Master techniques in orthopaedic surgery. The shoulder. Download PDF. Recommend Documents. Master techniques in orthopaedic surgery: The shoulder. Master techniques in orthopaedic surgery: The elbow. Master techniques in orthopaedic surgery: The wrist. Master techniques in orthopaedic surgery reconstructive knee surgery.
Home Contact us Help Free delivery worldwide. Free delivery worldwide. Bestselling Series. Harry Potter. Popular Features. Home Learning. Notify me. Description This volume of the acclaimed Master Techniques in Orthopaedic Surgery series is now in its completely revised and updated Third Edition. The world's foremost experts in knee arthroplasty describe their preferred techniques in step-by-step detail, explain the indications and contraindications, identify pitfalls and potential complications, and offer pearls and tips for improving results.
The book is thoroughly illustrated with full-color, sequential, surgeon's-eye view intraoperative photographs, as well as drawings that reveal underlying anatomy. Let's Change The World Together. Pdfdrive:hope Give books away. Patellar tracking is observed as the knee is extended from a flexed position.
The patella has a tendency to slip laterally as the knee approaches the last 20 degrees of extension and the patella is no longer constrained by the lateral trochlear ridge J sign.
Patellar translation is assessed by pushing on the medial side of the patella with the knee in full extension. The amount of translation is quantified in quadrants and compared to the normal contralateral knee.
An indistinct endpoint suggests MPFL incompetence. A feeling of apprehension apprehension sign supports the diagnosis of instability. Lateral retinacular tightness is assessed by manually elevating the lateral edge of the patella tilt test. The standard radiograph series includes anteroposterior, lateral 30 degrees flexion , tunnel, and sunrise 30 to 45 degrees flexion views.
The tunnel view may demonstratel osteochondritis dissecans lesions or loose bodies in the notch. The sunrise view shows the degree of subluxation and tilt. Computed tomography CT scan axial images 20 degrees flexion are occasionally helpful to identify subluxation and tilt.
Magnetic resonance imaging MRI demonstrates the characteristic bone bruise pattern involving the medial facet of the patella and the proximal lateral femoral condyle in patients who have recently sustained a dislocation.
MPFL reconstruction is indicated in skeletally mature patients with symptomatic recurrent lateral subluxation or dislocation. Patients have usually failed attempts at nonoperative treatment including activity modification, physical therapy, and knee bracing.
Some authors recommend MPFL repair for patients following their first patellar dislocation We usually recommend treating an initial dislocation episode nonoperatively, but will repair an acute MPFL tear when surgery is necessary for concomitant intra-articular pathology large loose body, meniscus tear.
MPFL repair techniques may also be used to treat recurrent instability. The MPFL becomes attenuated and functionally incompetent with repeated instability episodes, so it is tightened by cutting, shortening, and reattaching it at the patellar or femoral insertion, or by midsubstance imbrication.
Great care should be taken not to overtighten the MPFL or malposition the graft as this will result in excessive medial patellofemoral joint pressures and is likely to exacerbate patellofemoral pain, particularly in patients with medial patellofemoral chondral damage.
The distal femoral growth plate is at risk for injury in skeletally immature patients. The traditional MPFL reconstruction technique can be modified so that the graft is passed around the proximal superficial medial collateral ligament MCL , or sutured directly to adjacent soft tissue. Tibial tuberosity osteotomy procedures, such as the Elmslie-Trillat, have a theoretical advantage in patients with greater degrees of malalignment.
The Fulkerson anteromedialization osteotomy is preferred in patients with malalignment and degenerative changes involving the inferior pole of the patella or lateral facet 9. MPFL reconstruction or repair can be combined with distal osteotomy if either alone is insufficient to provide adequate stability. A vertical post is used to facilitate arthroscopic evaluation and can be removed before starting the open portion of the surgery.
A tourniquet is used to facilitate hemostatis and visualization. Surgery is performed on an outpatient basis using general or regional anesthesia. Prophylactic intravenous antibiotics are administered before incision. Exam under Anesthesia After induction of satisfactory anesthesia, a comprehensive examination is performed. Patellar stability, translation, and tilt are usually easier to characterize when the patient is anesthetized. With the knee extended, the position of the patella is determined at rest, and with a lateral translation force applied.
The amount of translation on the symptomatic side is compared to the normal lateral patellar translation in the contralateral knee Fig. The patella is pushed laterally, and the amount of translation and the consistency of the endpoint are assessed. The examiner everts the lateral edge of the patella to determine whether the lateral retinaculum is tight.
If the patient's symptoms and exam are consistent with excessive lateral retinacular tightness, then consideration should be given to performing a concomitant arthroscopic lateral retinacular release. Diagnostic Arthroscopy Arthroscopy is performed first using the standard superolateral, inferomedial, and inferolateral portals. The suprapatellar pouch, the medial and lateral parapatellar gutters, and the posteromedial and posterolateral compartments are carefully assessed for loose bodies.
The articular surfaces of the patella and trochlear are thoroughly scrutinized for chondral lesions. The medial facet of the patella and the proximal portion of the lateral femoral condyle are the areas most commonly injured during a traumatic patellar dislocation. Patellar tracking in the trochlear groove is visualized as the knee is ranged. Any large chondral lesions are addressed surgically with debridement, microfracture, or repair techniques as indicated. In some circumstances, large defects should be unloaded using tibial tuberosity anteromedialization.
Arthroscopic lateral retinacular release may be performed at this point, although we have not found that to be routinely necessary. Surface Landmarks After removing the arthroscopy equipment, a marking pen is used to identify the important bony landmarks Fig. Marks are made over the patella, tibial tuberosity, adductor tubercle, and medial femoral epicondyle.
The pes anserine tendon insertion site is palpated, and a 3- to 4-cm oblique mark is made over the sartorial fascia insertion on the proximal medial tibia for the harvest site incision.
A second 3- to 4-cm line is drawn directly over the MPFL, halfway between the medial border of the patella and the medial femoral epicondyle. The tourniquet is raised while the knee is in an extended position. A longitudinal incision is made midway between the medial edge of the patella and the medial epicondyle. Sharp and blunt dissection is used to expose the thick medial retinacular layer contiguous with the inferior border of the vastus medialis obliquus muscle. In patients who have sustained a recent dislocation, it may be possible P.
Comparison of patellar translation between symptomatic left and asymptomatic right knees with equal lateral forces applied under general anesthesia. Note lateral translation of the left patella is greater than two quadrants. The circle is drawn over the patella. The proximal line is over the midportion of the MPFL and is where the incision is made to expose the medial border of the patella and medial femoral epicondyle.
The distal line overlies the pes anserine insertion and is where the incision is made to harvest the gracilis tendon. Medial Patellofemoral Ligament Repair The medial edge of the patella is brought into the operative field by applying a medially directed force to the lateral border of the patella.
If the MPFL is torn at this location, a direct repair can be performed using bone tunnels or suture anchors.
The adductor tubercle and medial femoral epicondyle can be exposed through the same incision with posterior retraction. With midsubstance ruptures it is not always possible to identify the location of tissue failure. In chronic cases, it can be especially difficult to determine how much to shorten the attenuated ligament. Overtightening the ligament will cause repair failure or overconstrain the patella. We usually perform MPFL repairs in patients who have experienced recent instability episodes when acute surgical intervention is indicated for concomitant intra-articular pathology.
We prefer to use the gracilis tendon because it is adjacent to the reconstruction site and is relatively easy to harvest. An incision is made over the pes anserine insertion, and the sartorial fascia is exposed.
The superior edge of the sartorial fascia is identified just anterior to the superficial medial collateral ligament. It is incised and then everted to expose the underlying gracilis and semitendinosus tendons Fig. The gracilis tendon is dissected free from the undersurface of the sartorial fascia. The free end of the P. Although the gracilis is smaller and shorter than the semitendinosus tendon, it is still significantly stronger then the native MPFL 1,2,11 and long enough to construct an adequate graft.
The sartorial fascia is sutured back to its insertion on the proximal medial tibia. Muscle is removed from the surface of the gracilis tendon Fig. The length and diameter are measured. The proximal and distal poles of the patella are P. The surgeon must be careful while drilling not to violate either the anterior bony cortex or posterior articular surface. Lateral fluoroscopy can be used to confirm appropriate positioning Fig.
The 2. The length of the tunnel is then measured with a depth gauge. The appropriate length Continuous Loop EndoButton is chosen to complete the graft construct based on the length of the tendon and the amount of graft that the surgeon wants in the patellar tunnel. The gracilis tendon is passed through the loop of the EndoButton and sutured to itself using a 2 nonabsorbable woven suture Fig. Sutures are woven through the femoral end of the graft, which will be used later to pull the graft into the femoral tunnel.
If the graft diameter is greater than 4. The gracilis tendon is tagged with a 2 Ticron suture, then harvested with a tendon striper. The sutures from the EndoButton are loaded through the eyelet of the 2. With the EndoButton positioned lengthwise, the graft is pulled through the patellar tunnel. Once it clears the tunnel, tension is placed on the femoral end of the graft so that EndoButton is brought flush to the lateral edge of the patella.
The position of the EndoButton can be manually manipulated so that it lies flush and lengthwise along the lateral edge of the patella, which can be confirmed with fluoroscopy if desired Fig.
Femoral Tunnel A common error that occurs during MPFL reconstruction surgery is to place the femoral tunnel too far proximal. Therefore, it is crucial to distinguish between these 2 bony prominences Fig.
A recent biomechanical study suggests that malpositioning the femoral tunnel even 5 mm too far proximal results in increased graft force and pressure applied to the cartilage of the medial patellofemoral cartilage 6. The attachment site of the MPFL at the medial edge of the patella is exposed in preparation for drilling the patellar tunnel.
Fluoroscopy can be used to confirm the appropriate position of the drill bit in the patella proximal to the equator. The gracilis tendon is passed through the loop of the EndoButton and sewn back to itself with 2 Ticron suture. A loop is sewn into the free end so that the pull- through suture can be removed at the end of the case. The patellar tunnel size is increased to the appropriate depth based on the length of the EndoButton loop and diameter of the completed graft. The anatomic insertion site of the MPFL just anterior to the medial femoral epicondyle is exposed.
The graft is then passed underneath the medial retinaculum and the remnant of the MPFL and then wrapped around the drill bit, allowing for assessment of graft isometry as the knee is ranged Fig. The position of the drill bit can be adjusted to allow for fine-tuning of tunnel positioning. Once the femoral tunnel has been determined, the drill bit is replaced with a 2. The K-wire is then over drilled with a 6.
The suture ends are then passed through the eyelet of the K-wire and pulled into the femoral tunnel as the K-wire exits the lateral side of the knee. Graft Tensioning and Fixation With tension placed on the free suture ends, the surgeon moves the knee several times through a full range of motion.
In addition, the graft is directly palpated and visualized through the medial incision. It is crucial not to overconstrain the graft. Next, the knee is placed in full extension, and the patella is pushed laterally.
An attempt is made to identify the graft length, which allows the same amount of lateral translation noted on the normal contralateral side. Once the appropriate graft length is identified, fixation is obtained using a 7.
The surgeon should then confirm that the knee has full range of motion, the patella is no longer dislocatable, and the graft provides a firm checkrein to pathologic lateral translation. The wound is closed in layers. A subcuticular skin closure allows for excellent cosmesis Fig. A cryotherapy unit is used to help control pain and swelling. A compressive dressing is then applied, followed by a thigh-high compression stocking and a postop brace locked in full extension.
The femoral tunnel position may be modified if necessary. Once the correct femoral tunnel position is determined, it is drilled with a 6. Fixation is achieved using 7. Subcuticular wound closure allows for excellent cosmesis. TABLE An incision over the midportion of the MPFL allows exposure of both the medial border of the patella and the medial femoral epicondyle.
The correct location of the patellar tunnel is on the medial border of the patella proximal to the equator. The patellar tunnel should be initially drilled with a 2. When the free ends of the hamstring graft are sewn together, a suture loop is created so that the passing suture that is used to pull the graft into the femoral tunnel can be completely removed where it exits percutaneously on the lateral side of the knee.
The femoral tunnel should be distal to the adductor tubercle and anterior to the medial epicondyle. Final femoral fixation should occur at the knee flexion angle that causes the greatest amount of tension in the graft with the goal of reproducing the same amount of lateral patellar translation as was appreciated on the contralateral normal side with the knee extended during the examination under anesthesia.
It is better to leave the reconstructed MPFL graft slightly loose than to overconstrain the patellofemoral joint by making the graft too tight. The brace remains locked in full extension for 1 week, and then patients are encouraged to begin knee range of motion and to progress as tolerated.
Patients are instructed to attend formal physical therapy 3 times per week, where knee range of motion and quadriceps strengthening are emphasized. Weight bearing progresses as tolerated, and the brace is unlocked for ambulation as soon as quadriceps strength is sufficient. Patients are encouraged to reach degrees of knee flexion by 4 weeks postop, and the brace is generally discontinued by 6 weeks.
Full knee range of motion should be achieved by 8 weeks. Patients are allowed to progress to jogging and sports-specific drills by 12 weeks, and most patients are able to return to sports by 4 to 5 months. A rehabilitation plan is outlined in Table Motion deficits may be secondary to inadequate postoperative rehabilitation. Loss of flexion may also be secondary to intraoperative technical errors such as malpositioning or overtensioning the graft.
These errors could also overload the medial patellofemoral joint articular surfaces and result in arthrosis, especially if there is a pre-existing medial patellar chondral lesion. The saphenous nerve is at risk for injury during exposure of the femoral tunnel. Other potential complications include recurrent instability secondary to graft failure, painful hardware, and patella fracture.
Anatomy and biomechanics of the medial patellofemoral ligament. Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am. Techniques of medial retinacular repair and reconstruction. Clin Orthop Relat Res. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med.
Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation. Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage.
Ellera Gomes JL. Medial patellofemoral ligament reconstruction for recurrent dislocation of the patella: a preliminary report. Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: a follow-up study. Anteromedial tibial tubercle transfer without bone graft. Delayed proximal repair and distal realignment after patellar dislocation. Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: biomechanical evaluation of the use of multiple strands and tensioning techniques.
J Bone Joint Surg. A technique for reconstruction of the medial patellofemoral ligament. Medial patellofemoral ligament restraint in lateral patellar translation and reconstruction. Lotke and Jess H. Write a comment Comments: 0. Log in Log out Edit.
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