomie tibiale de valgisation
Problèmes techniques. Rev chir orthop 78:438–448
23. Agneskirchner JD, Hurschler C, Wrann CD, et al. (2007)
The effffects of valgus medial opening wedge high tibial
osteotomy on articular cartilage pressure of the knee: a
biomechanical study. Arthroscopy 23(8):852–861
24. Dohin B, Migaud H, Gougeon F, et al. (1993) Effets ff de
l'ostéotomie de valgisation par soustraction externe sur la
hauteur de la rotule et l'arthrose fémoro-patellaire. Acta
orthop Belg 59( 1):69–75
25. Westrich GH, Peters LE, Haas SB, et al. (1998) Patella
height after high tibial osteotomy with internal fixation
fi
and early motion. Clin Orthop Relat Res 354:169–174
26. Katz MM, Hungrford DS, Krackow KA, et al. (1987)
Results of total knee arthroplasty after failed proximal
tibial osteotomy for osteoarthritis. J Bone Joint Surg
69(A):225–232
27. Mont MA, Antonaides S, Krackow KA, et al. (1994) Total
knee arthroplasty after failed high tibial osteotomy. A
comparison with a matched group. Clin Orthop Relat Res
299:125–130
28. Amendola A, Rorabeck CH, Bourne RB, et al. (1989) Total
knee arthroplasty following high tibial osteotomy for
osteoarthritis. J Arthroplasty 4(Suppl):511–517
29. Bergenudd H, Sahlstrom, Sanztn L (1997) Total knee
arthroplasty after failed proximal tibial valgus osteotomy.
J Arthroplasty 12:635–638
30. Nizard RS, Cardinne L, Bizot P, et al. (1998) Total knee
replacement after failed tibial osteotomy: results of a
matched-pair study. J Arthroplasty 13:847–853
31. Staeheli JW, Cass JR, Morrey BF (1987) Condylar total
knee arthroplasty after failed proximal tibial osteotomy.
J Bone Joint Surg Am 69(1):28–31
32. Toksvig-Larsen ST, Magyar G, Onsten LR, et al. (1998)
Fixation of the tibial component of total knee arthroplasty
after high tibial osteotomy: a matched radiostereometric
study. J Bone Joint Surg 80B:295–297
33. Van Raaij TM, Reijman M, Furlan AD, et al. (2009) Total
knee arthroplasty after high tibial osteotomy. A system-
atic review. BMC Musculoskelet Disord 20(10):88
34. Meding JB, Keating EM, Ritter MA, et al. (2000) Total
knee arthroplasty after high tibial osteotomy: a compari-
son study in patients who had bilateral total knee replace-
ment. J Bone Joint Surg Am 82(9):1252–1259
35. Bae DK, Song SJ, Yoon KH (2010) Total knee arthroplasty
following closed wedge high tibial osteotomy. Int Orthop
Feb; 34(2):283–7
36. Kazakos KJ, Chatzipapas C, Verettas D, et al. (2008) Mid-
term results of total knee arthroplasty after high tibial
osteotomy. Arch Orthop Trauma Surg 128(2):167–173
37. Van Raaij TM, Bakker W, Reijman M, et al. (2007) The Th
eff
ffect of high tibial osteotomy on the results of total knee
arthroplasty: a matched case control study. BMC Musculo-
skelet Disord 2:8–74
38. Whitehead TS, Willits K, Bryant D, et al. (2009) Impact of
medial opening or lateral closing wedge tibial osteotomy
on bone resection and posterior cruciate ligament integ-
rity during total knee arthroplasty. J Arthroplasty Sep;
24(6):979–89
39. Haslam P, Armstrong M, Geutjens G, et al. (2007) Total
knee arthroplasty after failed high tibial osteotomy
long-term follow-up of matched groups. J Arthroplasty
22(2):245–250
40. Karabatsos B, Mahomed NN, Maistrelli GL (2002) Func-
tional outcome of total knee arthroplasty after high tibial
osteotomy. Can J Surg 45(2):116–119
41. Noda T, Yasuda S, Nagano K, et al. (2000) Clinico-radio-
logical study of total knee arthroplasty after high tibial
osteotomy. J Orthop Sci 5(1):25–36
42. Rozkydal Z, Pink T (2003) Total knee replacement follow-
ing high tibial osteotomy. Acta Chir Orthop Traumatol
Cech 70(3):158–163
43. Madan S, Ranjith RK, Fiddian NJ (2002–2003) Total knee
replacement following high tibial osteotomy. Bull Hosp Jt
Dis 61(1–2):5–10
44. Haddad FS, Bentley G (2000) Total knee arthroplasty after
high tibial osteotomy: a medium-term review. J Arthro-
plasty 15(5):597–603
45. Parvizi J, Hanssen AD, Spangehl MJ (2004) Total knee
arthroplasty following proximal tibial osteotomy:
risk factors for failure. J Bone Joint Surg Am Mar;
86-A(3):474–9
46. Gill T, Schemitsch EH, Brick GW, et al. (1995) Revision
total knee arthroplasty after failed unicompartmental
knee arthroplasty or high tibial osteotomy. Clin Orthop
Relat Res 321:10–18

T. Ait Si Selmi,
D. Carmody, Ph. Neyret
Total knee arthroplasty after
malunion
Introduction
L
ower limb malunion, although quite rare,
does provide us with an experimental in vivo
model of the eff
ffect of deformity on knee bio-
mechanics, degenerative changes, and the impact
of a particular deformity on knee arthroplasty
performance. Understanding the consequences
of such extra-articular deformities is also useful
when it comes to managing major valgus or varus
native knees, Paget’s disease, rickets or acquired
deformities as in distal femoral or proximal tibial
osteotomies…
There are few series regarding the outcome of TKA
Th
after malunion, all reporting fair results but an
increased rate of complications and revisions com-
pared to primary routine procedures (1–5). Long-
term good results are known to rely particularly
on achieving good re-alignment and appropriate
ligament balance (6–9). In the particular setting of
severe extra-articular deformity, two options are to
be considered – extensive ligament release (10) or
the use of an osteotomy (1, 11, 12). TheTh aim of the
present paper is to discuss the best option through
an overview of the specificfi situation of malunion.
Among the consequences of a deformity, we can
distinguish the primary effects,
ff which is how it
aff
ffects the knee biomechanics and may lead to
degenerative changes or compromise the outcome
of knee arthroplasty. As stressed by numerous
authors the long-term survival of this procedure is
related to an accurate re-alignment.
It is then essential to understand that re-align-
ment of an extra-articular deformity may interfere
with the bone cuts and compromise the ligament
balance. ThThese issues are referred as the secondary
effects
ff of deformity and require appropriate action
to be taken to achieve a successful long-term
arthroplasty.
The tertiary effects
ff refer to the specific
fi issues of the
surgical technique (implant and instruments) in a
modifi fied anatomy.
Having understood the numerous implications of
severe extra-articular deformities on the knee joint
there is a need to consider a combined osteotomy
with the arthroplasty. Nevertheless this combined
Chapter 89
procedure is a very demanding procedure and we
may also consider alternative options to osteot-
omy.
What are the eff
ffects of deformities?
Primary effect
ff of deformities
Coronal plane
Frontal deformities are usually well recognized
clinically or through evaluating the X-ray and
the mechanism that leads to OA are then easy to
understand. Varus deformity results in increased
varus moment while valgus deformity generates
a valgus moment about the AP axis, leading to
medial or lateral OA (11, 13, 14). Long-leg films
fi do
provide an overall view of the limb and enable us
to identify a deformity on a standard film
fi and to
assess the extent and the position of the deformity
relative to the joint. For a given degree of shaft
angle, the closer the deformity to the joint, the
bigger its eff
ffects on the limb alignment. Thus, only
the resulting mechanical axis should be consid-
ered. But the bony deformity can be overestimated
since the “apparent” overall deformity may include
joint wear in the convexity and ligament laxity
in the convex side of the knee joint. Th Therefore,
the assessment of a coronal plane deformity may
include both clinical and radiological stress testing
(Fig. 1). Th
The axis measured after a stress reduction
view determines the true extra-articular deformity
(15). Other contributions to the frontal defor-
mity, whether from intra-articular bone deformity
or from ligamentous origin, may not affect ff the
arthroplasty relative to re-alignment, nor the bone
cuts and the resulting gaps (11, 13). A lateral view
is also required to determine the presence of any
sagittal component in the deformity.
Axial plane
Rotational deformities, which are more likely to
aff
ffect the femur, are more diffi
fficult to assess clini-
934 Primary Total Knee Arthroplasty
Fig. 1 – (A) overall deformity as shown on the long leg film including the
extra-articular deformity related to shaft malunion (1) and the native tibial
varus (2). Intra-articular contribution to the overall mal alignment involves
stretching in the convex side (3) and intra-articular wear (4). (B) On stress
X-rays the remaining mal-alignment determines the overall extra-articular
contribution to the deformity.
cally but their impact in the development of knee
OA, while more complex, is certainly relevant. It
has been demonstrated that external femoral tor-
sion over 15° results in increased medial compart-
ment loading and thus in progressive OA. Internal
torsions, while less frequent have the opposite
eff
ffect (5). The location of the torsion relative
to the knee joint has no consequences at a first fi
glance: e.g., with the knee in full extension, 30°
of external torsion at the lesser trochanter level
leads to 30° out toeing position of the foot, with
no apparent eff ffect on the frontal alignment. But
there is more to torsion than meets the eye at the
first glance. Since the femur features an anterior
bow at its mid portion, any rotation applied near
its apex generates a varus moment by swinging
the knee joint out of the hip–ankle axis in the
frontal plane (medially for a given external tor-
sion and conversely). ThisTh also applies since the
knee is the apex of the lower limb during fl flexion.
When the knee is flexed, the torsion angle is pro-
gressively converted into a varus moment relative
to the frontal plane, with a maximal effectff at 90°
of flexion. Therefore it is useful to examine the
knee alignment with the patient seated. Th These
two static and dynamic eff ffects converting a defor-
mity along the vertical axis into a deformity into
the frontal plane are referred as the “static varus
moment” and the “dynamic varus moment” after
Ait Si Selmi et al. (13). In femoral malunion, extra-
articular rotation may also affect ff the patellar
tracking: an increased medial torsion leading to a
higher risk of lateral patellar dislocation, whereas
a lateral torsion may increase the medial femoro-
patellar pressure.
Sagittal plane
Sagittal deformities are even rarer and their pos-
sible implication in the degenerative process is
not proven. Nevertheless, sagittal deformities
are likely to compromise the functional outcome
whether because of a residual lack of extension
or an excessive hyper-extension with subsequent
functional instability related to quadriceps weak-
ness (16).
Secondary effect
ff of deformities
Secondary effects
ff are referred as the implications
of the deformity while performing a knee arthro-
plasty. The
Th presence of an extra-articular defor-
mity may first of all have repercussions on the
bone cuts while addressing the mal-alignment. The
Th
gaps will then be aff
ffected and the ligament balance
compromised. Then, patellar alignment may also
be affected.
ff
Coronal plane
In frontal plane deformities the cut perpen-
dicular to the mechanical axis will remove more
bone in the convex side of the mal-aligned knee,
referred to as asymmetrical resection. This effect
is similar at both femoral and tibial articular sur-
faces. The consequence is the creation of asym-
metrical gaps referred to as resection laxity. To
compensate for this relative laxity in the convex
side, there is a need for an extended ligament
release in the concave side of the joint to achieve
a square balanced gap. This latter effect has more
complex implications on the femoral side than
on the tibial side.
On the tibial side the asymmetrical cut results in
an asymmetrical gap in the same way either in
extension or through the range of flexion (Fig. 2).
Balancing the knee with an appropriate degree of
ligament release will restore a square gap in both
flexion and extension. The subsequent femoral cut
will not be aff
ffected (Fig. 3).
On the femoral side, an asymmetrical distal cut
will generate an asymmetrical gap. But in fl flexion,
the gap will not be affffected (Fig. 4). Releasing the
ligaments to address the extension gap will then
lead to compromise the initially unaffected
ff flex-
ion gap (Fig. 5). Therefore,
Th to address the flexion
gap there is a need to rotate the femoral compo-
nent along with an asymmetrical posterior condy-
lar cut, or alternatively to compensate the unbal-
 Total knee arthroplasty after malunion 935

Fig. 2 – varus from tibial origin. (A) the amount of lateral resection (arrows) Fig. 3 – Similar effect of the medial release resulting in square extension
as a similar effect on the gaps in both extension (A) and flexion (B). gap (C) and flexion gap (D).

Fig. 4 – Varus from femoral origin. The distal cut removes more bone on Fig. 5 – Varus from femoral origin. Medial release leading to a balanced
the lateral side (arrow) resulting in an asymmetrical extension gap (A). This extension gap (C), while compromising balance of the flexion gap to the
does not affect the flexion gap which remains parallel to the bi-epicondylar same extent (arrow) (D).
axis (BEA) (B).

anced flexion gap by using a constrained design,
or even an asymmetrical femoral component. In
the valgus knee, the medial over-resection will
be compensated to a certain extent by a lateral
release, which in turn will generate a larger lateral
gap in flexion. External rotation of the femoral
component may restore an adequate flexion gap
while improving the patellar tracking. But con-
versely, in a varus knee from femoral origin, there
would be a need for internal rotation of the femo-
ral component to achieve a square gap, along with
a high risk of patellar mal-tracking or dislocation.
Rotating the femoral component may also some-
how generate anterior cortical notching (Table 1).
Thus, addressing a frontal deformity of tibial
origin is easier than addressing a valgus femoral
deformity, or even more, a varus deformity from
a femoral origin.

Table 1 – Coronal deformity.

Deformity Cuts Gaps Action taken Alternative action
Asymmetrical wedged Asymmetrical but identical
Tibia Concave side release Tibial osteotomy
cut through extension/flexion ROM
Femur Lateral release
Asymmetrical medial cut Asymmetrical in extension Femoral osteotmy
valgus + femoral component external rotation
Persisting varus
Femur Medial release
Asymmetrical lateral cut Asymmetrical in extension Constrained TKA
Varus Flexion gap imbalance
Femoral osteotomy
936 Primary Total Knee Arthroplasty

How much can we release?

Asymmetrical cuts as a result of extra-articular
deformities may require a significant
fi release to
achieve a ligament balance. Nevertheless, there
are anatomical limitations in the extent of col-
lateral ligament release. It is actually difficult
ffi to
provide a precise figure in this matter. Neverthe-
less, one may consider 12–15 mm as being an
approximate limit. From the Wolf geometrical
construct (11), 12–15 mm asymmetrical resection
would be the result of approximately 8° of extra-
articular deformity with an average bone size (the
larger the epiphysis for a given angle, the bigger
the resection).
It is important to remember however, that evalu-
ation of the extra-articular contribution to the
overall deformity relies on stress X-rays in which
wear and pre-existing laxity are deducted. Th The
extent of release necessary on the concave side
may also be maximized when the collateral liga-
ments in the convex side are already stretched as
in chronic major deformities. This may be demon-
strated by the comparative AP monopodal stance
views, when the pathological knee displays exces-
sive opening of the convex femorotibial compart-
ment. Drawing the expected cuts relative to the
mechanical axis is a practical way to get an esti-
Fig. 6 – Left knee with medial OA. After having templated the bone cuts on
mate of the extent of the required release (Fig. 6).
the valgus stress reduction film, the amount of expected release is deter-
When the planning demonstrates a possible exces- mined as the convex side (B) minus the concave side (A).
sive asymmetrical cut and a subsequent excessive
imbalance, the need for an osteotomy is then to
be discussed. ponents with a possible subsequent patellar mal-
tracking. In mobile bearing platforms, attempts to
Axial plane correct the rotation of the tibial tray relative to the
bone cut will be negated due to the re-alignment of
Horizontal mal-alignments do not compromise the mobile bearing plateau.
the coronal femorotibial alignment of the leg dur- In femoral extra-articular torsions a corrective
ing TKA, since they do not affect ff the direction action would consist in rotating the femoral com-
of the bone cuts nor the shape of the extension ponent in the opposite direction in an attempt to
gap. Although the cuts may be well aligned in the re-align the patella. But this intra-articular rotation
axial plane with the bone at the level of the knee, would compromise the flexion/extension gap bal-
it will none the less result in persistent horizon- ance and would require a more constrained design.
tal mal-alignment with subsequent risk for patel- Rotation of the femoral component would also
lar mal-tracking, increased wear of either of the aff
ffect the femorotibial contact area, particularly in
bearing surfaces or loosening. A combined valgus fixed bearing designs where the tibial surface is not
may worsen the risk of patellar mal tracking. Let self-aligned relative to the femoral surface. There
Th
us keep in mind that there are no ways to balance is also the risk of anterior cortex notching when
the ligament sleeve through a hypothetical “axial rotating the femoral component.
release” to address any axial bone-ligament mis-
match.
In tibial extra-articular torsional deformities any Sagittal plane
re-alignment attempt using a rotation of the pros- Deformities affffecting the sagittal plane are not
thetic component may lead to detrimental effects.
ff known as being potentially harmful for the knee.
In fixed bearings any rotation of the tibial compo- On the femoral side the position of the femoral
nent would alter the femoral/tibial bearing contact implant is dictated by the geometry of the gaps
pattern then compromising the knee kinematics. and the anterior cortical reference. Inserting the
Rotating the tibial tray will also affect
ff the position femoral component in excessive flexion
fl or exten-
of the tibial tubercle relative to the prosthetic com- sion in order to address any extra-articular sagittal
 Total knee arthroplasty after malunion 937

deformity would aff ffect the prosthetic tracking or

may notch the anterior cortex. On the tibial side
correcting a sagittal deformity would affectff the
tibial slope along with the patellar height relative
to the tibial tubercle and potentially induce insta-
bility (17).

Tertiary eff
ffect of deformity
The last effffect of the malunion is its possible
interference with the TKA implantation. The Th first
concern would be the approach which may take Fig. 7 – Medial defect after asymmetrical bone cut as a result of a major
into account the previous scars, the skin qual- varus combine with advanced OA grade (A). A medial metallic augment has
ity, the need for hardware removal or a patella been used to compensate the bone defect along with an extended stem.
infera or a restricted range of motion… Th The pres-
ence of a malunion or of a major extra-articular
mal-alignment does also raise practical concerns,
since both implants and instruments are set for a
normal or nearly normal anatomy. First of all the
intramedullary rods have to be inserted accord-
ing to the aiming point in the center of the shaft.
The entry point which is slightly medial in a nor-
Th
mal anatomy has to be reconsidered according to
the AP and lateral X-rays when the epiphysis is
no longer aligned with the shaft. The rod guide
may encounter a canal obstruction or deformity,
or may have a limited range of angle which would
compromise the accuracy of the cuts (18). A jig
with removable end may facilitate the alignment. Fig. 8 – Major valgus resulting from a supra-condylar malunion (A). A
The use of an extra-medullary guide is very helpful
Th supracondylar osteotomy have been performed and fixed through the
at the tibial side, but for the femur a navigation femoral component augment. A standard TKA has been implanted through
system is to be considered (19). In some instances, a lateral approach including a tibial tubercle (TT) elevation. Note the pre-
typically when dealing with a severe deformity operative patella infera addressed with a proximal TT transfer (B).
with a high grade of OA displaying a deep cupula
in the tibial plateau, the obliquity of the cut may
require a thicker bone cut or alternatively the use Strategy and guideline
of a wedge to provide an adequate seating of the
tibial tray (Fig.7). Ligament balance is then con-
ducted using a standard progressive release of the Assessment and thresholds
concave side. One may consider ligament advance-
ment in extreme cases. Lateral retinacular release The clinical examination remains critical in identi-
and posterior release may be carried out system- fying the presence and circumstances of a previous
atically because of the high rate of post operative procedure or accident, and in the evaluation of the
stiff
ff knees (2). It is then important to consider an local conditions such as skin aspect, the range of
implant which may accommodate intramedullary motion, a laxity, or the presence of a non-union…
stems, ideally with a variable offset,
ff and a prosthe- Patient examination must be carried out in supine,
sis which comes with versatile constraint options standing, and sitting position to assess the defor-
(Fig. 8). In some instances, a customized implant mity in different
ff planes. The need for an osteot-
has to be discussed, or even resection prosthesis. omy is the key factor which aff ffects the strategy
When considering a one stage combined TKA and in addressing extra-articular deformities. Since a
osteotomy, an additional concern is the need for moderate deformity does not affect
ff the TKA pro-
additional fixation compatible with the presence cedure, one must first
fi determine the threshold
of the prosthesis or its stem extensions. However, over which the ligament balancing may be affected.
ff
in unstable knees a high constrained or a hinged Thus, long-leg films and stress X-rays are required
prosthesis is required provided that their specificfi to identify the deformity and determine its amount
long augments will not interfere with the defor- and contribution to the overall mal-alignment. CT-
mity (20). scan is essential to elicit a combined or isolated
938 Primary Total Knee Arthroplasty

rotational component in the deformity. The Th 8° promise the TKA. Alternatively, an over correction
frontal threshold and 15° axial threshold seem to may be considered in the youngest patients to relieve
be acceptable landmarks. As for the sagittal defor- the worn compartment pressure and to allow us to
mities, the functional impact seems to be more rel- delay a TKA as long as possible. Any pre-existing
evant rather than a fixed figure. Nevertheless the limb length discrepancy must be considered and ide-
patient’s age, condition, and expectations must be ally addressed at the time of the osteotomy by using
confronted with the alignment concerns. either an opening or closing wedge osteotomy.
When? The ideal timing is one setting as much as
possible. When the deformity is close to the knee
Osteotomy joint and may be addressed relatively simply in the
same setting there is no major reason to delay the
Considering an osteotomy is sometimes necessary TKA. In particular, attention must be paid to the
but raises additional questions such as where, how very stiff
ff knees where union of a femoral osteot-
many, how much, and when shall we do it? omy may be compromised due to the stiff ff limb
Where? While located near the joint (usually when forming a long-lever arm acting across the osteot-
the deformity comes from a previous osteotomy) it omy site. Performing the TKA at the same time
is convenient to address it in one setting during the will improve the stiffness
ff of the knee and reduce
knee arthroplasty procedure. The Th bone cuts are then the forces on the osteotomy site. If the local con-
available as a graft, and stem extensions may be used ditions are not favorable, such as soft tissue con-
to by-pass and fix the corrective osteotomy (12). On cerns, previous infection, or possible delayed bone
the other hand, when the deformity is located far union, it is safer to perform the osteotomy and
from the knee metaphysis it cannot be accessed and then to consider the TKA. In the young patients,
addressed trough one single incision and may not one may consider the osteotomy first since it may
be fixed through a by-pass stem extension. There- provide substantial relief and may allow delaying
fore, a correction at the site of the deformity may be of the TKA for a long period of time. When facing a
indicated using a nail or a plate. This
Th option is not complex deformity with frontal, horizontal or even
always achievable when the deformity is expected sagittal combined deformity, it is very challenging
to be diffi
fficult to heal from a previous delayed union to predict the final alignment without additional
or infection, when the presence of non-retrievable X-ray or CT-scan assessment. It is therefore more
hardware is suspected or when compromised soft convenient to address the deformity first
fi and to re-
tissue healing is suspected. In this instance, it is assess the remaining deformity prior to TKA.
better to consider another location.
How many? Ideally, one must consider one single
osteotomy at the site of the deformity in order to
restore the bone segment as close as possible to the
native anatomy. But in some instances this option
may be ruled out when the amount of expected
correction would compromise the fi fixation or the
bone healing process. Also, in younger patients,
one may expect to address the OA through a sepa-
rate high tibial osteotomy (HTO), usually at the
proximal tibia, in order to delay the arthroplasty,
even though the deformity has a different
ff location.
Typically, a femoral external torsion deformity in
a young patient leading to a medial knee OA, may
be addressed by performing a femoral corrective
osteotomy and a concomitant high tibial osteot-
omy to achieve 3–5° of hypercorrection (Fig. 9).
How much? Th The ideal correction is aimed to restore
the normal alignment, ideally at the site of the defor-
mity. This is often the most suitable option. One
should remember that the amount of correction
may diffffer from the measured angle at the site of
Fig. 9 – Left femur with mid shaft malunion and medial knee OA (A). The
the deformity. The use of templates is highly recom- CT-scan displays a 34° external torsion of the left femur as compared to
mended, not to say mandatory, in order to prefi figure the right femur (B). Because of previous multiple procedures and the pres-
the eff
ffect of the corrective action. But an incomplete ence of hardware a rotation osteotomy has been performed proximally to
correction may be acceptable, provided that the final
fi address the deformity. In the same setting a valgus HTO has been conducted
alignment is below the threshold and will not com- to address the knee OA (B).

Alternative to osteotomy
If a corrective osteotomy is the more logical option
it is not always suitable since the local conditions
may not allow a safe procedure, or when the patient
age and condition require a fast recovery and/or
immediate weight bearing. Th Thus, a constrained
design may be considered in addressing a frontal
deformity and the subsequent ligament imbal-
ance related to the resection laxity. But the more
the implant constraints, the more the stem length
which may interfere with the deformity if close to
the knee joint. Difficulties
ffi in canal permeation or in
hardware removal must also be considered. There-Th
fore, a customized stem or in extreme cases a resec-
tion prosthesis allowing the removal of the defor-
mity may be considered. Alternatively a standard
TKA will be performed with a residual frontal mal-
alignment. This
Th latter option must be considered in
elderly patients with a shorter life expectancy. In the
particular scenario of the varus knee from a femoral
origin, one may also consider keeping some degree
of residual varus rather than internally rotate the
femoral component to balance the flexion gap.
In rotational deformity, the use of a constrained
implant may not address the patellofemoral mal-
alignment. In this situation rotating the implants
may require an extensive release of the collateral
ligament. An anterior tubercle transfer may then
be considered along with soft tissue re-alignment.
In the elderly one may consider an arthroplasty
alone and to leave the torsional deformity if it is
not compromising the patellar alignment.
Sagittal deformities generally do not compromise
the fate of a knee arthroplasty. Th Therefore it is
usually acceptable to keep the sagittal deformity
since it may not be corrected in the arthroplasty.
In major deformities with major functional conse-
quences an osteotomy is then required.
Conclusion
There is no doubt that the use of navigation sys-
tems will enhance the accuracy of the correction
or, even more, the amount of correction required
when coupled with the arthroplasty software. But
the management of a severe extra-articular defor-
mity does not only rely on software! The X-ray
assessment must include AP and lateral views,
long-leg films and stress X-rays along with a CT-
Scan in order to get a precise “mapping” of the
deformity and to evaluate possible limitations of
the TKA procedure (frontal 8° and horizontal 15°
thresholds). Planning using handmade templates
to simulate the consequences of the bone cuts, the
effect
ff of the osteotomy, the expected alignment
Total knee arthroplasty after malunion 939
and the final limb length, the need for internal
fixation or the use of stem augments… is of crucial
importance in this demanding surgery.
The osteotomy is discussed according to the site of
the deformity, the local conditions, the patient con-
dition and above all the patient expectations and
his/her compliance with this demanding program.
An osteotomy is to be considered mostly in femo-
ral varus deformities or rotational deformities. We
must keep in mind, however, that the osteotomy is
a good alternative to arthroplasty in the young.
In some instances, particularly in the elderly, we
may consider the use of constrained implants to
address coronal deformities or alternatively to
keep the deformity in an acceptable range of resid-
ual angulation when long-term longevity is not the
main concern.
References
1. Ait Si Selmi T, Zanone X, Neyret P (2003) Prothèses du
genou sur cal vicieux. In Chirurgie Prothétique du Genou.
Sauramps Medical, pp 221–239
2. Bonin N, Ait Si Selmi T, Dejour D, Neyret P (2004) Knee
para-articular fl
flexion and extension osteotomies in adults.
Orthopade 33(2):193–200
3. Chou W, Ko J, Wang C-J, et al. (2008) Navigation-assisted
total knee arthroplasty for a knee with malunion of the
distal femur J Arthroplasty 23(8):1239–1239
4. Gill GS, Joshi AB, Mills DM (1999) Total condylar knee
arthroplasty; 16- to 21-year results. Clin Orthop 367:210
5. Jiang CC, Insall JN (1989) Effect
ff of rotation on the axial
alignment of the femur. Pitfalls in the use of femoral
intramedullary guides in total knee arthroplasty. Clin
Orthop Relat Res (248):50–56
6. Kettelkamp DB, Hillberry BM, Murrish DE, Heck DA
(1988) Degenerative arthritis of the knee secondary to
fracture. Clin Orthop 234:159
7. Lonner JH, Pedlow FX, Siliski JM (1999) Total knee arthro-
plasty for post-traumatic arthrosis. J Arthroplasty 14:969
8. Mann JW III, Insall JN, Scuderi GR (1997) Total knee
arthroplasty in patients with associated extra-articular
angular deformity Orthop Trans 21:59
9. Moreland JR, Bassett LW, Hanker GJ (1987) Radiographi-
canalysis of the axial alignment of the lower extremity. J
Bone JointSurg 69A:745
10. Papadopoulos EC, Parvizi J, Lai CH, et al. (2002) Total
knee arthroplasty following prior distal femoral fracture.
Knee 9:267
11. Ritter MA, Herbst SA, Keating EM, et al. (1994) Long-term
survival analysis of a posterior cruciate-retaining total
condylar total knee arthroplasty. Clin Orthop 309:136
12. Roffi
ffi RP, Merritt PO (1990) Total knee replacement after
fractures about the knee. Orthop Rev 19:614
13. Sah A, Scott R, Iorio R (2008) Angled polyethylene insert
exchange for sagittal tibial malalignment in total knee
arthroplasty. J Arthroplasty 23(1):141–144
14. Sharkey PF, Hozack WJ, Rothman RH, et al. (2002) Why
are total knee arthroplasties failing today? Clin Orthop
Relat Res 404:7
15. Vince KG, Insall JN (1988) Long-term results of cemented
total knee arthroplasty. Orthop Clin North Am 19:575
16. Wang J-W, Wang C-J (2002) Total knee arthroplasty for
arthritis of the knee with extra-articular deformity. J
Bone Joint Surg Am 84:1769
940 Primary Total Knee Arthroplasty
17. Wolff
ff AM, Hungerford DS, Pepe CL (1991) The eff ffect of
extraarticular varus and valgus deformity on total knee
arthroplasty. Clin Orthop 271:35–51
18. Yercan HS, Ait Si Selmi T, Sugun TS, Neyret P (2005)
Tibiofemoral instability in primary total knee replace-
ment: a review part 2: diagnosis, patient evaluation, and
treatment. Knee 12(5):336–340
19. Zanone X, Ait Si Selmi T, Neyret P (2003) Cals Vicieux,
Gonarthrose et Prothèses Totales du Genou In Chirurgie
Prothétique du Genou. Sauramps Med:211–220
20. Zanone X, Ait Si Selmi T, Neyret P (1999) Total knee pros-
thesis and simultaneous corrective tibial osteotomy, for
osteoarthritis and severe congenital tibia varum deformity.
Rev Chir Orthop Reparatrice Appar Mot 85(7):749–756
 Chapter 90

J. R. Laurent Revision total knee arthroplasty

after failed unicompartmental knee
replacement

Introduction previous osteotomy), events having occurred

during the rehabilitation phase, prolonged fever,

T
he place of unicompartmental knee arthro-
plasty (UKA) in the management of uni-
compartmental knee arthritis is still under
debate. Some advantages of UKA over tricom-
partmental knee replacement were highlighted:
better proprioception due to preservation of the
cruciate ligaments, higher range of motion, faster
functional recovery (1), lower rate of intraopera-
tive morbidity regarding pain, blood loss or throm-
boembolic complications, good preservation of
either patellofemoral and healthy compartment
bone stock (2), lower global cost.
A more demanding insertion technique and strict
criteria for patient selection account for the poor
clinical outcome reported in some of the fi first
series (3, 4). In the light of the results published
by the Swedish register (5) thus providing a better
understanding of the failure mechanisms, the out-
comes were markedly improved. The Th survival rates
reported in the literature for medial UKA range
from 90 to 98% at 10 years (6–8). Series of lateral
compartment UKA are uncommon and their sur-
vival rate varies from 95% at 4 years for Dejour
(9) to 76% at 8 years for Gunther (10) using the
Oxford prosthesis.
However, unicompartmental knee arthroplasty
revision might be considered when patient has an
extended life expectancy. ThThe success of the proce-
dure requires the need for a rigorously performed
pre-operative planning as well as surgical gesture.
It should help determine the reasons for failure
and give the opportunity to anticipate the poten-
tial diffi
fficulties.
discharge. The surgical protocol will inform about
the type of implant, the quality of the other com-
partments and ACL as well as the amount of bone
resection. Pre-operative, early post-operative and
follow-up radiographic views are of major impor-
tance.
During clinical examination, tegument analysis
informs about the surgical approach and the neigh-
boring scars that could interfere with the re-use of
a previous incision. The quadriceps muscle strength
was assessed, the quality of which will determine
the functional outcome. Flexion–extension range
of motion was analyzed. Stability in the A/P and
sagittal plane should be accurately evaluated.
Radiographic assessment represents the basic com-
plementary examination. It should include stand-
ing anteroposterior and lateral radiographs of the
knee as well as a patellofemoral view at 30° of knee
flexion. Wear of the polyethylene tibial compo-
nent, the cartilaginous quality of the healthy com-
partments (Fig. 1), the occurrence of radiolucent

Pre-operative planning modalities

Anamnesis will assist in revealing the precise
complaints of the patient: Pain? In which com-
partment? At which rate? Since when? Is there
any swelling? instability? Is there any trauma
history? Review of the implant should be carried
out: Initial indication (arthrosis, osteonecrosis, Fig. 1 – Chondrolysis in the opposite side.
942 Primary Total Knee Arthroplasty

lines, the amount of potential bone loss, implant Further analyses such as laboratory tests (sedi-
migration (Fig. 2), flexum or recurvatum malalign- mentation rate, CRP), joint aspiration (bacteriol-
ment of the femoral component and the slope of ogy, PCR), Tecnetium-99m, or leukocyte scintigra-
the tibial component (Fig. 3) should be evaluated. phy are required to confirm
fi the aseptic character
It is imperative to perform stress radiographs for of the loosening.
varus/valgus stability assessment for the detection
of potential laxity.
Long leg X-rays measurements in bipodal stance
should help determine:
– The HKA angle.
– The varus/valgus alignment of the tibial compo-
nent relative to the tibial mechanical axis.
– Any excessive or insuffifficient tibial resection by
measuring each limb mechanical tibial angle.
– The varus/valgus alignment of the femoral compo-
nent relative to the femoral mechanical axis (Fig. 4).
– The presence of overpositioning or not of the
femoral component using bilateral measurement
of the femoral mechanical angle (Fig. 5).
CT scans provide accurate measurement of the
posterior condylar angle to help achieve optimal
posterior femoral cut.

Fig. 4 – Measurement of tibial and femoral implant

Fig. 2 – Bone loss and tibial implant migration. varus/valgus.

Fig. 5 – Mechanical tibial–femoral angle assessment

Fig. 3 – Sagittal positioning of the femoral and tibial of over- or under-positioning of both implants due to
components. an insuffi
fficient or excessive bone cut.
 Revision total knee arthroplasty after failed unicompartmental knee replacement 943

Identifification of failure cause
Th previous stage should help determine accu-
The
rately the cause(s) of implant failure. Actually, it
highly contributes to the success of the revision
surgery (Table 1).
Three situations may be encountered, each one
requiring a specifi
fic surgical strategy.
Aseptic loosening of one or two components
It results in pains of mechanical aspect combined
with instability in case of implant migration. Stan-
dard radiographs reveal a radiolucent line associ-
ated or not with implant migration. (Fig. 6)
According to a review of the literature (1, 8, 11–18),
it was confifirmed to be the leading cause of UNI
prostheses failure. Actually, it almost systematically
accounts for 50–60% of all revision cases. It is most
commonly isolated in the tibial component, then
occurs in both the tibial and femoral components,
and, in some cases, is found to be isolated in the
femoral implant. Let us point out that in series of the
Oxford mobile bearing knee prosthesis (16), loosen-
ing most commonly occurs in the femoral compo-
nent rather than in the tibial implant. Besides the
implant design such as in the PCA prosthesis (19),
loosening of the medial UNI is induced by a residual
post-operative varus greater than 8° (9). No correla-
tion could be established between the lateral UNI
loosening rate and the post-operative HKA axis.
When loosening is associated with implant migra-
tion, reconstruction of bone loss is required.
Wear of the polyethylene component
The clinical presentation of PE wear is pain, joint insta-
bility and/or joint effusion
ff due to the wear particles.
Radiographic assessment confirmsfi the presence of
a more or less narrowed prosthetic joint space which
may be associated with loosening. (Fig. 7). Goniometric
analysis demonstrates deformity of the HKA angle.
This second type of failure represents 15–20% among
the various series (1, 8, 11–18). The
Th use of a tibial

Fig. 6 – Occurrence of a tibial radiolucent line. Fig. 7 – Polyethylene wear.

Table 1 – Identification of unicompartmental prosthesis failure.

Degradation on other
Loosening Polywear Instability
compartments
Frequency 50–60% 15–20% 15–20% 5–10%
Symptoms Pain Pain Pain on other compartment Instability
Instability Instability
Swelling Swelling
XR Radiolucencies Joint narrowing on operated Joint narrowing opposite compartments Laxity on varus-valgus stress XR
Migration of side Anterior drawer on AP stress XR
components
Supporting Implant design PE < 8 mm Overcorrection Wrong indication (ACL rupture,
factors Hypocorrection ACL rupture Medial instability, Hip disorder…)
Malalignment
Overweight
Diffi
fficulties Correction of No specific technical diffi
fficulties Ligt balancing
bone loss (graft, Choice of constraint in TKA
stem, blocks)
944 Primary Total Knee Arthroplasty

plate of less than 8 mm thick combined with a metal- sions, the most lateral incision will be chosen,
back appears as a contributing factor (20). In such a considering medial skin vascularization via the
case, isolated polyethylene replacement leads to fail- descending genicular artery (23).
ure recurrence in 71% of the cases (21). Anterior cru- Actually few cutaneous complications are reported
ciate ligament tear (22) and significant
fi pre-operative with revision TKA after UKA (24).
deformity in the coronal plane are other contribut- A medial or lateral parapatellar arthrotomy will be
ing factors to PE wear. performed according to the cases. Any detachment
should be performed exclusively in the avascular
plane of the pre-patellar bursa. Once arthrotomy
Laxity has been completed, patellar eversion in extension
should be carried out. This manipulation is facili-
It accounts for 5–10% of all revision indications (1).
tated by a high incision performed at the level of
It mostly occurs in the sagittal plane but rarely in the
the quadriceps tendon, with release of the exist-
coronal plane. It might be associated with polyethyl-
ing adhesions on the opposite condylar surface,
ene wear or loosening. Patients complain of instabil-
detachment of the patellar tendon of the tibial
ity during walking. The reducibility of the deformity
plateau from the anterior border to the opposite
should be evaluated during clinical examination.
posterior angle (Fig. 8). Progressive knee fl flexion
Standard radiographs reveal an anterior tibial
is carried out with continuous control of the tibial
translation on the lateral view or a gap in the con-
insertion of the patellar tendon. Synovectomy is
vexity on the anteroposterior views. Varus and val-
thus improved at the level of the condylar surface
gus stress radiographs are helpful in determining
to provide better visualization.
the degree of laxity and its potential reducibility.
Surgical approach diffi
fficulties are rarely reported in
Laxities resulting from secondary ACL tear are
the studies (14, 15, 17). Technically assisted patel-
uncommon (22), and therefore are more related to
lar eversion using anterior tibial tubercle osteot-
a prior tear, unknown at the time of the operation.
omy or L/VY plasty of the quadriceps tendon are
In the coronal plane, medial laxity mainly occurs
therefore rarely necessary.
with lateral UNI prostheses.
Finally, the tibiofemoral joint is carefully dislocated
The technical diffi
fficulty lies in the type of implant
while controlling patellar tendon insertion.
(posterostabilized or posterior cruciate retaining
prosthesis) and its level of constraint.

Degradation of other knee compartments

It accounts for 15–20% of all revision indications
(1, 12, 13, 15) in the majority of the series. More-
over, it is the first
fi cause of revision in the series
of Saldanha (16) which reports the results of the
Oxford prosthesis.
Degradation mainly occurs in the tibiofemoral
compartment. The patellofemoral compartment
is rarely involved. When it is the case, degradation
is often related with a lateral unicompartmental
knee replacement (21).
Attention should be paid when pain occurs in the
healthy compartment.
Overcorrection is reported to be the main con-
tributory factor. Goniometric analysis will help
determine if it is secondary to the lack of femoral
digging or to an insufficient
ffi tibial cut.

The stages of the surgical strategy

The surgical approach Fig. 8 – Joint approach (1) release of the suprapatellar pouch (2) release of
the condylar surface (3) release from the anterior border of the tibial pla-
Re-use of the initial incision should be performed teau up to the posterior angle. Continuous control of the patellar tendon
in case of single incision. In case of multiple inci- insertion during patellar eversion.
 Revision total knee arthroplasty after failed unicompartmental knee replacement 945
Implant removal
Contrary to TKA revisions, the level of the natural
joint space is preserved on one side, thus allowing
implant removal without any specific
fi prior consid-
eration.
The polyethylene is either removed from its metal
base using lever arm manipulation and gentle taps
on a chisel, or carefully separated from the bone
using an oscillating saw, taking care not to aggra-
vate potential bone loss.
Once the polyethylene has been removed, knee
flexibility is improved thus providing increased
flexion and therefore good access to the tibial and
femoral components in its posterior segment.
The femoral implant is released using osteotomes
which are inserted between the implant and the
cement, from the trochlea up to the posterior
condyle. Then it is removed following the axis by
avoiding any lever arm movement to prevent fur-
ther bone loss. It might sometimes be preferable
to leave the femoral component in place while
performing posterior and distal cuts if goniomet-
ric measurements confi firm its good positioning
(Fig. 9). Removal of the metallic tibial base plate,
if present, should be carried out according to the
same procedure (Fig. 10).
When moderate initial tibial resection has been
made, the TKA tibial cut may be performed in
a standard manner below the UNI tibial compo-
nent.
Fig. 9 – Polyethylene extraction. Careful removal of the femoral implant
using osteotomes from back to front successively.
Fig. 10 – Careful removal of the tibial implant, when present. Use of osteot-
omes or of an oscillating saw.
Bone cuts and assessment of bone loss
Bone loss is promoted by the use of a thick cement
mantle combined with large pegs on the tibial
component, the use of a large central peg femoral
implant, or by the use of a femoral resection rather
than resurfacing knee prosthesis as well as the use
of a thick tibial plateau. Bone loss occurs in about
30–75% of the cases, depending on the series (1,
11, 15). The tibial compartment is most commonly
involved.
Aggressive curettage of residual cement pegs
should be avoided to prevent bone loss worsening.
Therefore, bone cuts should come after implant
removal (except in case of a well-positioned femo-
ral component or moderate tibial resection). After
that, the degree of bone loss will be evaluated and
managed. Resected bone must be kept for bone
grafting and a bacteriological sample should be
systematically taken from the resected bone.
– Proximal tibial cut: It is performed in a standard
manner using intramedullary guides to assess
the slope, and/or extramedullary guides to con-
trol the varus/valgus position. The healthy tibial
plateau should be used as a reference. Bone resec-
tion should not exceed 12 mm.
– Posterior femoral cut: Given that the posterior
cut should be parallel to the bi-epicondylar axis
(25), a CT scan of the knee is performed pre-
operatively to measure the posterior condylar
angle formed between the bi-epicondylar axis
and the posterior bicondylar line (including the
prosthetic condyle and the contralateral healthy
condyle) (Fig. 11). The measured angle is then
reproduced on the posterior femoral cut instru-
mentation. The cut is initiated either with the
femoral condyle in place or with the help of an
946 Primary Total Knee Arthroplasty

A B

Fig. 11 – (a) The posterior condylar angle, with the prosthesis in place. (b)
CT scan measurement of the posterior condylar angle, with the prosthesis
in place.

equivalent thickness wedge replacing the poste- excessive bone cutting if the initial femoral cut was
rior prosthetic condyle. too important.
– Distal femoral cut: Based on the pre-operative
planning and bilateral measurement of mechani-
cal femoral angle, if femoral component was well Management of bone loss
positioned, the distal femoral cut may be initi-
ated with the prosthesis in place, in accordance Three situations might be diff
fferentiated (Fig. 12):
with the divergence angle or with the help of an (1) Small bone loss: Bone loss is limited to the peg
equivalent thickness wedge replacing the pros- holes. No cortex damage is observed. The Th lesion
thetic condyle. involves 1/4 of the condylar or tibial plateau sur-
If the femoral component was initially over-posi- face. In that case, the bone defect is filled
fi with an
tioned, it should be removed and the healthy con- autograft prepared from the resected bone or with
dyle taken as a reference to prevent an insufficient
ffi cement in case of poor bone quality. A non-keeled
cut. The same procedure is applied to avoid any total knee prosthesis may be implanted (1, 26)

Bone loss

<¼ condylar/tibial ¼-1/3 condylar/tibial 1/3 condylar/tibial

plateau surface plateau surface
No cortex damage

Depht

autograft/cement cavitary segmentary >10 mm <10 mm

Standard TKA autograft/ Metallic wedge Metallic wedge Allograft

cement

TKA + stems

Fig. 12 – Management of bone loss.

 Revision total knee arthroplasty after failed unicompartmental knee replacement 947
(2) Mild bone loss: Bone loss involves 1/4–1/3 of
the tibial or femoral surface. In case of cortex pres-
ervation, the defect is filled with an autograft or
cement. In case of peripheral bone loss, a metal
wedge is placed, once re-cut has been performed, to
be parallel to the healthy side (27). In all cases, the
use of a non-cemented centromedullary femoral
stem or an extended tibial keel is recommended.
(3) Major bone loss: Bone loss involves more than
⅓ of the tibial or femoral surface. The peripheral
cortex is damaged. Bone defect is managed with
insertion of a metal wedge or restored by a struc-
tural allograft once re-cut has been performed to
be parallel to the healthy side. The
Th use of a tibial
keel and/or femoral stem is essential (1, 13).
Trial implant positioning and stability assessment
Lateral knee laxity rarely compromises the liga-
mentous balance in revision TKA after failed medial
UNI arthroplasty (Fig. 13). On the other hand, in a
failed lateral UNI prosthesis, medial laxity can lead
to use a constrained knee prostheses. It is gener-
ally induced by a faulty initial indication since lat-
eral arthrosis associated with medial laxity should
contra-indicate the use of a UNI prosthesis.
In a practical way, this procedure correlates the
standard evaluation approach of ligament balance
in flexion and extension in TKA.
Various situations might occur:
Asymmetric laxity in flexion
fl : Positioning of the fem-
oral component relative to the bi-epicondylar line
should be assessed as well as proper filling of the
bone defect.
If component positioning is correct, failure is
attributable to a ligament defi ficiency. In that case,
a release combined with an increase in the poly-
ethylene size or a ligament retightening should be
performed. In case of failure, a constrained pros-
thesis should be selected.
Symmetrical laxity in flexion
fl : It might be attribut-
able to an excessive posterior femoral cut. In that
case, there is no laxity in extension. Excessive tib-
ial cut will result in laxity in extension. This
Th matter
is corrected with placement of posterior wedges in
the first case and an increase in the PE thickness or
use of tibial wedges in the second case.
Stiff
ffness in flexion: The absence of reverse tibial
slope and over-sizing of the femoral component
should be investigated. If present, these elements
should be corrected. Otherwise, if stiffness
ff is asso-
ciated with knee extension stiff ffness, a tibial recut-
ting is performed. In case of isolated stiffness, ff
conversion to a smaller femoral implant is advised
after posterior condylar recutting.
Asymetric laxity in extension: Tibial and femoral
component positioning in the anteroposterior
plane as well as proper filling of the bone defect
should be assessed. If component positioning
appears correct, a release with adaptation of the
PE thickness or a retightening should be carried
out without disturbing flexion.
fl In case of failure, a
more constrained implant should be chosen.
Symmetrical laxity in extension: Apart from the
excessive tibial cut theoretically resolved, it may
only be attributable to a distal femoral over-cut
and corrected with placement of metallic wedges
in the over-cut region.
Stiffness
ff in extension: An insuffi
fficient distal femoral
cut should be investigated. In case of insufficient
ffi
tibial cut, it is associated with stiffness
ff in flexion.
Moreover, in case of laxity in the coronal plane
requiring a ligament gesture, PCL sacrifice fi and use
of a posterior-stabilized implant would markedly
simplify ligament.
Patella, final implants, and wound closure
This stage demonstrates no signifi
ficant diffi
fficulty
compared with a primary total knee replacement.
Results and complications
Analysis of results from the diff fferent series (1,
11, 13, 15, 24, 27–29) is made difficult
ffi due to the
variety of implants and evaluation scores avail-
able and to the inhomogeneous aspect of the
series, particularly regarding their proportion of
medial and lateral unicompartmental prostheses
(Table 2). However, some remarks may be allowed
here:
– The poorest scores were obtained from patients
operated on for unspecifified pain. These findings
strengthen the idea that revision of unicompart-
mental knee prosthesis, as in any other revision
surgery, should be suggested only when the cause
of the failure has been identified.
fi
– Revision TKA for failed unicompartmental
replacement achieves either similar or slightly
lower results than primary TKA especially regard-
ing mobility. Moreover, they are comparable with
or better than results from revision TKA after
failed TKA.
– The complication rate after unicompartmental
prosthesis revision is lower than that obtained
after revision for failed tibial osteotomy which
may report palsy of the common peroneal nerve
or patellar tendon rupture due to the diffi
fficulty in
achieving satisfactory exposition.
– Revision TKA demonstrates better results after
unicompartmental replacement than after val-
gus tibial osteotomy excepted in case of exten-
sive bone loss. Overall, the extent of these bone
948 Primary Total Knee Arthroplasty

Trial in Flexion

Good stability Symetric laxity Asymetric laxity

Size femur Alignement / TEA

Treat Postre bone loss
Check Postre Offset
Persisting laxity

Persisting Laxity

Ligament release

thickness of PE

Check extension Persisting laxity

Ligament tensionning ??

Good extension Loss of extension

Check femoral cut level

Re-cut distal femur Re-cut impossible

Good Extension

Test stability in extension Asymetric laxity

Symetric laxity Ligt release ±Ê PE

Good stability Distal augments femur Persisting Laxity

Non constrained TKA Constrained TKA

Fig. 13 – Decision-making drawing. TEA: transepicondylar axis; BL: bone loss; MFA: mechanical femoral angle; MTA: mechanical tibial angle.
 Revision total knee arthroplasty after failed unicompartmental knee replacement 949

Table 2 – TKA after UKA, main series

Author Date Cohort Follow- Failure mode Bone HSS or IKS Complications Revision’s failure
up defect score
(years)
Lai (1) 1993 N = 48 5.4 65% loosening 50% HSS = 81 10.5% Patellar dislocation
21% arthrosis Hematoma n = 2 n=1
6% instability Sciatic nerve Loosening n = 2
palsy n = 1 Arthrolysis n = 1
Stiffness n = 3
Gill (11) 1995 N = 30 3.8 Loosening>PE 77% IKS knee 17% Laxity n = 1
wear>arthrosis = 78,3 Manipulation Loosening n = 3
IKS function n=5 Patellar resurfacing
= 67.7 n=1
Lewold (12) 1998 N = 750 Medial UKA: Loosening n = 14
45% loosening Instability n = 5
25% arthrosis
Lateral UKA:
31% loosening
35% arthrosis
Bohm (13) 2000 N = 35 4 49% loosening 37% HSS = 69 26% Sepsis n = 2
17% PE wear Wound n = 7 Tibial loosning n = 1
11% arthrosis Hematoma n = 1 Revision UKA failure
Stiffness n = 1 n=6
Mc Auley 2001 N = 39 4.4 66% PE wear 31% IKS knee = 89 7.6% PE wear n = 3
(14) 28% loosening IKS function Tibial fracture
= 81 n=1
Manipulation
n=2
Chatain (15) 2004 N = 54 4 57% loosening 45% tibia IKS knee = 85 20 % Sepsis n = 2
13% arthrosis 22% IKS DVT n = 8 Pain n = 4
femur function = 62 Stiffness n = 3 Instability n = 1
Osteolysis n = 1
Saldanha 2007 N = 36 2 36% arthrosis 16% IKS knee 22% Tibial loosening
(16) 28% femoral = 86,3 Wound n = 5 n=1
loosening IKS function Sciatic nerve Femoral loosening
11% bearing = 78.5 palsy n = 2 n=1
dislocation DVT n = 1 Instability
5% tibial n=1
loosening
Saragaglia 2008 N = 33 6 67 % loosening 60% tibia IKS global N=0 Loosening n = 0
(17) 15% PE wear = 166
12% arthrosis
Padget (29) 1991 N = 21 5 33% arthrosis 76% HSS = 84 Wound n = 2 Tibial loosening
28% loosening n=4
19%
malalignment
14% instability
Chakrabarty 1998 N = 73 4.7 32% arthrosis 58% HSS = 79 N=0 Sepsis n = 1
(28) 16% PE wear Loosening n = 1
15% loosening
Levine (27) 1996 N = 31 3.8 68% PE wear 52% IKS knee = 91 N=0 Sepsis n = 3
32% arthrosis IKS function
= 81
950 Primary Total Knee Arthroplasty
Fig. 14
defects remains lower than that reported during
TKA revision.
– Radiographically, no signifi
ficant tendency was
noted regarding the tibial or femoral origin of
malpositioning which could explain a tibiofemo-
ral axis over 180° ± 3°.
Conclusions
The success of a unicompartmental prosthesis
revision first depends on an accurate pre-operative
planning which help properly determine:
– The cause of failure
– The extent of bone loss, mostly of tibial origin
– The ligament status
The surgeons should benefi fit from a prosthetic
device allowing the use of centromedullary stems
and metallic wedges in case of massive bone loss
(Fig. 14).
In the hypothesis of an unmanageable laxity, either
a more constrained prosthesis or even a rotatory
hinge should be chosen.
In these conditions, there is firm
fi evidence that the
overall TKA outcome will be satisfactory which
encourages the use of a unicompartmental knee pros-
thesis as far as its specifi
fic indications are respected.
References
1. Lai CH, Rand J (1993) Revision of failed unicompart-
mental total knee arthroplasty. Clin Orthop Relat Res
287:193–201
2. Thornill TS (1989) Unicompartmental total knee arthro-
plasty. Orthop Clin North Am 20:245
3. Insall JN, Aglietti P (1980) A five to seven-year follow-up
of unicondylar arthroplasty. J Bone Joint surg Am
62:1329–1337
4. Laskin RS (1978) Unicompartmental tibiofemoral resur-
facing arthroplasty. J Bone Joint Surg Am 60:182–185
5. Robertsson O, Borgquist L, Knutson k, et al. (1999) Use
of unicompartmental instead of tricompartmental pros-
theses were compared with 10624 primary medial or
lateral unicompartmental prosthese. Acta Orthop Scand
70:170–175
6. Naudie D, Guerin J, Parker D, et al. (2004) Medial uni-
compartmental knee arthroplasty with the Miller-Galante
prosthesis. J Bone Joint Surg Am 86:1931–1935
7. Price AJ, Waite JC, Svard U (2005) Long term clinical
results of the medial Oxford unicompartmental knee
arthroplasty. Clin orthop 435:171–180
8. Lustig S, Paillot JL, Servien E, et al. (2009) Cemented all
polyethylene tibial insert unicompartmental knee arthro-
plasty: a long term follow-up study. Orthop Traumatol
Surg Res 95:12–21
9. Dejour D, Chatain F, Dejour H (1998) Résultats cliniques
de la prothèse unicompartimentale HLS. In: Cartier P,
Epinette J, Deschamps G, Hernigou P (eds) Prothèse uni-
compartimentale de genou, vol 65. Expansion Scientifique
fi
Française, Paris, pp 227–232
10. Gunther T, Murray D, Miller R et al. (1996) Lateral uni-
compartmental arthroplasty with the Oxford meniscal
knee. Knee 3:33–39
11. Gill T, Brick G, Thornill T (1995) Revsion total knee
arthroplasty after failed unicompartmental knee arthro-
plasty or high tibial osteotomy. Clin Orthop Relat Res
321:10–18
12. Lewold S, Robrtsson O, Knutson K, Lidgren L (1998) Revi-
sion of unicompartmental knee arthroplasty: outcome
in 1135 cases from the Swedish knee arthroplasty study.
Acta Orthop Scand 69:469–474
13. Böhm I, Landsiedl F (2000) Revsion surgery after failed
unicompartmental knee arthroplasty: a study of 35 cases.
J Arthroplasty 15:982–989
14. Mc Auley J, Engh G (2001) Revision of failed unicompart-
mental knee arthroplasty. Clin Orthop Rel Res 392:279–
282
15. Chatain F, Richard A, Deschamps G, et al. (2004) Reprise
de prothèse unicompartimentale fémorotibiale par pro-
thèse totale de genou Résultats d’une série de 54 cas. Rev
Chir Orthop 90:49–57
16. Saldanha K, Keys G, Sward U, et al. (2007) Revision of
Oxford unicompartmental knee arthroplasty to tal knee
arthroplasty-results of multicenter study. Knee 14:275–
279
17. Saragaglia D, Estour G, Nemer C, Colle PE (2008) Rev-
sion of 33 unicompartmental knee prostheses using total
knee arthroplasty:strategy and results. Int Orthop Jun
18:224–229
18. Järvenpää J, Kettunen J, Miettinen H, Kröger H (2009)
The clinical outcome of revision knee replacement after
unicompartmental knee arthroplasty versus primary
total knee arthroplasty: 8–17 years follow-up study of 49
patients.
19. Riebel GD, Werner FW, Ayers DC, Bromka J (1995) Early
failure of the femoral component in unicompartmental
knee arthroplasty. J Arthroplasty 10(5):615–621
20. Scott R (1997) Mistakes made and lesson learned after
two decades of unicompartmental knee. In: Cartier P,
Epinette J, Deschamps G, Hernigou P (eds) Unicompart-
mental knee arthroplasty, vol 61. Expansion scientifique
fi
Française, Paris, pp 163–166.
21. Hernigou Ph, Deschamps G (1996) Les prothèses unicom-
partimentales du genou. Symposium 70ème réunion annu-
elle de la sofcot. Rev Chir Orthop 82(Suppl I):23–60
22. Deschamps G, Lapeyre B (1987) La rupture du ligament
croisé antérieur: une cause d'échec souvent méconnue des
prothèses unicompartimentales du genou. A propos d'une
série de 79 prothèses Lotus revues au-delà de 5 ans. Rev
Chir Orthop 73:544–551
23. Dennis DA (1997) Wound complications in total knee
arthroplasty. Instr Course Lect 46:168–169
24. Jackson M, Sarangi P-P, Newman J-H (1994) Revsion total
knee arthroplasty-comparison of outcome following pri-
mary proximal osteotomy or unicompartmental arthro-
plasty. 9(5):539–542
 Revision total knee arthroplasty after failed unicompartmental knee replacement 951
25. Bonnin M (2006) La rotation dans les prothèses totales
du genou in La gonarthrose Ed Springer-Verlag, France,
pp 678–694
26. Deschamps G, Cartier P (1998) Echecs et modalités de
reprise des prothèses unicompartimentales. In: CartierP,
Epinette J, Deschamps G, Hernigou P (eds) Prothèses uni-
compartimentale du genou, vol 65. Expansion scientifique
fi
Française, Paris, pp 161–164
27. Levine WN, Ozuna RM, Scott RD, Thornill TS (1996).
Conversion of failed modern unicompartmental knee
arthroplasty to total knee arthroplasty. J Arthroplasty
11:797–801
28. Chakrabarty G, Newman j, Ackroyd C (1998) Revision
of unicompartmental arthroplasty of the knee. Clinical
and technical considerations. J Arthroplasty 13(2):191–
196
29. Padgett DF, Stern SH, Insall JN (1991) Revision total knee
arthroplasty for failed unicompartmental replacement. J
Bone Joint Surg 73(A):186–190
Failures and Revision in TKA

M. Bonnin
Introduction
T
otal knee arthroplasty (TKA) is a reliable,
reproducible procedure with a high survival
rate. Failures may nevertheless occur due to
objective mechanical problems or infection, which
requires replacement of all or part of the compo-
nents or residual “unexplained pain.” Sometimes,
the “objective result” can be considered as cor-
rect by the surgeon but the patient is dissatisfiedfi
because he is unable to reach his pre-operative
expectancies (1). Therefore, objective and subjec-
tive results are not systematically correlated. Th The
main motivation for surgery for older patients is
mostly to obtain a pain-free or symptom-free knee
but younger patients often consider restoring
function as a more important goal (2).
We will deal here only with problems related to
mechanical failure of the tibiofemoral implants.
Complications specifi fically related to the exten-
sor apparatus as well as the problem of infected
implants or unexplained pain will be addressed
elsewhere.
Management of a failed total knee replacement
has a double goal: firstly diagnosis of the imme-
diate reason of the failure, such as loosening or
instability, which we will call the “cause of failure”,
(Table 1) and secondly analysis of the mechanisms
which led to this failure, which we will call “fac-
Table 1 – Causes of revision in the 490 cases series of the French Orthopae-
dic & Traumatologic Society (SoFCOT) (3).
Causes of revisions (%) (series = 490 case)a
Aseptic loosening & osteolysis
Patella
Stiffness
Tibio-femoral laxity
Mecanical failure of implant
Unexplained pain
Periprosthetic fracture
Clunk syndrom
Patellar or Quadriceps tendon rupture
a
11 cases had two causes of revision.
Chapter 91
Causes of failures in TKA
tors of failure.” These may be related to the surgi-
cal technique (malpositioning, poor soft tissue
balance, faulty implant fixation), implant-related
(quality of the polyethylene, alloys used, design) or
patient related (concomitant arthritis or deformity
in adjacent joints, major bone defificiency, previous
knee surgery…).
The incidence of these “secondary” factors of failure has been assessed
at 36% (technique), 14% (implant), and 33% (patient). (4) Analysis of
these factors of failure is of fundamental importance, so that the initial
underlying cause is not reproduced in case of revision.
Precise, complete evaluation is a necessity in order
to anticipate the technical diffi
fficulties of any revi-
sion surgery and to plan any additionnal proce-
dures. If implant failure was related to an under-
lying hip disorder (hip arthrodesis, congenital
dislocation) this should be treated before consider-
ing TKA revision. Also a valgus flat foot deformity
related to degenerative posterior tibial tendon rup-
ture might cause progressive valgus tilt of a TKA.
The hindfoot axis must then be corrected before
considering TKA revision.
“Standard” investigations should include: analysis
of successive radiographs since implantation of the
index prosthesis, complete clinical examination,
without forgetting the adjacent joints, and full
X-rays work-up with weightbearing views, axial
views of the patella and goniometry. In some cases
more specifific investigations are required. A com-
plete laboratory work-up should always be done to
look for an infl
flammatory syndrome. Joint aspira-
tion may be useful for diagnosis (bacterial culture,
34.9 search for bacterial nucleic acids, polyethylene
17.1 particles) and some authors (5) believe it should
14.7 be routinely performed before total knee revision
13.3 so that infection can be defifinitely excluded. Some
authors did investigate the role of MRI in that con-
6.9
text (6) (Tables 2 and 3).
6.5 After these investigations, the reasons for failure
4.3 are generally clear and total knee revision is then
2.7 only a technical problem. In some cases, no objec-
tive cause of pain can be found and a decision of
1.8
systematic revision arthroplasty or surgical or
arthroscopic investigation can be discussed.
956 Primary Total Knee Arthroplasty
Table 2 – Interest of complementary examinations in a painfull TKA.
Investigations
Preop XR and XR since
implantation
Clinical and XR examination of
the adjacent joints
Dynamic XR in extension and
in flexion
Fluoroscopic views
Lateral views in full flexion
Comparative views
CT-scan
Bone scan (Technetium,
gallium, or labeled leukocytes)
Joint aspiration
MRI
Table 3 – Causes of pain after TKA (from Seil et al. (7)).
Intra-articular mechanical
Oversizing
Laxity
Aseptic loosening
Component failure
Periprosthetic osteolysis
Malrotation
Loose body
Impinging osteophyte/cement
Pseudo – meniscus (impinging soft-tissues)
Lateral patellar facet syndrome
Fabellar impingement
Popliteus tendon dysfunction
Tibial component overhang
Intraarticular adhesions
Intra-articular biological
Infection/septic loosening
Synovitis
Arthrofibrosis
Heterotopic ossification
Recurrent hemarthrosis
Extra-articular
Cutaneous neuroma
Osteoarthritis of the hip
Degenerative spine disorders
Neurological disorders
Vascular disorders
Interest
Aseptic loosening
Initial malalignment
Apparition of lucencies or cysts
Mechanism
Hip or Foot & Ankle pathology
Aseptic loosening is the main cause of implants
Laxity in extension failure, occurring on average 7 years after the fi
first
Laxity in flexion insertion (3, 4, 8). It is due to failed component
Bone/prosthesis interface fixation, generally involving the tibia and leading
Posterior drawer to revision arthroplasty. Loosening can be related
to progressively increasing micromotion at the fixa-
fi
Tilting of components
Oversized prosthesis tion, (9) or to the implant sinking into demineral-
ized or necrotic bone.(10, 11) In any case, loosening
Joint line level modifications
Malrotation of femur and/or tibia generally follows excessive strain on the implant,
Over-sized implants due sometimes to faulty initial fixation;
fi sometimes
to pre-mature polyethylene wear which causes
Osteolysis
Lucencies osteolysis by release of intra-articular foreign bod-
Localized fixation ies. This complication occurs in both cemented
Infection and cementless implants. The diagnosis is gener-
Germs (or nucleic acid)
ally made when secondary pain appears after a
Polyethylene debris
pain-free interval. More rarely, the prosthesis was
painful immediately after surgery, which should
Metallosis
Infection raise the suspicion of early infection or faulty ini-
tial fixation. Sometimes it is routine radiographic
Osteolysis (?)
check-up, which reveals signs of loosening. In all
Diagnosis
Comparative XR, pre-op KR, CT-scan
Clinical exam, WB XR, Dynamic XR
XR, Fluoroscopy, Dynamic XR, Bone-scan
XR
XR, CT-scan
CT-scan
XR, CT-scan
XR, CT-scan, Arthroscopy
Arthroscopy
XR, CT-scan
Clinical exam, Injection
Clinical exam, Injection, Arthroscopy
XR
Arthroscopy
Aspiration, Bone scan, Biology, Biopsy
Arthroscopy
XR
Aspiration
Clinical exam, Injection
Clinical exam, XR
Clinical exam, Spine specialist, MRI
Clinical exam, Neurologist
Clinical exam, Vascular explorations
 Causes of failures in TKA 957

Fig. 1 – Progressive apparition of femoral radiolucencies in a painful TKA. Technetium bone-scan is

positive on the femur side. Pre-revision joint aspiration was done. Results were positive for Coryne-
bacterium. A two-stage revision was successfully done.

cases of loosening thorough investigation is imper-
ative to detect latent infection (Fig. 1).
Diagnosis
Diagnosis relies primarily on XR, which can reveal
radiolucencies, component displacement, or oste-
olytic lesions. It is easy when radiolucent lines or
components displacements are evident. It may be
diffi
fficult, and new XR obtained with fluoroscopic
control, with the ray perfectly parallel to the metal
baseplate can be necessary. A 3° deviation of the
X-ray beam relative to the bone/prosthesis inter-
face is enough to obscure a radiolucent line 2 mm
wide (12). However the existence of a radiolucent
line is not in itself a synonym of loosening. TheTh
cement/bone interface is in fact not static and
even if initially the cement penetrates the trabe-
cular bone satisfactorily, localized bone resorp-
tion may occur and intervening fibrous tissue may
be built up. This generally occurs during the first
6 months and in order to affiffirm that a radiolucent
line is abnormal, its gradual progression after that
time is of fundamental importance. Criteria of
loosening have been well codified:fi a radiolucent
line of more than 2 mm whatever its location, a
radiolucent line extending over the entire surface
of the tibial plateau, a radiolucent line in zones
5-6-7 or a progressive radiolucent line. Sometimes,
particularly in cementless prostheses, diagnosis is
based on isolated indirect signs such as metallosis
or osteolytic lesions (Fig. 2).
Dynamic views or fluoroscopic evaluation may
sometimes be necessary to reveal minimal loosen-
ing. Fehring (13), in 20 patients with unexplained
pain on plain radiographs, found that fluoroscopi-
fl
cally guided radiographs revealed a significant fi
radiolucent line in 14 cases. Loosening was always
confi
firmed at revision.
958 Primary Total Knee Arthroplasty
Fig. 2 – In this painful TKA, neither radiolucencies nor osteolysis or poly wear can be identified. Careful analysis of the lateral
views shows a metallosis seen as densification of the supra-patellar bursa.
Routine investigation has usually included tech-
netium 99 bone scan but its diagnostic value is
limited, as increased isotope uptake, particularly
in the tibia, can persist for several years after sur-
gery. False positives are frequent (4) and it is diffi-
ffi
cult to decide on revision on bone scan arguments
alone.
Isolated loosening of the femoral component is
diffi
fficult to demonstrate on radiographs, particu-
larly with a cementless prosthesis (14, 15). If it
is associated with osteolysis of the posterior con-
dyles leading to tilt of the femoral component in
flexion, diagnosis is based on XR. Stresses in this
fl
area are high and these authors emphasize the
quality of posterior cementing and criticize the use
of cementless femoral components. Isolated femo-
ral loosening often presents as unexplained pain
because standard radiographs are not informative.
Etiology
1. Several causes can account for aseptic loosen-
ing, the main cause being initial malposition of
the prosthesis (27% of cases) (4). This is usually
tibial varus but may sometimes be an abnormal-
ity of the tibial slope or an oblique joint line on
a globally well-aligned limb. Th
The harmful impact
of varus malalignment has been stressed by sev-
eral clinical (10, 16–18) and biomechanical (19)
studies, which have shown increased stresses
on the medial compartment. Others, however,
found no evident relation between malposition
and loosening (20)
2. In a varus deformity associated with loosening,
study of serial radiographs, goniometry, and
dynamic views will differentiate
ff between initial
inaccurate surgical cuts, secondary tilt due to
tibial component subsidence or tilt due to poor
soft tissue balancing (Fig. 3).
3. Overweight is a theoretical cause of total knee
prosthesis failure through loosening related
to excessive strain. However, this is debated
and has not been confi firmed by studies with a
follow-up of up to 7 years (21–23). Griffin
ffi (23),
with a follow-up of more than 10 years, did
not observe more frequent loosening in over-
weight patients. Nevertheless, after this time,
25% of obese patients presented a radiolucent
line (<2 mm) compared with 4% of non-obese
patients. In this study, the criterion for obesity
was a body mass index greater than 30 kg/m2.
4. Implant size has been incriminated by some
authors, as an implant which is too small may
have a high risk of subsidence (24, 25). Dero-
ches (26) did not corroborate this finding, and
obtaining peripheral cortical support for the
tibial component at any cost is not an absolute
requirement.
5. Faulty initial fixation (18) may be a cause of
loosening for both cemented and cementless
implants. Cementing must be done with meticu-
lous care, with good preparation of the resected
surfaces; these must be flat to allow homoge-
neous support of the tibial plate and cement
penetration, which may require local preparation
if there is bone condensation. If the procedure is
carried out without a tourniquet, the bony sur-
faces must be clean and dry when cementing is
done, and here a pulsed lavage gun is useful.
6. The patient's physical activity is a factor of
loosening which should not be neglected, par-

Fig. 3 – Tibial loosening is due to a varus malalignment with excessive tibial slope in this non-cemented TKA.
ticularly in the young subject. In the hip, some
authors observed an increased irisk in young
(27, 28) or active (29) patients and some found
opposite results with decreased risk of loos-
ening if patients participated in sports (30).
Regarding the knee, such a relation has not been
clearly established and most series on TKA in
young patients include a majority of cases of
rheumatoid arthritis, where low activity leads to
bias in the results. Lonner (31) in a series of 32
total knee arthroplasties in patients aged under
40 years observed 9.4% aseptic loosening requir-
ing revision at 8 years follow-up and 11.5% if
radiographic loosening was taken into account.
Bradbury (32) noted that 65% of patients who
practice sport pre-operatively resumed sporting
activity after TKA and that at 5 years follow-up
the number of revisions was not higher in this
group. Healy (32) with golfers and LaPorte with
tennis players made the same observation at
3-year follow-up. However, increased sports-re-
lated risk of implant loosening only became evi-
dent after 10 years for the hip and follow-up is
still too short in total knee replacement series.
7. Polyethylene wear is a factor in loosening as it
releases particles, which cause osteolysis (see
below).
8. Theoretically, bone quality may be a cause of
loosenning. In rheumatoid arthritis (RA), the
strength of trabecular bone is decreased and
depending on the area it may be only 11% up
to 260% of normal values (34). However, this
relative osteopenia is not refl flected in a higher
rate of mechanical implant loosening in RA and
Ranawat (24) observed a 15-year survival rate of
95.2% in RA compared with 91.1% in arthrosis.
Tayot (35) found the risk of septic loosening was
higher in the first 3 years but after that time the
Causes of failures in TKA 959
survival curve in RA was stable and at 14 years
the HLS prosthesis had an 86% survival rate, all
causes and reasons for revision included, com-
pared with 94% in RA.
9. Prosthesis design plays an important role
through the constraint. In case of constrained
bearing surfaces, the increased strain is trans-
ferred to the fixation, thus increasing the rate
of loosening. An extreme case is the hinged
implant, which has a high rate of aseptic loosen-
ing after 2 years of follow-up (36).
Instability
Instability is a frequent cause of knee replacement
failure, necessitating revision on average 4 years
after the initial procedure (3, 4). The problem of
knee instability in total knee prostheses may arise
in two different
ff situations.
Laxity in extension
In these cases instability is symptomatic (37): varus
or valgus tilt while walking, genu recurvatum,
repeated episodes of instability or even tibiofemo-
ral dislocation. Clinically, instability is easily diag-
nosed by clinical examination (tilting on walking
and knee laxity on full extension, usually asym-
metric in varus-valgus). Dynamic views in varus-
valgus or plain monopodal stance radiographs may
confi
firm the diagnosis, showing asymmetric lift-off ff
(Fig. 4). This instability in extension is generally
related to a technical error during implantation.
1. Initial soft tissue imbalance, if substantial, is
enough to cause disabling frontal instability
960 Primary Total Knee Arthroplasty
Fig. 4 – Lateral instability visible on a
plain radiograph with the patient stand-
ing on one foot.
in particular in late-stage lateral osteoarthritis
with medial collateral ligament insuffi fficency. It
accounts for 28% of cases of instability requir-
ing implant revision in our series (4).
2. Inadequate correction of a pre-operative defor-
mity is a decisive factor. It is enough on its own
to lead to considerable instability, particularly
in genu valgum, but it generally acts as a con-
tributory factor. Moderate residual instability in
extension, which could be well tolerated in a well-
aligned knee, will rapidly deteriorate if case of
malalignment. ThThis situation represents 35% of
revision procedures for instability in our series.
3. Other aggravating factors have been noted such
as hip dysplasia or congenital dislocation which
has not been surgically corrected or has been
poorly corrected, in particular with persisting
excessive femoral anteversion or femoral adduc-
tion due to lateralization of the femoral head.
When several factors are involved, overall reflec-
fl
tion is required before any decision of revision
surgery and a custom-made prosthesis, which
corrects femoral rotational dysplasia, may help
to solve complex problems. Underlying defor-
mities of the ankle or hindfoot, particularly in
valgus, may also require correction before con-
sidering insertion of a new implant. A too small
prosthesis may also cause instability.
Most substantial instability requires revision, in
general to replace the prosthesis, and raises the
problem of correction of deformity and of any
peripheral ligament lesions. If there is no defor-
mity, some authors propose ligament reconstruc-
tion or allografts, alone or in association with
implant replacement.
The main problem raised by genu recurvatum
in total knee prostheses is that of its etiology. It
may be related to faulty quadricipital locking of
mechanical origin (rupture of the patellar or quad-
ricipital tendon) and its treatment is then difficult,
ffi
ranging from simple repair to allograft. If there is
a neurological defi
ficiency, treatment may consist of
Fig. 5 – Genu recurvatum due to
progressive ligament distension.
an orthotic device, arthrodesis or for some authors
a hinged implant with the risk of rupture or loos-
ening. In general, the problem is merely ligamen-
tous and implant replacement is required (Fig. 5).
Laxity in flflexion
In these cases, the prosthesis is stable in extension
and instability only becomes evident in flexion. fl
The symptoms are equivocal (eff ffusion, knee giving
way, diffffuse pain) and clinical examination yields
little information. Here the risk is that these “con-
cealed” instabilities will be classifified as persistent
“unexplained” pain (38). Th These flexion instabilities
may be of two types:
1. Direct symmetric instability: Too lax a flexion
space in a posterior stabilized prosthesis may
occur if the femoral component is too small, if
posterior condylar resection is excessive or the
polyethylene is not thick enough. Functional
disability then persists after the procedure. In
posterior cruciate ligament retaining prostheses,
flexion instability may appear in the immediate
post-operative period in case of technical error
(excessive release, too marked a tibial slope,
faulty component resection). More frequently it
is due to secondary rupture or distension of the
posterior cruciate ligament and the symptoms
appear after a “free interval” of several months
or years. Diagnosis is based on precise clinical
and radiographic analysis looking for anteropos-
terior instability with the knee in 90° flexion.
fl
Treatment generally involves implant replace-
ment; more rarely, it may be sufficient
ffi to increase
the thickness of the tibial polyethylene.
2. Lateral flexion instability: Malposition of the
femoral component in internal rotation may
lead to an asymmetric fl flexion space with per-
sistent lateral instability, generally manifested
by pain and a poor functional result. Clinical
diagnosis is difficult.
ffi It is based either on dem-
 Causes of failures in TKA 961

onstration of rotational malposition itself by CT
scan (Fig. 6), or of flexion instability on dynamic
views under fluoroscopic guidance (39). It is
treated by implant replacement and correction
of rotational malposition.
Wear and osteolysis
Tibial polyethylene wear has been variously evalu-
ated in the literature and it is to a large degree
multi-factorial. It depends on the polyethylene
itself (intrinsic quality, mode of sterilization, length
of storage before use), on the quality of position-
ing and on implant design, which governs its kine-
matic qualities. This last factor is probably decisive
since cases of catastrophic polyethylene wear (40,
41) are more often reported in posterior cruciate
retaining prostheses with flat trays (Fig. 7).
Polyethylene wear is inevitable over time. It occurs at
the upper surface of the polyethylene (tibiofemoral
joint line) and also on the lower surface, in the case
of a metal-back plateau. The degree of wear can be
assessed in volumetric terms (volume of particles
produced per unit of time) or linear terms (decreased
thickness). Wear leads to release of polyethylene
particles in the joint; these build up in the synovial
fluid and gradually migrate to the bone/cement junc-
tion or the bone/prosthesis interface for cementless
implants, and along the tibial screws if present (42,
43). They generate a foreign-body reaction producing
an affl
fflux of osteolytic factors leading to focal osteoly-
sis, which creates the conditions for loosening.

Fig. 6 – Comparative CT-scan in a patient with a malrotated femoral component on the left knee. The Posterior Condylar
Angle (PCA) measured between the posterior condylar line and the surgical Transepicondylar axis is 4° on the right (non-
operated) knee and 11° on the left (operated) side.

Fig. 7 – Poly wear with a severe loosening and metallosis in an 8 years old TKA. The femur attacks the metallic base-plate (A) and osteolysis can
be seen on the lateral XR (B). A major metallosis has been observed at surgery (C).
962 Primary Total Knee Arthroplasty

Marked osteolysis is generally associated with

loosening. In 490 total knee replacement revi-
sions for aseptic complications (3) no case of iso-
lated osteolysis required revision. This relative
"protection" of knee replacements from osteoly-
sis, compared to the hip joint is related to the
following (42): (1) greater capacity of the syn-
ovial membrane of the knee to absorb particles,
(2) better adaptation of the cement to the can-
cellous bone in knee replacements than to the
cortical bone in hip replacements, which makes
for fewer fractures and fissures in the cement,
and (3) polyethylene particles are smaller in hip
replacements.
The last factor is essential, because it is the
Th
release of polyethylene microparticles (<1μm),
which stimulates the macrophage reaction that Fig. 8 – Fracture of the tibial base-plate.
releases “osteoclast recruiting factors” (TNF-al-
pha). In the knee, wear is pre-dominantly related
to the rolling-sliding-translation movement lead-
ing to the formation of macroparticles (>2μm)
which are biologically much more inert. However,
Schmalzreid (44) observed however that 71% of
polyethylene particles released by a TKA are <1
μm. This observation underlines the fact that
several types of wear can occur in a knee replace-
ment, releasing particles of varying sizes. Also,
the pre-dominant type of wear can differ ff from
one prosthesis to another. The rate of osteolysis
in total knee replacements is variable, ranging
from 0% (43) to 30% (45). The diagnosis is gen-
erally made at the loosening stage and treatment
then consists of changing the prosthesis. In cer-
tain cases (42) the prosthesis is stable and some
authors propose simply filling in the osteolytic
areas by bone grafts. However, this situation was
never observed in the Sofcot series (3).

Fig. 9 – Tibial polyethylene dislocation.

Mechanical failure of the implant
Implant-related problems are unfrequent. The Th
implant itself may fracture (tibial baseplate
(Fig. 8), condyles or intra-medullary stem) or
there may be detachment of polyethylene from its
tibial baseplate (Fig. 9) or a fracture of a ceramic
condyle (Fig.10). Prevention needs improving
design and the biomaterials used. Whiteside (46)
observed that femoral component rupture rate
decreased from 0.51 to 0.0061% of cases after
improvements in the covering layers. In another
respect, these failures raise the issue of notifica-
fi
tion of the administrative authorities, for better
collection and analysis of these rare problems.
Lastly, from a technical viewpoint revision should
be performed before osteolysis becomes too wide-
spread. Fig. 10 – Fracture of a ceramic femoral condyle.

Stiff
ffness
Depending on the published series, the flexion
which can generally be expected after total knee
replacement varies between 100 and 120° and
is obtained during the early months. No signifi-
cant improvement can be expected later than 1
year. Inadequate flexion after total knee replace-
ment is a frequent complication: 8–12% for
Daluga (47), 54–60% for Shoji (48) and 10.4%
for Scranton (49). The causes of stiffness are
multiple and are often interwoven with poorly
controled factors such as patient motivation
and reflex sympathetic dystrophy. Latent infec-
tion can cause stiffness and should always be
suspected.
Causes of stiff
ffness after total knee replacement
Patient-related causes
The range of pre-operative flexion is one of the
main factors found in most studies. A stiff pre-
operative knee will have less good flexion after
rehabilitation (50, 51). However, final range of
motion tends to converge toward median values
and patients with good pre-operative mobility
loose a little whereas stiff patients gain. Anouchi
(52) found that patients with pre-operative flex-
ion of less than 90° gained 26° flexion more than
those whose pre-operative flexion was greater
than 105°. In total knee replacement after anky-
losis or knee arthrodesis, results vary with final
flexion of 94° for Montgomery (53), 62° for
Naranja (54), and 75.9° for Kim (55). The post-
operative complication rate in all these series
was high, with up to 53.3% of cutaneous necro-
sis (55).
Other risk factors associated with stiffness
ff after
TKA are (1) associated hip disorder (related to
quadriceps stiff
ffness (18). Anouchi (52) observed a
decreased final mobility of 11.43° in patients with
several arthritic joints (Fig. 11). (2) Multi-oper-
ated knee is more likely to be stiff.ff For Scranton
(49), 77% of knees, which required post-operative
manipulation under anaesthesia after TKA had
previously undergone surgery.
Abnormal wound healing may lead to extensive
intra-articular fibrosis, in particular in some cases
of rheumatoid arthritis, which are stiff ff in both
flexion and extension. Ries (56) demonstrated
fibrocartilaginous metaplasia in five cases of revi-
sion surgery for stiffffness. In all of these, a new
prosthesis brought functional improvement but
only moderate gain in range of motion, suggesting
some patients may be constitutionally predisposed
to fibrosis (57).
Causes of failures in TKA 963
Fig. 11 – Failure of total knee replacement under a hip arthrodesis: appari-
tion of peri-prosthetic ossifications. Flexion after 5 years was 30°. Loss of
extension was 20°.
Technique-related causes
Closure technique may influence fl final mobility,
depending on whether it is done in flexion
fl or in exten-
sion. Emerson (58) observed signifi ficantly better final
flexion after closure in flexion (114.7° compared with
108.1°) as well as easier, shorter post-operative reha-
bilitation. Masri (59) did not share these conclusions
and found no diff fference related to type of closure.
Malpositioning or bone resection errors may be
responsible, in particular on the patella (asymme-
try, inadequate resection). Th These patellar factors
were found in 55% of revisions for stiff ffness (3).
On tibio-femoral components stiffness ff can be due
to an insuffi
fficient tibiofemoral resection, a reversed
tibial slope, a malrotation, or an inapropriate posi-
tioning of the joint line. The Th last is an important
factor in stiff ffness: a too distal joint line due to
excessive tibial resection, compensated for by min-
imal femoral resection, "lengthens" the patellar
track and causes excessive femoropatellar strains.
A too proximal joint line if stabilization is obtained
only by tibial polyethylene thickness leads to a low
patella and stiffness
ff in flexion.
Inadequate posterior capsular release, osteophytes
removal or retaining too tight a posterior cruciate
ligament may be responsible. Generally, any abnor-
mality in frontal or rotational position will have an
even more damaging eff ffect on mobility especially
in case of CR prosthesis, as tolerance is less.
Any oversized TKA, either in a frontal or sagittal
plane causes capsular and synovial tension and
impingement causing stiff ffness and pain. (49) A
too large femoral component in an anteroposterior
dimension has an impact on both the posterior
space in flexion and on the anterior femoropatel-
lar space. If these two spaces are too constricted,
flexion is limited (Fig. 12).
The type of rehabilitation plays a part in regaining
a good mobility. Too brief, inappropriate or poorly
964 Primary Total Knee Arthroplasty
Fig. 12 – Oversized femoral component (right knee) diagnosed on com-
parative CT-scan. AP dimension was measured on axial views, at the level of
the epicondyles, perpendicular to the posterior condylar line, on both con-
dyles. Medial condyle: right = 64mm/left = 59mm (+8%); lateral condyle:
right = 67mm/left=60mm (+12%).
supervised rehabilitation as well as unsatisfactory
post-operative pain control may lead to stiffness
ff
(see chapter on rehabilitation).
Treatment
There is no single attitude to treatment of stiff ffness
after total knee replacement. It depends on the
delay since surgery, the cause of stiff ffness, the type
of prosthesis, and the functional disability of the
patient. Moreover, the attitude is not the same in
case of loss of extension or loss of flexion.
Four treatments can be considered: simple manip-
ulation under anaesthetic, arthroscopic or open
arthrolysis or prosthesis replacement.
1. Manipulation is a simple and eff ffective procedure
which results in an average gain of 42° fl flexion
for Letenneur (60) and Scranton (49). However,
fficacy is restricted to post-operative period.
its effi
The risks of manipulation (fracture, extensor
apparatus rupture, wound dehiscence) are less
if it is done early during the first
fi 6 weeks. It is
therefore important to plan a visit for control,
4–6 weeks post-operatively so that to start
manipulation if flexion
fl has not reached 90°.
Scranton considered this time period may be
extended to 10 weeks post-operatively.
2. Arthroscopic arthrolysis is an accessory to
simple manipulation but cannot resolve major
ffness. It may be debated if the patient is
stiff
seen 2–6 months post-operatively or dur-
ing simple manipulation if range of motion
is not completely restored. Arthroscopy for
resection of intra-articular fibrous bands then
makes it possible to avoid dangerous force-
ful manipulation. Some authors consider the
posterior cruciate ligament may be resected
or debrided. Scranton (49) proposed improv-
ing this technique by "mini-invasive" arthroly-
sis using three limited approaches (supero-
lateral, infero-medial, and infero-lateral) and
obtained a 62° increase in range of motion in
four patients.
3. Classic open arthrolysis is technically difficult.
ffi
The approach must be extremely cautious to
avoid avulsion of the patellar tendon. Osteotomy
of the anterior tibial tuberosity or release of the
quadriceps tendon is often necessary. Removal of
tibial polyethylene makes it possible to approach
the posterior tibial compartment and to release
the posterior capsule. Th The release must also
include the medial and lateral condylar gutters
and above all recreate a free suprapatellar poach.
For optimal resection of fibrous tissue, Ries (56)
advises removal of the femoral component at
the beginning of the procedure, leaving only the
metal tibial baseplate. This has the advantage of
allowing replacement by a smaller component at
the end of the procedure and re-cutting the dis-
tal femur in case of severe loss of extension.
If a prosthesis retaining one or both cruciate liga-
ments is used, these are often totally or partially
sacrifi
ficed during "simple" arthrolysis. This option
would appear open to criticism since the design of
the prosthesis is no longer appropriate to the new
mode of functioning. Insertion of an entirely new
implant should then be considered. Letenneur (60)
found that overall open arthrolysis gives a mean
improved range of motion of 20°.
4. Implant replacement should be considered when-
ever the device is malpositioned or oversized.
In marked stiff ffness, replacement gave a better
range of motion than soft tissue release (60) and
if flexion is less than 60° it is the treatment of
choice. Mont (61) and Bonnin (4) obtained good
functional results after replacement because of
stiff
ffness, partially related to improved flexion
but also and above all to relief from pain.
Clunk syndromes
From the early 1980s, Figgie (62) stressed the
problems of patellofemoral crepitation and patel-
lar catching in poster-stabilized total knee replace-
ment. In 1989 Hozack (63) identifi fied the clunk syn-
drome, describing three cases. In 1990 Thorpe (64)
reported 11 cases of patellar crepitation and catch-
ing related to the development of "intra-articular
fibrous bands". He described three types: type I a
transverse band above the trochlea of the implant,
type II a band extending from the superolateral
angle of the patella to the patellar tendon, type III
a band extending from the distal pole of the patella
to the intra-condylar notch. Arthroscopic resec-
tion was effi
fficient in all cases. Since then, several
series of clunk syndromes have been published.
(48, 65, 66)
A fibrous nodule develops on the distal part of the
quadricipital tendon, at its insertion on the patella;

when the knee is flexed the nodule wedges into
the posterior stabilizing chamber of the femoral
component, causing painful locking at about 40°
of flexion, and suddenly dislodges during active
extension (Fig. 13).
This complication occurs almost exclusively in pos-
terior stabilized prostheses and it appears to have
become less frequent with improved design of the
trochlear part of the femoral components. It mainly
occurs when the implant has a patellar component
but some authors have described clunk syndromes
in knees without patellar resurfacing (48). Sev-
eral causes have been discussed in the literature: a
proximal position of the patellar button (Hozack),
an abnormal patellar height, whether too high or
too low (Figgie, Beight, Lucas) an abnormal thick-
ness of the patella (Beight) or an abnormal posi-
tion of the joint line (Beight).
Treatment of clunk syndrome is based on surgical
excision of the fibrous nodule, either by an open
procedure or under arthroscopy. Good results have
been obtained in the various series with both tech-
niques (66, 67).
Unexplained pain after TKA
Revision for unexplained pain can represent as much
as 7% (4) to 11.5% (3) of all TKA revisions. The appro-
priate strategy is generally difficult
ffi to establish and
requires an answer to the two following questions:
(1) What is a “normal pain” after TKA and (2) Which
level can we reach in the explorations?
Brander (68) analyzed the post-operative evolu-
tion of the pain following uncomplicated TKA. The Th
mean pre-op level of pain on a VAS (from 0 – no
pain to 100 – maximum pain tolerable) was 50. It
was decreased 20 at 6 months post-op and 18 after
Causes of failures in TKA 965
Fig. 13 – Clunk syndrome. In full extension (0°), a fibrous
nodule is visible between the patellar above and the femoral
component below. At 20° flexion, the nodule slides between
the patellar and femoral components. At 45° flexion, the
nodule is wedged into the posterior stabilizing chamber
of the prosthesis. The nodule is removed in extension by
arthroscopy.
1 year. The score was still superior to 40 in 61% of
the patients pre-operatively, 16% after 6 months
and 13% after 1 year.
Management of a TKA, with unexplained pain
starts with meticulous investigation in order to
exclude infection. Chronic infection is in fact the
main cause of persistent pain in total knee replace-
ments (49) (Table 3).
A minor mechanical abnormality may be present
and a meticulous search should be carried out
for minimal or exclusively femoral loosening,
wear, unsatisfactory kinematics due to poor soft
tissue balance (particularly in posterior cruciate
ligament retaining prostheses) or rotational mal-
position. An oversized prosthesis may be pain-
ful. Daluga (47) considers that an anteroposte-
rior diameter, which is increased by 12% results
in significantly increased pressures. Similarly,
lateral overlap of the tibial plateau may be the
cause. "Hidden" instability, which occurs only
in flexion may account for equivocal symptoms
with effusion and an impression of the knee giv-
ing way, with a clinical examination, which is
normal if the knee is not specifically examined
in flexion.
Prosthesis replacement for persistent pain without
associated stiff
ffness generally gives poor results,
less good than those of revision for other causes (4,
61, 69). However, signifificantly better results are
obtained in our series when pain appeared after a
pain-free interval of some years. In this situation,
prosthesis replacement gave good results (pain
score 39 ± 11). (69)
So in the case of a painful prosthesis with no evi-
dent anomaly on radiologic work-up or labora-
tory tests, care must be taken before deciding on
surgical revision. The decision is generally based
on a range of arguments, none of which is con-
clusive.
966 Primary Total Knee Arthroplasty
References
1. Noble PC, Conditt MA, Cook KF, Mathis KB. (2006)
Patients expectations aff ffect satisfaction with total knee
arthroplasty. Clin Orthop Relat Res 452:35–43
2. Dorr LD, Chao L. (2007) The emotional state of the patient
after total hip and knee arthroplasty. Clin Orthop Relat
Res 463:7–12
3. Burdin P, Huten D (2001) Les reprises de prothèses totales
du genou. Symposium de la Sofcot. Rev Chir Orthop 87,
Suppl 5S:143-198
4. Bonnin M, Deschamps G, Neyret P, Chambat P (2000) Les
changements de prothèses totales du genou non infectées.
Analyse des résultats à propos d’une série continue de 69
cas. Rev Chir Orthop 86:694–706
5. Duffff GP, Lachiewicz PF, Kelley SS (1996) Aspiration of
the knee joint before revision arthroplasty. Clin Orthop
331:132–139
6. Vessely MB, Frick MA, Oakes D, et al. (2006) Magnetic
resonance imaging with metal suppression for evaluation
of periprosthetic osteolysis after total knee arthroplasty. J
Arthroplasty 21(6):826–831
7. Seil R. (2004) Unexplained pain in TKA. In Chambat P,
Deschamps G, Neyret P, et al. La prothèse du genou, Sau-
ramps medical, Montpellier, ISBN 2-84023-388-6
8. Laskin RS (1999) The patient with a painful total knee
replacement. In: Lotke PA, Garino JP (eds) Revision total
knee arthroplasty. Lippincott-Raven, Philadelphia, pp
91–106
9. Brassard MF, Insall JN, Scuderi (2001) Complications of
total knee arthroplasty. In: Insall JN, Scott WN (eds) Sur-
gery of the knee. Churchill Livingstone, Philadelphia, pp
1801–1844
10. Hvid I, Bentzen SM, Jorgensen J (1988) Remodelling of
the tibial plateau after knee replacement. Acta Orthop
Scand 59:567–573
11. Seitz P, Ruegsegger P, Gschwend N, Dubs L (1987) Changes
in local bone density after total knee arthroplasty: the use
of quantitative computed tomography. J Bone Joint Surg
Br 69:407–411
12. Magee FP, Weinstein AM (1986) Th The eff
ffect of position on
the detection of radiolucent lines beneath the tibial tray.
Trans Orthop Res Soc 11:357
13. Fehring TK, Mc Avoy (1996) Fluoroscopic evaluation of the
painful total knee arthroplasty. Clin Orthop 331:226–333
14. Campbell MD, Duffy ff GP, Trousdale RT (1998) Femoral
component failure in hybrid total knee arthroplasty. Clin
Orthop 356:58–65
15. King TV, Scott RD (1985) Femoral component loosening
in total knee arthroplasty. Clin Orthop 194:285–290
16. Johnson F, Leitl S, Waugh W (1980) The Th distribution of
load across the knee. A comparison of static and dynamic
measurements. J Bone Joint Surg Br 62:346–349
17. Lotke PA, Ecker ML (1977) Infl fluence of positioning of
prosthesis in total knee replacement. J Bone Joint Surg
Am 59:77–79
18. Moreland JR (1988) Mechanisms of failure in total knee
arthroplasty. Clin Orthop 226:49–64
19. Hsu HP, Garg A, Walker PS, et al. (1989) Effect ff of knee
component alignment on tibial load distribution with
clinical correlation. Clin Orthop 248:135–144
20. Tew M, Waugh W (1985) Tibiofemoral alignment and the
results of knee replacement. J Bone Joint Surg Br 67:551–
556
21. Smith BE, Askew MJ, Gradisar IA, et al. (1992) The Th effffect
of patient weight on the functional outcome of total knee
arthroplasty. Clin Orthop 276:237–244
22. Mont MA, Mathur SK, Krackow KA, et al. (1996) Cement-
less total knee arthroplasty in obese patients: a compari-
son with a matched control group. J Arthroplasty 11:153–
156
23. Griffi
ffin FM, Scuderi GR, Insall JN, Colizza W (1998)
Total knee arthroplasty in patients who were obese with
10 years follow up. Clin Orthop 356:28–33
24. Ranawat CS, Flynn WF, Saddler S, et al. (1993) Long term
results of the total condylar knee arthroplasty: a 15 year
survivorship study. Clin Orthop 286:94–102
25. Walker PS, Greene D, Reilly D, et al. (1981) Fixation of
tibial component of knee prostheses. J Bone Joint Surg
Am 63:258–267
26. Deroches P (1992) La prothèse totale à glissement du
genou HLS I. Résultats d’une série de 375 cas. Th Thèse Med
Lyon N°34
27. Chandler HP, Reineck FT, Wixson RL, McCarthy JC (1981)
Total hip replacement in patients younger than 30 years
old. J Bone Joint Surg Am 63:1426–1434
28. Dorr LD, Luckett M, Conaty JP (1990) Total hip arthro-
plasties in patients younger than 45 years. A nine- to ten-
year follow-up study. Clin Orthop 260:215–219
29. Kilgus DJ, Dorey FJ, Finerman GA (1991) Patient activ-
ity, sports participation and impact loading on the dura-
bility of cemented total hip replacement. Clin Orthop
269:25–31
30. Dubs L, Gschwend N, Munzinger U (1983) Sport after
total hip arthroplasty. Arch Orthop Trauma Surg 101:
161–169
31. Lonner JH, Hershman S, Mont M, Lotke PA (2000) Total
knee arthroplasty in patients 40 years of age and younger
with osteoarthritis. Clin Orthop 380:85–90
32. Bradbury N, Borton D, Spoo G, Cross MJ (1998) Participa-
tion in sport after total knee replacement. Am J Sports
Med 26:530–535
33. Healy WL, Iorio R, Lemos MJ (2001) Athletic activity after
joint replacement. Am J Sports Med 29:377–388
34. Behrens JC, Walker PS, Shoji H (1974) Variation in
strength and structure of cancellous bone at the knee. J
Biomech 7:201–207
35. Tayot O, Adam Ph, Neyret Ph (1999) Résultats des pro-
thèses totales du genou HLS 1. Chirurgie Prothétique du
genou, Sauramps Medical, Montpellier, pp 113–124
36. Nordin JY, Parent H, the GUEPAR Group (1989) La pro-
thèse GUEPAR II scellée. Cahiers d’enseignement de la
SOFCOT :171–184
37. Fehring TK, Valadie AL (1994) Knee instability after total
knee arthroplasty. Clin Orthop 299:157–162
38. Pagano MW, Hanssen AD, Lewallen DG, Stuart MJ (1998)
Flexion instability after primary posterior cruciate retain-
ing total knee arthroplasty. Clin Orthop 356:39–46
39. Stähelin T, Kessler O, Pfifirrmann C, et al. (2003) Fluoro-
scopically assisted stress radiography for varus-valgus sta-
bility assessment in flexion after total knee arthroplasty. J
Arthroplasty 18(4):513–515
40. Lewis P, Rorabeck CH, Bourne RB, Devane P (1994) Pos-
teromedial tibial polyethylene failure in total knee replace-
ment. Clin Orthop 299:11–17
41. Kilgus DJ, Moreland JR, Finerman GA, et al. (1991) Cata-
strophic wear of tibial polyethylene inserts. Clin Orthop
273:223–231
42. Engh GA (1994) Tibial osteolysis in cementless total
knee arthroplasty. A review of 25 cases treated with
and without tibial component revision. Clin Orthop
309:33–43
43. Whiteside LA (1995) Eff ffect of porous coating confi figura-
tion on tibial osteolysis after total knee arthroplasty. Clin
Orthop 321:92–97
44. Schmalzreid TP, Campbell P, Brown IC, et al. (1995) Poly-
ethylene wear particles generated in vivo by total knee
replacement compared to total hip replacements. Trans
Orthop Res Soc 20:63
45. Ezzet KA, Garcia R, Barrack RL (1995) Eff ffect of compo-
nent fixation method on osteolysis in total knee arthro-
plasty. Clin Orthop 321:86–91

46. Whiteside LA, Fosco DR, Brooks JG (1993) Fracture of
the femoral components in cementless total knee arthro-
plasty. Clin Orthop 286:71–77
47. Daluga D, Lombardi AV, Mallory TH, Vaughan BK (1991)
Knee manipulation following total knee arthroplasty: anal-
ysis of prognostic variables. J Arthroplasty 6:119–128
48. Shoji H, Shimozaki E (1996) Patellar clunk syndrome in
total knee arthroplasty without patellar resurfacing. J
Arthroplasty 11:198–201
49. Scranton PE (2001) Management of knee pain and stiffnessff
after total knee arthroplasty. J Arthroplasty 16:428–435
50. Harvey IA, Barry, Kirby SP, et al. (1993) Factors affffecting
the range of movement of total knee arthroplasty. J Bone
Joint Surg Br 75:950–955
51. Parsley BS, Engh GA, Dwyer KA (1992) Preoperative fl flex-
ion. Does it infl
fluence postoperative flexion after posteri-
or-cruciate-retaining total knee arthroplasty? Clin Orthop
275:204–210
52. Anouchi YS, McShane M, Kelly F, et al. (1996) Range of
motion in total knee arthroplasty. Clin Orthop 331:87–92
53. Montgomery W, Insall JN, Haas S (1998) Primary total
knee arthroplasty in stiff
ff and ankylosed knees. Am J Knee
Surg 11:20–23
54. Naranja RJ, Lotke PA, Pagano MW, et al. (1996) Total knee
arthroplasty in a previously ankylosed or arthrodesed
knee. Clin Orthop 331:234–237
55. Kim YH, Kim JS, Cho SH (2000) Total knee arthroplasty
after spontaneous osseous ankylosis and takedown of for-
mal knee fusion. J Arthroplasty 15:453–460
56. Ries MD, Badalamente M (2000) Arthrofibrosis
fi after total
knee arthroplasty. Clin Orthop 380:177–183
57. Furia JP, Pellegrini VD (1995) Heterotopic ossification
fi
following primary total knee arthroplasty. J Arthroplasty
10:413–419
58. Emerson RH, Ayers C, Head WC, Higgins LL (1996) Sur-
gical closing in primary total knee arthroplasties. Clin
Orthop 331:74–80
Causes of failures in TKA 967
59. Masri BA, Laskin RS, Windsor RE, et al. (1996) Knee clo-
sure in total knee replacement. A randomised prospective
trial. Clin Orthop 331:81–86
60. Letenneur J, Guilleux Ch, Gerber Ph, Danty M (2001)
Les reprises de PTG pour raideur. Rev Chir Orthop
87(Suppl):1S149–1S151
61. Mont MA, Serna FK, Krackow KA, Hungerford DS (1996)
Exploration of a radiographically normal total knee
replacement for unexplained pain. Clin Orthop 331:216–
219
62. Figgie HE, Goldberg VM, Heiple KG, et al. (1986) Th The
infl
fluence of tibial-patellofemoral location on function
of the knee in patients with the posterior stabilized con-
dylar knee prosthesis. J Bone Joint Surg Am 68:1035–
1040
63. Hozack WJ, Rothman RH, Booth RE, Balderston RA
(1989) The patellar clunk syndrome. A complication of
posterior stabilised total knee arthroplasty. Clin Orthop
241:203–208
64. Thorpe CD, Bocell JR, Tullos HS (1990) Intra-articular
fibrous bands. Patellar complications after total knee
replacement. J Bone Joint Surg Am 72:811–814
65. Beight JL, Yao B, Hozack WJ, et al. (1994) The patellar
“clunk” syndrome after posterior stabilized total knee
arthroplasty. Clin Orthop 299:139–142
66. Lucas TS, DeLucas PF, Nazarian DG, et al. (1999) Arthro-
scopic treatment of patellar clunk. Clin Orthop 367:226–
229
67. Bonnin M (2001) Les reprises de prothèses totales
du genou pour clunk syndrome. Rev Chir Orthop
87(Suppl):1S164–1S166
68. Brander VA, Stulberg SD, Adams AD, et al. (2003) Predict-
ing total knee replacement pain: a prospective, observa-
tional study. Clin Orthop Relat Res 416:27–36
69. Bonnin M (2001) Les reprises de prothèses totales du
genou pour douleurs inexpliquées. Rev Chir Orthop
87(Suppl) 1S166–1S172

G. Van Damme,
J. Victor
The painful total knee arthroplasty
Introduction
T
otal knee arthroplasty is a highly success-
ful procedure that competes favorably with
other medical and surgical interventions, and
is associated with a high patient satisfaction rate
(90%) (1). Failures can occur however and are frus-
trating for both the patient and the surgeon. Th The
most frequent failure mechanisms include infec-
tion, tibiofemoral instability, loosening, extensor
mechanism dysfunction, and wear (2–4). The Th pre-
dominant symptoms of a failed total knee arthro-
plasty can be pain, instability, or stiff
ffness. A study
involving more than 8000 patients reported that
19.8% had persistent pain one year after TKA (5).
The aetiology of failure can be diffi
Th fficult to defi
fine,
and requires a systematic evaluation. Appropri-
ate treatment of a painful total knee replacement
starts with a correct diagnosis and identification
fi of
the underlying causes. In this chapter we propose a
comprehensive and practical approach for dealing
with the painful total knee arthroplasty. Once the
etiology has been established, symptomatic treat-
ment may be achieved by the appropriate treat-
ment, which may include revision TKA.
Diagnostic evaluation
History
Evaluation starts with the original etiology of the
knee pathology, previous injuries and treatments
on the aff
ffected knee before the index arthroplasty
was done. The level of pre-operative pain and func-
tion and associated symptoms of stiffness
ff or insta-
bility are documented. Review of prior records and
radiographs is helpful to understand the indication
for the index arthroplasty. Th
The course of the post-
operative pain is questioned. It is important to dis-
tinguish pain beginning in the early post-operative
period and pain occurring after an asymptomatic
interval. Early post-operative pain usually resolves
within several weeks. Continuous post-operative
pain from the beginning can be caused by an acute
Chapter 92
infection, malalignment, instability, soft-tissue
impingement, neuroma, or complex regional
pain syndrome. Late onset pain is more likely to
be caused by loosening, wear, late hematogenous
infection, or a stress fracture. The nature of the
pain, the location, and radiation are questioned,
including the relieving methods such as the use
of analgesics. According to Laskin (6), pain after
TKA can be categorized into seven types: start-up
pain, pain on weight bearing, early post-operative
pain, pain associated with full extension, pain
associated with full flexion, pain with stair climb-
ing or descent and rest pain (Table 1). Radiating
pain may be related to the hip, the lumbar spine,
or vascular insuffi
fficiency. Early complications such
as hematoma, wound healing problems, swelling,
and deep venous thrombosis can occur also. Pro-
longed wound drainage may be associated with
subsequent deep infection. TheTh evolution in reha-
bilitation and motion is analyzed. If the nature of
the pain is unchanged following the index surgery,
an alternative etiology for the pain must be consid-
ered, such as lumbar pathology, vascular claudica-
tion, referred hip pain, etc.
One has to be aware of the presence of certain
risk factors: diabetes, higher body mass index,
infl
flammatory arthropathy, previous knee sur-
gery, and immunocompromised status. It is also
important to review the patient’s expectations,
the level of activity, and mental health. A greater
expectation of pain relief after joint arthroplasty
predicts a greater reported pain relief at 1 year of
follow-up (7). Patients that had severe functional
Table I – pain categories after TKA.
Pain category Cause
Starting pain Suggestive of loosening
Pain on weight bearing Mechanical cause
Early postoperative pain Effusion
Pain with full extension Tight extension space
Pain with full flexion Posterior impingement – tight flexion
space
Pain with stair Dysfunction of the extensor mechanism
climbing–descent
Rest pain Infection, neurogenic or CRPS
970 Primary Total Knee Arthroplasty
impairment before surgery have worse outcomes
compared with patients getting surgery when
their functional levels are better (8). Female gen-
der, younger age (<60), and worse pre-operative
pain predict greater risk of moderate-severe pain
post-operatively (9, 10). A less favorable outcome
in terms of pain relief was observed for patients
with a high pre-operative VAS score for pain at rest
and a low pain threshold. Both factors may reflect
fl
a central sensitization mechanism (11). Pre-oper-
ative depression, anxiety, and pain are associated
with greater pain, more utilization of healthcare
resources and worse outcome 1 year after total
knee arthroplasty. Although anxiety is associated
with more pain, worse function, and more use
of resources in the first year after surgery, anxi-
ety does not affect
ff the ultimate outcome. Most
patients require a full year to recover from surgery
but have progressive improvement in pain over
several years. Therefore, assuming good range of
motion and well-aligned implants, most patients
with pain 1 year after surgery can be reassured
pain may further improve. Depression affects ff
long-term outcomes. (12, 13) Outcomes of pri-
mary TKA in patients receiving worker’s compen-
sation benefits
fi are inferior to those who did not
received any worker’s compensation, especially on
short term (14).
Physical examination
Visual inspection of the gait pattern should be
performed in order to document stiffness,
ff loss of
extension, alignment, varus or valgus thrust or
any abnormal rotation. An externally rotated foot
may indicate an internally rotated tibial compo-
nent and vice versa.
A general orthopaedic examination is performed to
exclude radiating or referred pain from the spine or
ipsilateral hip. Skin changes and temperature, arte-
rial pulses, and the venous system are examined.
Swelling of the knee can be secondary to hemar-
throsis, which may occur in patients with insta-
bility, hemophilia, platelet function defects, use
of anticoagulants, proliferative synovitis causing
impingement between joint surfaces, pigmented
villonodular synovitis, false aneurysms, and vascu-
lar erosion due to a prominent component or loose
particle (15, 16).
The range of motion of the aff
Th ffected knee is noted
with distinction of the active and passive ROM and
with attention for a painful arc or a painful end
point.
The function of the extensor mechanism is examined
with regard to strength, patellar tracking, and exten-
sor lag. An audible pop as the knee moves from fl flex-
ion to extension is described as patellar “clunk” (17).
The medial-lateral and anteroposterior stability of
the knee is assessed in 0, 30, and 90° of flexion.
fl
Localization of the pain should be examined care-
fully. A positive Tinel’s sign may indicate the pres-
ence of a neuroma, typically at the level of the
infrapatellar branch of the saphenous nerve. Ten-
derness at the joint line may indicate overhang of
the implant, or impingement of an osteophyte or
a retained cement fragment. Tenderness on the
proximal tibia just below the joint line may indicate
loosening. Tenderness on the proximal tibia may
indicate pes anserinus bursitis or an overhanging
of the tibial component causing irritation of the
medial collateral ligament. Tenderness on the lat-
eral border of the patella is seen with a lateral facet
syndrome.
Tenderness with or without a snapping sensation
over the posterolateral aspect of the knee is suspi-
cious of either impingement of the popliteus ten-
don over a retained lateral femoral osteophyte or
over the edge of the prosthesis (18).
Imaging
Technical investigation starts with good quality
standard radiographs including standing antero-
posterior, lateral, axial skyline, and full-leg views
(Fig. 1). For obtaining the AP and lateral radio-
graphs, the X-ray beam should be parallel to the
baseplate of the tibial component to optimally
evaluate the prosthesis–cement–bone interface.
An angulation of 6° of an x-ray beam can obscure
a 1-mm radiolucent line (19). For this reason flu-fl
oroscopy-guided positioning prior to obtaining
plain film radiographs is essential. The radiographs
are checked for alignment, component position-
ing, sizing, radiolucencies, loosening, osteolysis,
joint space narrowing, stress fracture, component
overhang, patella baja and heterotopic ossification.
fi
The position of the prosthetic joint line in relation
to the native joint line should be evaluated by iden-
tifying the position of the joint line in relation to
the patella and fibular
fi head. The skyline view is
important to evaluate the patellofemoral joint,
especially with regard to the position of the patella
in the femoral groove. Sequential radiographs are
important in identifying subtle changes in posi-
tion of the components and radiolucencies.
Computed tomography (CT) examination in
patients with painful knee prostheses is recom-
mended particularly for assessing rotational align-
ment of the femoral (Fig. 2) and tibial (Fig. 3)
component using anatomic landmarks (20). CT
is superior to radiographs for the diagnosis of
osteolysis. It is useful in showing the extent and
width of lucent zones that may be less apparent on
radiographs, and in detecting occult periprosthetic

fractures. Arthro-CT may be useful in document-
ing large intra-articular loose bodies, like bony,
cement or polyethylene fragments (21).
Modifification of MRI pulse sequence parameters
has facilitated the evaluation of the periprosthetic
soft tissues and bone, allowing demonstration of
focal osteolysis and inflflammatory synovitis, as
well as ligament and tendon abnormalities (22).
Scintigraphic evaluation of a painful total knee
replacement has a high sensitivity but has a low
Fig. 1 – Full leg radiograph showing valgus
malalignment.
Fig. 2 – CT-scan showing an internal malrotation of the femoral component.
The painful total knee arthroplasty 971
specifi
ficity. Increased uptake may persist up to
2 years after the index arthroplasty because of
bone remodeling (23 ). A triple-phase technetium
Tc-99m-labeled diphosphonate bone scan is most
commonly used. The Th first phase demonstrates per-
fusion, the second demonstrates the relative vascu-
larity and the third the relative osteoblastic activity
and thus the bone turnover. A positive bone scan
can be indicative of loosening, infection, or a stress
fracture. A diff
ffuse uptake may indicate the presence
of a complex regional pain syndrome. Bone scintig-
raphy is therefore typically used as a screening test
or in conjunction with other radionuclide studies.
Combined bone gallium imaging, with an accuracy
of 65–80%, off ffers only modest improvement over
bone scintigraphy alone. A negative labeled leuko-
cyte scan indicates a low probability of infection.
A positive WBC is non-specifi fic because of infl flam-
matory changes or marrow redistribution around
the prosthesis. In adults, hematopoietic marrow
is usually not present around the joint. However,
joint replacement surgery can prompt conversion
of fatty marrow to hematopoietic marrow. There- Th
fore accurate interpretation of a positive WBC scan
requires comparison to the technetium bone scan.
Incongruent uptake with a differentff distribution
or with greater intensity than on thetechnetium
scan is highly suggestive of infection. WBC scans
are not recommended as a routine because of their
cost, complexity, and long delay time before imag-
ing. Leukocytes can be labeled with Indium-111 or
Tc-99m HMPAO. Tc-99m HMPAO is advantageous
in that it is cheaper and allows more rapid imag-
ing. However, based on a study on 166 revision
arthroplasty cases, the routine use of sequential
technetium-99-hydroxymethyl diphosphonate and
indium-11 leukocyte imaging cannot be advocated
for diff
fferentiating occult infection from mechani-
cal failure in painful loose total joint arthroplasties.
This study showed that this sequential scanning was
64% sensitive and 78% specifi fic (24). In order to deal
with the problem of increased uptake on the WBC
scan around the prosthesis, due to marrow redistri-
bution, a Tc-99m sulfur colloid bone marrow scan
can be added immediately following the Indium-
111 WBC scan. Both radiolabeled leukocytes and
sulfur colloid accumulate in the bone marrow, but
only radiolabeled leukocytes accumulate at the site
of infection. Therefore if the indium and marrow
scans match, they are considered congruent, indi-
cating a low likelihood of infection. If there is a mis-
match, with labeled white cells being present but no
bone marrow activity on the marrow scan, the fi find-
ings correlate with a high likelihood of infection.
The reported accuracy of combined leukocyte/mar-
row imaging is about 90% (25). Indium-111-labeled
polyclonal immunoglobulin lacks specifi ficity. Tc-99-
m-ciprofl floxacin does not consistently diff fferentiate
972 Primary Total Knee Arthroplasty
infection from aseptic infl
flammation (26). FDG-PET
(Fluorine-18 fluorodeoxyglucose positron emission
tomography) seems to offerff no additional benefifit
(27). Based upon the above we can conclude that
radionuclide scanning has a high sensitivity in
detecting complications, but is not very helpful in
determining the diagnosis of a failed TKA.
Laboratory analysis
Laboratory analysis is used in order to differenti-
ff
ate septic versus aseptic etiologies of the pain. Th The
erythrocyte sedimentation rate (ESR) and the level
of C-reactive protein (CRP) are widely used as serum
markers for assessing bacterial infection in patients
with total joint arthroplasty (28). Th The ESR is a non-
specifi
fic indicator of inflflammation. It can be elevated
in both inflflammatory arthropathies as well as infec-
tions. It typically increases after joint replacement,
with a peak at 5–7 days after operation, and then
slowly decreases to pre-operative levels in approxi-
mately 3 months time (29). Continued elevation of
the ESR is suggestive of prosthetic infection. Th The
level of C-reactive protein is a better diagnostic aid
for the early detection of post-operative infection as
it is more sensitive, with an early peak at 2–3 days
after surgery, dropping to normal within the fi first 3
weeks after surgery (30). Greidanus et al. evaluated
the diagnostic test characteristics ofthe erythrocyte
sedimentation rate and C-reactive protein level for
the assessment of infection in 145 patients pre-
senting for revision total knee arthroplasty. A diag-
nosis of infection was established for 45 of the 151
knees that underwent revision total knee arthro-
plasty. The receiver-operating-characteristic curves
indicated that the optimal positivity criterion was
22.5 mm/h for the erythrocyte sedimentation rate
and 13.5 mg/L for the C-reactive protein level. Both
the erythrocyte sedimentation rate (sensitivity,
0.93; specifificity, 0.83; positive likelihood ratio, 5.81;
accuracy, 0.86) and the C-reactive protein level (sen-
sitivity, 0.91; specifi ficity, 0.86; positive likelihood
ratio, 6.89; accuracy, 0.88) have excellent diagnostic
test performance (31).
The serum level of interleukin 6 is also associated
with infl flammatory activity but exhibits a more
rapid increase and quicker return-to-normal values
than either the C-reactive protein level or the ESR,
suggesting that theIL-6 level may be a superior
indicator of post-operativeinfl flammatory response.
IL-6 levels peak in the first 6–12 h after surgery
and fall back to their baseline range by 48–72 h
post-operatively. With a normal serum IL-6 level
defi
fined as <10 pg/ml, the serum IL-6 test had a
sensitivity, specifi ficity, positive predictive value,
negative predictive value, and accuracy of 1.0, 0.95,
0.89, 1.0, and 97%, respectively (32).
Aspiration of joint fluid
fl
Aspiration and analysis of joint fluid is mandatory
to exclude an infected knee. Needle aspiration can
be perfomed from the lateral side into the supra-
patellar pouch with the knee extended, or from
anteromedial into the intercondylar space with the
knee in the flexed position. The synovial fluid is
analyzed for leukocyte count and microbiological
culture. Gram staining is not reliable for determin-
ing the presence of infection. It lacks any acceptable
level of sensitivity. For the microscopic evaluation
2–4 ml of joint fluid
fl is collected in an EDTA col-
lecting tube to prevent clotting in case the fl fluid is
mixed with blood. The synovial fluid cell count and
neutrophile diff fferential are important. Ghanem
et al. identifified cutoff
ff values for the leukocyte
count (>1100 cells/mm³) and neutrophil percent-
age (>64%) that can be used to diagnose infection.
Combining the peripheral blood tests with the syn-
ovial fluid cell count and diff fferential can improve
their diagnostic value (33). The
Th presence of needle-
shaped negatively bi-refringent urate crystals in
the synovial fl fluid confi
firm the diagnosis of gout.
For the microbiological evaluation early growth in
culture media is critical. For this reason the aspirate
is directly inoculated in multiple couples of aerobic
and anaerobic blood culture vials and immediately
sent to the microbiology department. Patients
should not be receiving any antibiotic treatment
for a period of 2 weeks before a knee aspiration is
performed to avoid false-negative culture results.
If the first examination is negative, a repeat aspi-
ration is considered if the suspicion of infection is
high. Routine aspiration has a sensitivity of 55%
and specifificity of 96% (34). A positive culture in
two separate samples with the same antibiogram
is the gold standard for the diagnosis of an infec-
tion. Frozen section and cultures of tissue samples
during revision surgery are sometimes necessary
to complete the evaluation of the infection.
Advances in molecular biology have enabled the
detection of infection in culture negative cases.
Synovial fluid aspirates can be analyzed by means
of the polymerase chain reaction (PCR) for the
presence of bacterial deoxyribonucleic acid indica-
tive of infection (35). The technique relies on the
use of forward and reverse primers designed to
match specifi fic sequences of target DNA. The most
common target gene for bacterial identification
fi is
the 16S rRNA gene that is conserved in nearly all
species of bacteria. TheTh main problem with this
technique is related to the apparently high preva-
lence of false-positive results. One way to improve
the specifi
ficity of polymerase chain reactions is to
use primers and probes directed against a specific fi
organism, or group of organisms, most likely to be
involved in clinically important orthopaedic infec-
 The painful total knee arthroplasty 973

tions. Thus, combinations of specifi

fic polymerase - Anteroposterior
chain reaction assays may ultimately prove to be – Malalignement
more useful than broad-spectrum, so-called “uni- – Patella
versal” bacterial assays (36). - Maltracking
- Patellofemoral overstuffi
ffing
- Unresurfaced patella
Arthroscopy - Lateral facet impingement
- Baja/alta
Arthroscopy can be helpful for intra-articular diag- – Wear, osteolysis, loosening
nosis and to treat certain conditions that would – Soft-tissue impingement
otherwise require an arthrotomy. Arthrofibrosis,
fi - Component overhang
impacted soft tissue, synovitis, and intra-artic- - Post-impingement
ular foreign bodies are potential indications for - Anterior impingement against anterior edge of
arthroscopy (Fig. 4). Arthroscopy is particularly PE insert
helpful for obtaining a specimen for histopatholo- - Popliteus tendon impingement
gicial analysis and culture. - Patella clunk

Infection
Modes of failure – causes
The incidence of peri-prosthetic infection following
The most frequent failure mechanisms include total knee replacement ranges from 1.1 to 12.4%
infection, tibiofemoral instability, loosening, and is reported to be the most frequent early com-
extensor mechanism dysfunction, and wear. When plication (37). Post-operative infection is mainly
confronted with a patient who has a painful TKA, related to the surgical technique and host factors.
several variables have to be differentiated:
ff Administration of prophylactic antibiotics reduces
(1) The patient the prevalence of infection but does not eradicate
– Psychological disorder this complication. The treatment options for an
– Unrealistic expectations infected total knee replacement include aggressive
– Complex regional pain syndrome wound debridement, drainage, and antibiotic sup-
(2) The system pression therapy; resection arthroplasty; arthrod-
– Limb deformity esis; two-stage re-implantation; antibiotic suppres-
– Hip pathology sion alone and amputation. Classifying infection
– Spinal disorder into acute versus late infection aids in the treatment
– Vascular plan. For acute infections, irrigation, and debride-
- Deep venous thrombosis ment with polyethylene exchange and retention of
- Vascular claudication components may be possible. When attempting this
– Neurological disorder option, thorough debridement and rapid treatment
(3) The knee (soft tissues, biology) of the infection prior to the accumulation of any bio-
– Infection film is paramount for a successful outcome. Other
– Extensor mechanism disruption important prognostic factors to consider include
- Patellar fracture the virulence of the micro-organism as well as the
- Patellar tendon rupture immune status of the host. For chronic infections,
- Quadriceps tendon rupture a successful outcome depends on several factors
– Instability due to ligament insuffi
fficiency including the baseline health status of the patient.
– Peri-prosthetic stress fracture Two-stage re-implantation has been the most con-
– Infl
flammatory disease: RA, pigmented villonod- sistent option, with many current studies demon-
ular synovitis, gout strating >90% success (38).
– Arthrofifibrosis
– Recurrent hemarthrosis
– Heterotopic ossification
fi Instability
– Tendinopathy
- Patellar The second most frequent cause of early failure is
- Quadriceps instability. Instability after TKA can be attributed
– Cutaneous neuroma to surgical technique, prosthesis design or a com-
(4) The implant bination of both. Medial-lateral instability is the
– Soft tissue imbalance due to malpositioning most common type of instability and is related to
- Mediolateral failure to balance the medial and lateral side and/
974 Primary Total Knee Arthroplasty
or component malalignment. It is most commonly
identifified in extension and was recognized early
on as a major complication of TKA (2). Patients
with medial-lateral instability may ambulate with
a stiff
ff-legged gait to avoid the pain.
Anteroposterior instability is predominantly a
problem in flexion and is closely related to the
surgeon’s ability to create a well balanced and ten-
sioned flexion gap (39–41). Restoration of the the
joint line and the posterior condylar off
ffset (42) are
key factors to success. Anteroposterior instability
results in posterior sagging of the tibia in flexion.
fl
Instability is usually caused by undersizing the
femoral component resulting in more bone resec-
tion of the posterior femoral condyles, especially
when using an anterior referencing instrumenta-
tion. Flexion instability can also be caused by an
excessive tibial slope or by an insufficient
ffi pos-
terior cruciate ligament (PCL) in PCL-retaining
knees. Patients may complain of pain and insta-
bility especially when going up and down stairs.
Recurrent knee eff ffusion may manifest. If flex-
ion instability occurs, the role of non-operative
treatment is limited. In most cases, revision TKR
using the same basic principles is required. When
symmetric flexion and extension spaces cannot
be obtained intra-operatively, the use of a con-
strained condylar prosthesis or hinged prosthesis
may be required.
Stiff
ffness
Post-operative stiffffness is a disabling complication
after total knee arthroplasty. Stiffness
ff is defi
fined as
inadequate range of motion with a fl flexion contrac-
ture >15° and/or limited fl flexion <75°. This results
in a painful knee with functional limitations dur-
ing activities of daily living. Biomechanical studies
and quantitative gait analysis have shown that the
average range of motion required for stair descent
is 90°, and for raising from a chair is 93° (43). In one
series of 1000 knees, 1.3% had limited motion after
primary total knee arthroplasty (44). Pre-operative
diagnosis as well as pre-operative range of motion
signifi
ficantly aff
ffect the post-operative range of
motion of total knee arthroplasties (45–49). Intra-
operative risk factors include improper balancing
of the flexion and extension gap, and the use of
oversized or malaligned components. A tight fl flex-
ion space can occur when there is excessive resec-
tion of the distal femur, oversizing of the femoral
component, upward slope of the tibial component
or contracture of the PCL (50). A tight exten-
sion space can be the consequence of inadequate
resection of the posterior condylar osteophytes,
insuffi
fficient posterior release of the capsule, insuf-
ficient resection of the distal femur or excessive
downslope of the tibial component. Overstuffi ffing
of the patellofemoral articulation may result from
anterior seating of the femoral component or if
the thickness of the resurfaced patella is increased
after patellar resurfacing. Patella baja can decrease
flexion by impingement of the patella on the tibial
component or tibial post in posterior stabilized
designs (51). Post-operative risk factors include
infection, complex regional pain syndrome, poor
patient motivation and compliance, hematoma,
biologically pre-disposed arthrofibrosis
fi and het-
erotopic ossification.
fi
The first steps in treating stiff ffness is adequate
physical therapy with active mobilization with ade-
quate analgesia and/or anti-inflflammatory medica-
tion. If these fail, options include manipulation,
open adhesiolusis with or without exchange of
the PE insert, and revision arthroplasty. Manipu-
lation and subsequent continuous passive motion
(CPM) under continuous epidural anesthesia for
2–3 days is the preferred method in the author’s
institution. Closed manipulation is most suc-
cessful within the first
fi 3 months after total knee
arthroplasty (52). For the best results, it is prefer-
able to perform the manipulation early in the post-
operative period, usually between 6 and 12 weeks.
Arthroscopic or open adhesiolysis can be consid-
ered after 3 months. Occasionally, in well-fixed fi
and well-aligned knees with a fl flexion contracture
and limited range of motion, it may be appealing
to exchange the modular tibial articulation to a
thinner size. However, it has been reported that
isolated tibial insert exchange generally has a poor
outcome (49, 53). Arthroscopic adehsiolysis with
release of all fibrous bands in the suprapatellar
pouch, re-establishing the medial and lateral gut-
ter, release of the patella, resection of remaining
remnants of meniscal tissue, can increase range
of motion and improve the pain (54, 55) (Fig. 4).
Arthroscopic release of the posterior cruciate liga-
Fig. 3 – CT-scan showing an internal malrotation of the tibial component.
 The painful total knee arthroplasty 975

ment can be of value (56, 57). Revisionarthroplasty

is preferred for stiff
ffness caused by malpositioned
or oversized components.

Loosening
Aseptic loosening is the third most common cause
of failure (Fig. 5, Fig. 6). It is a time-related phe-
nomenon which interferes with the long-term
results. Loosening results in activity related pain
because of (micro)motion between the component
and the bone. The radiographic signs of prosthetic
loosening are the presence of a periprosthetic radi-
olucency, any change in position of the implant
on serial radiographic examinations, or a cement
fracture.
Surgical factors such as malalignment and fixation,
fi
as well as design issues like constraint (aff ffecting
force transmission) and metal backing (aff ffecting
force distribution) play an important role.
On the short and mid-term, the tibial component
is most at risk for loosening. Tibial components act
as surface replacements and, as such, transfer loads
directly to the underlying trabecular bone. Failure Fig. 5 – Radiograph showing an example of loosening of a TKA. The
of the underlying bone under excessive stress leads tibial component migrated into a varus position. The femoral component
to loosening of the tibial component. Load trans- migrates into a valgus position.
fer across the proximal tibia can be improved by
metal backing of the polyethylene (58). Long term
results of identical designs available in a metal of early failure does not outweigh the potential
backed and all polyethylene version confirmed
fi this advantages. In a comparative study of 9200 cases,
hypothesis (59). Rand an Ilstrup reported 98% good or excellent
The main surgical factor that is associated with results with cemented implants versus only 93%
loosening is varus alignment. Residual post-oper- with uncemented implants (68).
ative deformities of more than 3° lead to a signifi- fi The timing for surgical intervention for aseptic loos-
cant increase in failures (60–67). ening after total knee is based on the presence of
Early failure of cementless fixation in Fehrings symptoms and the presence of apparent sings on the
(37) follow-up raises concern about this mode roentgenogram. Surgery is recommended in symp-
of fixation. Although there may be arguments in tomatic patients and in most asymptomatic patients
favor of cementless fixation, the additional risk when osteolysis is rapidly increasing in size and seems
to be eroding the cortical support for the implant.

Wear and osteolysis

Fig. 4 – Arthroscopic image showing removal of fibrous scar tissue
entrapped in the intercondylar box of the femoral component.
Wear remains a major long-term failure mode in
TKA. Wear is the removal of material, with the
generation of wear particles, that occurs as a result
of the relative motion between two opposing sur-
faces under load. Polyethylene wear in TKA occurs
from a combination of rolling, sliding, and rota-
tional motions through the bearing surface, which
may lead to delamination, pitting, and fatigue fail-
ure of the polyethylene surface (69). Polyethylene
wear also has been observed on the undersurface,
or backside, of modular tibial knee inserts (39, 70,
71, 72, 73, 74). The main causative factor leading
to periprosthetic osteolysis (Figs. 6, 7) is small par-
976 Primary Total Knee Arthroplasty
Fig. 6 – Radiograph showing an example of loosening of a TKA with bone
loss.
Fig. 7 – Intra-operative image showing the massive bone defects.
ticulate debris, which stimulates a foreign-bodycel-
lular response resulting in bone resorption (75, 76)
(Fig. 6, Fig. 7). The generation of polyethylene wear
is caused by a combination of patient, implant, and
surgical factors.
Activity level may be the most important patient
factor affffecting the loads placed on a total knee
replacement, but it is the most difficult
ffi to man-
age (77).
Multiple factors related to the material properties
infl
fluence its wear resistance. One should be cau-
tious in considering enhanced polyethylene. Pro-
cesses like heat pressing and carbon fiber
fi reinforce-
ment have been abandoned, because these changes
induced more rapid fatigue wear. Until now it is
not clear that the gains in wear by using highly
cross-linked polyethylene in total hip arthroplasty
will translate to knees (78). Th The mechanics of
articulation in a knee are markedly different
ff and
will impose more severe stress on the polyethylene
material than in hip arthroplasties. Sterilizing by
gamma radiation in air creates free radicals result-
ing in oxidation of the polyethylene, contributing
to a decrease in mechanical strength (79). Th The opti-
mal design of the articular bearing surface remains
controversial. One should be aware of backside
wear and understand the problems associated with
modular baseplates (77, 80). The tibial post of pos-
terior stabilized knee has been recognized as an
additional source of wear (51, 81). Damage to the
posterior surface of the post can occur as a conse-
quence of the cam-post-mechanism.
Surgical factors are important for long-term dura-
bility of the implant. Loose cement particles may
cause third body wear. Scratching of the femoral
component has been reported as a potential wear
accelerator. Malalignment may result in increased
loading forces across the bearing surface, lead-
ing to early degradation of the polyethylene. A
long unrecognized cause of accelerated wear in
TKA is instability. TheTh mode of failure has been
described by in vitro research showing that a cyclic
force exerted at a single point on the polyethyl-
ene causes little damage. When sliding is super-
imposed, surface damage and subsurface cracking
occur (82).
Fig. 8 – Two examples of non-anatomic tro-
chlear grooves in combination with a non resur-
faced patella. This raises a potential conflict
between the patellar cartilage and the femoral
component.

Usually, the early stages of osteolysis are asymp-
tomatic, as long as the amount of wear and bone
resorption is limited. In such cases, serial radio-
graphs are essential to evaluate the progression.
Surgery is recommended in most symptomatic
patients and in asymptomatic patients when the
osteolytic lesion is rapidly increasing in size and
seems to be eroding the cortical support for the
implant. In the absence of instability, malalign-
ment and significant
fi backside wear, an isolated
insert exchange with component retention and
morcellized bone grafting of the osteolytic defect
can be considered. However, in most cases wear is a
multifactorial phenomenon. In the study by Babis
et al. (83), 25% of the knees needed re-revision at a
mean of only 3 years. In the study by Brooks et al.
(84), 29% of the knees failed at less than 5 years.
Extensor mechanism dysfunction
The most common extensor mechanism problems
include patellar maltracking and patellar instability.
Other patellofemoral complications are extensor
mechanism disruption, soft-tissue impingement,
prosthetic wear or loosening and osteonecrosis.
Anterior knee pain after total knee arthroplasty
has often been associated with a patellofemoral
etiology. However, before symptoms are attributed
to the patellofemoral articulation, it is important
to consider other possible causes, as the results of
resurfacing or not resurfacing the patella may not
depend exclusively on replacement or preservation
of articular cartilage (85). The controversy about
whether to resurface the patella or not continues
to be debated. Overall, surgeons performing total
knee arthroplasty without resurfacing the patella
can expect a 10% prevalence of anterior knee pain,
which may require subsequent patellar resurfacing
(86). If one elects to resurface the patella during
primary total knee arthroplasty, one can expect a
rate of patellofemoral complications of <10%. A
meta-analysis (87) showed that patellar resurfacing
reduces the risks of re-operation and anterior knee
pain after total knee arthroplasty. The Th observed
eff
ffects are clinically important despite their mod-
est magnitude. Carefully designed randomized tri-
als are required to strengthen this claim.
The design of the trochlear groove of the femoral
component should resemble the natural geometry
as close as possible. The
Th combination of a non-ana-
tomic trochlear design and a non-resurfaced patella
can create a potential confl
flict (88) (Fig. 8). The high
failure rate of metal-backed prostheses led to the
development of all polyethylene patellar compo-
nents. Failure of the metal-backed implants was pre-
dominantly caused by wear of the thin polyethylene
and by loosening of the uncemented implant.
The painful total knee arthroplasty 977
Impingement between the extensor mechanism
and the polyethylene has recently been described
as a potential source of anterior knee pain (51).
The tibial component should have a large frontal
concavity and obliquity to accommodate for the
patellar tendon and the fat pad (Fig. 9).
A number of surgical variables relating to patell-
ofemoral tracking have been described (89). Cor-
rect tibiofemoral alignment aff ffects the Q-angle and
thus the lateral force vector acting on the patella.
Medial-lateral positioning of the femoral compo-
nent can shift the position of the trochlear groove
and affffect patellar tracking. Rotational positioning
has recently received more attention. Internal rota-
tion of the femoral and tibial component can cause
pain and instability (89, 90). Asymmetric patellar
resection or lateral positioning of the patellar com-
ponent also can cause patellar subluxation (91). If
the component is placed too far medially or if there
is a retained lateral osteophyte, the lateral aspect
of the patella may impinge on the femoral condyle,
causing pain. Correct component alignment and
soft-tissue balance should ensure good patellar
tracking in most cases. Despite the fact that trans-
fer of the tibial tubercle is rarely necessary, Kirk
et al. (92) reported 15 cases of patellar dislocation
after TKA that were all successfully treated with a
tibial tubercle transfer.
Also, the restoration of the correct “offset”
ff of the
patellofemoral joint is important. The Th thickness of
the patellar button-patella construct should mimic
the thickness of the original patella. TheTh trochlear
groove should be positioned at the level of the
original trochlear line. This is not only a matter
of femoral component design but also of correct
sizing and positioning. A too large or too anterior
placed femoral component will also overstuff ff the
patellofemoral compartment.
Finally, joint line restoration also affects
ff patel-
lofemoral function. Raising the joint line creates
a patella baja. Patella baja is commonly seen in
patients who have had previous surgery, with sub-
sequent shortening of the patellar tendon (93).
Patella baja can produce pain due to impingement
between the patella and the anterior surface of
the tibial component or between the patella and
the tibial post in posterior stabilized designs has
(51).
A suprapatellar fibrous nodule may develop at the
junction between the patella and the quadriceps
tendon after TKA. Such a nodule may cause catch-
ing as the knee extends from fl flexion at 30–45°.
This soft-tissue impingement problem is called a
patellar clunk syndrome (17). It is well recognized
in posterior stabilized total knees, with a reported
incidence of up to 3.5% (94). Prosthetic design
seems to be the main risk factor for patellar clunk.
Most newer prostheses have a smaller box with a
978 Primary Total Knee Arthroplasty
deeper patellar groove and a more posterior posi-
tion of the femoral cam, thereby decreasing the
chance of soft tissue articulating with this region.
Initially a patient may respond well to an exercise
program and anti-infl flammatory medication (95).
Patients that do not respond to non-surgical treat-
ment have benefi fit from an arthroscopic debride-
ment of the fibrous nodule (94, 96). Thorpe et
al. described peripatellar fibrous bands causing
painful patellofemoral dysfunction by tethering,
with resolution of symptoms after arthroscopic
removal (97).
Fracture of the patella after total knee arthro-
plasty is an infrequent complication, with a
reported prevalence of 0.05% in unresurfaced
patellae and a prevalence ranging from 0.2 to 21%
in resurfaced patellae (98–101). Patellar fractures
after TKA may be due to trauma or fatigue (insuf-
ficiency or stress fractures). In most cases the
fi
fracture is not associated with a traumatic event.
Pre-disposing factors include loss of blood supply
to the patella leading to osteonecrosis, improper
patellar tracking, component malalignment,
patellar component design and technical errors
including asymmetric or excessive resection of
bone. More than 50% of fractures are associated
with a loose implant which complicates the frac-
ture management (102). Prevention is the best
treatment. Treatment can be guided by three
main criteria: integrity of the extensor mecha-
nism, fixation status of the patellar implant, and
quality of the remaining bone. Ortiguera et al.
Fig. 9 – The tibial insert does not follow the anatomic curve (dotted black
line)of the anterior tibia and causes impingement with the patellar tendon
that is tenting around the anterior edge (arrow).
(103) classifified patellar fractures as Type I (a sta-
ble implant and an intact extensor mechanism),
Type II (a disruption of the extensor mechanism),
or Type III (a loose patellar component with an
intact extensor mechanism). If a disrupted exten-
sor mechanism co-exists with a loose implant,
the fracture is classifified as Type II. Type-III frac-
tures are divided according to the remaining bone
stock: Type IIIa indicates reasonable remaining
bone stock and Type IIIb, poor bone stock. Poor
bone stock is defi fined as patellar bone thickness
of <10 mm, or marked comminution. When it is
feasible, non-operative treatment off ffers accept-
able functional results and pain relief, with mini-
mal complications. Virtually all Type-I fractures
should initially be treated non-operatively with
3–6 weeks of immobilization. Rarely, a symp-
tomatic non-union may later require fragment
excision. Operative treatment usually is required
for patellar fracture associated with extensor dis-
ruption (Type II), but it is important to realize
that, under these circumstances, operative treat-
ment frequently is associated with complications
(104). Open reduction and internal fixation fi of
these fractures is rarely successful, probably in
part because of the thin remaining patellar bone.
Thus, re-establishment of continuity of the exten-
sor mechanism by excision of small, poor-quality
osseous fragments and repair with or without
augmentation of the remaining extensor tendon
to bone may be considered. However, the com-
plication and re-operation rate is high in these
cases. Non-operative treatment may be consid-
ered for some Type-III fractures associated with
minimal symptoms on presentation, as some of
these patients continue to function well. Opera-
tive treatment is only required if symptoms are
suffi
fficiently troublesome. Surgical options depend
on the quality of the remaining patellar bone
stock. Fractures with good remaining bone stock
(Type IIIa) may be treated with revision of the
patellar component or with resection of the com-
ponent and patelloplasty. In the presence of poor
remaining bone stock (Type IIIb), removal of the
implant with partial or complete patellectomy is
recommended (103).
Other causes of pain
Pain may occur as a result of formation of a neu-
roma after surgical laceration of the infrapatellar
branch of the saphenous nerve. It is recognized
as localized tenderness along the incision with a
positive Tinel’s sign. If the pain re-occurs after a
nerve blockade with 1% lidocaine injection, an
operative denervation can be beneficial
fi in selected
patients (105).

Medial component overhang can impinge upon the
medial collateral ligament causing medial knee pain
and mechanical irritation of the ligament (106).
Referred pain to the knee may originate from
either the hip, pelvis or spine and can be confusing
in patients with a TKA. Insuffi fficiency fractures of
the femoral neck or pubis are described after ipsi-
lateral total knee arthroplasty (107, 108).
Gout in a knee with a total knee prosthesis is rare
and can mimic septic arthritis. Early diagnosis is
of particular importance as the therapy of the two
conditions diffffers considerably. Gout is treated
with medication while surgical treatment is neces-
sary in a case of septic arthritis (109).
A rare phenomenon that should be considered in
the diff
fferential diagnosis of continuing pain and
eff
ffusion, is synovial metastasis. The lung is the
most common primary site for synovial metasta-
sis with the knee as the most frequently affected
ff
joint (110).
Summary
Pain following TKA can occur as a result of mul-
tiple intrinsic and extrinsic causes. A systematic
approach with complete history and physical
examination followed by radiographs and further
investigations based on the clinical examination, is
critical to explain the etiology of the pain. Once the
etiology of the pain has been determined, a symp-
tomatic relief may be achieved with the appropri-
ate treatment.
References
1. Bourne RB (2008) Measuring tools for functional outcomes
in total knee arthroplasty. Clin Orthop 466:2634–2638
2. Cameron HU, Hunter GA (1982) Failure in total knee
arthroplasty: mechanism revisions and results. Clin
Orthop 170:141–146
3. Rand JA, Bryan RS (1982) Revision after total knee
arthroplasty. Orthop Clin North Am 13:201–212
4. Sharkey PF, Hozack WJ, Rothman RH, et al. (2002) Why
are total knee arthroplasties failing today? Clin Orthop
404:7–13
5. Baker PN, Van der Meulen JH, Lewsey J, Gregg PJ (2007)
The role of pain and function in determining patient
satisfaction after total knee replacement: data from the
National Joint Registry for England and Wales. J Bone
Joint Surg 89-B:893–900
6. Laskin RS (1999) The patient with a painful total knee
replacement. In: Lotke PA Garino JP (eds) Revision total
knee arthroplasty. Lippincott, Philadelphia, pp 91–107
7. Gandhi R, Davey JR, Mahomed N (2009) Patient expecta-
tions predict greater pain relief with joint arthroplasty. J
Arthroplasty 24:716-721
8.Lavernia c, D’Apuzzo M, Rossi MD, Lee D (2009) Is post-
operative function after hip or knee arthroplasty influenced
fl
by preoperative functional levels? J Arthroplasty 24:1033–
1043
The painful total knee arthroplasty 979
9. Singh JA, Gabriel S, Lewallen D (2008) The impact of gen-
der age and preoperative pain severity on pain after TKA.
Clin Orthop 466:2717–2723
10. Elson DW, Brenkel IJ (2006) Predicting pain after total
knee arthroplasty. J Arthroplasty 21:1047–1053
11. Lundblad H, Kreichbergs A, Jansson KA (2008) Predic-
tion of persistent pain after total knee replacement for
osteoarthritis. J Bone Joint Surg 90:166–171
12. Brander VA, Stulberg SD, Adams AD, et al. (2003) Predict-
ing total knee replacement pain: a prospective observa-
tional study. Clin Orthop 416:27–36
13. Brander V, Gondek S, Marin E, Stulberg SD (2007) Pain
and depression infl fluence outcome 5 years after knee
replacement surgery. Clin Orthop 464:21–26
14. de Beer J, Petruccelli D, Gandhi R, Winemaker M (2005)
Primary total knee arthroplasty in patients receiving work-
er’s compensation benefi fits. Can J Surg. 48(2):100–105
15. Ohdera T, Tokunaga M, Hiroshima S, et al. (2004) Recur-
rent hemarthrosis after knee joint arthroplasty: etiology
and treatment. J Arthroplasty 19:157–161
16. Omary R, Stulberg SD, Vogelzang RL (1991) Th Therapeutic
embolisation of false aneurysms of the superior medial
genicular artery after operations on the knee: a report of
two cases. J Bone Joint Surg 73-A:1257–1259
17. Beight JL, Yao B, Hozack WJ, et al. (1994) The patellar
“clunk” syndrome after posterior stabilized total knee
arthroplasty. Clin Orthop 299:139–142
18. Barnes CL, Scott RD (1995) Popliteus tendon dysfunction
following total knee arthroplasty. J Arthroplasty 10:543–
545
19. Ecker ML, Lotke PA, Windsor RE, Cella JP (1987) Long-
term results after total condylar knee arthroplasty: Sig-
nifi
ficance of radiolucent lines. Clin Orthop 216:151–158
20. Berger RA, Rubash HE (2001) Rotational instability and
malrotation after total knee arthroplasty. Orthop Clin
North Am 32:639–647
21. Clarke HD, Math KR, Scuderi GR (2004) Polyethylene post
failure in posterior stabilized total knee arthroplasty. J
Arthroplasty 19:652–657
22. Potter HG, Foo LF (2006) Magnetic resonance imaging of
joint arthroplasty. Orthop Clin North Am 37:361–373
23. Verlooy H, Victor J, Renson L, et al. (1993) Limitations of
quantitave radionuclide bone scanning in the evaluation
of total knee replacement. Clin Nucl Med 18:671–674.
24. Teller RE, Christie MJ, Martin W, et al. (2000) Sequen-
tial indium-labeled leukocyte and bone scans to diagnose
prosthetic joint joint infection. Clin Orthop 373:241–247
25. Palestro CJ, Torres MA (1997) Radionuclide imaging in
orthopedic infections. Sem Nucl Med 27:334–345
26. Love C, Marwin SE, Palestro CJ (2009) Nuclear medi-
cine and the infected joint replacement. Semin Nucl Med
39:66–78
27. Van Acker F, Nuyts J, Maes A, et al. (2001) Eur J Nucl Med
28:1496–1504
28. White J, Kelly M, Dunsmuir R (1998) C-reactive protein
level after total hip and total knee replacement. J Bone
Joint Surg 80-B:909–911
29. Mandalia V, Eyres K, Schranz P, Toms AD (2008) Evalua-
tion of patients with a painful total knee replacement. J
Bone Joint Surg 90-B:265–271
30. Larsson S, Thelander U, Friberg S (1992) C-reactive pro-
tein levels after elective orthopaedic surgery. Clin Orthop
275:237–242
31. Greidanus NV, Masri BA, Garbuz DS, et al. (2007) Use of
erythrocyte sedimentation rate and C-reactive protein
level to diagnose infection before revision total knee
arthroplasty. J Bone Joint Surg 89-A:1409–1416
32. Di Cesare PE, Chang E, Preston CF, Liu C (2005) Serum
interleukin-6 as a marker of periprosthetic infection fol-
lowing total hip and knee arthroplasty. J Bone Joint Surg
A-87:1921–1927
980 Primary Total Knee Arthroplasty
33. Ghanem E, Parvizi J, Burnett RS, et al. (2008) Cell count
fferential of aspirated fluid in the diagnosis of infec-
and diff
tion at the site of total knee arthroplasty. J Bone Joint
Surg 90-A:1637–1643
34. Barrack RL, Jennings RW, Wolfe MW, Bertot AJ (1997)
The Coventry Award: the value of preoperative aspiration
before total knee revision. Clin Orthop 345:8–16
35. Mariani BD, Martin DS, Levine MJ, et al. (1996) Poly-
merase chain reaction detection of bacterial infection in
total knee arthroplasty. Clin Orthop 331:11–22
36. Bauer TW, Parvizi J, Kobayashi N, Krebs V (2006) Diag-
nosis of periprosthetic infection. J Bone Joint Surg
88-A:869–882
37. Fehring TK, Odum SM, Griffin ffi WL, et al. (2001) Early
failures in Total Knee Arthroplasty. Clin Orthop 392:315–
318
38. Moyad TF, Thornhill T, Estok D (2008) Evaluation and
management of the infected total hip and knee. Orthope-
dics 31:581–588
39. Wasielewski RC, Parks N, Williams I, et al. (1997) Tibial
insert undersurface as a contributing source of polyethyl-
ene wear debris. Clin Orthop Relat Res 345:53–59
40. Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ
(1998) Flexion instability after primary posterior cruciate
retaining total knee arthroplasty. Clin Orthop 356:39–46
41. Clarke HD, Scuderi GR (2003) Flexion instability in pri-
mary total knee arthroplasty. J Knee Surg 16:123–128
42. Bellemans J, Banks S, Victor J, et al. (2002) Fluoroscopic
analysis of the kinematics of deep fl flexion in total knee
arthroplasty. Infl fluence of posterior condylar off ffset. J
Bone Joint Surg 84-B:50–53
43. Laubenthal KN, Smidt GL, Kettelkamp DB (1972) A quan-
titative analysis of knee motion during activities of daily
living. Phys Ther
Th 52:34–43
44. Kim J, Nelson CL, Lotke PA (2004) Stiffness ff after total
knee arthroplasty. Prevalence of the complication and out-
comes of revision. J Bone Joint Surg 86-A:1479–1484
45. Kotani A, Yonekura A, Bourne RB (2005) Factors influenc-fl
ing range of motion after contemporary total knee arthro-
plasty. J Arthroplasty 20:850–856
46. Ritter MA, Stringer EA (1979) Predictive range of motion
after total knee arthroplasty. Clin Orthop 143:115
47. Parsley BS, Engh GA, Dwyer KA (1992) Preoperative fl flex-
ion: does it infl
fluence postoperative flexion after posteri-
or-cruciate-retaining total knee arthroplasty. Clin Orthop
275:204
48. Ritter MA, Leesa HD, Davis K, et al. (2003) Predicting
range of motion after total knee arthroplasty: clustering
log-linear regression and regression tree analysis J Bone
Joint Surg 85-A:1278
49. Babis GC, Trousdale RT, Pagnano MW et al. (2001) Poor
outcomes of isolated tibial insert exchange and arthroly-
sis for the management of stiff ffness following total knee
arthroplasty. J Bone Joint Surg 83-A:1534
50. Lombardi AV, Berend KR, Aziz-Jacobo J, Davis MB
(2008) Balancing the flexion gap: relationship between
tibial slope and posterior cruciate ligament release and
correlation with range of motion. J Bone Joint Surg
A-90(Supplement):121–132
51. Verborgt O, Victor J (2004) Post impingement in poste-
rior stabilized total knee arthroplasty. Acta Orthop Belg
70:46–50
52. Fox JL, Poss R (1981) The role of manipulation following
total knee replacement. J Bone Joint Surg 63-A:357–362
53. Engh GA, Koralewicz LM, Pereles TR (2000) Clinical
results of modular polyethylene insert exchange with
retention of total knee arthroplasty components. J Bone
Joint Surg 82-A:516–523
54. Dijan P, Christal P, Witvoet J (2002) Arthroscopic release
for knee joint stiffffness after total knee arthroplasty. Rev
Chir Orthop Reparatrice Appar Mot 88:163–167
55. Jerosh J, Aldawoudy AM (2007) Arthroscopic treatment
of patients with moderate arthrofibrosis
fi after total knee
replacement. Knee Surg Sports Traumatol Arthrosc
15:71–77
56. Williams RJ 3rd, Westrich GH, Siegel J, Windsor RE (1996)
Arthroscopic release of the posterior cruciate ligament for
stiff
ff total knee arthroplasty. Clin Orthop 331:185–191
57. Ries MD, Badalamente M (2000) Arthrofibrosisfi after total
knee arthroplasty. Clin Orthop 380:177–183
58. Bartel DL, Burnstein AH, Santavicca EA, Insall JN (1982)
Performance of the tibial component in total knee replace-
ment – conventional and revision designs. J Bone Joint
Surg 64-A:1026–1033
59. Victor J (2001) The tibial component should routinely be
modular and metal-backed rather than all polyethylene.
In: Laskin RS (ed) Controversies in total knee replace-
ment. Oxford University Press, New York
60. Bargren JH, Blaha JD, Freeman MA (1983) Alignment
in total knee arthroplasty: Correlated biomechanical and
clinical observations. Clin Orthop 173:178–183
61. Green GV, Berend KR, Berend ME, et al. (2002) The Th eff
ffects
of varus tibial alignment on proximal tibial surface strain
in total knee arthroplasty. J Arthroplasty 17:1033–1039
62. Hsu HP, Garg A, Walker PS, et al. (1989) Effect ff of knee
component alignment on tibial load distribution with
clinical correlation. Clin Orthop 248:135–144
63. Jeff
ffery RS, Morris RW, Denham RA. (1991) Coronal align-
ment after total knee replacement. J Bone Joint Surg
73:709–714
64. Kumar PJ, Dorr LD (1997) Severe malalignment and soft-
tissue imbalance in total knee arthroplasty. American J
Knee Surg 10:36–41
65. Lotke PA, Ecker ML (1977) Infl fluence of positioning of
prosthesis in total knee replacement J Bone Joint Surg
59-A:77–79
66. Ritter MA, Faris PM, Keating M, et al. (1994) Postopera-
tive alignment of total knee replacement. Clin Orthop
299:153–156
67. Tew M, Waugh W (1985) Tibiofemoral alignment and the
results of knee replacement. J Bone Joint Surg 67-B:551–
556
68. Rand JA, Ilstrup DM (1991) Survivorship analysis of total
knee arthroplasty. J Bone Joint Surg 73-A:397–409
69. Collier JP, Mayor MB, McNamara JL, et al.(1991) Analysis
of the failure of 122 polyethylene inserts from uncemented
tibial knee components. Clin Orthop 273:232–242
70. Parks NL, Engh GA, Topoleski LD, Emperado J (1998) Th The
Coventry Award: Modular tibial insert micromotion. A
concern with contemporary knee implants. Clin Orthop
356:10–15
71. Engh GA, Lounici S, Rao AR, Collier MB (2001) In vivo
deterioration of tibial baseplate locking mechanisms in
contemporary modular total knee components. J Bone
Joint Surg 83-A:1660–1665
72. Conditt MA, Ismaily SK, Alexander JW, Noble PC (2004)
Backside wear of ultra-high molecular weight polyethylene
tibial inserts. J Bone Joint Surg 86-A:1031–1037
73. Engh GA, Ammeen DJ (2004) Epidemiology of osteolysis:
Backside implant wear. Instr Course Lect 53:243–249
74. Conditt MA, Thompson MT, Usrey MM, et al. (2005) Back-
side wear of polyethylene tibial inserts: Mechanism and mag-
nitude of material loss. J Bone Joint Surg 87-A:326–331
75. Howie DW, Vernon-Roberts B, Oakeshott R, Manthey B
(1988) A rat model of resorption of bone at the cement-
bone interface in the presence of polyethylene wear par-
ticles. J Bone Joint Surg 70-A:257–263
76. Jacobs JJ, Roebuck KA, Archibeck M, et al. (2001) Osteoly-
sis: Basic science. Clin Orthop 393:71–77
77. Naudie DD, Ammeen DJ, Engh GA, Rorabeck CH (2007)
Wear and osteolysis around total knee arthroplasty. J Am
Acad Orthop Surg 15:53–64

78. Rodriquez JA (2008) ross-linked polyethylene in total
knee arthroplasty: in opposition. J Arthroplasty 23(7
Suppl):31–34
79. Bohl JR, Bohl WR, Postak PD, Greenwald AS (1999) The Th
Coventry Award: the effects
ff of shelf life on clinical out-
come for gamma sterilized polyethylene tibial compo-
nents. Clin Orthop 367:28–38
80. Engh GA, Dwyer KA, Hanes CK (1992) Polyethylene wear
of metal backed tibial components in total and unicompar-
timental knee prostheses. J Bone Joint Surg 74-B:9–17
81. Puloski SK, McCalden RW, MacDonald SJ, et al. (2001)
Tibial post wear in posterior stabilized total knee arthro-
plasty. An unrecognized source of polyethylene debris. J
Bone Joint Surg 83-A:390–397
82. Blunn GW, Walker PS, Joshi A, Hardinge K (1991) The Th
dominance of cyclic sliding in producing wear in total knee
replacements. Clin Orthop 273:253–260
83. Babis GC, Trousdale RT, Morrey BF (2002) The Th eff
ffective-
ness of isolated tibial insert exchange in revision total
knee arthroplasty. J Bone Joint Surg 84-A:64–69
84. Brooks DH, Fehring TK, Griffin ffi WL, et al. (2002) Polyeth-
ylene exchange only for prosthetic instability. Clin Orthop
405:182–188
85. Burnett RS, Bourne RB (2003) Indications for patellar
resurfacing in total knee arthroplasty. J Bone Joint Surg
85-A:728–743
86. Parvizi J, et al. (2005) Failure to resurface the patella dur-
ing total knee arthroplasty may result in more knee pain
and secondary surgery. Clin Orthop 438:191
87. Pakos EE, Ntzani EE, Trikalinos TA (2005) Patellar resur-
facing in total knee arthroplasty. A meta-analysis. J Bone
Joint Surg 87-A:1438–1445
88. Whiteside LA, Nakamura T (2003) Effect ff of femoral com-
ponent design on unresurfaced patellas in knee arthro-
plasty. Clin Orthop 410:189–198
89. Malo M, Vince KG (2003) The unstable patella after total
knee arthroplasty: etiology prevention and management.
J Am Acad Orthop Surg 11:364–371
90. Hofmann s, Romero J, Roth-Schiffl ffl E, Albrecht T (2003)
Rotational malalignment of the components may cause
chronic pain or early failure in total knee arthroplasty.
Orthopade 32:469–476
91. Barnes CL, Scott RD (1988) Patellofemoral complications
of total knee replacement. Instr Course Lect 42:303–307
92. Kirk P, Rorabeck CH, Bourne RB, et al. (1992) Manage-
ment of recurrent dislocation of the patella following total
knee arthroplasty. J Arthroplasty 7:229–233
93. Scuderi GR, Windsor RE, Insall JN (1989) Observations
on patellar height after proximal tibial osteotomy. J Bone
Joint Surg 71-A:245–248
94. Lucas TS, DeLuca PF, Nazarian DG, et al. (1999)
Arthroscopic treatment of patellar clunk. Clin Orthop
367:226–229
95. Parker DA, Dunbar MJ, Rorabeck CH (2003) Extensor
mechanism failure associated with total knee arthro-
plasty: prevention and management. J Am Acad Orthop
Surg 11:238–247
The painful total knee arthroplasty 981
96. Koh YG, Kim SJ, Chun YM, et al. (2008) Arthroscopic treat-
ment of patellofemoral soft tissue impingement after pos-
terior stabilized total knee arthroplasty. Knee 15:36–39
97. Thorpe CD, Bocell JR, Tullos HS (1990) Intra-articular
fibrous bands: patellar complications after total knee
replacement. JBJS 72-A:811–814
98. Goldberg VM, Figgie HE, Inglis AE, et al. (1988) Patellar
fracture type and prognosis in condylar total knee arthro-
plasty. Clin Orthop 236:115–122
99. Grace JN, Sim FH (1988) Fracture of the patella after total
knee arthroplasty. Clin Orthop 230:168–175
100. Tria AJ Jr, Harwood DA, Alicea JA, Cody RP (1994) Patel-
lar fractures in posterior stabilized knee arthroplasties.
Clin Orthop 299:131–138
101. Windsor RE, Scuderi GR, Insall JN (1989) Patellar fractures
in total knee arthroplasty. J Arthroplasty 4(Suppl):63–67
102. Chalidis BE, Tsiridis E, Tragas AA, et al. (2007) Manage-
ment of periprosthetic patellar fractures. A systematic
review of literature. Injury 38:714–724
103. Ortiguera CJ, Berry DJ (2002) Patellar fracture after total
knee arthroplasty. J Bone Joint Surg 84-A:532–540
104. Bourne RB (1999) Fractures of the patella after total knee
replacement. Orthop Clin North Am 30:287–289
105. Dellon AL, Mont MA, Krackow KA, Hungerford DS (1995)
Partial denervation for persistent neuroma pain after total
knee arthroplasty. Clin Orthop 316:145–150
106. Hirsch DM, Sallis JG (1989) Pain after total knee arthro-
plasty caused by soft tissue impingement. J Bone Joint
Surg 71-B:591–592
107. Thienpont E, Simon JP, Spaepen D, Fabry G (2000) Bifo-
cal pubic stress fracture after ipsilateral total knee arthro-
plasty in rheumatoid arthritis. A case report. Acta Orthop
Belg 66:197–200
108. Atalar H, Aytekin MN, Gunay C, Yavuz OY (2008) Stress
fracture of the femoral neck as a complication of revision
arthroplasty of the knee: a case report. Acta Orthop Belg
74:418–420
109. Rompen JC, Kuiper-Geertsma DG, Verheyen CC (2008)
Ned Tijdschr Geneeskunde 152:1117–1119
110. Currall VA, Dixon JH (2008) Synovial metastasis: an unu-
sual cause of pain after total knee arthroplasty. J Arthro-
plasty 23:631–636
111. Brown EC, Clarke HD, Scuderi GR (2006) The painful total
knee arthroplasty: diagnosis and treatment. Orthopedics
29:129–136
112. Christensen CP, Crawford JJ, Olin MD, Vail TP (2002)
Revision of stiffff total knee arthroplasty. J Arthroplasty
17:409–415
113. Major DO, Nicholls DW, Dorr LD (1990) Revision surgery
for stiff
ff total knee arthroplasty. J Arthroplasty 5(Suppl):
S73–S77
114. Scranton PE Jr (2001) Management of knee pain and
stiff
ffness after total knee arthroplasty. J Arthroplasty
16:428–435
115. Waslewski GL, Marson BM, Benjamin NB (1998) Early inca-
pacitating instability of posterior cruciate ligament-retaining
total knee arthroplasty. J Arthroplasty 13:763–767

E. J. Graham,
S. J. MacDonald
Pre-operative planning
for revision TKA
Introduction
P
re-operative planning for revision total knee
arthroplasty (TKA) is necessary to maximize
success in these diffi
fficult cases (1, 2, 3). A step-
wise approach is presented. These are the 10 steps
that this author thinks through pre-operatively as
part of the planning process: mechanism of fail-
ure, clinical workup, implant evaluation, incision,
exposure, component removal, bone stock restora-
tion, component selection, cementing, and post-
operative issues.
Mechanism of failure
It is important to understand the reason of the pri-
mary knee failed (4). A revision surgery should cor-
rect the shortcomings of the original surgery and
not simply restore or repeat a mechanical situation
that has failed (5).
The common causes of failure listed in order of
prevalence are demonstrated by Sharkey (6).
These are polyethylene wear, loosening, instabil-
ity, infection, arthrofifibrosis, malalignment and
malposition, extensor mechanism defi ficiency,
avascular necrosis of patella, periprosthetic frac-
ture and isolated patella resurfacing. Failures are
divided into early and late. More than half of the
revisions were done less than 2 years after the
initial surgery. In the early failure group the most
common mode of failure was infection. In the late
failure group the most common mode of failure
was polywear.
In Vince’s paper (5) nine causes of failure are pre-
sented. His first four categories are from an earlier
study by Jacobs et al. (7). These are aseptic loos-
ening, instability from collateral incompetence,
patella instability related to component malro-
tation and the mystery knee. The mystery knee
had no diagnosis and underwent revision surgery
with poor results. The
Th five further categories were
breakage of components, sepsis, extensor mecha-
nism rupture, stiffffness, and fracture.
The majority of patients exhibit more than one
Th
cause of failure (8). Of patients with wear, approxi-
Chapter 93
mately half had instability. Of patients with loose,
implants approximately half had osteolysis.
Clinical workup
The clinical workup for revision TKA includes his-
tory, physical examination, laboratory tests, and
imaging.
History
In taking the clinical history we need to exclude
infection and determine the main symptom,
which is normally, but not exclusively, pain. The Th
pain needs to be profi filed with the usual questions
regarding site, nature, severity, radiation, exacer-
bating and relieving factors, onset, duration, and
associated symptoms. Specifi fically start up pain
that is felt when first arising from sitting is sugges-
tive of loosening. Pain on weight bearing felt when
walking suggests a mechanical problem such as
loosening or instability. Rest pain indicates inflam-
fl
mation as occurs in sepsis. Pain that was present
from the outset also may suggest infection.
Particular diagnoses have characteristic histories.
Infection should be suspected in the setting of post-
operative problems with persistent wound drain-
age, delayed wound healing, and hematoma forma-
tion. Pre-operative risk factors for infection include
rheumatoid arthritis, diabetes mellitus, psoriasis,
obesity, steroid, and methotrexate use. Infection
should also be considered when the pain is present
at night, at rest, and when there was never a pain
free interval. Patients should be asked if they have
ever been placed on a course of antibiotics post-
operatively because of their TKA – this is often a
forgotten detail until an inquiry is performed.
Loosening, wear and osteolysis should be consid-
ered with a history of startup pain, mechanical
symptoms, a pain free interval, and activity related
pain. Instability should be suspected with histories
of episodes of the knee giving way or sudden col-
lapse. Stiff
ffness presents with diffi
fficulty with activi-
ties of daily living and with limitations with cer-
tain activities such as biking. Extensor mechanism
dysfunction can present with weakness or fatigue
984 Primary Total Knee Arthroplasty
of the quadriceps. It is also important to check
for a history of nerve injury or weakness to knee
extension.
Physical examination
Physical examination should rule out hip and spine
pathology. Referred pain in the knee of hip origin
is usually reproduced with hip internal rotation.
Inspection focuses on alignment, prior incisions,
quadriceps atrophy, and a gait assessment. Range
of motion will reveal patella maltracking and clunk-
ing or crepitus if present. Squeaking and pain indi-
cate metal on metal wear. Blocks to full extension
can be due to a fi
fixed flexion deformity, malposition
of the components, flexion of the femoral compo-
nent, or overstuffiffing the extension space. Blocks
to full flexion may be due to retention of posterior
osteophytes, a reverse tibial slope or overstuffi
ffing
the patellar component, or flexion/extension gap
mismatch with the flexion gap being tighter than
the extension gap.
Instability is tested for in full extension and 15°
of flexion. Varus/valgus malalignment needs to
be critically assessed for the presence or absence
of a fixed end point. Posterior cruciate function
should be considered in a case where the posterior
cruciate has been retained initially. Late posterior
cruciate rupture can produce instability. An exten-
sor lag may indicate dysfunction of the quadriceps
mechanism. Infection should be suspected with
an eff
ffusion, warmth, erythema, and reduced pain-
ful range of motion. Distal examination should
include an assessment of neurovascular function,
as well as ruling out the presence of post-operative
neuromas (9).
Laboratory tests
The blood work for pre-operative planning should
include WCC, ESR, and CRP. In cases of infection
the white blood count is usually not elevated. Eryth-
rocyte Sedimentation Rate and C-Reactive Protein
are non-specifific markers of acute infl flammation.
They rise following arthroplasty and return to
normal at 3 weeks and 2 months post-operatively
respectively. ESR of approximately 50 mm/hr is
reported in several series of patients with infected
knee arthroplasty. A recent paper recommends an
ESR of 22.5 and CRP of 13.5 as cutoff ff to diagnose
infection with a sensitivity of more than 90% and
a specifi
ficity of greater than 80% (10). Combining
the two tests yields a greater sensitivity of 95 %
but lower specifi ficity and is useful in ruling out
infection.
Aspirate
It is controversial whether an aspiration should
be performed in every case, however any case in
which an infection is suspected based on history,
physical findings, or baseline blood work should
be aspirated. Knee aspirate should be evaluated for
aerobic, anaerobic, crystals, and cell count. Knee
aspirate has a sensitivity of 55% (1). Prior admin-
istration of antibiotics increases the risk of false
negatives, so patients should be offff of all oral anti-
biotics for at least 2 weeks prior to a knee aspira-
tion being performed.
Historically cell counts of greater than 25,000/mm
with 75% polymorphs and a low glucose level were
suggestive of infection. Parvizi et al. (11) recently
published on a series of infected TKA’s and used
an aspirate fluid count of 1100/mm and 64%
neutrophils. When both tests had results below
those cutoffff levels the negative predictive value
was 99.6%. When both tests were above those lev-
els, the positive predictive value was 100%. Poly-
merase chain reaction has been used to detect bac-
teria by amplifying DNA production and detecting
a gene for a ribosomal subunit. This technology is
evolving.
Imaging
Standard X-rays for planning for revision TKA are
an AP weight bearing hip to ankle view, lateral view
and skyline view. The surgeon needs to be aware
that radiographs classically underestimate the
bone loss that is actually present (12). Interpreta-
tion of the X-rays focuses on several factors – align-
ment, component position, bone cement interface,
and bone stock. Loosening can be determined by
specifi
fic X-ray findings:
1. A change in component position (with the tibial
tray usually tilting into varus).
2. A radiolucent line greater than 2mm at any
interface, a radiolucent line that extends around
the entire periphery of an implant, a radiolucent
line that is progressive in serial X-rays.
3. Cement fracture.
4. Shedding of beads if a cementless component is
present.
In cases of infection the X-rays are usually normal.
Occasionally one may see radiolucencies around
the component and in the case of a more chronic
infection periosteal new bone formation may be
present. The most common abnormality seen on
X-ray in cases of infection is periprosthetic oste-
olysis and is non-specific.
fi
The skyline view shows patellar tracking, wear, and
fracture. The lateral view should be assessed care-
fully for bone loss around the femoral component
that may not be obvious on the AP view.
Fluoroscopy may be helpful to evaluate the tibial
and femoral components separately (13). Selectively
centering the image intensifier
fi beam allows for cov-
ering of radiolucencies by the base plate metal.

Excessive internal rotation of femoral and tibial
components is associated with an increase in inci-
dence of patella-femoral problems. Implant rota-
tional alignment can be accurately assessed by CT
(14). Jazwari found using the epicondylar axis and
the posterior tibial axis CT could detect differences
ff
of 5° which was significant.
fi
Scintagraphic evaluation of the implant is useful
in investigation for loosening, but less so for infec-
tion. Technetium 99 disphosponate bone scan
has an initial phase where tracer is concentrated
in areas of high-blood flow
fl such as in infection. In
the late phase tracer concentrates in areas of bone
activity and is suggestive of loosening, fracture or
infection. Bone scan has a high negative predic-
tive value for infection. Further tests with gallium,
indium, and sulfur colloid can help to differentiate
ff
infection and loosening in a positive bone scan
PET scanning with deoxy glucose has also been
used to detect infection and is highly sensitive.
Implant evaluation
It is important to obtain the primary surgical pro-
cedure operative note. Additionally the implant
stickers that contain the specifi fic implant informa-
tion are important to obtain if the surgeon is not
familiar with the implant, or if partial component
retention is being contemplated. Specifi fically were
there any particular diffi
fficulties encountered during
the surgery, any injury to structures. What was the
quality of the bone and was there much bone loss
or a fracture are important considerations. How
was the stability, range of motion, drop angle? Was
there a lateral retinacular release?
Some implants have had specifi fic problems and
the implant record is important. For example,
metal backing on patella’s in the 1980s led to
high rates of failure. Early fixed hinge prosthesis
placed increased strain on bone cement interfaces
leading to loosening. Polycentric trays placed high
stress on proximal tibial cancellous bone resulting
in subsidence. A boxy AP profile fi is associated with
quadriceps tendon scarring and patella clunk. A
flat non-conforming tibial spacer results in early
delamination of the polyspacer and possible frac-
ture. Identifification of an existing implant and
understanding any unique failure mechanism is
helpful in planning for a revision.
Options are needed for the poly in case a simple
exchange is all that is required. The surgeon must
first confi
firm if there are still polyethylene inserts
available. There may be a specifi fic locking device or
extraction equipment required. A thick poly is often
needed in revision cases and the availability of the
diff
fferent sizes and shelf life and method of steril-
ization are all important variables to consider.
Pre-operative planning for revision TKA 985
Incision
A standard midline incision is used whenever
possible. Prior incisions may make this difficult.
ffi
Skin necrosis can occur from narrow skin bridges
between two incisions or with excessive undermin-
ing of skin flflaps. The medial blood supply to the
anterior knee is better than lateral so in multiple
incisions a laterally based incision is best (15).
The blood supply travels from the deep tissues
through the superficial
fi fascia to the skin and does
not run superfi ficially through the subcutaneous
flap (16). Transverse incisions should be transected
at a right angle. In cases where soft tissue cover is
problematic plastic surgical consultation should be
sought. Local flaps can be from medial head of gas-
trocnemius which is longer, larger, and more easily
mobilized than the lateral head. Skin expansion is
a technique to provide adequate skin cover. Inflat- fl
able reservoirs are placed subcutaneously and are
expanded slowly with regular saline injections. The Th
author has no experience with this technique and
therefore would look to alternate methods. If it is
diffi
fficult to identify tissue planes, proximal exten-
sion beyond the level of the scar will help.
Exposure
The major impediment to exposure is the extensor
mechanism (16). The exposure involves appropri-
ate release of the tethers located laterally, medially,
proximally and distally. For the typical varus knee
a medial parapatellar capsular incision has been
employed. This
Th is used in the revision and for the
vast majority of cases is all that will be required.
Historically the teaching has been that at the begin-
ning of a revision TKA one must achieve enough
exposure to be able to evert the patella. However,
if that is indeed done, extensile exposures will be
required more frequently. These
Th authors' approach
instead is to perform the adequate local releases at
the time of the arthrotomy and to just sublux and
not evert the patella, and then to remove the poly-
ethylene insert. This immediately frees up at least
1 cm of tissue tension. Next the femoral compo-
nent is removed followed by the tibial component.
At that point the patella will be able to easily be
everted. A quadriceps snip may also aide in expo-
sure, but even that should not be required rou-
tinely. More extensive techniques such as a quad-
riceps turndown and tibial tubercle osteotomy are
rarely indicated.
The quadriceps snip relieves proximal tension on
the extensor mechanism. The standard release is
extended obliquely 45° to the fibers
fi of the vastus
lateralis running distal medial to proximal lat-
eral. Post-op exercises may include active range of
986 Primary Total Knee Arthroplasty
motion at day one and full weight bearing. Barrack
(17,18) found quadriceps snip and standard medial
parapatellar capsular incision to be equivalent in
terms of post-op recovery. Quadriceps turndown
and tibial tubercle osteotomy had lower post-op
scores. Quadriceps turndown had greater range of
motion and less knee pain but more extensor lag
than tibial tubercle osteotomy.
Tibial tubercle osteotomy is preferred to quadri-
ceps turndown when a more extensile exposure
is required. The osteotomy fragment should be at
least 8 cm long and 2 cm wide with preservation of
the lateral soft tissue hinge. Osteotomy is carried
out with an oscillating saw and fixation
fi with wire
to allow canal occupying press-fit fi stems. Post-op
bracing is recommended for 6 weeks, locked in
extension for walking and no active extension for
6 weeks.
Quadriceps turndown described by Coonse and
Adams allows lengthening or shortening of the
extensor mechanism. This proximal extension of
the exposure involves making a second division
in the extensor mechanism at 45° to the proximal
end of the parapatellar arthrotomy. Th The problems
with this include stiff
ffness, extensor lag, and injury
to the superior lateral geniculate artery, which may
result in avascular necrosis and subsequent frag-
mentation of the patella. It is important to protect
the repair by avoiding active extension for 6 weeks
(19).
More extensive exposures have been described.
A medial epicondylar osteotomy allows greater
medial exposure. The superfi ficial medial collateral
ligament is raised as a flflap with the medial epi-
condyle as a bone fragment within the soft tissue
sleeve. The fragment can be fixed back with a screw
after the component insertion if required. Th The
femoral peel is another more extensive exposure
and involves stripping of essentially the entire soft
tissue envelope from the distal femur.
Component removal
The focus of component removal is to minimize
host bone destruction and ligament damage but
obtain adequate exposure of the component inter-
face (20). All of the details involved with com-
ponent removal will be discussed at length in an
alternate chapter.
Bone stock restoration
Bone stock may be restored by cement, bone, aug-
ments, sleeves, trabecular metal augments, and
custom implants. Grafting options include morsel-
ized femoral head and structural allograft. Graft
preparation technique requires screws and ream-
ers. Bone loss is frequently underestimated on
pre-operative X-rays due to visual obstruction by
implant, further bone loss after implant removal
and the insensitivity of the radiograph to detect
bone loss. (11) Therefore it is advisable to be pre-
pared for greater degrees of bone loss than pre-
operative assessment indicates, particularly when
diffi
fficult extraction of well fixed implants is antici-
pated (21).
Metal augments are usually limited to 10–15 mm.
They are helpful to restore loss of distal and pos-
terior femoral surfaces. The common pattern of
tibial component failure collapsing into varus may
be treated with a metal wedge augmenting the pla-
teau defect.
Segmental loss can be managed with allograft or in
the worst case scenario with ligamentous involve-
ment modular implants such as a hinge. ThereTh are
also newer implants on the market, including tra-
becular augments which can be used with all man-
ufacturers’ implants, or implant specific fi sleeves.
There is very little published on these techniques
to date.
The Anderson Orthopaedic Research Institution
has classifi
fied bone defect in revision TKA (22).
A.O.R.I. classification
Type 1: intact metaphyseal bone.
Type 2: damaged metaphyseal bone.
Type 3: defificient metaphyseal bone.
Type 1 defects are minor and do not compromise
stability and may be managed with particulate
bone graft or cement. Type 2 defects have loss of
cancellous bone needing cement fill (up to 1 cm)
augment or bone graft to restore a reasonable joint
line level and possibly stems. Type 3 defects involve
collateral ligament or patellar tendon detachment
and require structural bone graft, rotating hinge,
or custom implant.
Historically contained defects in both tibia and
femur regardless of age of patient or size of cav-
ity have been managed with bone grafting. Densely
packed morselized allograft and autograft will
incorporate over time. Very large defects require
a combination of morselized and bulk allograft.
Stems will unload graft prior to incorporation but
require intact cortical bone. Again today many
revision surgeons are dealing with these defects
with either trabecular metal augments or sleeves.
Tibial defects are usually peripheral whereas femo-
ral defects commonly are a combination of distal
and posterior condylar bone loss. A varus defor-
mity will usually lead to posterior medial tibial
wear and peripheral rim bone loss. A valgus defor-
mity will similarly cause lateral femoral condylar
defi
ficiency.

Component selection
There are many revision systems available and it
is important to have options for varying degrees
of deformity, bone loss, and stability. Use of stems
allows transfer of load to the diaphysis, bypassing the
weakened, or defificient metaphysis. Anterior femoral
notching can cause a stress riser and can be protected
by a stem. The
Th use of an off ffset attachment allows the
option of altering the take off ff point for the stem. A
stem may then be more anterior to the central aspect
of the prosthesis avoiding overstuffi ffing the patellar
femoral compartment. Component selection is dis-
cussed in detail in an alternate chapter.
Cementing
Cement may be used to fill fi defects and to fix the
components. Small contained bone defects not
requiring augments or wedges may be fi filled with
cement, typically less than 5 mm. Fixation of the
component with cement will always involve the
joint surface, historically has included the metaph-
ysis and may or may not include the stem. Fixation
at the metaphyseal interface is often forgotten
in discussions. It is critical to achieve metaphy-
seal fixation with cement (or alternative sleeves
or trabecular augments) and techniques on how
to achieve this are further discussed in alternate
chapters. The pros and cons of cementless versus
cemented stems is also discussed elsewhere.
Post-operative Issues
– Physiotherapy
– Antibiotic prophylaxis
– DVT prophylaxis
Physiotherapy
Post-operative physiotherapy is most effective
ff in
the first 3 months and improvement tends to pla-
teau after that time. As with primary knee replace-
ment the aims in the short term are adequate range
of motion, straight leg raising against gravity and
stair walking. All patients require some form of
upper extremity assistance device.
The range of motion achievable in revision surgery
Th
is often lower than in primary surgery. Functional
scores are also lower.
Some surgeons limit weight bearing after cement-
less designs. Full weight bearing is permitted after
cemented prostheses unless there is underlying
bone compromise. Active extension is avoided for
6 weeks if exposure involves quadriceps turndown
or tibial tubercle osteotomy.
Pre-operative planning for revision TKA 987
Antibiotic prophylaxis
This is fully discussed in the medical management
chapter.
DVT prophylaxis
This is fully discussed fully in the medical manage-
ment chapter.
Conclusion
Revision total knee arthroplasty cases are often
very challenging (23) and the many issues involved
may seem at first daunting. However, the same
steps in planning should be performed for every
case. A step-wise approach has been presented
here that will allow the reconstructive surgeon to
logically progress through the steps of pre-opera-
tive planning.
References
1. Dennis DA, Berry DJ, Engh G, et al. (2008) Revision total
knee arthroplasty. J Am Acad Orthop Surg 16:442–454
2. Goldberg VM (2001) Principles of revision total knee
arthroplasty. J Bone Joint Surg 50:357–375
3. Gustke KA (2005) Preoperative planning for revision total
knee arthroplasty. J Arthroplasty 20:37–40
4. Saleh KJ, Mulhall KJ (2006) Current etiologies and modes
of failure in total knee arthroplasty revision. Clin Orthop
446:45–50
5. Vince KG (2003) Why knees fail. J Arthroplasty 18:39–44
6. Sharkey PF, Hozack WJ, Rothman RH, et al. (2002) Why
are total knee arthroplasties failing today? Clin Orthop
404:7–13
7. Jacobs MA, Hungerford DS, Krackow KA, Lennox DW
(1988) Revision total knee arthroplasty for aseptic failure.
Clin Orthop 226:78–85
8. Mulhall KJ, Ghomrawi HM, Engh GA, et al. (2006) Radio-
graphic prediction of intraoperative bone loss in knee
arthroplasty revision. Clin Orthop 446:51–58
9. Dellon AL, Mont MA, Krackow KA, Hungerford DS, et al.
(1995) Partial denervation for persistent neuroma pain
after total knee arthroplasty. Clin Orthop 316:145–150
10. Greidanus NV, Bassam AM, Garbuz DS, et al. (2007) Use
of ESR and CRP to diagnose infection before total knee
arthroplasty. J Bone Joint Surg 89:1409–1416
11. Parvizi J, Ghanem E, Sharkey P, et al. (2008) Diagnosis of
infected total knee: findings of a multicenter database.
Clin Orthop 466:2628–2633
12. Nadaud MC, Fehring TK, Fehring K (2004) Underestima-
tion of osteolysis in posterior stabilized total knee arthro-
plasty. J Arthroplasty 19:110–115
13. Fehring TK, McAvoy G (1996) Fluroscopic evaluation of
the painful total knee arthroplasty. Clin Orthop 331:226–
233
14. Jazrawi LM, Birdzell L, Kummer FJ, Di Cesare PE, et
al. (2000) The accuracy of CT for determining femoral
and tibial total knee arthroplasty component rotation.
J Arthroplasty 15:761–766
15. Windsor RE, Insall JN, Vince KG (1989) Technical consid-
erations of total knee arthroplasty after proximal tibial
osteotomy. J Bone Joint Surg 70:547–555
988 Primary Total Knee Arthroplasty
16. Younger AS, Duncan CP, Masri BA (1998) Surgical expo-
sures in revision total knee arthroplasty. J Am Acad
Orthop Surg 6(1):55–64
17. Barrack R, Smith P, Munn B, et al. (1998) Comparison
of surgical approaches in total knee arthroplasty. Clin
Orthop 356:16–21
18. Barrack R (1999) Specialized exposure for revision total
knee arthroplasty. J Bone Joint Surg 81:138–141
19. Della Vale CJ, Berger RA, Rosenberg AG (2006) Surgical
exposures in revision total knee arthroplasty. Clin Orthop
446:59–68
20. Mason JB, Fehring TK (2006) Removing well fixed
fi total
knee arthroplasty implants. Clin Orthop 446:76–82
21. Rorabeck CH, Smith PN (1998) Results of revision total
knee arthroplasty in the face of significant
fi bone defi
fi-
ciency. Orthop Clin North Am 29:361–371
22. Engh GA, Rorabeck CH (1997) Bone defect classification.
fi
Revision total knee arthroplasty. 63–120
23. Bourne RB, Crawford HA (1998) Principles of revision
total knee arthroplasty. Orthop Clin North Am 29:331–
337

M. Tanzer,
S. Burnett
Technique of revision:
surgical approach
Introduction
S
uccessful revision total knee arthroplasty
(TKA) requires careful pre-operative planning
and the surgical approach to the knee is one
of the most critical elements of this plan. Safely
obtaining the necessary exposure to allow implant
removal and proper implantation of the revision
components while protecting the extensor mecha-
nism and the delicate soft tissues around the knee
should be the goal of revision TKA. The surgical
exposure for treating a failed TKA should planned
pre-operatively, be carried out in a stepwise fash-
ion and if required, be flexible enough to allow a
more extensile approach during surgery.
Although adequate exposure is required to per-
form revision TKA, it should not result in uncon-
trolled bone and soft tissue damage or devitaliza-
tion. Wound complications after knee arthroplasty
result in increased length and cost of hospitaliza-
tion, re-admissions, additional surgeries, increase
the risk of deep infection, and even amputation.
Failure to protect the extensor mechanism during
the surgical exposure can be devastating. Avulsion
of the patellar tendon from its tibial insertion is an
extremely diffi
fficult complication to treat and gen-
erally has unsatisfactory results, with few patients
regaining full active extension or a satisfactory
degree of flexion (1). Therefore, prevention of
these complications by careful pre-operative plan-
ning and meticulous, stepwise surgical dissection
is crucial.
Pre-operative assessment and management
A thorough history should be taken to identify
patients at higher risk of for wound complications.
These high risk factors include a previous history
of wound healing problems, multiple previous
procedures, rheumatoid arthritis, diabetes melli-
tus, chronic corticosteroid use, cigarette smoking,
previous infection, previous irradiation, scarring
from a previous burn, and severe knee stiffness
ff
(2, 3). A thorough history and physical examina-
Chapter 94
tion of the vascular system of the lower extremity
should be carried out to eliminate claudication as
the source of pain and to assess the risk of post-
operative wound necrosis or limb ischemia. Poor
venous return can cause venous engorgement of
the wound and subsequent ischemia. Any patient
with compromised circulation should be assessed
by a vascular surgeon pre-operatively. Obesity is
also associated with an increased risk of wound
complications because the skin flaps tend to be
forcefully retracted to provide the necessary expo-
sure, thereby putting the soft tissues at increase
risk of devascularization (2). As well, the skin is
less adherent to its underlying vascularity in the
thick adipose layer predisposing the dermis to
separate from the subcutaneous layer with skin
retraction (4).
Prior to deciding on the appropriate skin incision,
the skin over the knee must be carefully assessed
to identify the previous incisions, the mobility of
the anterior soft tissues, the quality of the skin
and the presence of any pre-existing ulcerations
that would need to be treated prior to revision sur-
gery. Multiple scars or thin skin with scarring to
the underlying tibia should alert the surgeon to the
possibility of developing a wound dehiscence and
skin necrosis following revision TKA. It is essential
to anticipate potential wound complications pre-
operatively and deal with the problem at that time.
These patients should be evaluated pre-operatively
by a plastic surgeon to assist in determining the
appropriate skin incision as well as the need for a
sham incision, soft tissue expansion or a muscle
flap pre-operatively or a muscle flap for coverage
at the end of the surgical procedure. Muscle flaps
fl
are particularly helpful in revision of infected knee
arthroplasties since the flap provides the necessary
soft tissue coverage as well as increases the blood
flow in the area.
In a complex case, a sham incision can be used prior
to the revision to assess the viability of the skin.
The skin incision is made in the planned location
for the revision TKA. The incision is taken down to
the underlying capsule and flaps
fl are developed as
if an arthrotomy was to be done. ThThe capsule is not
opened and the wound is closed. If the wounds heal
990 Primary Total Knee Arthroplasty
without any necrosis or dehiscence, the definitive
fi
procedure can be planned using the same incision.
The sham incision has the advantage of predicting
the outcome of the proposed surgical incision and
since the capsule is not opened, it avoids the risk of
periprosthetic infection if the wound breaks down.
As well, the sham incision promotes the formation
of collateral circulation thereby increasing the sur-
vival of the skin flaps at the time of the revision
surgery. If there are wound complications, muscle
flap coverage is required for the revision TKA.
Soft tissue expansion has been designed to provide
additional skin and soft tissue coverage in surgical
cases where there is concern regarding the viability
of the soft tissues at the end of the procedure. Th
The
procedure was first
fi described for breast reconstruc-
tion by Neumann in 1957 and was subsequently
popularized by Radovan (5, 6). ThThe same principles
and technique have been used to successfully deal
with potential soft tissue problems in primary TKA
(7–9). Santore et al. were the first to describe the
use of a tissue expander in revision total knee sur-
gery (10). The
Th tissue expander was used in the case
of a 76-year-old female with an infected TKA. As a
result of multiple debridements and skin grafting,
she was left with an extremely adherent scar tissue
on the anterior proximal tibia. The tissue expander
was inserted prior to her revision TKA and allowed
for complete excision of the scar and a tension-free
closure with normal skin. The pre-emptive tissue
expansion eliminated the need for flaps and the
primary closure without tension allowed immedi-
ate post-operative range of motion and standard
rehabilitation which are contraindicated following
a muscle flap.
Soft tissue expanders act by increasing the sub-
cutaneous tension and thereby stimulating the
growth of skin and subcutaneous tissue. Th The skin
is not just merely stretched and the increase in skin
volume is proportional to size and volume of the
tissue expander. In addition, soft tissue expansion
improves the local blood supply as well it stimu-
lates neovascularization in the capsule around
the expander which enhances circulation to the
surrounding skin (11, 12). Soft tissue expansion
can also be used in cases where the prior incision
is not adequate for revision TKA. A new longitu-
dinal standard midline incision can be made and
at the end of the knee revision either the skin can
be closed routinely or, if there is redundant excess
tissue, the skin bridge between the prior incision
and the new midline incision can be excised and
the remaining edges re-approximated.
The technique involves the surgical insertion of the
tissue expansion device into a subcutaneous pocket
that is created underneath the healthy skin in the
region of the knee adjacent to the scar. This is typi-
cally in line with the planned arthrotomy incision.
One or more expanders have been used about the
knee and have even been expanded below previous
incisions if the skin is mobile and has a modest
amount of subcutaneous tissue (7, 10). TheTh tissue
expanders are of varying shapes and sizes and the
surface area of the base of the expander should
correspond to the size of the defect. With expan-
sion, the tissue should double in size, leaving half
to replace the skin of the defect. The remote port
used for subsequent saline injections to expand the
device, is placed in a small subcutaneous pocket
away from the expander so as to avoid inadvertent
puncture of the expander. The tissue expander is
partially expanded at the time of insertion to oblit-
erate the dead space and meticulous hemostasis is
obtained in order to avoid a post-operative seroma
or hematoma, which can cause skin necrosis. Th The
knee is immobilized in a splint for 1 week post-
operatively. Extreme care must be taken to avoid
compressive dressings that can result in skin ero-
sion. Serial infl
flation of the device is done on an
outpatient basis every 6–8 days. Sterile saline is
injected through the subcutaneous portal. The Th
amount injected is typically 10–15% of the current
volume of the expansion bag or until the patient
experiences pain. Pain is associated with an oxy-
gen skin tension of zero which can result in skin
necrosis (13). The average time for flap develop-
ment is typically between 3 and 6 weeks and the
last expansion is 2–3 weeks prior to the planned
revision TKA. The soft tissue expander is removed
at the time of revision surgery leaving the pseudo-
capsule that formed around it to be closed at the
end of the case. Leaving the pseudocapsule can
help maintain the vascularity of the area since the
region between the expander pseudocapsule and
the host tissue contains the majority of the new
blood vessels to the expanded skin (11).
Skin incision and vascularity
Although a straight midline incision is ideal for
exposure, the skin incision is usually dictated by
the previous incisions. Prior to making an incision,
all previous skin incisions should be identified
fi and
marked out so that can be easily seen after the leg
is prepped and draped. Utilization of the previous
skin incision is usually recommended. If making a
new incision, it is generally safe to ignore previous
short medial or lateral peripatellar incisions, but
wide scars with thin or absent subcutaneous tissue
can indicate damage to the underlying blood sup-
ply and should not be disregarded (4). Short skin
bridges, less than 2.5–6 cm, between long parallel
incisions can result in skin necrosis and must be
avoided. (7, 14) Longitudinal incisions can cross

transverse incisions at a right angle with almost
no risk to the underlying skin. However, incisions
that cross the previous incision at an angle less
than 60°, put the skin at the intersection of the
incisions at a risk of circulatory compromise and
subsequent necrosis.
Selecting the safe place to make a new incision in a
failed TKA with a previous incision requires knowl-
edge of the circulation to the skin of the anterior
aspect of the knee. Unlike the skin circulation to
the distal thigh, there are no underlying muscles
directly anterior to the knee to provide a direct
pathway for arterial perforators. (4, 15) Instead,
the skin anterior to the knee relies on the dermal
plexus which originates directly from arterioles
traveling within the subcutaneous fascia. Overall,
the vascular supply to the anterior knee area has a
pentagonal or hexagonal shape that is centered on
the patella (16) (Fig. 1).
The lateral side of the integument is always vascu-
larized by the superior and inferior lateral genicu-
lar arteries. The superior lateral genicular artery
gives off
ff an ascending cutaneous branch
to vascularize the upper lateral part of the patellar
area and anastomoses with a similar branch from
the descending genicular artery. In almost 70% of
knees, the longer and lateral part of the patellar
area is vascularized by the anterior tibial recurrent
artery, a branch of the anterior tibial artery. There
Th
is an increased risk of post-operative ischemia and
wound complications by division of the superior or
inferior lateral genicular arteries during a lateral
retinacular release (2, 16, 17). Therefore, if a lat-
Fig. 1 – Schematic drawing of the subdermal arterial network supplying
the skin of the anterior aspect of the knee – 1: anterior genicular artery, 2:
superior lateral genicular artery, 3: inferior lateral genicular artery, 4: ante-
rior tibial recurrent artery, 5: inferior medial genicular artery, 6: superior
medial genicular artery, 7: descending genicular artery, and 8: saphenous
artery.
Technique of revision: surgical approach 991
eral release is required, an attempt should be made
to try to preserve the superior lateral genicular
artery.
Generally, the integumental blood supply of the
medial side of the knee is by the descending genicu-
lar artery, the saphenous branch of the descending
genicular artery, and an anterior genicular branch
of the femoral artery. In 27% of knees, the medial
side of the integument is vascularized only by the
superior and inferior medial genicular branches of
the popliteal artery.
A series of subdermal anastomoses between the
medial and lateral sides is responsible for the sub-
dermal blood supply of the patellar integuments.
Although, the saphenous branch of the descending
genicular artery provides most of the blood supply
of the patellar area, the anterior genicular artery
and the inferior medial genicular artery are also
important in supplying the patellar integuments.
These smaller branches also provide transverse
anastomoses and probably increase the blood sup-
ply of the medial side of the patellar area.
The diameter of the cutaneous and anastomotic
vessels of the medial side of the knee are larger
than that of the lateral side, suggesting that the
subdermal cutaneous blood supply is mainly sup-
ported by the vessels of the medial side. However,
a well-developed network of subdermal anastomo-
ses between the medial and lateral vessels may also
provide a signifificant supply to the patellar integu-
ments. None-the-less, in the case of multiple, long,
parallel incisions, the most lateral incision allow-
ing appropriate exposure should be used. Th This
avoids the possibility of a large lateral skin fl flap
with marginal circulation. Furthermore, large, lat-
erally based flaps are frequently stretched during
the exposure and are forcefully retracted, which
can result in mechanical compromise of the lateral
skin. Similarly, wide, medial parapatellar skin inci-
sions which create a large, laterally based skin flflap
are associated with a higher rate of wound compli-
cations (2).
The network of arterial vessels of the anterior knee
is located in a superfi ficial subdermal plane ante-
rior to the patellar bursae. As a result, the skin
flaps should be limited in their size, kept as thick
as possible and all dissection should be below to
the deep fascia. Post-operative skin necrosis can
occur with extensive subcutaneous dissection in a
false plane. This is most likely to occur when try-
ing to find the correct plane in the region of the
previous scar. Therefore, it can be helpful to extend
the incision proximally into native tissue so that
the subcutaneous fascia can be identified fi and the
distal dissection can be carried out deep to it. The
Th
incision should also be extended distally if there is
excessive tension on the skin with flexion
fl of the
knee to avoid skin edge necrosis. TheTh skin should
992 Primary Total Knee Arthroplasty
be handled carefully with forceps and retractors
since excessive retraction can disrupt the perforat-
ing arterioles in the subcutaneous layer (3). Careful
hemostasis is important to avoid a post-operative
hematoma that can compromise the local blood
supply. Finally, the skin must be closed without
tension in order to help prevent skin necrosis.
Capsular incision and deep dissection
Identifi
fication of the medial border of the patella,
the apex of the quadriceps tendon, the patellar
tendon and the tibial tubercle is necessary prior to
the accessing the knee joint. A medial parapatellar
capsular incision is most commonly used because
of its extensile capabilities. This longitudinal cap-
sular incision extends from the from the junction
of the medial and central thirds of the quadriceps
tendon near its apex, runs parallel to the vastus
medialis, continues just medial to the patella and
the patellar tendon and ends just medial to the
tibial tubercle (Fig. 2).
After the capsular incision, all intra-articular
fibrous adhesions and scarring need to be released
or ressected. The scarring tends to be thick and
non-pliable, making the knee and patellar exposure
diffi
fficult. The adhesions and scarring in the medial
and lateral gutters are taken down. The Th proximal
tibia is then exposed. A medial sleeve, including
the medial capsule and the deep medial collateral
Fig. 2 – Schematic diagram of the knee illustrating a medial parapatellar
capsular incision (dotted line).
ligament, is elevated subperiosteally offff the medial
aspect of the tibia to the insertion of the semi-
membranosus tendon at the level of the midcoro-
nal plane (14). External rotation of the flexed
fl tibia,
as one exposes the proximal medial tibia, further
facilitates the exposure and relaxes tension on the
patellar tendon attachment thereby decreasing the
risk of tendon avulsion. Any further medial release
can be accomplished by extending the medial sub-
periosteal dissection more distally and elevating
the superfificial medial collateral ligament.
The next step is to mobilize the extensor mecha-
nism. The interval between the patellar tendon
and the tibia is recreated by excising any peripa-
tellar fibrotic tissue and fibrosed fat pad from the
inferior pole of the patella to the insertion of the
patellar tendon on the tibial tubercle. Care should
be taken not to release the patellar tendon from
the tubercle in order to avoid an intra-operative or
post-operative tendon avulsion. Fixation devices
such as a pin, towel clip, or staple can be passed
into the tibial tubercle to help stabilize the patellar
tendon and prevent tendon avulsion (14). Proxi-
mally, the interval between the extensor mecha-
nism and the underlying scar should be identified fi
at the level of the patellar after removal of the
meniscus of scar around the patellar component
(18). The quadriceps tendon and suprapatellar
adhesions and scar tissue are then lysed and debri-
ded to expose the tenosynovium of the tendon and
the anterior femur (19). With the knee in exten-
sion, any residual adhesions or scarring in the lat-
eral gutter can now be easily assessed and released
or excised.
If present, the modular tibial polyethylene liner can
now be removed in order to decrease the tension
on the patellar tendon. At this point, the patella
can either be subluxed laterally out of the way or
everted. If adequate exposure can be obtained
with subluxation of the patella, the patella should
not be everted so as to avoid the risk of avulsion
of the patellar tendon. If necessary, a lateral reti-
nacular release can be carried out to improve the
lateral exposure or allow eversion of the patella
(20). A lateral retinacular release is only helpful
in eversion of the patella in those cases where the
patella can almost, but not quite be everted (14).
The lateral retinacular release is performed from
inside out, releasing the retinaculum from the vas-
tus lateralis muscle to the proximal tibia (20). Care
should be taken to preserve the superior genicular
artery which is an important blood supply to the
lateral skin flap.
At this time, the patella can be everted and the
knee can be flexed up slowly while externally rotat-
ing the tibia. The
Th insertion of the patellar tendon
on the tibial tubercle must be carefully assessed to
make certain that the tendon is not being peeled
 Technique of revision: surgical approach 993

off
ff the tubercle or that there is excessive tension border of the patella, extending from the vastus
on the tendon so that it is at increased risk of avul- lateralis muscle to the proximal tibia. Care should
sion later on during the procedure. be taken to try to preserve the superior genicular
These principles of exposure can frequently pro-
Th artery. If after performing a quadriceps snip and a
vide the necessary exposure during revision TKA. lateral release the exposure is still not adequate, a
Sharkey et al. reported obtaining ample exposure tibial tubercle osteotomy can be performed. After
in 98% of the 207 consecutive revision TKAs using completing the revision TKA, the quadriceps snip
a standard medial arthrotomy with release of adhe- is closed in a side-to-side fashion using an absorb-
sions binding the extensor mechanism (19). Della able suture. Post-operative rehabilitation and
Valle et al. found that a medial capsular approach weight bearing status of the patient are unaffected
ff
combined with an extensive intra-articular syn- by the quadriceps snip.
ovectomy provided adequate exposure in 92% of
121 revision TKAs they evaluated (20). However,
if the exposure is inadequate and/or the knee can- Technique
not be flexed to 110° with the patella everted or
laterally translated without undue tension on the The quadriceps snip is a technically simple and
patellar tendon then further mobilization of the eff
ffective method of gaining exposure during revi-
extensor mechanism is required (3, 18, 20, 21). A sion TKA without injuring the extensor mecha-
more extensile approach can be obtained by releas- nism. Clinical results have demonstrated that
ing the extensor mechanism proximally, distally, this extensile approach does not interfere with
or both. Proximally, release of the extensor mecha- the patient’s clinical outcome. The initial report
nism can be done with a quadriceps snip or a quad- reviewed 16 patients who underwent a quadriceps
riceps turndown while distal release can be accom- snip (22). Using the Hospital for Special Surgery
plished with a tibial tubercle osteotomy. knee score, the knees of 10 patients were rated
as excellent and six were good. No patients had
an extensor lag. Objective assessment of these
patients by isokinetic testing demonstrated that
Quadriceps snip the operated knee that had a quadriceps snip was
not as strong as the contralateral normal knee in
Th quadriceps snip is a frequently used tech-
The patients with a unilateral knee replacement. How-
nique to obtain extensile exposure. This Th tech- ever, when testing patients with a contralateral pri-
nique was first conceived by Insall in 1998 while
assisting another surgeon, he observed that the
proximal portion of the quadriceps tendon had
been transected obliquely (22). After repairing the
tendon in a standard fashion, the patient had an
uneventful post-operative course. ThisTh fortuitous
observation resulted in the use of the quadriceps
snip as an alternative to the V–Y quadricepsplasty
and the tibial tubercle osteotomy in cases in which
exposure was difficult.
ffi
The surgical technique involves the modifi
Th fication
of a standard medial parapatellar arthrotomy.
Starting at the uppermost portion of the arthro-
tomy, the quadriceps tendon is incised in a lateral
oblique direction from distal to proximal at a 45°
angle into the vastus lateralis, allowing the patella
to be displaced distally and laterally (23) (Fig. 3).
This oblique incision has the advantage of being
directed in line with the vastus lateralis muscle
and away from the lateral superior genicular artery
and vastus lateralis tendon (20, 21, 23). Also, the
oblique snip avoids the need for an end-to-end
closure that would be required with a more trans-
verse incision. If the quadriceps snip does not pro-
vide adequate exposure, it can be combined with Fig. 3 – Schematic diagram of the knee illustrating the oblique extension
a lateral retinacular release done from inside out. of the medial parapatellar capsular incision in the orientation of the fibers
A longitudinal incision is made 1 cm lateral to the of the vastus lateralis to perform a quadriceps snip (dotted line).
994 Primary Total Knee Arthroplasty
mary TKA done through a standard medial parapa-
tellar arthrotomy to knees with a quadriceps snip,
there was no diff
fference (23).
Results
There is no discernable disadvantage of using a
quadriceps snip for exposure during revision TKA.
In a review of 123 consecutive revision TKAs, Bar-
rack et al. compared 63 knees that underwent a
standard medial parapatellar capsular incision to
31 knees that also had a quadriceps snip (24). At
2–4 year follow-up, the knees that had a quad-
riceps snip were equivalent to the knees with a
standard medial parapatellar approach in terms
of Knee Society clinical score, range of motion,
patellofemoral symptoms and patient satisfac-
tion. These results were signifi ficantly better than
those knees that had a tibial tubercle osteotomy or
quadriceps turndown. Corroborative findings have
been reported by Meek et al. in a review of 117 con-
secutive revision TKAs followed for an average of
40.5 months (25). They compared 57 knees with
a medial parapatellar approach to 50 knees with
a quadriceps snip and found no difference
ff in the
WOMAC, Oxford, SF-12, and Hospital of Special
Surgery scores, as well as patient satisfaction and
range of motion. The authors concluded that the
quadriceps snip had no effect
ff on the patient out-
come following revision TKA.
The combination of a quadriceps snip and lateral
Th
release is adequate for exposing the majority of
revision TKAs in which a standard approach with
a medial parapatellar arthrotomy alone does not
provide suffi
fficient exposure (21, 24). Garvin et
al. noted that the quadriceps snip had been used
exclusively to expose the difficult
ffi knee and had
completely eliminated the use of the patellar
turndown (22). In their review of 117 consecu-
tive TKAs, Meek et al. noted that the quadriceps
snip provided adequate exposure in those knees in
which a medial parapatellar approach was insuffi- ffi
cient and no patients required any other extensile
techniques (25). However, if the exposure gained
by a quadriceps snip is not sufficient
ffi at the time of
revision TKA, it can be easily supplemented with a
tibial tubercle osteotomy.
Tibial tubercle osteotomy
The extended tibial tubercle osteotomy (TTO)
extensile exposure has been described in associa-
tion with revision TKA as a useful technique for
extensile exposure of the knee joint (26–34). Ini-
tially described by Dolin, and subsequently modi-
fied and popularized by Whiteside, this osteotomy
allows access to the knee and proximal tibia dur-
ing revision TKA with excellent exposure (29, 32,
33) Indications for the TTO in revision TKA sur-
gery include suboptimal exposure with the use of
non-extensile measures or quadriceps snip, severe
patella infera, removal of well-fixed
fi cemented or
cementless stemmed/keeled tibial components,
proximal advancement of the extensor mechanism,
and at the second stage of a 2-stage re-implanta-
tion procedure for a previous infected TKA in asso-
ciation with a static/non-mobile cement spacer. A
TTO is infrequently required during revision TKA,
and is performed usually only after other measures
have failed to improve exposure. The advantages of
the TTO exposure include extensile access to the
knee joint by allowing safe lateral retraction of the
extensor mechanism, protection of the soft tis-
sue attachment of the patellar tendon at the tibial
tubercle, bony re-attachment with secure internal
fixation, immediate access to the proximal and
upper third of the tibia, and preservation of the
blood supply to the host extensor mechanism. Th The
disadvantages and limitations of the TTO include:
an osteotomy with the potential for non-union,
delayed union, osteotomy proximal migration, fail-
ure of internal fixation, hardware prominence over
the proximal tibia, periprosthetic fracture of the
tibia, and the need for a protected post-operative
physiotherapy program in order to reduce the risks
of osteotomy complications.
If the surgeon anticipates the use of a TTO at revi-
sion TKA, pre-operative templating and planning
allow for determination of length of osteotomy,
length of stemmed revision tibial component, and
the type of internal fixation
fi that will be required.
Adequate pre-operative radiographs include AP
and lateral views of the knee and entire tibia. If
there is osteolysis or compromise of the tibial
tubercle bone stock, this must be identifi fied pre-
operatively and is a relative contraindication to
TTO, as secure fixation is required to stabilize the
osteotomy (31).
Technique
Following completion of the medial parapatel-
lar capsular approach, synovial releases, medial
proximal tibial release, and release of the antero-
lateral fibrous tissue posterior and posterolateral
to the patellar tendon, the exposure is assessed. If
the surgeon feels that a proximal quadriceps snip
will allow suffi
fficient exposure for the revision TKA,
then this is completed. However, prior to perform-
ing a proximal extensile exposure such as a quad-
riceps snip or V–Y turndown, the surgeon should
assess whether the exposure is limited more dis-

tally or proximally. If the exposure is signifi
ficantly
limited distally and over the tibia, consideration
for a TTO is assessed. In addition, if there is the
need to remove a well-fifixed tibial component, or, if
the procedure involves a 2nd stage re-implantation
with significant
fi arthrofifibrosis, a TTO often facili-
tates exposure in such cases (30, 33).
The skin incision is extended 8–10 cm distally
beyond the region of the tibial tubercle and distally
over the anterior tibia (30, 33). The osteotomy may
be performed with the knee in extension or slight
flexion. High flexion is avoided due to the tension
on the extensor mechanism. The medial aspect of
the tibial tubercle and tibia distal to this are then
marked for the appropriate length of the osteot-
omy (Fig. 4). Ideally it is useful for the proximal
aspect of the osteotomy to end 7–10 mm below
the extent of proximal tibial host bone in order to
preserve a bone bridge proximal to the osteotomy
and prevent migration. However, this is not always
possible due to tibial preparation, removal of host
bone to accept the revision tibial base plate, and
the option of translating the osteotomy proxi-
mally. The osteotomy proximally should be thick
enough to prevent fragmentation, and typically
is 10–20 mm deep (31). It is better to create a
larger osteotomy segment, as too small of a tibial
tubercle segment may reduce the surface area for
healing and increase the potential for fragmenta-
tion or osteotomy fracture. As the osteotomy is
completed distally, it is beveled out of the anterior
cortex of the tibia in order to create a smooth exit
Fig. 4 – Illustration outlining the proposed tibial tubercle osteotomy. The
length is typically 8–10 cm, but will vary depending upon the indication
(Adapted from Ref. (3).).
Technique of revision: surgical approach 995
transition and reduce the risk of stress riser at the
distal aspect (30, 31). The length of the osteotomy
will vary depending on the indication, however a
length of 8–10 cm is typically used (26, 27, 30, 31,
33, 34). While a shorter length osteotomy may be
an option, extending the length slightly allows for
a larger segment and surface area for healing and to
secure internal fixation. The osteotomy is started
proximally with a small microsagittal saw using a
thin blade in order to minimize bone loss. TheTh saw
is used to carefully perforate the lateral cortex of
the tibia, with caution not to violate the soft tis-
sues of the anterior compartment. The Th saw is then
advanced distally and the osteotomy is finally bev-
eled at the distal aspect. The distal aspect may also
be completed using a transverse cut, however this
creates an abrupt ending and may increase the risk
of a stress riser at the distal aspect (32, 33). Alter-
natively, the medial aspect of the osteotomy may
be performed with the saw, and the lateral side
completed with multiple small drill-hole perfora-
tions, or with the use of a ¼” osteotome. Using
two flat osteotomes, the osteotomy is carefully
opened proximally and distally (Fig. 5). Caution to
not abruptly lever open the osteotomy will reduce
the risk of osteotomy breakage. One key aspect
of performing the TTO successfully is recogniz-
ing that following completion of the osteotomy,
Fig. 5 – Intra-operative photograph illustrating the lateral opening of the
tibial tubercle osteotomy with a broad osteotome. The osteotomy is hinged
laterally, with preservation of the lateral muscular and soft-tissue attach-
ments. The tibial side of the osteotomy bed is outlined in black.
996 Primary Total Knee Arthroplasty
the proximal anterolateral tibia is attached with
fibrous tissue to the osteotomy segment. Release
of this tissue is required only at the very proximal
aspect of the tibia, adjacent and for 2–5 mm below
the tibial surface in order to be able to evert, mobi-
lize, and laterally retract the osteotomy and exten-
sor mechanism. In addition, the lateral soft tissue
attachments of the anterior compartment muscle
must be retained and protected in order to main-
tain vascularity to the osteotomized tibial tuber-
cle. The knee is then gently flexed and the foot and
lower leg externally rotated to reduce tension on
the extensor mechanism. The osteotomy will then
slide laterally, and may be partially everted, allow-
ing access to the entire proximal tibia for the revi-
sion TKA.
Fixation of the osteotomy must be considered prior
to placing the final
fi stemmed tibial component since
the tibial stem will affffect the type and placement
of the fixation. Following trial reduction of the tib-
ial component, the proximal tibia is prepared for
fixation of the osteotomy. Two methods of fixation
may be considered: wire/cable fixation,
fi or screw fix-
ation (or a combination). Classically, wire fixation
fi
with the use of 2–4 stainless steel #16 g wires are
used (32, 33). Three
Th small drill holes (1.5–2.0 mm)
are made in the lateral aspect of the tubercle frag-
ment approximately 2 cm apart. ThreeTh similar drill
holes are then made in the medial tibia, slightly
distal to the holes in the tubercle, in order for the
Fig. 6 – Illustration demonstrating fixation of the osteotomy. The cables/
wires are passed beneath the osteotomy bed, perforate through the lateral
muscular soft tissue attachment, then over the osteotomy fragment and are
tightened medially (Adapted from Ref. (3).).
fixation to act in tension. The wires/cables are then
inserted into the host bone and brought to their
position for tightening. ThThe stemmed tibial compo-
nent (with or without cement) is then inserted. At
this stage it is important to ensure that if cement is
used, the cement does not enter into the tibial side
of the trough or bed for the osteotomy. Once the
components have been inserted, the osteotomy is
reduced into an anatomical position with the knee
in extension, and held secure with a provisional
reduction tenaculum. At this stage, if there is an
indication to advance the osteotomy proximally,
this may be performed. If an advancement is per-
formed, trimming of a small amount of bone with
a rongeur may be required at the proximal tip of
the tubercle osteotomy segment. The Th wires or
cables are then tightened and secured, cut over
the medial tibia, and then bent against the medial
tibial bone in order to reduce hardware promi-
nence. Alternatively, the drill is used to drill across
the anterior tibia just at the depth or base of the
osteotomy, and the wires are passed from medial
to lateral at the base of the osteotomy (Fig. 6). They
are then passed by making a small perforation in
the anterior-lateral compartment soft tissues,
bringing them over top of the osteotomy segment,
and tightened medially, with secure fixation
fi over
the top of the osteotomy segment (26, 27, 30, 31).
The use of stainless steel wires may be associated
with wire breakage during twisting and tensioning
of the fixation, which can be a problem once the
tibial component has already been inserted. Th This
problem is largely eliminated with the use of low-
profifile 2 mm cables (Whiteside Biomechanics, St
Louis MO) instead of wires. These cables provide
increased fixation strength, reduce the risk of fixa-
tion failure, and off
ffer low-profi
file cable locking over
the medial tibia compared to other bulky cable sys-
tems (Fig. 7). Autogenous cancellous bone graft is
then packed into any areas of the osteotomy that
are visible.
Fixation of the TTO with the use of screws may be
considered in larger osteotomies and in patients
with adequate host bone (26, 27, 31). Screws
may also provide for better compression perpen-
dicular to the osteotomy (26, 27). With the use
of stemmed tibial components, screws must be
angled obliquely medially and laterally in order to
bypass the stem. Two to four small fragment 3.5
mm (or 4.5 mm large fragment) cortical screws
may be used (Fig. 8). The Th use of titanium screws
may be preferred since stainless steel screws that
come in contact with a titanium or cobalt-chrome
tibial stem may be associated with galvanic corro-
sion (31). Due to the long length of these screws,
it is often necessary to have the pelvic small frag-
ment screw set available. The disadvantages of
screw fixation include the potential for osteotomy

segment breakage or fragmentation during drilling
or screw insertion (34).
Intra-operatively the TKA range of motion is
assessed by gently flexing the knee to determine
the strength of the repair and the degree of safe
active flexion that will be allowed post-operatively.
Post-operative rehabilitation and physiotherapy
following a revision TKA with the use of a TTO is
Fig. 7 – Post-operative lateral radiograph of a knee demonstrating the
use of low-profile 2 mm cables instead of wires to close the tibial tubercle
osteotomy following revision TKA.
A B
Fig. 8 – Anteroposterior (a) and lateral (b) radiographs following revision TKA demonstrating fixation of a tibial tubercle osteotomy with two,
3.5 mm small-fragment cortical screws. The suture anchors are from a previous patellar tendon avulsion repair.
Technique of revision: surgical approach 997
more conservative in order to protect the osteot-
omy repair and reduce the risk of osteotomy com-
plications. Active range of motion is permitted,
to a maximum determined by the intra-operative
stability and fixation of the osteotomy. No passive
or passive assisted ROM is allowed for the first fi
12–16 weeks in order to protect the repair. Weight
bearing as tolerated is permitted with a hinged
rehabilitation brace locked in full extension. Dur-
ing physiotherapy, the maximum flexion is ‘locked
out’ on the brace in order to limit flexion. Progres-
sion of physiotherapy and motion exercises will
depend upon the intra-operative findings, patient
compliance, and fixation of the osteotomy. Brac-
ing is typically discontinued at 12 weeks at the
discretion of the surgeon. Attempts at achieving
high flexion should be discouraged in the initial
12–16 weeks, and direct communication between
surgeon, physical therapist, and patient will help
reduce post-operative osteotomy complications.
Results
The original technique of TTO used in primary
TKA, reported no complications with the use of a
thin and short osteotomy segment, single screw-
in-cement fixation, and an osteotomy that did not
involve the full cortex of the anterior tibia (29, 35).
Wolff
ff et al. later reported on the complications with
the use of a TTO in revision TKA (34). In 26 knees,
there was a 23% major complication rate including
998 Primary Total Knee Arthroplasty
loss of osteotomy fixation,
fi extensor mechanism
disruption, and significant
fi wound problems. An
increased failure rate was associated with a short
(<3 cm) osteotomy and fixation with only a single
screw or staple. This technique has been modifi fied by
Whiteside to include the use of a longer (8–10 cm),
thicker osteotomy segment, fixed
fi with three cobalt
chrome wires passed through the medial tibia
and the lateral tubercle osteotomy segment, and
angled inferiorly at 45° (32, 33). With the use of
this technique, Whiteside has reported on 136
knees undergoing a TTO at revision (86 knees),
primary (26 knees), and TKA infection (24 knees)
surgery (33). All the osteotomies united and the
post-operative range of motion averaged 94°. Th The
complication rate was only 5% with two knees hav-
ing an extensor lag, two proximal avulsions of the
osteotomy segment, and 3 tibia fractures.
Two studies have compared the use of two screws
to cerclage wire fixation in a cadaveric model using
a TTO with a stemmed tibial component (26, 27).
A proximal bevel cut to the osteotomy was also
compared to a shelf of bone maintained proximally.
The use of two 4.5 mm cortical screws for fixation
showed signif
nism, a V–Y turndown may not provide adequate
exposure distally. In such cases the use of a TTO is
preferable, and avoids the devascularization of the
V–Y turndown.
The V–Y turndown was originally described by
Coonse and Adams as an extensile exposure for
contracture of the extensor mechanism of the knee
(36) (Fig. 9). Th
The technique was modifi fied by Scott
and Siliski to preserve the superior lateral genic-
ulate artery and to facilitate exposure and gain
flexion during TKA in the ankylosed knee (37).
However, with preservation of the superior lateral
geniculate artery (SLGA), a limited turndown of
the extensor mechanism occurs. Aglietti et al. and
Insall further modifi fied the exposure to describe
the patellar turndown for TKA in the stiff ff or anky-
losed knee (38, 39). The
Th modifi fication extends the
lateral arm of the ‘V’ distally, through the SLGA
but allows for preservation of the inferior lateral
geniculate artery (ILGA) while maintaining the
integrity of the vastus medialis (Fig. 10). However,
in the multiply operated knee and prior TKA sur-
gery, the ILGA may already be compromised. Th The
primary concern with this exposure is the poten-