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Knee Videos: Other
Fresh Femoral Osteochondral Allograft Transplantation Using a Single-Plug Technique for Large Osteochondral Defects of the Knee
Osteochondral allograft (OCA) transplantation has been used to treat a wide spectrum of cartilage deficiencies in the knee, including spontaneous necrosis of the knee. Studies reporting outcomes after OCA transplantation have shown reliable improvement in pain and return to activities of daily living. We describe a single-plug, press-fit technique for OCA transplantation with concomitant high tibial osteotomy to treat femoral condyle chondral defects in a varus knee. Pearls and pitfalls of this technique are presented; attention should be paid to correction of concomitant joint pathology and malalignment to facilitate osseointegration and survivorship of the allograft plug into host bone.Arthroscopic Posterolateral Corner Stabilization With Popliteus Tenodesis
The injuries of the posterolateral corner (PLC) of the knee often remain misdiagnosed. Because most structures in this anatomical region have low potential to heal, the posterolateral rotational instability results in a deterioration in patient quality of life, impaired biomechanics of the knee, and increased tension on other ligaments and the meniscus. Many open and a few arthroscopic techniques have been developed to repair or reconstruct the damaged structures of the PLC. Creating an additional midlateral arthroscopic portal on the lateral side of the knee was the key to developing the technique to recreate a static stabilizer against external rotational instability of the PLC by fixing the popliteus tendon as a native, vascularized material to the tibia.Patella Footprint Technique—A Surgical Method for Medial Patellofemoral Ligament Reconstruction
Recurrent patella instability is a common condition that may potentiate substantial knee dysfunction resulting in loss of time from work and sports. There are numerous factors that contribute to recurrent patella instability including tearing of the medial patellofemoral ligament (MPFL), shallow trochlea, valgus alignment, externally rotated tibia tubercle, ligamentous laxity, elevated Q angle, and increased tibial tuberosity trochlear groove distance. Reconstruction of the MPFL has been shown to restore patella stability where concomitant pathology is within acceptable limits.How to Rapidly Abolish Knee Extension Deficit After Injury or Surgery: A Practice-Changing Video Pearl From the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group
Knee extension deficit is frequently observed after anterior cruciate ligament reconstruction or rupture and other acute knee injuries. Loss of terminal extension often occurs because of hamstring contracture and quadriceps inactivation rather than mechanical intra-articular pathology. Failure to regain full extension in the first few weeks after anterior cruciate ligament reconstruction is a recognized risk factor for adverse long-term outcomes, and therefore, it is important to try to address it.The Adjustable Locking Suspension Sling Technique for Fixation of the Tibial Eminence Fracture in Adolescents
Avulsion fractures of the tibial eminence, although generally a rare injury pattern, are more common in children and adolescents than in adults. Many open and arthroscopic techniques are available with variable degrees of satisfying results and incidence of complications and adverse effects. Arthroscopic fixation appeared to improve the functional outcomes with fewer complications than the open fixation. New techniques were reported using commercially available suspension sling devices for the acromioclavicular joint that offers an easy and rapid method of fixation.Suture Pullout Technique of Acute Anterior Cruciate Ligament Femoral Avulsion Repair
It was in the early 1900s that anterior cruciate ligament (ACL) repair was first described with its resurgence in the mid-1900s. It however failed to gain popularity because of unsatisfactory early outcomes as a result of poorly selected patients. We describe a suture pullout technique of acute ACL repair in a carefully selected cohort of patients. Healing capabilities similar to that of the proximal medial collateral ligament have been shown in the proximal ACL avulsions. Adding microfracture of the lateral wall of the notch further enhances the healing environment by countering the synovial fluid environment.Surgical Management of Proximal Tibiofibular Joint Instability Using an Adjustable Loop, Cortical Fixation Device
A technique for proximal tibiofibular joint stabilization using an adjustable loop, cortical fixation device is presented. A standard diagnostic arthroscopy is performed to exclude intra-articular pathology. After arthroscopy, a 5-cm posterior-based curvilinear incision is made over the fibular head with dissection of the fascia and decompression of the common peroneal nerve ensuring adequate exposure of the fibular head. A guidewire is placed across 4 cortices using fluoroscopic guidance from the fibular head to the anteromedial tibia.Diagnostic Evaluation of the Knee in the Office Setting Using Small-Bore Needle Arthroscopy
Arthroscopy is currently the gold standard for diagnosing intra-articular knee pathology. Magnetic resonance imaging (MRI) can be a clinical adjunct for diagnosis; however, it is not without its shortcomings. Although highly accurate, even advanced imaging misdiagnoses the condition in 1 in 14 patients with regard to anterior cruciate ligament pathology. Previous studies have indicated that MRI fails to identify meniscal pathology when one exists in 1 of every 10 cases, and diagnoses pathology when pathology truly does not exist in 1 of every 5 patients.How to Test the Anterolateral Ligament With Ultrasound
Ultrasonography (US) is a nonirradiating, low-cost, real-time imaging modality that has very good spatial resolution. US can be used to view the anterolateral ligament (ALL) and injuries to the ALL. Several authors have sought to analyze the anterolateral aspect of the knee using US with varying luck. All of them analyzed the ALL statically only. The goal of this Technical Note is to describe in detail the technique that we use to analyze the anterolateral aspect of the knee in patients with an anterior cruciate ligament tear.Arthroscopic Delivery of Injectable Bone Graft for Staged Revision Anterior Cruciate Ligament Reconstruction
Bone defects caused by femoral and tibial tunnel enlargement can pose a significant technical challenge when planning to perform revision anterior cruciate ligament reconstruction. A number of options have been described for managing osseous deficiencies, including the use of large autograft or allograft bone dowels to provide sufficient tunnel fill and subsequent structural support for revision surgery. These techniques can be time-consuming and technically demanding to ensure proper tunnel fill and press-fit stability of the bone graft.The Crossing Internal Suture Augmentation Technique to Protect the All-Inside Anterior Cruciate Ligament Reconstruction Graft
The crossing internal suture augmentation technique is an all-inside technique of anterior cruciate ligament reconstruction with augmentation of the hamstring tendon autograft with a braided ultrahigh-molecular-weight polyester–polyethylene suture tape resting on the adjustable cortical buttons on both the femoral and tibial sides. The internal suture augmentation acts as a backbone supporting and protecting the graft until the process of healing and ligamentization of the graft is completed. The ends of the suture tape are tied on the tibial button and additionally fixed to the tibia with a knotless anchor as a backup fixation with the knee in full extension.Patellar Tendon Repair With Ipsilateral Semitendinosus Autograft Augmentation
Patellar tendon ruptures are rare but potentially devastating injuries. Acute repair after patellar tendon rupture affords the best opportunity for tension-free restoration of the extensor mechanism. Biological augmentation of primary repair is believed to decrease strain across the repair site and reduce the risk of rerupture. We present a technique for primary patellar tendon repair with bidirectional fixation using transosseous tunnels, suture anchor fixation, and ipsilateral hamstring autograft augmentation in a distal patellar pole socket.The External Rotation Radiographic Technique for Posterolateral Injury
Posterolateral corner injuries are a severe and often unrecognized pathology. Injuries to these structures are difficult to identify using magnetic resonance images. Physical examination tests including the dial test, frog-leg test, and varus stress test can be difficult to perform. In addition it is difficult to correctly evaluate the results in a multiligament injury setting. The correct diagnosis of this pathology is essential to determine the proper treatment and improve outcomes. Furthermore, failure to recognize this pathology is associated with a high risk of failure following isolated anterior cruciate ligament reconstructions.Open Repair of Quadriceps Tendon With Suture Anchors and Semitendinosus Tendon Allograft Augmentation
Quadriceps tendinopathy in an increasingly recognized diagnosis can lead to quadriceps tendon rupture, especially in the older population. It can be caused by repeated micro trauma or also predisposed by systemic diseases such as diabetes mellitus and connective tissue disorders that can in turn lead to extensor mechanism deficits. Although a trial of conservative treatment is advocated, operative treatment should be performed in cases of persistent pain, extension deficit, or complete rupture of the tendon.Meniscal Repair With Fibrin Clot Augmentation
Meniscal injuries and meniscal loss are associated with changes in knee kinematics and loading, ultimately leading to poor functional outcomes and increased risk of progression to osteoarthritis. Biomechanical studies have shown restored knee function, and clinical studies have reported improved outcomes and decreased risk of osteoarthritis after meniscal repair. This has led orthopaedic surgeons to try and save the meniscus by repair whenever possible, as shown by increasing incidence of meniscal repair surgeries.Medial Closing-Wedge Distal Femoral Osteotomy with Medial Patellofemoral Ligament Imbrication for Genu Valgum with Lateral Patellar Instability
A varus-producing distal femoral osteotomy (DFO) is an effective technique for the treatment of lateral patellar instability (LPI) in patients with concomitant moderate to severe valgus malalignment. Patellar maltracking and subluxation are corrected via neutralization of some of the laterally directed forces on the patella due to the valgus deformity. This can be accomplished with a distal femoral lateral opening-wedge or medial closing-wedge osteotomy and medial soft tissue stabilization. A medial closing-wedge osteotomy offers the advantages of immediate weight bearing and a single incision in cases requiring patellofemoral soft tissue stabilization.Medial Patellofemoral Ligament Reconstruction Using Dual Patella Docking Technique
Medial patellofemoral ligament (MPFL) injuries are common in children and young adults. In patients with recurrent patellar dislocations with normal lower-extremity alignment, anatomic reconstruction of the MPFL has been shown to restore patellar stability. We describe a technique that creates an anatomic reconstruction using a dual docking technique into the patella. Our technique is simple and efficacious for reconstructing the MPFL without implant fixation in the patella, allowing a maximal bone-tendon interface for healing.Simultaneous Bilateral Knee Valgus Stress Radiographic Technique
The medial collateral ligament is the most commonly injured knee ligament. Valgus stress radiographs are reported to be an effective way to quantify the medial compartment opening. However, most of the techniques require the presence of a physician in the radiograph room to apply a manual valgus stress force, and can only be performed in 1 knee at a time. These techniques, although extremely effective, increase radiation exposure to physicians, are time consuming, and require additional radiographs to compare the side-to-side difference.Medial Patella Femoral Ligament Reconstruction With Periosteal Tunnels and Suture Fixation
Lateral patellar dislocations can damage the medial patella femoral ligament. Nonoperative care is preferred but some tears may require a surgical intervention. Patella fractures are considered a risk factor after surgery. The technique described in this Technical Note avoids any bone tunnel drilling, which may eliminate the possibility of a patella fracture. The surgical procedure uses periosteal fibro-osseous tunnels to a double-limbed gracilis graft to reconstruct the upper and lower borders as conventionally used for medial patella femoral ligament reconstruction.Multicompartmental Osteochondral Allografts of Knee and Concomitant High Tibial Osteotomy
Chondral lesions of the knee can occur secondary to limb malalignment. To address these interrelated problems, a high tibial osteotomy with concomitant osteochondral allograft transfer may be performed. It is important to address these chondral lesions as they often affect the young and active population and cause morbidity in an otherwise healthy population. Although numerous approaches for the treatment of chondral lesions have been described, long-term results demonstrating regeneration of hyaline cartilage have yet to be reported.Platelet-Rich Fibrin Clot–Augmented Repair of Horizontal Cleavage Meniscal Tear
Although horizontal tears of the meniscus have historically been treated with partial meniscectomy due to poor vascularity within the tear, evidence suggests that repair of horizontal meniscal tears may be advantageous to partial meniscectomy. Furthermore, the addition of platelet-rich plasma has shown promise in improving meniscal healing. We present our technique of platelet-rich fibrin clot–augmented repair of horizontal cleavage meniscal tear.Internal Suture Augmentation Technique to Protect the Anterior Cruciate Ligament Reconstruction Graft
The anterior cruciate ligament suture augmentation technique is a method to augment anterior cruciate ligament reconstruction (ACLR) with autologous hamstring tendons using a braided ultrahigh–molecular weight polyester or polyethylene suture or suture tape and fixed on both the femoral and tibial sides independent of the graft to act as a backup or secondary stabilizer until complete integration and ligamentization of the graft take place. The technique is proposed to allow early rehabilitation and return to sports after ACLR and may be advantageous in patients with a high body mass index and in cases with small grafts (7 or 7.5 mm in diameter).Quadriceps Tendon Repair Using Knotless Anchors and Suture Tape
Repair of a torn quadriceps tendon is necessary to restore the extensor mechanism of the knee. Traditional repair involves transosseous sutures tied over bone bridges on the inferior pole of the patella. Suture anchor repair has been shown to be stronger than transosseous repair and facilitates a smaller incision. Suture tape can improve the strength of the suture-tendon interface, and when combined with knotless anchors, leads to a stronger repair construct than even traditional suture anchors and surgeon-tied knots.Systematic Arthroscopic Treatment of Diffuse Pigmented Villonodular Synovitis in the Knee
Pigmented villonodular synovitis (PVNS) is a benign aggressive disease that presents in either a localized (LPVNS) or diffuse (DPVNS) form. Arthroscopic synovectomy is the standard operative treatment for LPVNS, and when used to treat DPVNS, it is usually combined with an open posterior procedure. The purpose of this Technical Note is to report the technique that we have refined to allow for arthroscopic synovectomy as the sole treatment for DPVNS. We describe our technique with the factors we have found to be important to ensure adequate arthroscopic synovectomy, while minimizing risks and complications.Circumferential Suture Repair of Isolated Horizontal Meniscal Tears Augmented With Fibrin Clot
Traditionally, horizontal cleavage meniscus tears have been associated with osteoarthritis, indicative of the degenerative process. Recent treatment measures have focused on maintaining as much meniscal tissue as possible, despite the routine extension of these tears into the central white-white zones. In the absence of tunnel drilling for cruciate ligament reconstructions, the use of an exogenous fibrin clot is a useful adjunct to increase the local growth factors at the tear repair to aid in healing.
