Lower Extremity Joint Preservation: Techniques for Treating the Hip, Knee, and Ankle

Foreword
Preface
Contents
Part I: Hip
1: Comprehensive Hip Preservation: Correction of Adult Hip Dysplasia and Repair of High-Grade Cartilage Injury
1.1 Introduction
1.2 Diagnostic Imaging in Adult Hip Dysplasia
1.3 Correction of Hip Dysplasia and Open Treatment of High-Grade Cartilage Injury
1.3.1 Periacetabular Osteotomy: Surgical Technique
1.3.2 Surgical Dislocation of the Hip: Surgical Technique
1.4 Cartilage Repair in the Setting of Alignment Correction
1.4.1 Marrow Stimulation in the Hip
1.4.2 Autologous Chondrocyte Implantation in the Hip
1.4.3 Mesenchymal Stem Cell/Signaling Cell Treatment of Hip Chondral Defects
1.4.4 Osteochondral Transfer and Transplantation in the Hip
1.5 Summary
References
2: Anatomy of the Hip Joint Preservation Point of View
2.1 Introduction
2.2 Blood Supply
2.3 Nerves
2.4 Hip Muscles
2.5 Hip Flexors
2.6 Hip Extensors
2.7 Hip Abductors
2.8 Hip Adductors
2.9 External Rotators
2.10 Internal Rotators
2.11 Remarks
References
3: Anatomy, Surgical Management, and Postoperative Outcomes of Acetabular Labral Tears
3.1 Introduction
3.2 The Anatomy of the Labrum
3.2.1 Innervation
3.2.2 The Vascular Supply
3.3 The Aetiology of Hip Labrum Disorders
3.3.1 Types of Labral Lesions
3.4 The Role of the Acetabular Labrum in Hip Disorders
3.4.1 The Function of the Labrum
3.4.2 Changes in Load Distribution
3.4.3 The Radiographic Characteristics of Labral Tears
3.4.4 Labral Tears and OA
3.4.5 Labral Tears and Hip Dysplasia
3.5 Patient Evaluation
3.5.1 Clinical Examination
3.5.2 Diagnostic Imaging
3.6 Surgical Treatment
3.6.1 Indications for Surgery
3.6.2 Surgical Technique for Labral Reconstruction
3.6.3 Postoperative Management (Debridement, Repair, Reconstruction)
3.6.3.1 Outcomes and Prognosis
3.6.3.2 Return to Sports
References
Part II: Knee
4: Bone Marrow Stimulation Techniques for Cartilage Repair
4.1 Introduction
4.2 The Different Basic Techniques for Bone Marrow Stimulation
4.2.1 Subchondral Drilling
4.2.2 Abrasion Arthroplasty
4.2.3 Microfracture
4.2.4 Mobilization (According to Steadman [3])
4.2.4.1 Femoral Condyle and Tibia Plateau
4.2.4.2 Patella
4.3 Matrix-Associated Bone Marrow Stimulation Techniques (MA-BMS)
4.3.1 Carbon Rods and Pads
4.3.2 Trans Arthroscopic Implant
4.3.3 Implant of Carbon Fiber Plate
4.4 AMIC (Autologous Matrix-Induced Chondrogenesis)
4.4.1 Osteochondral Matrix Plugs
4.4.2 Coral Exoskeleton
4.4.3 Blood Clot Augmentation
4.4.4 UV Light Stabilized Gel for Cartilage Repair
4.4.5 Large Cartilage Bone Damage Treated with Bone Marrow Stimulation
4.5 Conclusion
References
5: One-Step Cell-Based Cartilage Repair in the Knee Using Hyaluronic Acid-Based Scaffold Embedded with Mesenchymal Stem Cells Sourced from Bone Marrow Aspirate Concentrate (HA-BMAC)
5.1 Introduction
5.2 Cartilage Repair: An Ongoing Evolution of Technique
5.3 Mesenchymal Stem Cells and Associated Bioactive Factors
5.4 HA-BMAC Cartilage Repair
5.5 HA-BMAC Cartilage Repair: Preoperative Considerations
5.5.1 Diagnostic Imaging
5.5.1.1 Plain Radiography
5.5.1.2 Magnetic Resonance Imaging
5.5.2 Correction of Malalignment: The Role of Osteotomy
5.6 HA-BMAC Surgical Technique
5.6.1 Rehabilitation Protocol
5.7 Summary
References
6: Chondrocyte Implantation
6.1 Indication and Basic Science
6.2 General Techniques
6.2.1 Cartilage Harvest
6.2.2 Harvest Sites
6.2.3 In Vitro Cell Expansion
6.2.4 The Chondrocyte Implantation
6.2.5 Coexisting Knee Pathology
6.2.6 Biomechanical Malalignment
6.2.7 Joint Stability
6.2.8 Meniscal Damage and Loss
6.2.9 Osteochondral Defects
6.3 More Exact Technical Descriptions
6.3.1 First- and Second-Generation ACI
6.3.2 Harvest of Periosteum
6.3.3 Periosteal or Collagen Patch Suturing (Fig. 6.1a–d)
6.3.4 ACI Third-Generation ACI
6.3.4.1 Chondrocytes Grown Inside a Scaffold
6.3.4.2 Chondrocyte Implantation as a Cell Carrier
6.4 Postoperative Rehabilitation
6.5 Expected Outcomes
6.5.1 Imaging Evaluation of the Cartilage Repair
6.6 Conclusion
References
7: Joint Preservation with Stem Cells
7.1 Introduction
7.2 The Stem Cells
7.3 Stem Cell Sources and Delivery
7.4 The Mode of Action of Stem Cells
7.5 Stem Cells, Chondrocytes, or Chondrons in Cocultures
7.6 One-Stage Procedures
7.7 Summary
References
8: Cartilage Pathology and Repair: Fresh Allografts
8.1 Introduction
8.2 Indications (Table 8.1)
8.3 Contraindications
8.4 Preoperative Planning
8.5 Operative Procedures
8.6 Surgical Techniques
8.6.1 Dowel Technique (Plug Technique) (Figs. 8.3, 8.4, and 8.5)
8.6.2 Shell Graft Technique
8.7 Postoperative Care
8.8 Outcomes
8.9 Return to Sports
8.10 Complications
8.11 Conclusion
References
9: Synthetic and Mini-metal Implants in the Knee
9.1 Introduction
9.2 Indications
9.3 Episealer Implant (Episurf, Sweden)
9.4 HemiCAP/UniCAP System (Arthrosurface, USA)
9.5 BioPoly (Schwartz Biomedical, USA)
9.6 Mini-metal Implants Basic Science
9.7 Surgical Technique
9.7.1 Episealer Technique
9.7.1.1 Technique for Insertion of Twin Episealer
9.7.2 HemiCAP and UniCAP Surgical Technique
9.7.3 BioPoly Surgical Technique
9.8 Postoperative Care and Rehabilitation
9.9 Published Clinical Results
9.10 Discussion
9.11 Conclusion
References
10: Knee Joint Preservation Rehabilitation
10.1 Introduction and Background
10.1.1 Principles of Knee Joint Preservation Rehabilitation
10.1.1.1 Overview of the Rehabilitation Process
10.1.2 Pre-operative Rehabilitation Management (Prehabilitation)
10.1.2.1 Education
10.1.2.2 Conditioning
10.1.3 Post-operative Rehabilitation Management
10.1.3.1 Progressive Motion
10.1.3.2 Progressing Weight Bearing
10.1.3.3 Muscle Strengthening
10.1.3.4 Neuromuscular Re-education
10.1.3.5 Therapeutic Exercises and Return to Activity
10.2 Rehabilitation Outcome Measures
10.3 Summary
References
11: Meniscus Anatomy
11.1 Medial Meniscus
11.1.1 Zone 1 Anterior Root
11.1.2 Zone 2 Anteromedial Zone
11.1.3 Zone 3 Medial Zone
11.1.4 Zone 4 Posterior Zone
11.1.5 Zone 5 Posterior Root
11.1.6 Differences Between Male and Female
11.2 Lateral Meniscus
11.2.1 Anterior Root
11.2.2 Anterior Horn
11.2.3 Popliteus Hiatus Area
11.2.4 Menisco-femoral Ligaments
11.2.5 Posterior Root
References
12: Current Concepts in Meniscus Pathology and Repair
12.1 Introduction
12.2 Meniscus Pathology
12.2.1 Typical Meniscus Injuries and Healing Potential
12.2.2 Meniscus Root Injuries
12.2.3 Ramp Lesions
12.2.4 Discoid Meniscus
12.3 Meniscus Repair
12.3.1 Typical Meniscus Injuries
12.3.1.1 Indications
12.3.1.2 Techniques
12.3.1.3 Outcomes
12.3.2 Meniscus Root Injuries
12.3.2.1 Indications
12.3.2.2 Techniques
12.3.2.3 Outcomes
12.3.3 Ramp Lesions
12.3.3.1 Indications
12.3.3.2 Techniques
12.3.3.3 Outcomes
12.3.4 Discoid Meniscus
12.3.4.1 Indications
12.3.4.2 Techniques
12.3.4.3 Outcomes
12.3.5 Biologic Augmentation
12.3.6 Post-operative Rehabilitation
12.3.7 Revision Meniscal Repair
12.3.8 Meniscal Deficiency
12.4 Conclusion
References
13: Meniscus Allograft Transplantation
13.1 Introduction
13.2 Evaluation of the  Post-meniscectomy Knee
13.3 Indications
13.4 Types of Graft
13.5 Sizing of Allograft
13.6 Surgical Technique
13.7 Rehabilitation
13.8 Results
References
14: Biomaterials in Meniscus Repair
14.1 Introduction
14.2 Biomaterials in Clinical Practice of Meniscus Repair Technique
14.2.1 Augmentation of Meniscus Repair with Fibrin/Blood Clots [21–25]
14.2.1.1 Indication
14.2.1.2 Techniques
Technique 1
Fibrin Clot Preparation I
Implantation of the Graft to the Meniscal Defect
Technique 2
Fibrin Clot Preparation II
Implantation of the Graft to the Meniscal Defect
Fibrin Clot Preparation III
Implantation of the Graft to the Meniscal Defect
Fibrin Clot Shuttling/Suture Tying
Post-op Rehab
Expected Outcomes
14.2.2 Augmentation of Meniscus Repair with Platelet-Rich Plasma [26, 27]
14.2.2.1 Indication
14.2.2.2 Techniques
Technique 1
Technique 2
Post-op Rehab
Expected Outcomes
14.2.3 Augmentation of Meniscus Repair by Wrapping [28, 29]
14.2.3.1 Indication
14.2.3.2 Techniques
Post-op Rehab
Expected Outcomes
14.2.4 CMI: Collagen Meniscus Implant [30–33]
14.2.4.1 Indication
14.2.4.2 Techniques
Post-op Rehab
Expected Outcomes
14.2.5 Actifit: Polyurethanes (PU) (Orteq Ltd, London, UK) [34, 35]
14.2.5.1 Indication
14.2.5.2 Techniques
Post-op Rehab
Expected Outcomes
14.3 Biomaterials in Preclinical Study of Meniscus Repair Technique
14.3.1 Augmentation of Meniscus Repair with Tissue Adhesives
14.3.2 Non-resorbable Polymers and Resorbable Polymers
References
15: Internal Bracing of the Anterior Cruciate Ligament and Posterior Cruciate Ligament with Suture Tape Augmentation
15.1 Introduction
15.2 Anterior Cruciate Ligament Internal Bracing
15.2.1 Surgical Technique
15.2.2 Rehabilitation
15.2.3 Expected Outcomes and Discussion
15.2.4 Conclusion
15.3 Posterior Cruciate Ligament Internal Bracing
15.3.1 Surgical Technique
15.3.2 Rehabilitation
15.3.3 Expected Outcomes and Discussion
15.3.4 Conclusion
15.3.5 Conclusion
References
16: Anterior Cruciate Ligament Reconstruction
16.1 Introduction
16.1.1 Anatomy
16.1.2 Biomechanics
16.1.3 Operative Techniques
16.1.3.1 Timing
16.1.3.2 Graft Options
16.1.3.3 Techniques
Single-Bindle ACL Reconstruction
Double-Bundle ACL Reconstruction
16.1.4 Anterolateral Complex (ALC) Reconstruction
16.1.4.1 Outcomes
16.1.4.2 Rehabilitation
References
17: Preservation of the Anterior Cruciate Ligament: Arthroscopic Primary Repair of Proximal Tears
17.1 Introduction
17.2 History of Primary Repair
17.3 Rationale for Modern-Day Repair
17.3.1 Limitations of Traditional Open Repair
17.3.2 Advantages of ACL Preservation
17.4 Patient Selection
17.4.1 Tear Type and Tissue Quality
17.4.2 Incidence of Primary Repair
17.4.3 Timing
17.4.4 Patient Characteristics
17.5 Surgical Technique
17.5.1 Surgical Setup
17.5.2 Ligament Suturing
17.5.3 Ligament Fixation
17.5.4 Additional Internal Brace Augmentation
17.6 Rehabilitation
17.7 Outcomes of Primary ACL Repair
17.8 Future Directions
17.9 Conclusions
References
18: The Anterolateral Ligament
18.1 Introduction
18.1.1 Indications
18.2 Surgical Techniques
18.2.1 Anatomical ALL Reconstruction
18.2.2 Lateral Extra-articular Tenodesis (LET)
18.3 Outcomes
18.3.1 Biomechanical Outcomes
18.3.2 Clinical Outcomes
18.3.2.1 Effect on Subjective Outcome Scores
18.3.2.2 Effect on Graft Re-rupture Rates
18.3.2.3 Effect on Medial Meniscus Repair
18.3.3 Complications
References
19: ACL and Cartilage Lesions
19.1 Introduction
19.1.1 Epidemiology
19.2 Cartilage Lesion and Timing of the ACL Surgery
19.2.1 Effect of Cartilage Injuries on ACL Reconstruction Outcomes
19.2.2 Results of Cartilage Repair and ACLR
19.2.3 Which Cartilage Lesion Must Be Repaired at the Time of ACL Reconstruction?
19.2.4 Influence on Physiotherapy Protocol
19.3 Technical Considerations
19.3.1 Patient Information
19.4 Conclusion
References
20: Repair and Reconstruction of the Medical Collateral Ligament
20.1 Anatomy
20.2 Biomechanical Properties of the Medial Knee Structures
20.3 Injury Classifications (Table 20.1)
20.4 Clinical Evaluation of Valgus Instability
20.4.1 Stress Radiography
20.4.2 Anteromedial Instability and Posteromedial Injury Assessment (Table 20.1)
20.5 Indications for Surgical Treatment of MCL Lesion (Table 20.2)
20.5.1 Indication for Medial Repair
20.5.2 Indication for Medial Reconstruction
20.6 Surgical Techniques
20.6.1 MCL Repair Techniques
20.7 Anatomical MCL Reconstruction Techniques
20.7.1 LaPrade–Engebretsen MCL Reconstruction Technique
20.7.2 Danish MCL Reconstruction Technique (Fig. 20.1)
20.8 Post-op Rehab
20.9 Expected Outcomes
20.9.1 Clinical Outcome After MCL Repair Surgery
20.9.2 Clinical Outcome After Anatomical MCL Reconstruction
References
21: The Posterolateral Ligament Complex of the Knee
21.1 Introduction
21.2 Anatomy
21.3 Epidemiology
21.4 Evaluation
21.5 Imaging
21.6 Treatment
21.7 Conclusion
References
22: Patellar Instability
22.1 Introduction
22.2 History
22.3 Anatomy, Biomechanics, and Risk Factor Stratification
22.3.1 Dynamic and Static Soft Tissue Stabilizers
22.3.2 Q Angle and Lateralized Force Vector
22.3.3 Coronal and Axial Alignment
22.3.4 Patellar Height
22.3.5 Trochlear Dysplasia
22.4 Treatment Plan
22.4.1 Nonoperative Treatment
22.4.2 Surgical Treatment
22.5 Surgical Indications
22.5.1 Soft Tissue Procedures
22.5.1.1 Medial Patellofemoral Restraint Reconstruction (MPRR)
Proximal Restraints: MPFL and/or MQTFL
Distal Restraint: MPTL
22.5.1.2 Lateral Retinacular Lengthening (LRL)
22.5.2 Bony Procedures
22.5.2.1 Tibial Tuberosity Osteotomy (TTO)
22.5.2.2 Coronal Plane or Rotational Osteotomy
22.5.2.3 Trochleoplasty
22.6 Surgical Technique
22.6.1 Soft Tissue Procedures
22.6.1.1 Medial Patellofemoral Restraint Reconstruction (MPRR)
Proximal Restraints: MPFL and/or MQTFL Reconstruction
Distal Restraint: MPTL Reconstruction
22.6.1.2 Lateral Retinacular Lengthening (LRL)
22.6.2 Bony Procedures
22.6.2.1 Tibial Tuberosity Osteotomy (TTO)
22.6.2.2 Trochleoplasty
22.7 Rehabilitation
22.7.1 Soft Tissue Procedures
22.7.2 Bony Procedures
22.8 Outcomes and Complications
22.8.1 Soft Tissue Procedures
22.8.1.1 MPRR: Proximal Restraints – MPFL and/or MQTFL Reconstruction
Outcomes
Complications
22.8.1.2 MPRR: Distal Restraint – MPTL Reconstruction
Outcomes
Complications
22.8.1.3 Lateral Retinacular Lengthening (LRL)
Outcomes
Complications
22.8.2 Bony Procedures
22.8.2.1 Tibial Tuberosity Osteotomy (TTO)
Outcomes
Complications
22.8.2.2 Coronal Plane or Rotational Osteotomy
Outcomes
Complications
22.8.2.3 Trochleoplasty
Outcomes
Complications
22.9 Conclusion
References
23: Arthroscopic Trochleoplasty
23.1 Introduction and Basic Science
23.2 Indications
23.3 Contraindications
23.4 Technique
23.5 Preparation and Portal Placement
23.6 Creation of the Cartilage Flap
23.6.1 Formation and Shaping of a Deeper Trochlear Groove
23.6.2 Fixation of the Cartilage Flap
23.7 Postoperative Regime
23.8 Expected Outcomes
23.9 Complications
23.10 Discussion
23.11 Conclusion
References
24: Open Trochleoplasty
24.1 Introduction and Basic Science
24.1.1 Trochlear Dysplasia and Trochleoplasty
24.1.2 Factors of Patellofemoral Stability
24.1.3 “Pathologic” Anatomy of Trochlear Dysplasia
24.1.4 Pathomechanism of Patella Dislocation in Trochlear Dysplasia
24.1.5 Surgical Indication for a Trochleoplasty
24.1.6 Target of Trochleoplasty
24.1.7 Surgical Technique
24.1.7.1 The Surgical Procedure
24.1.7.2 The Role of the MPFL
24.2 Postoperative Management
References
25: Patellofemoral Osteotomies
25.1 Introduction
25.2 Indications
25.2.1 Diagnostic Parameters
25.3 Techniques
25.3.1 Tibial Tubercule Osteotomies
25.3.1.1 Distalization (Lyon Procedure)
25.3.1.2 Proximalization
25.3.1.3 Medialization-Distalization (Elmslie-Trillat Technique, ET)
25.3.1.4 Anteromedialization (Fulkerson) [18]
25.3.1.5 Partial Medialization [MPTL Reconstruction acc. Zaffagnini]
25.3.2 Rotational and Frontal Malalignment
25.3.2.1 Tibial Derotational Osteotomies
25.3.2.2 Femoral Osteotomies
25.3.3 Patella Osteotomies (Patelloplasty)
25.3.3.1 Partial Facetectomy
25.4 Fractures, OA and Patellectomy
25.5 HTO for the OA and PFJ
25.5.1 Technical Note
25.6 Rehabilitation
References
26: Unloading Osteotomies Around the Knee
26.1 Introduction
26.2 Indication and Goals of Osteotomies
26.3 Procedure and Techniques
26.4 Expected Outcomes and Possible Joint Restoration
26.5 Return to Work and Sports
26.6 Conclusion
References
27: Joint Preservation by Articular Joint Unloading
References
28: Overload Assessment and Prevention in Knee Joint Malalignment Using Gait Analysis
28.1 Introduction
28.2 Gait Analysis
28.2.1 Optical and Optoelectronic Systems
28.2.2 Inertial Systems
28.2.3 Electromyography
28.2.4 Systems for the Substrate Reaction Measurement
28.2.5 Medical Imaging Technique
28.2.6 Application of Gait Analysis
28.2.7 At What Stages of Rehabilitation Should the Gait Assessment Be Used?
References
29: Return to Sports After Knee Surgery for Intraarticular Pathology
29.1 Introduction
29.2 Return to Sports After ACL Reconstruction Procedures
29.3 Return to Sport After Osteotomies Around the Knee
29.4 Return to Sport After Meniscal Repair, or Transplantation
29.4.1 Meniscal Repair
29.4.2 Meniscal Allograft Transplantation (MAT)
29.5 Return to Sports After Patellofemoral Stabilisation Procedures
29.6 Return to Sports After Cartilage Repair Procedures
29.6.1 RTP After Debridement
29.6.2 RTP After Bone Marrow Stimulation
29.6.3 RTP After Osteochondral Transfer
29.6.4 RTP After Autologous Chondrocyte Implantation
References
Part III: Ankle
30: Ankle Joint Cartilage Pathology and Repair
30.1 Introduction
30.1.1 Pathology
30.2 Treatments
30.2.1 Bone Marrow Stimulation (BMS): Microfracture/Drilling
30.2.2 Cartilage Allograft Augmentation
30.2.3 Autologous Osteochondral Transplantation
30.2.4 Osteochondral Allograft Transplantation
30.2.5 Autologous Chondrocyte Implantation
30.2.6 Scaffold-Based Therapies
30.2.6.1 Matrix-Induced Autologous Chondrocyte Implantation (MACI)
30.2.6.2 Autologous Matrix-Induced Chondrogenesis (AMIC)
30.2.6.3 Bone Marrow-Derived Cell Transplantation (BMDCT)
30.2.7 Biologic-Based Therapies
30.2.7.1 Platelet-Rich Plasma (PRP)
30.2.7.2 Concentrated Bone Marrow Aspirate (CBMA)
30.3 Summary
References
31: Ankle Rehabilitation
31.1 Introduction
31.2 General Instructions for the Ankle Rehabilitation
31.2.1 Rehabilitation in Reconstruction of Anterior Talofibular Ligament (ATFL)
31.2.1.1 Preoperative Phase
31.2.1.2 Postoperative Phase
31.2.2 Rehabilitation in Ankle Arthroscopy for Anterolateral Impingement
References