**Meet the editor**

Hiran Amarasekera is a Consultant Orthopaedic Surgeon from Sri Lanka currently undergoing a hip preservation fellowship at the University Hospitals of Coventry and Warwickshire, UK. His special interests include young adult hip and knee problems, sports injuries, hip and knee arthroplasty, and keyhole joint surgery. He graduated from Kasturba Medical College, Manipal, In-

dia, and obtained the MBBS. He did post-graduate training in trauma and orthopaedics at the Postgraduate Institute of Medicine, Colombo, and was awarded his MS by The University of Colombo. He was initially trained at the National Hospital of Sri Lanka and then completed advance training at the Oldchurch Hospital in Essex, UK; The Avenue Hospital Melbourne, Australia; and University Hospitals of Coventry and Warwickshire, UK. After completion of training, he obtained the board certification in trauma and orthopaedics from the Postgraduate Institute of Medicine, Colombo, and passed the FRCS from the Royal College of Surgeons of Edinburgh. Later, he was elected as a fellow of the Sri Lanka College of Surgeons and awarded the FCSSL. He has a keen interest in academia and research. He worked as a clinical research fellow in Warwick Medical School and obtained his MPhil in Medical Sciences during this training and completed a research fellowship at the University of California Los Angeles (UCLA). His main research areas are the study of blood flow to the hip, failure mechanisms of hip implants, designing new hip prostheses, developing surgical approaches to the hip and femoral acetabular impingement, and research and developments in arthroscopy.

He has over 30 international publications, presentations and several book chapters to his credit. He works as a reviewer for international orthopaedic journals and has reviewed over 60 papers and is a member of the editorial board of Sri Lanka Journal of Surgery.

Contents

**Preface VII**

Chia-Liang Ang

Chapter 1 **Successful Knee Arthroscopy: Techniques 3**

**Augmentation Technique 43**

**the Patellofemoral Joint 67**

Adinun Apivatgaroon

Ponce de León

**and Repair 79** Laurent Baverel

**Shoulder 101**

**Section 2 Shoulder 77**

Chapter 2 **Single-Bundle Anterior Cruciate Ligament Reconstruction 27**

Chapter 3 **Anatomic Single-Bundle ACL Reconstruction with Remnant**

Chapter 4 **Office-Based Small Bore Needle Arthroscopy of the Knee 57**

Chapter 5 **Arthroscopic Technique to Treat Articular Cartilage Lesions in**

Chapter 6 **Subscapularis Tendon Tears: Classification, Diagnosis**

Chapter 7 **Diagnosis and Treatment of the Meso-Acromion of the**

Genevieve Mazza and Alex McIntyre

Kyle Williams, Kelly Scott, Donald Dulle III and Anikar Chhabra

Anell Olivos-Meza, Antonio Madrazo-Ibarra and Clemente Ibarra

William B. Stetson, Stephanie Morgan, Brian Chung, Nicole Hung,

Kavin Khatri, Darsh Goyal and Deepak Bansal

**Section 1 Knee 1**

### Contents

### **Preface XI**

**Section 1 Knee 1**


### **Section 3 Hip 115**

Chapter 8 **Hip Arthroscopy Made Simple, Easy, and Elegant. A Novel Variant of the Outside-In Technique 117** Antonio Porthos Salas, John M. O'Donnell and Jacek Macek

Preface

Over the last decade, arthroscopy (keyhole surgery of the joints), has developed rapidly. Ar‐ throscopic procedures were previously limited to large joints; however, with modern technolo‐ gy, it has been possible to perform arthroscopy in almost any joint, including small joints of the hand and foot. Over the years, arthroscopic work has shifted from a diagnostic procedure to‐ wards more therapeutic procedures. Modern arthroscopic surgeons perform major operative work through keyhole surgery either as a total procedure or as an arthroscopic-assisted open procedure. With the development of technology and innovation, it has been possible to perform

This book discusses the advances and techniques of arthroscopic procedures on a region-

The chapters are arranged according to the four major joints where common keyhole sur‐

The knee section has chapters discussing the traditional arthroscopic ACL reconstruction, modern role of arthroscopy in articular cartilage replacement, and feasibility of arthroscopy

The shoulder section has chapters on arthroscopic treatment of subscapularis repair and

The book also has chapters on the complications of arthroscopy, mainly concentrating on the elbow joint and role of modern arthroscopy in hip surgery. Every chapter offers information and discusses the authors' experiences regarding these procedures, which will enable the reader not only to understand the procedure but also to learn from the authors' experience. This book will give readers and practitioners of orthopaedics an overview and scope of ar‐

*Many thanks go to all authors and contributors for submitting the chapters, to all the staff including Author Service Manager, Anita Condic, at IntechOpen Publishing, and finally as always to my wife Anuji and my daughter Nuwanji, for having patience and supporting me through all my research*

MBBS (Manipal), MS (Colombo), FRCS (Ed), FCSSL, MPhil (Warwick)

University Hospitals of Coventry and Warwickshire

**Hiran Amarasekera**

Hip preservation fellow

Coventry, United Kingdom

more and more complex procedures through keyhole joint surgery.

gery is practised today; namely knee, hip, shoulder, and elbow.

wise basis, concentrating on major joints.

being performed as an out-patient procedure.

throscopic surgery in modern day practice.

management of meso-acromion.

*and publication work.*

#### **Section 4 Elbow 125**

Chapter 9 **Neurological Complications of Elbow Arthroscopy 127** William B. Stetson, Kevin Vogeli, Brian Chung, Nicole J. Hung, Stephanie Morgan and Milan Stevanovic

## Preface

**Section 3 Hip 115**

**VI** Contents

**Section 4 Elbow 125**

Chapter 8 **Hip Arthroscopy Made Simple, Easy, and Elegant. A Novel Variant of the Outside-In Technique 117**

Chapter 9 **Neurological Complications of Elbow Arthroscopy 127**

Stephanie Morgan and Milan Stevanovic

Antonio Porthos Salas, John M. O'Donnell and Jacek Macek

William B. Stetson, Kevin Vogeli, Brian Chung, Nicole J. Hung,

Over the last decade, arthroscopy (keyhole surgery of the joints), has developed rapidly. Ar‐ throscopic procedures were previously limited to large joints; however, with modern technolo‐ gy, it has been possible to perform arthroscopy in almost any joint, including small joints of the hand and foot. Over the years, arthroscopic work has shifted from a diagnostic procedure to‐ wards more therapeutic procedures. Modern arthroscopic surgeons perform major operative work through keyhole surgery either as a total procedure or as an arthroscopic-assisted open procedure. With the development of technology and innovation, it has been possible to perform more and more complex procedures through keyhole joint surgery.

This book discusses the advances and techniques of arthroscopic procedures on a regionwise basis, concentrating on major joints.

The chapters are arranged according to the four major joints where common keyhole sur‐ gery is practised today; namely knee, hip, shoulder, and elbow.

The knee section has chapters discussing the traditional arthroscopic ACL reconstruction, modern role of arthroscopy in articular cartilage replacement, and feasibility of arthroscopy being performed as an out-patient procedure.

The shoulder section has chapters on arthroscopic treatment of subscapularis repair and management of meso-acromion.

The book also has chapters on the complications of arthroscopy, mainly concentrating on the elbow joint and role of modern arthroscopy in hip surgery. Every chapter offers information and discusses the authors' experiences regarding these procedures, which will enable the reader not only to understand the procedure but also to learn from the authors' experience.

This book will give readers and practitioners of orthopaedics an overview and scope of ar‐ throscopic surgery in modern day practice.

*Many thanks go to all authors and contributors for submitting the chapters, to all the staff including Author Service Manager, Anita Condic, at IntechOpen Publishing, and finally as always to my wife Anuji and my daughter Nuwanji, for having patience and supporting me through all my research and publication work.*

> **Hiran Amarasekera** MBBS (Manipal), MS (Colombo), FRCS (Ed), FCSSL, MPhil (Warwick) Hip preservation fellow University Hospitals of Coventry and Warwickshire Coventry, United Kingdom

**Section 1**

**Knee**

**Section 1**

### **Knee**

**Chapter 1**

**Provisional chapter**

**Successful Knee Arthroscopy: Techniques**

**Successful Knee Arthroscopy: Techniques**

DOI: 10.5772/intechopen.79268

Knee arthroscopy is one of the most common arthroscopic procedures required of an orthopedic surgeon. A successful case hinges primarily on adequate pre-operative planning, proper intra-operative set-up and thoughtful portal placement. This chapter will discuss in detail the necessary ingredients of a smooth and successful knee arthroscopy case. Advanced techniques to deal with intra-operative difficulties will be presented. Though uncommon, complications arising from knee arthroscopy will be presented and their management techniques described. Common procedures will be discussed, including simple knee arthroscopic debridement, arthroscopic cartilage reconstruction, anterior cruciate ligament reconstruction, and meniscus repair. Surgical steps for a safe

**Keywords:** knee arthroscopy, arthroscopic techniques, arthroscopic debridement, microfracture, anterior cruciate ligament reconstruction, meniscus repair,

Knee arthroscopy is one of the most commonly performed orthopedic surgeries today. Its first reported use was by a Danish surgeon, Dr. Nordentoft, who made his own endoscope with a 5 mm trocar. He presented his work on knee endoscopy in 1912 at the 41st Congress of the German Society of Surgeons in Berlin [1]. Over the last century, technological advances in illumination and optical systems for viewing have facilitated the development of arthroscopic surgery, to the point where today, a large proportion of intra-articular pathology can be successfully treated with arthroscopic techniques. Arthroscopic surgeries involve much smaller incisions through skin, subcutaneous tissues, fascia and muscle, allowing rapid healing of these structures and early mobility of the patient, which is vital in reducing two key

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79268

and smooth case will be presented.

Chia-Liang Ang

Chia-Liang Ang

**Abstract**

cartilage repair

**1. Introduction**

#### **Successful Knee Arthroscopy: Techniques Successful Knee Arthroscopy: Techniques**

#### Chia-Liang Ang Chia-Liang Ang

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79268

**Abstract**

Knee arthroscopy is one of the most common arthroscopic procedures required of an orthopedic surgeon. A successful case hinges primarily on adequate pre-operative planning, proper intra-operative set-up and thoughtful portal placement. This chapter will discuss in detail the necessary ingredients of a smooth and successful knee arthroscopy case. Advanced techniques to deal with intra-operative difficulties will be presented. Though uncommon, complications arising from knee arthroscopy will be presented and their management techniques described. Common procedures will be discussed, including simple knee arthroscopic debridement, arthroscopic cartilage reconstruction, anterior cruciate ligament reconstruction, and meniscus repair. Surgical steps for a safe and smooth case will be presented.

DOI: 10.5772/intechopen.79268

**Keywords:** knee arthroscopy, arthroscopic techniques, arthroscopic debridement, microfracture, anterior cruciate ligament reconstruction, meniscus repair, cartilage repair

### **1. Introduction**

Knee arthroscopy is one of the most commonly performed orthopedic surgeries today. Its first reported use was by a Danish surgeon, Dr. Nordentoft, who made his own endoscope with a 5 mm trocar. He presented his work on knee endoscopy in 1912 at the 41st Congress of the German Society of Surgeons in Berlin [1]. Over the last century, technological advances in illumination and optical systems for viewing have facilitated the development of arthroscopic surgery, to the point where today, a large proportion of intra-articular pathology can be successfully treated with arthroscopic techniques. Arthroscopic surgeries involve much smaller incisions through skin, subcutaneous tissues, fascia and muscle, allowing rapid healing of these structures and early mobility of the patient, which is vital in reducing two key

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

complications that threaten the success of any knee surgery: wasting of the quadriceps and stiffness of the knee. Furthermore, arthroscopy allows access to the posterior parts of the knee joint much more effectively compared to open surgery, where accessing the posterior horn of the menisci requires a subluxation of the knee joint. Arthroscopy can also be an adjunct to fixation of peri-articular fractures, where a direct intra-articular view can help dictate fracture reduction [2]. However, one issue in such uses is the potential lack of a contained space where a constant stream of arthroscopic fluid provides a clear visualization. In such cases, the periarticular fractures would have to be almost nearly reduced before a proper visualization can be obtained via arthroscopy to guide the final reduction.

should be placed (**Figure 4**). Placement of this side support must facilitate two functions: one, to allow the knee to be placed at a 90° angle, and two, to act as a post against which a valgus force can be applied to the knee to open the medial joint. For a right knee scope,

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 5

**Figure 2.** Arthroscopic tower 1. From top the bottom, the components are: screen, arthroscopic camera system, image

management system, shaver console, arthroscopic light source, photo printer.

**Figure 1.** Operating theater set-up.

Arthroscopy is a completely different skill set from performing open surgery. One of the key differences is that in open surgery, the surgeon's hand movements directly correlate with movements at the tip of the instruments, whereas in arthroscopy, the surgeon's hand movements are in opposite directions with movements of the tip of instruments due to the presence of a pivot point at the incision. This negative correlation with the surgeon's hands is the primary difficulty for any learning arthroscopist and is the main component of the learning curve. The second major difficulty with arthroscopy is the locations of the portals. The incisions will have to be precisely situated to create a cone of movement that allows the best access to intra-articular structures. The third difficulty is learning how to improve access to the posterior parts of the knee joint, in particular when repairing meniscal tears or meniscal roots. Also, to interpret the anatomy of intra-articular pathology, the arthroscopist should correlate what he views through the scope with a mental overview of normal knee anatomy. These will be discussed further in the chapter.

Notwithstanding the benefits of arthroscopic surgery, a successful clinical outcome depends almost as much on the surgical technique as on good post-operative rehabilitation. Selfexercises such as isometric quadriceps contraction and active ankle and toe movement should be started immediately post-operation. Weight bearing and knee range of movement would depend on the pathology treated and the surgeon's comfort level.

### **2. Basic set-up**

### **2.1. Patient and OT positioning**

The surgeon will stand on the side of the knee to be operated on (**Figure 1**). An assistant surgeon, if available, stands proximal to the surgeon, and the scrub nurse stands distal to the surgeon with her instrument trolley further distal to her. Across the operating table, the arthroscopic towers stand at the level of the opposite knee (**Figures 2** and **3**). Proximal to the tower is the Mayo stand which holds all the arthroscopic instruments. A separate table may be utilized adjacent to the scrub nurse instrument trolley for graft preparations. The operation bed and surgeon should be within the confines of the laminar flow ceiling.

The patient should be supine on the operation table. For a routine arthroscopy, a side support on the lateral side of the thigh and a sandbag or an attachable foot rest beneath the foot should be placed (**Figure 4**). Placement of this side support must facilitate two functions: one, to allow the knee to be placed at a 90° angle, and two, to act as a post against which a valgus force can be applied to the knee to open the medial joint. For a right knee scope,

**Figure 1.** Operating theater set-up.

complications that threaten the success of any knee surgery: wasting of the quadriceps and stiffness of the knee. Furthermore, arthroscopy allows access to the posterior parts of the knee joint much more effectively compared to open surgery, where accessing the posterior horn of the menisci requires a subluxation of the knee joint. Arthroscopy can also be an adjunct to fixation of peri-articular fractures, where a direct intra-articular view can help dictate fracture reduction [2]. However, one issue in such uses is the potential lack of a contained space where a constant stream of arthroscopic fluid provides a clear visualization. In such cases, the periarticular fractures would have to be almost nearly reduced before a proper visualization can

Arthroscopy is a completely different skill set from performing open surgery. One of the key differences is that in open surgery, the surgeon's hand movements directly correlate with movements at the tip of the instruments, whereas in arthroscopy, the surgeon's hand movements are in opposite directions with movements of the tip of instruments due to the presence of a pivot point at the incision. This negative correlation with the surgeon's hands is the primary difficulty for any learning arthroscopist and is the main component of the learning curve. The second major difficulty with arthroscopy is the locations of the portals. The incisions will have to be precisely situated to create a cone of movement that allows the best access to intra-articular structures. The third difficulty is learning how to improve access to the posterior parts of the knee joint, in particular when repairing meniscal tears or meniscal roots. Also, to interpret the anatomy of intra-articular pathology, the arthroscopist should correlate what he views through the scope with a mental overview of normal knee anatomy.

Notwithstanding the benefits of arthroscopic surgery, a successful clinical outcome depends almost as much on the surgical technique as on good post-operative rehabilitation. Selfexercises such as isometric quadriceps contraction and active ankle and toe movement should be started immediately post-operation. Weight bearing and knee range of movement would

The surgeon will stand on the side of the knee to be operated on (**Figure 1**). An assistant surgeon, if available, stands proximal to the surgeon, and the scrub nurse stands distal to the surgeon with her instrument trolley further distal to her. Across the operating table, the arthroscopic towers stand at the level of the opposite knee (**Figures 2** and **3**). Proximal to the tower is the Mayo stand which holds all the arthroscopic instruments. A separate table may be utilized adjacent to the scrub nurse instrument trolley for graft preparations. The operation

The patient should be supine on the operation table. For a routine arthroscopy, a side support on the lateral side of the thigh and a sandbag or an attachable foot rest beneath the foot

be obtained via arthroscopy to guide the final reduction.

4 Recent Advances in Arthroscopic Surgery

These will be discussed further in the chapter.

**2. Basic set-up**

**2.1. Patient and OT positioning**

depend on the pathology treated and the surgeon's comfort level.

bed and surgeon should be within the confines of the laminar flow ceiling.

**Figure 2.** Arthroscopic tower 1. From top the bottom, the components are: screen, arthroscopic camera system, image management system, shaver console, arthroscopic light source, photo printer.

**Figure 4.** Set-up for standard knee arthroscopy.

**Figure 6.** Set-up allowing hyperflexion for ACL reconstruction.

**Figure 5.** Placing the patient's foot in the surgeons' left groin, the surgeon can exert a valgus force on the knee.

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 7

**Figure 3.** Arthroscopic tower 2. The top console is the fluid pump management system, and the bottom console is the radiofrequency ablation system.

the surgeon can place the patient's foot into his left hip and use his body to exert a valgus force with the patient's knee at 20–30° of flexion (**Figure 5**). The operation table may have to be lowered or the surgeon may place his left foot onto a stool. Therefore, the surgeon must check both positions before instructing the attendant to secure the side support in place. If a sandbag is used, it should be securely taped down to the table to prevent movement during the surgery.

A tourniquet is applied to the patient's proximal thigh. A properly applied tourniquet is a great aid to visualization during the surgery, especially during femoral drilling for Anterior Cruciate Ligament (ACL) reconstruction. A thick wad of cotton should be applied first to the thigh, and it is important that the width of the applied cotton is larger than the width of the tourniquet. This allows the even distribution of pressure from the tourniquet to the thigh. The tourniquet itself should be tightly applied over the cotton such that it will not admit even one finger. A crepe bandage is then secured over the lower half of the tourniquet and the lower edge is folded inwards beneath the lower edge of the tourniquet. For ACL reconstruction, an additional foot rest is applied to allow the knee to achieve maximum flexion during surgery (**Figure 6**). Positioning of this more proximal foot rest should be slightly less than full knee flexion. If the knee were fully flexed during positioning, the foot rest will not be able to hold the knee properly after draping adds bulk to the entire set-up.

**Figure 4.** Set-up for standard knee arthroscopy.

the surgeon can place the patient's foot into his left hip and use his body to exert a valgus force with the patient's knee at 20–30° of flexion (**Figure 5**). The operation table may have to be lowered or the surgeon may place his left foot onto a stool. Therefore, the surgeon must check both positions before instructing the attendant to secure the side support in place. If a sandbag is used, it should be securely taped down to the table to prevent movement during

**Figure 3.** Arthroscopic tower 2. The top console is the fluid pump management system, and the bottom console is the

A tourniquet is applied to the patient's proximal thigh. A properly applied tourniquet is a great aid to visualization during the surgery, especially during femoral drilling for Anterior Cruciate Ligament (ACL) reconstruction. A thick wad of cotton should be applied first to the thigh, and it is important that the width of the applied cotton is larger than the width of the tourniquet. This allows the even distribution of pressure from the tourniquet to the thigh. The tourniquet itself should be tightly applied over the cotton such that it will not admit even one finger. A crepe bandage is then secured over the lower half of the tourniquet and the lower edge is folded inwards beneath the lower edge of the tourniquet. For ACL reconstruction, an additional foot rest is applied to allow the knee to achieve maximum flexion during surgery (**Figure 6**). Positioning of this more proximal foot rest should be slightly less than full knee flexion. If the knee were fully flexed during positioning, the foot rest will not be able to hold the knee properly

the surgery.

radiofrequency ablation system.

6 Recent Advances in Arthroscopic Surgery

after draping adds bulk to the entire set-up.

**Figure 5.** Placing the patient's foot in the surgeons' left groin, the surgeon can exert a valgus force on the knee.

**Figure 6.** Set-up allowing hyperflexion for ACL reconstruction.

#### **2.2. Equipment**

The arthroscopic lens used most commonly for knee arthroscopy is the 30° lens (**Figure 7**). This means that the line of visualization is at a 30° angle to the scope. When visualizing the posterior horn of the meniscus, this is important because the direction of the lens should be turned upside down to direct the angle of visualization towards the back (**Figure 8**). An upright image is maintained by adjusting the scope handle. In the author's experience, there has not been a need for a straight lens. The 70° lens can be used for the following situations: treating pathology behind the patella tendon, such as scar tissue; inspecting the superior portions of the medial and lateral gutters, and visualizing the posterior tibial step-off for Posterior Cruciate Ligament (PCL) reconstructions.

An arthroscopic debrider, commonly called a shaver, is used to debride damaged tissues. The author routinely uses a 4.5 mm shaver with serrated cutting edges for maximal debridement efficiency, especially for a torn ACL. When using this for cartilage or menisci, the shaver edge is first used to debride the damaged tissue, and the shaver gradually moved towards normal tissue with a controlled gradual movement to achieve a smooth tissue edge. When used carefully, there is no risk of accidentally debriding normal tissue.

cartilage or meniscal debridement and wash-out, a fluid management pump is not required. The author uses a fluid management pump for ACL surgeries, in particular for the drilling of the femoral tunnel. This is because hyperflexion of the knee for drilling of the femoral tunnel may decrease the tourniquet effectiveness due to the extreme positioning. At this stage, the irrigation pressure can be increased to 80 mmHg to maintain adequate visualization. At other times of the surgery, the fluid pressure can be at 50–60 mmHg to maintain just a clear view

**Figure 8.** The diagram on the left illustrates the correct way of directing the angle of visualization to the posterior part of

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 9

A standard knee arthroscopy starts with the positioning and set-up as detailed in the previous section. A dose of intravenous antibiotics as according to each surgeon's institution guidelines should be given at least 5 minutes before the inflation of the tourniquet. Following cleansing and draping of the knee, surface markings are drawn followed by inflation of the tourniquet and commencement of the procedure (**Figure 9**). The first portal to be established is the anterolateral portal. This should be situated at the level of the inferior pole of the patella with the knee in 90°, and as close to the lateral edge of the patella tendon as possible. Correspondingly, the anteromedial portal is at the same level and situated as close to the medial edge of the patella tendon as possible. Taking in mind that the tibial plateaus are dish-shaped, the height of the portal at the inferior pole of the patella allows access to the posterior part of the tibiofemoral articulation. In the author's experience, portals established any lower to this height

The incision of the portal should be with a Size 11 surgical blade, made with the knee in 90°, and aimed towards the trochlear. In the author's experience, fluid injection into the knee before incision is not necessary. Furthermore, a wrong injection into synovium will cause marked synovial swelling that will severely obstruct visualization. Following incision, a straight arterial haemostat is inserted through the synovial tissue with a controlled force and the tip of the haemostat felt to touch the trochlear. A controlled insertion is important to avoid inadvertent

without excessive risk of fluid extravasation into tissues.

will have poorer access to the posterior of the knee.

**3. Standard knee arthroscopy**

the knee. The diagram on the right is the wrong way.

The next important instrument is the radiofrequency ablation probe, or commonly called a wand. The wand delivers electrical energy to its tip, generating intense localized heat that coagulates tissues. There are two modes, cutting and coagulation. The cutting mode delivers a continuous high-frequency current, which heats the tissue so strongly that the cells are explosively destroyed, severing the tissue. The coagulation mode delivers high-frequency current in pulsed mode, delivering a lower energy such that the tissue dries out without being severed. The wand is a useful instrument for shrinking synovial tissue, smoothing out a rough meniscal edge or cartilage edge with fibrillations, and dissecting tissue off bone, for example when preparing the lateral femoral condyle in ACL surgery.

The most commonly used arthroscopic fluid is 0.9% Sodium Chloride, which is a physiological irrigation solution compatible with living tissues. For standard arthroscopy cases such as

**Figure 7.** Arthroscopic instruments. From top to bottom, they are: arthroscopic viewing camera, radiofrequency ablation instrument (wand), arthroscopic debrider (shaver).

**Figure 8.** The diagram on the left illustrates the correct way of directing the angle of visualization to the posterior part of the knee. The diagram on the right is the wrong way.

cartilage or meniscal debridement and wash-out, a fluid management pump is not required. The author uses a fluid management pump for ACL surgeries, in particular for the drilling of the femoral tunnel. This is because hyperflexion of the knee for drilling of the femoral tunnel may decrease the tourniquet effectiveness due to the extreme positioning. At this stage, the irrigation pressure can be increased to 80 mmHg to maintain adequate visualization. At other times of the surgery, the fluid pressure can be at 50–60 mmHg to maintain just a clear view without excessive risk of fluid extravasation into tissues.

### **3. Standard knee arthroscopy**

**2.2. Equipment**

8 Recent Advances in Arthroscopic Surgery

Cruciate Ligament (PCL) reconstructions.

instrument (wand), arthroscopic debrider (shaver).

fully, there is no risk of accidentally debriding normal tissue.

example when preparing the lateral femoral condyle in ACL surgery.

The arthroscopic lens used most commonly for knee arthroscopy is the 30° lens (**Figure 7**). This means that the line of visualization is at a 30° angle to the scope. When visualizing the posterior horn of the meniscus, this is important because the direction of the lens should be turned upside down to direct the angle of visualization towards the back (**Figure 8**). An upright image is maintained by adjusting the scope handle. In the author's experience, there has not been a need for a straight lens. The 70° lens can be used for the following situations: treating pathology behind the patella tendon, such as scar tissue; inspecting the superior portions of the medial and lateral gutters, and visualizing the posterior tibial step-off for Posterior

An arthroscopic debrider, commonly called a shaver, is used to debride damaged tissues. The author routinely uses a 4.5 mm shaver with serrated cutting edges for maximal debridement efficiency, especially for a torn ACL. When using this for cartilage or menisci, the shaver edge is first used to debride the damaged tissue, and the shaver gradually moved towards normal tissue with a controlled gradual movement to achieve a smooth tissue edge. When used care-

The next important instrument is the radiofrequency ablation probe, or commonly called a wand. The wand delivers electrical energy to its tip, generating intense localized heat that coagulates tissues. There are two modes, cutting and coagulation. The cutting mode delivers a continuous high-frequency current, which heats the tissue so strongly that the cells are explosively destroyed, severing the tissue. The coagulation mode delivers high-frequency current in pulsed mode, delivering a lower energy such that the tissue dries out without being severed. The wand is a useful instrument for shrinking synovial tissue, smoothing out a rough meniscal edge or cartilage edge with fibrillations, and dissecting tissue off bone, for

The most commonly used arthroscopic fluid is 0.9% Sodium Chloride, which is a physiological irrigation solution compatible with living tissues. For standard arthroscopy cases such as

**Figure 7.** Arthroscopic instruments. From top to bottom, they are: arthroscopic viewing camera, radiofrequency ablation

A standard knee arthroscopy starts with the positioning and set-up as detailed in the previous section. A dose of intravenous antibiotics as according to each surgeon's institution guidelines should be given at least 5 minutes before the inflation of the tourniquet. Following cleansing and draping of the knee, surface markings are drawn followed by inflation of the tourniquet and commencement of the procedure (**Figure 9**). The first portal to be established is the anterolateral portal. This should be situated at the level of the inferior pole of the patella with the knee in 90°, and as close to the lateral edge of the patella tendon as possible. Correspondingly, the anteromedial portal is at the same level and situated as close to the medial edge of the patella tendon as possible. Taking in mind that the tibial plateaus are dish-shaped, the height of the portal at the inferior pole of the patella allows access to the posterior part of the tibiofemoral articulation. In the author's experience, portals established any lower to this height will have poorer access to the posterior of the knee.

The incision of the portal should be with a Size 11 surgical blade, made with the knee in 90°, and aimed towards the trochlear. In the author's experience, fluid injection into the knee before incision is not necessary. Furthermore, a wrong injection into synovium will cause marked synovial swelling that will severely obstruct visualization. Following incision, a straight arterial haemostat is inserted through the synovial tissue with a controlled force and the tip of the haemostat felt to touch the trochlear. A controlled insertion is important to avoid inadvertent

and reduce the size of the fat pad and synovium just enough for visualization. There is often a rudimentary ligament at the anterior aspect of the tibiofemoral articulation which can be safely excised. The fat pad can also be downsized using the 90° wand, alternating between coagulation (for hemostasis of bleeding points) and cutting (for shrinking tissues). Adequate visualization is achieved when the anterior horn of both medial and lateral menisci are easily visualized together with the intermeniscal ligament. The ACL and PCL can be checked for laxity using a probe.

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 11

With the knee at different angles of flexion, the direction of the portal changes slightly due to the difference in position of the skin relative to the capsule and synovium. With experience, primarily through development of muscle memory, the surgeon is able to quickly locate the right direction of entry without forcefully creating another tract. Additional tracts through the capsule or synovium should be avoided as these are all potential sites for joint fluid extravasation and represents unnecessary additional tissue damage. To enhance easy insertion of instruments and changing of the scope through different portals, the track should be adequately dilated using the haemostat. With the scope in the anteromedial portal, the wand should be inserted through the anterolateral portal and used to shrink the synovium around

To visualize the posterior horn of the medial meniscus, the knee is held at a 20–30° flexion with the patient's foot resting in the surgeons' hip. Putting the knee at 20–30° eliminates the ACL's contribution to stability, leaving only the medial collateral ligament (MCL) as a restraint against a valgus force. The patient's thigh is blocked by the side support, and the surgeon can exert a valgus force on the knee by moving his entire body outwards. Additionally, an assistant can help to apply more valgus force onto the knee (**Figure 10**). By slowly varying the angle of flexion using his hip, the surgeon will be able to find an angle of best access. Sometimes, this maneuver does not suffice to allow access to the posterior horn in muscular young adult male patients or patients with post-traumatic knee arthritis and joint stiffness. A method of improving access is by needling the MCL from within. An 18G spinal needle is inserted from the anterolateral portal. The spinal needle is directed towards the body of the medial meniscus, inferior to it. The curved tip is pointed inferiorly to avoid injury to the meniscus. The deep MCL and superficial MCL is then needled below the meniscus, with a gap of about 2–3 mm in between each penetration. This is done with the knee in 20–30° with a constant valgus force applied to gradually open up the medial compartment. It is important to apply a sustained gradual force and avoid sudden excessive valgus forces to avoid creating an iatrogenic MCL tear. This technique is sufficient to open up the medial compartment for visualization and instrument access. A similar method is needling the MCL from outside the skin and observing the needle penetrating the joint below the meniscus [3]. Both techniques work well but doing it from within avoids puncture marks on the skin and is more accurate in avoiding the meniscus. To visualize just the posterior root of the medial meniscus, the scope can be inserted from the anterolateral portal and driven through the notch. This can easily be done in patients with a lax ACL and a wide notch. In patients with an intact ACL, a trans-patellar tendon portal is sometimes required in order for the scope to adopt the right direction to penetrate the notch. The direction of the scope should be medial to the ACL and inferior to the femoral insertion

the opening of the tract and vice versa.

of the PCL.

**Figure 9.** Standard incisions for ACL reconstruction.

damage to the trochlear cartilage. The haemostat is then opened to dilate the track. The scope trocar is inserted in the same direction, and similarly felt to contact the trochlear, before the knee is extended and the trocar driven beneath the patella into the suprapatellar pouch. The trocar is then removed, leaving the sheath, and the 30° lens inserted and locked into place. Following visual confirmation of placement in the suprapatellar pouch, fluid irrigation can be started. Where there is a lot of synovial debris, a washout of the suprapatellar pouch will first be performed using the irrigation.

A diagnostic arthroscopy starts with examination of the suprapatellar pouch with the knee in extension. Pathology that can be observed at this stage includes loose bodies, synovitis or plicae. The lens is directed upwards and the undersurface of the patella cartilage inspected. Following inspection of the suprapatellar pouch, the lens is taken over the medial side of the medial femoral condyle while the knee is allowed to flex over the side of the table. The medial gutter can be inspected at this juncture. The medial femoral condyle should be inspected in its entirety, followed by the anterior horn of the medial meniscus and the ACL. Frequently though, the fat pad posterior to the patellar tendon can interfere with visualization and it is at this point that a 21G hypodermic needle can be inserted through the surface marking of the anteromedial portal. The direction of the needle should be checked and confirmed to be able to give a direct line of access to the posterior horn of the medial meniscus. A stab incision is then made and the track dilated with a straight haemostat. The author routinely use a 4.5 mm incisor shaver to debride adhesions and reduce the size of the fat pad and synovium just enough for visualization. There is often a rudimentary ligament at the anterior aspect of the tibiofemoral articulation which can be safely excised. The fat pad can also be downsized using the 90° wand, alternating between coagulation (for hemostasis of bleeding points) and cutting (for shrinking tissues). Adequate visualization is achieved when the anterior horn of both medial and lateral menisci are easily visualized together with the intermeniscal ligament. The ACL and PCL can be checked for laxity using a probe.

With the knee at different angles of flexion, the direction of the portal changes slightly due to the difference in position of the skin relative to the capsule and synovium. With experience, primarily through development of muscle memory, the surgeon is able to quickly locate the right direction of entry without forcefully creating another tract. Additional tracts through the capsule or synovium should be avoided as these are all potential sites for joint fluid extravasation and represents unnecessary additional tissue damage. To enhance easy insertion of instruments and changing of the scope through different portals, the track should be adequately dilated using the haemostat. With the scope in the anteromedial portal, the wand should be inserted through the anterolateral portal and used to shrink the synovium around the opening of the tract and vice versa.

To visualize the posterior horn of the medial meniscus, the knee is held at a 20–30° flexion with the patient's foot resting in the surgeons' hip. Putting the knee at 20–30° eliminates the ACL's contribution to stability, leaving only the medial collateral ligament (MCL) as a restraint against a valgus force. The patient's thigh is blocked by the side support, and the surgeon can exert a valgus force on the knee by moving his entire body outwards. Additionally, an assistant can help to apply more valgus force onto the knee (**Figure 10**). By slowly varying the angle of flexion using his hip, the surgeon will be able to find an angle of best access. Sometimes, this maneuver does not suffice to allow access to the posterior horn in muscular young adult male patients or patients with post-traumatic knee arthritis and joint stiffness. A method of improving access is by needling the MCL from within. An 18G spinal needle is inserted from the anterolateral portal. The spinal needle is directed towards the body of the medial meniscus, inferior to it. The curved tip is pointed inferiorly to avoid injury to the meniscus. The deep MCL and superficial MCL is then needled below the meniscus, with a gap of about 2–3 mm in between each penetration. This is done with the knee in 20–30° with a constant valgus force applied to gradually open up the medial compartment. It is important to apply a sustained gradual force and avoid sudden excessive valgus forces to avoid creating an iatrogenic MCL tear. This technique is sufficient to open up the medial compartment for visualization and instrument access. A similar method is needling the MCL from outside the skin and observing the needle penetrating the joint below the meniscus [3]. Both techniques work well but doing it from within avoids puncture marks on the skin and is more accurate in avoiding the meniscus.

damage to the trochlear cartilage. The haemostat is then opened to dilate the track. The scope trocar is inserted in the same direction, and similarly felt to contact the trochlear, before the knee is extended and the trocar driven beneath the patella into the suprapatellar pouch. The trocar is then removed, leaving the sheath, and the 30° lens inserted and locked into place. Following visual confirmation of placement in the suprapatellar pouch, fluid irrigation can be started. Where there is a lot of synovial debris, a washout of the suprapatellar pouch will first

A diagnostic arthroscopy starts with examination of the suprapatellar pouch with the knee in extension. Pathology that can be observed at this stage includes loose bodies, synovitis or plicae. The lens is directed upwards and the undersurface of the patella cartilage inspected. Following inspection of the suprapatellar pouch, the lens is taken over the medial side of the medial femoral condyle while the knee is allowed to flex over the side of the table. The medial gutter can be inspected at this juncture. The medial femoral condyle should be inspected in its entirety, followed by the anterior horn of the medial meniscus and the ACL. Frequently though, the fat pad posterior to the patellar tendon can interfere with visualization and it is at this point that a 21G hypodermic needle can be inserted through the surface marking of the anteromedial portal. The direction of the needle should be checked and confirmed to be able to give a direct line of access to the posterior horn of the medial meniscus. A stab incision is then made and the track dilated with a straight haemostat. The author routinely use a 4.5 mm incisor shaver to debride adhesions

be performed using the irrigation.

**Figure 9.** Standard incisions for ACL reconstruction.

10 Recent Advances in Arthroscopic Surgery

To visualize just the posterior root of the medial meniscus, the scope can be inserted from the anterolateral portal and driven through the notch. This can easily be done in patients with a lax ACL and a wide notch. In patients with an intact ACL, a trans-patellar tendon portal is sometimes required in order for the scope to adopt the right direction to penetrate the notch. The direction of the scope should be medial to the ACL and inferior to the femoral insertion of the PCL.

debriding damaged cartilage or menisci down to a stable and smooth rim with a combination of the shaver and wand. Degenerated menisci involving the white-white zone can be safely debrided. However, if the meniscal damage involves the red-red zone, an attempt should be made to repair the meniscus wherever possible and biologically feasible. Intra-articular loose bodies or prominent osteophytes, especially patellar osteophytes, can also be removed. Plicae, if present, are usually abnormal condensations of the capsule/retinaculum and can create pain when they abrade or impinge against the femoral condyles. They can be excised with a combination of the arthroscopic scissors and the shaver. Boggy synovial hypertrophy can be downsized as synovitis is also often an important contributor of pain. At the completion of the procedures, the knee is repeatedly washed out using the arthroscopic fluid to remove debris and inflammatory cytokines. The wounds are closed with non-absorbable sutures to achieve a water-tight closure, and generous local anesthetic can be infiltrated around the wounds. A

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 13

A lateral release is a commonly performed step of routine knee arthroscopy for patients who have tight lateral retinaculum causing a lateral patellar tilt. Patients will commonly have anterior knee pains after walking or running, and examination will show reduced medial translation of the patella and lateral patellar facet tenderness. This should be corroborated by a skyline x-ray view of the knee showing abnormal lateral patellar tilt. Patients with these findings will then do well with a simple lateral release. This step is usually performed at the end of the arthroscopy, because there will be fluid extravasation into the subcutaneous tissues once the lateral release is done. With the knee in extension, a small incision into the suprapatellar pouch is made about 1 cm proximal to the superolateral corner of the patella. A hook radiofrequency ablation tip is inserted through the incision and used to incise the retinaculum longitudinally about 1–1.5 cm from the lateral edge of the patella. The release of the retinaculum should be performed from 1 cm above the superior edge of the patella to 1 cm below the inferior edge of the patella. It is important that only the retinaculum be ablated and released, without ablating the more superficial subcutaneous layer. Another method of doing this is to insert the radiofrequency hook through the anterolateral portal. The patella should be checked for increased medial mobility and the knee taken through flexion to check for an

In standard arthroscopy cases without meniscal or cartilage repair/reconstruction, the patient is allowed to weightbear fully after the surgery as pain allows. Static quadriceps contractions, straight leg raise, and active flexion of the knee is encouraged from immediately after surgery.

Cartilage repair or restoration is a group of surgical techniques of treating cartilage lesions in suitable cases [4]. Generally, these are middle-aged patients with fairly localized Outerbridge grade 3–4 degenerative cartilage wear, usually over the medial femoral condyle or beneath the patella facet. Patients with Outerbridge grade 1–2 cartilage wear can usually be satisfactorily treated with debridement. Young active patients with very localized cartilage lesions will benefit

bulky post-operative dressing is applied.

**4. Arthroscopic cartilage repair/restoration**

adequate release.

**Figure 10.** Applying valgus force on the knee with an assistant's hand acting as a pivot.

To visualize the posterior horn of the lateral meniscus, the tip of the scope is first placed just lateral to the ACL with the knee at 90°. The leg is then brought over the other leg to adopt a 'figure of 4' position. A downward force on the knee is applied by an assistant and the scope can be inserted into the lateral tibiofemoral compartment (**Figure 11**). This position allows work to be done on the posterior horn of the lateral meniscus, with the scope inserted from the anteromedial compartment and the instruments inserted from the anterolateral compartment.

Following an arthroscopic inspection of the whole joint, the required work is then performed. Standard knee arthroscopies are often done as a debridement procedure in middle-aged patients with knee osteoarthritis. Worn-down or damaged cartilage is graded according to the Outerbridge or International Cartilage Repair Society (ICRS) classification. Menisci damage is classified according to the morphology (fraying, tear, horizontal cleavage) and location (within the white-white, white-red, or red-red zone). Routine debridement procedures involve

**Figure 11.** Applying downward force with the knee in a 'Figure-of-4' position opens up the lateral joint.

debriding damaged cartilage or menisci down to a stable and smooth rim with a combination of the shaver and wand. Degenerated menisci involving the white-white zone can be safely debrided. However, if the meniscal damage involves the red-red zone, an attempt should be made to repair the meniscus wherever possible and biologically feasible. Intra-articular loose bodies or prominent osteophytes, especially patellar osteophytes, can also be removed. Plicae, if present, are usually abnormal condensations of the capsule/retinaculum and can create pain when they abrade or impinge against the femoral condyles. They can be excised with a combination of the arthroscopic scissors and the shaver. Boggy synovial hypertrophy can be downsized as synovitis is also often an important contributor of pain. At the completion of the procedures, the knee is repeatedly washed out using the arthroscopic fluid to remove debris and inflammatory cytokines. The wounds are closed with non-absorbable sutures to achieve a water-tight closure, and generous local anesthetic can be infiltrated around the wounds. A bulky post-operative dressing is applied.

A lateral release is a commonly performed step of routine knee arthroscopy for patients who have tight lateral retinaculum causing a lateral patellar tilt. Patients will commonly have anterior knee pains after walking or running, and examination will show reduced medial translation of the patella and lateral patellar facet tenderness. This should be corroborated by a skyline x-ray view of the knee showing abnormal lateral patellar tilt. Patients with these findings will then do well with a simple lateral release. This step is usually performed at the end of the arthroscopy, because there will be fluid extravasation into the subcutaneous tissues once the lateral release is done. With the knee in extension, a small incision into the suprapatellar pouch is made about 1 cm proximal to the superolateral corner of the patella. A hook radiofrequency ablation tip is inserted through the incision and used to incise the retinaculum longitudinally about 1–1.5 cm from the lateral edge of the patella. The release of the retinaculum should be performed from 1 cm above the superior edge of the patella to 1 cm below the inferior edge of the patella. It is important that only the retinaculum be ablated and released, without ablating the more superficial subcutaneous layer. Another method of doing this is to insert the radiofrequency hook through the anterolateral portal. The patella should be checked for increased medial mobility and the knee taken through flexion to check for an adequate release.

In standard arthroscopy cases without meniscal or cartilage repair/reconstruction, the patient is allowed to weightbear fully after the surgery as pain allows. Static quadriceps contractions, straight leg raise, and active flexion of the knee is encouraged from immediately after surgery.

### **4. Arthroscopic cartilage repair/restoration**

To visualize the posterior horn of the lateral meniscus, the tip of the scope is first placed just lateral to the ACL with the knee at 90°. The leg is then brought over the other leg to adopt a 'figure of 4' position. A downward force on the knee is applied by an assistant and the scope can be inserted into the lateral tibiofemoral compartment (**Figure 11**). This position allows work to be done on the posterior horn of the lateral meniscus, with the scope inserted from the anteromedial compartment and the instruments inserted from the anterolateral

**Figure 10.** Applying valgus force on the knee with an assistant's hand acting as a pivot.

Following an arthroscopic inspection of the whole joint, the required work is then performed. Standard knee arthroscopies are often done as a debridement procedure in middle-aged patients with knee osteoarthritis. Worn-down or damaged cartilage is graded according to the Outerbridge or International Cartilage Repair Society (ICRS) classification. Menisci damage is classified according to the morphology (fraying, tear, horizontal cleavage) and location (within the white-white, white-red, or red-red zone). Routine debridement procedures involve

**Figure 11.** Applying downward force with the knee in a 'Figure-of-4' position opens up the lateral joint.

compartment.

12 Recent Advances in Arthroscopic Surgery

Cartilage repair or restoration is a group of surgical techniques of treating cartilage lesions in suitable cases [4]. Generally, these are middle-aged patients with fairly localized Outerbridge grade 3–4 degenerative cartilage wear, usually over the medial femoral condyle or beneath the patella facet. Patients with Outerbridge grade 1–2 cartilage wear can usually be satisfactorily treated with debridement. Young active patients with very localized cartilage lesions will benefit from Autologous Cartilage Implantation (ACI), where the first stage involves arthroscopically harvesting cartilage from the anterior non-weightbearing surface of the medial or lateral trochlear. The cartilage chondrocytes are then cultivated in the laboratory. The second stage 4–6 weeks later involves an open procedure where a periosteal patch is first harvested from the proximal tibia, stitched in a water-tight fashion over the defect, and the chondrocytes injected beneath the periosteal patch. This procedure aims to regenerate 'hyaline-like' cartilage and has been shown in studies to have results comparable or superior to microfracture [5].

When using the scaffold mesh, it should be cut to the defect size or slightly larger, as the mesh will usually shrink when in contact with fluid. The mesh should be lightly dampened with saline to make it more firm and easier to manipulate. The superior point of the mesh is grasped with an arthroscopic grasper, and the mesh brought into the knee, laying the mesh first in the superior portion of the defect. An accessory anteromedial or anterolateral portal is essential to allow insertion of a probe to assist in seating the rest of the mesh. Following seating of the mesh, a fibrin sealant glue (such as Evicel or Tisseel) is laid over the edges of the mesh. It is important that synovium is kept far from the defect so that the glue will not inadvertently stick to the synovium. If it does so, the glue can be allowed to harden first before snipping the adhesion with an arthroscopic scissors. Two minutes is allowed to lapse for the hardening of the glue, and the knee is then ranged carefully to check for the stability of the mesh. It is imperative that throughout the implantation process, the area is

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 15

For patella lesions, a mini-arthrotomy is often required as there is no conceivable way to implant the scaffold since the patella is downward-facing. With the knee extended, the incision can be done at the midpoint between the edge of the patella and the femoral condyle. Strong vicryl sutures are inserted into the deepest layer of the retinaculum and used to evert the patella, assisted by an assistant's finger on the outside of the patella as a pivot point. It is often possible to satisfactorily treat the lesion with the patella everted to just vertical. The cartilage defect is prepared and the microfracture performed, followed by implantation of the

Post-operative care for cartilage restoration includes bracing the knee in a hinged brace, allowing for 0–30° of movement as tolerated. Toe-touch weight bearing with two crutches is allowed. This is applicable for both femoral condyle and patella lesions. Isometric gentle quadriceps exercises and active ankle movement exercises can be started immediately after surgery. The allowable range of movement is gradually increased, and free range of move-

**Figure 12.** Open view of a 1.5cm x 1.8cm patella cartilage lesion through a mini-open arthrotomy.

kept dry.

scaffold as described above (**Figures 12** and **13**).

ment can be allowed after 6 weeks.

For most patients, the most basic method of treating cartilage lesions is microfracture, known as a marrow stimulation technique. The idea is to allow the release of mesenchymal stem cells from within the marrow into the cartilage defect, forming a blood clot. The blood clot then forms fibrocartilage over 3–6 months. This works well for Outerbridge grade 3–4 lesions about 1 cm × 1 cm in dimension and is more effective for the weight-bearing femoral condyles than for a patella lesion [6]. The area of damaged cartilage is first sized using the tip of the probe (which measures 5 mm), and the damaged cartilage debrided down to subchondral bone. It is important to create vertical wall edges wherever possible. This allows more effective trapping of the resultant blood clot within the defect. An arthroscopic awl is then used to create subchondral punctures in the bone to allow the escape of fat globules from within the marrow. The punctures should be spaced about 3 mm apart. Patients who had microfracture alone do not require protected weight-bearing after surgery. In fact, weight-bearing is beneficial because it compresses the femoral condyles against the tibia, closing off the cartilage defect and allowing formation of a contained blood clot.

Patients who have areas of cartilage damage larger than 1 cm × 1 cm will benefit from a cartilage reconstruction procedure using a commercially available hyaluronic acid scaffold. The scaffold traps the in-coming blood clot effectively, allowing the mesenchymal cells to differentiate and grow along the scaffold. This can come in the form of either a mesh (e.g. Hyalofast) or an injectable gel (e.g. Cartifill). The lesion should not be any larger than 3 cm × 3 cm, and should not have any associated subchondral bone defects. Disease processes such as OsteoChondritis Dissecans (OCD) or Spontaneous OsteoNecrosis of the Knee (SONK) with involvement of the subchondral bone will benefit from Osteochondral Autograft Transfer System (OATS).

Reconstruction using a hyaluronic acid scaffold can be done arthroscopically for lesions on the femoral condyles or tibial plateaus. Following debridement and microfracture of the defect, the surgical field must be adequately dried to prevent loosening of the scaffold during implantation. The fluid inflow is first turned off and remnant intra-articular fluid is drained. Small surgical patties can be used to dry the area around the defect. The knee can be infused with carbon dioxide which effectively dries the area and pushes surrounding synovium away. For lesions on the weightbearing surfaces of the femoral condyles, the knee is place at 90°. Any flexion angle higher than this should be avoided because the anterior knee structures will begin to press downwards onto the condyles. The foot should be propped higher using towels while keeping the knee at 90°, thus flexing the hip. An assistant is vital to keep the leg in this position during implantation. The defect is thus made more horizontal, allowing easier implantation.

When using the scaffold mesh, it should be cut to the defect size or slightly larger, as the mesh will usually shrink when in contact with fluid. The mesh should be lightly dampened with saline to make it more firm and easier to manipulate. The superior point of the mesh is grasped with an arthroscopic grasper, and the mesh brought into the knee, laying the mesh first in the superior portion of the defect. An accessory anteromedial or anterolateral portal is essential to allow insertion of a probe to assist in seating the rest of the mesh. Following seating of the mesh, a fibrin sealant glue (such as Evicel or Tisseel) is laid over the edges of the mesh. It is important that synovium is kept far from the defect so that the glue will not inadvertently stick to the synovium. If it does so, the glue can be allowed to harden first before snipping the adhesion with an arthroscopic scissors. Two minutes is allowed to lapse for the hardening of the glue, and the knee is then ranged carefully to check for the stability of the mesh. It is imperative that throughout the implantation process, the area is kept dry.

from Autologous Cartilage Implantation (ACI), where the first stage involves arthroscopically harvesting cartilage from the anterior non-weightbearing surface of the medial or lateral trochlear. The cartilage chondrocytes are then cultivated in the laboratory. The second stage 4–6 weeks later involves an open procedure where a periosteal patch is first harvested from the proximal tibia, stitched in a water-tight fashion over the defect, and the chondrocytes injected beneath the periosteal patch. This procedure aims to regenerate 'hyaline-like' cartilage and has

For most patients, the most basic method of treating cartilage lesions is microfracture, known as a marrow stimulation technique. The idea is to allow the release of mesenchymal stem cells from within the marrow into the cartilage defect, forming a blood clot. The blood clot then forms fibrocartilage over 3–6 months. This works well for Outerbridge grade 3–4 lesions about 1 cm × 1 cm in dimension and is more effective for the weight-bearing femoral condyles than for a patella lesion [6]. The area of damaged cartilage is first sized using the tip of the probe (which measures 5 mm), and the damaged cartilage debrided down to subchondral bone. It is important to create vertical wall edges wherever possible. This allows more effective trapping of the resultant blood clot within the defect. An arthroscopic awl is then used to create subchondral punctures in the bone to allow the escape of fat globules from within the marrow. The punctures should be spaced about 3 mm apart. Patients who had microfracture alone do not require protected weight-bearing after surgery. In fact, weight-bearing is beneficial because it compresses the femoral condyles against the tibia, closing off the cartilage

Patients who have areas of cartilage damage larger than 1 cm × 1 cm will benefit from a cartilage reconstruction procedure using a commercially available hyaluronic acid scaffold. The scaffold traps the in-coming blood clot effectively, allowing the mesenchymal cells to differentiate and grow along the scaffold. This can come in the form of either a mesh (e.g. Hyalofast) or an injectable gel (e.g. Cartifill). The lesion should not be any larger than 3 cm × 3 cm, and should not have any associated subchondral bone defects. Disease processes such as OsteoChondritis Dissecans (OCD) or Spontaneous OsteoNecrosis of the Knee (SONK) with involvement of the subchondral bone will benefit from Osteochondral Autograft Transfer

Reconstruction using a hyaluronic acid scaffold can be done arthroscopically for lesions on the femoral condyles or tibial plateaus. Following debridement and microfracture of the defect, the surgical field must be adequately dried to prevent loosening of the scaffold during implantation. The fluid inflow is first turned off and remnant intra-articular fluid is drained. Small surgical patties can be used to dry the area around the defect. The knee can be infused with carbon dioxide which effectively dries the area and pushes surrounding synovium away. For lesions on the weightbearing surfaces of the femoral condyles, the knee is place at 90°. Any flexion angle higher than this should be avoided because the anterior knee structures will begin to press downwards onto the condyles. The foot should be propped higher using towels while keeping the knee at 90°, thus flexing the hip. An assistant is vital to keep the leg in this position during implantation. The defect is thus made more horizontal, allowing easier implantation.

been shown in studies to have results comparable or superior to microfracture [5].

defect and allowing formation of a contained blood clot.

System (OATS).

14 Recent Advances in Arthroscopic Surgery

For patella lesions, a mini-arthrotomy is often required as there is no conceivable way to implant the scaffold since the patella is downward-facing. With the knee extended, the incision can be done at the midpoint between the edge of the patella and the femoral condyle. Strong vicryl sutures are inserted into the deepest layer of the retinaculum and used to evert the patella, assisted by an assistant's finger on the outside of the patella as a pivot point. It is often possible to satisfactorily treat the lesion with the patella everted to just vertical. The cartilage defect is prepared and the microfracture performed, followed by implantation of the scaffold as described above (**Figures 12** and **13**).

Post-operative care for cartilage restoration includes bracing the knee in a hinged brace, allowing for 0–30° of movement as tolerated. Toe-touch weight bearing with two crutches is allowed. This is applicable for both femoral condyle and patella lesions. Isometric gentle quadriceps exercises and active ankle movement exercises can be started immediately after surgery. The allowable range of movement is gradually increased, and free range of movement can be allowed after 6 weeks.

**Figure 12.** Open view of a 1.5cm x 1.8cm patella cartilage lesion through a mini-open arthrotomy.

tendon on its own especially in large muscular adults, where the sartorius may be more round and tendinous at its insertion instead of spread out like a sheet. The sartorius should not be harvested because it has multiple attachments to the medial tibial surface and surrounding structures due to its sheet-like insertion. Once the semitendinosus and gracilis tendons are identified, the interval between them can be identified and then dissected distally to its insertion, thereby properly separating the tendons. The tendon insertions can then incised, keeping in mind to preserve as much length as possible, the tendon end whipped-stitched, and surrounding adhesions dissected and cut before stripping the tendon. Before stripping the tendon, the ubiquitous band to the gastrocnemius should be cut. The entire length of the surgeon's index finger should be inserted into the wound and felt circumferentially around the tendon and the soft muscular portion of the hamstrings should be felt before proceeding to strip. A closed, blunt stripper is then inserted over the tendon and the tendon stripped from its muscle belly with sustained controlled force. The stripper tip should comfortably pass into the muscle belly before encountering much resistance. If there were resistance felt within the first few centimeters of inserting the stripper, it is likely that there are remnant adhesions. Failure to properly dissect off adhesions to the tendons may result in truncation of

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 17

The saphenous nerve is in the vicinity during harvest of the hamstrings. The reported incidence of post-operative sensory disturbance is as high as 74–88% as reported in the literature [8, 9]. The infrapatellar branch of the saphenous nerve is also commonly damaged during hamstring harvest. While it is not possible to completely eliminate the risk every time due to anatomical variabilities, steps can be taken to minimize the risk. It has been found that an oblique incision carries a lower risk compared to a vertical incision [10]. After incising the sartorial fascia, dissecting the fascia separate from the tendons is done carefully and in a blunt manner. This is because the saphenous nerve can be closely apposed to the sartorial fascia at this level. Any obvious nervous structure should be preserved. Also, the nerve is also in close proximity with the distal portion of the gracilis tendon. Cutting of bands from the gracilis tendon must be done under direct visualization, and all sartorial and surrounding adhesions must be bluntly freed before stripping the tendon. During closure of the wound, stitching of the fascia must be done with only small needle bites, and the fascia is merely apposed but not bundled tightly together. Using these steps, the author finds a rate of less than 10% of patients reporting persistent post-operative numbness or sensory disturbance in the infrapatellar area of the knee, and perhaps 1–2% of patients reporting saphenous nerve sensory disturbances. The graft is prepared on the back-table by first removing all remnant muscular attachments. For a quadrupled graft, both ends of the both tendons are whip-stitched and the folded quadrupled graft sized and then kept under tension. After drilling of the femoral tunnel and measurement of the tunnel length (usually femoral tunnel length will be about 40 mm), the appropriate endobutton will be opened and the graft threaded through the endobutton. The intra-articular portion of the quadrupled graft is then stitched together. If a particularly long graft is obtained (e.g. more than 24 cm), each graft can potentially be tripled to produce a sextupled graft. Generally at least 8–9 cm of graft will be a sufficient length for appropriate fixation in both femoral and tibial ends using a femoral endobutton and a tibial interference screw. If a sextupled graft is used, then the whip stitches will only be at one end of the graft.

the tendons during stripping.

**Figure 13.** Following debridement of damaged cartilage and microfracture, an injectable collagen scaffold has been injected into the lesion, filling up the cavity and forming a smooth surface contour.

### **5. Arthroscopic anterior cruciate ligament reconstruction**

ACL reconstruction is one of the most common arthroscopic surgeries performed today. Different graft types (hamstring autograft, allograft, bone-patellar tendon-bone), different fixation methods (interference screw, suspensory, transfixion) and different techniques (single-bundle, double-bundle) exist and this chapter will not discuss the large amount of medical literature studying the pros and cons of each. The author performs ACL reconstructions primarily using single-bundle hamstring autografts. Allografts are used for example in revision cases, or if it is a combined ACL/PCL reconstruction. Double-bundle reconstructions are performed only for competitive athletes. The author's method is a trans-portal method that recreates the femoral attachment at the anatomical location. Transportal techniques have been shown to have better clinical outcome and knee laxity scores as compared to transtibial techniques [7]. The following technique describes a single-bundle hamstring autograft reconstruction using a femoral endobutton and a tibial interference screw.

The patient's own hamstrings can be harvested using a 3–4 cm oblique incision placed directly over the palpable 'speed-bumps' that insert into the anteromedial surface of the tibia. Where the speed-bumps are not well-felt, the lowest-most end of the incision should be 2 cm medial and 1 cm inferior to the tibial tubercle. The hamstrings consist of the sartorius, the gracilis, and the semitendinosus and the latter two are harvested. The hamstrings should be harvested with the knee in 90° flexion to allow the tendons to relax and allow for easy identification. Following incision and dissection through subcutaneous fat, the sartorius fascia will be encountered. An incision in line with the skin incision is made in the sartorius fascia and the fascia dissected and peeled away from the tendons. The sartorius fascia will be overlying the terminal tendons of the gracilis and the semitendinosus and will be effectively merged with the tendons at the insertion, so they cannot be properly identified at its insertion. Identification of the tendons should start at the proximal-most end of the incision, where the tendons are still separate. Glistening white tendons should be identified, and from the lowest semitendinosus up. This is because the sartorius may occasionally be mistaken for a tendon on its own especially in large muscular adults, where the sartorius may be more round and tendinous at its insertion instead of spread out like a sheet. The sartorius should not be harvested because it has multiple attachments to the medial tibial surface and surrounding structures due to its sheet-like insertion. Once the semitendinosus and gracilis tendons are identified, the interval between them can be identified and then dissected distally to its insertion, thereby properly separating the tendons. The tendon insertions can then incised, keeping in mind to preserve as much length as possible, the tendon end whipped-stitched, and surrounding adhesions dissected and cut before stripping the tendon. Before stripping the tendon, the ubiquitous band to the gastrocnemius should be cut. The entire length of the surgeon's index finger should be inserted into the wound and felt circumferentially around the tendon and the soft muscular portion of the hamstrings should be felt before proceeding to strip. A closed, blunt stripper is then inserted over the tendon and the tendon stripped from its muscle belly with sustained controlled force. The stripper tip should comfortably pass into the muscle belly before encountering much resistance. If there were resistance felt within the first few centimeters of inserting the stripper, it is likely that there are remnant adhesions. Failure to properly dissect off adhesions to the tendons may result in truncation of the tendons during stripping.

**5. Arthroscopic anterior cruciate ligament reconstruction**

injected into the lesion, filling up the cavity and forming a smooth surface contour.

16 Recent Advances in Arthroscopic Surgery

struction using a femoral endobutton and a tibial interference screw.

ACL reconstruction is one of the most common arthroscopic surgeries performed today. Different graft types (hamstring autograft, allograft, bone-patellar tendon-bone), different fixation methods (interference screw, suspensory, transfixion) and different techniques (single-bundle, double-bundle) exist and this chapter will not discuss the large amount of medical literature studying the pros and cons of each. The author performs ACL reconstructions primarily using single-bundle hamstring autografts. Allografts are used for example in revision cases, or if it is a combined ACL/PCL reconstruction. Double-bundle reconstructions are performed only for competitive athletes. The author's method is a trans-portal method that recreates the femoral attachment at the anatomical location. Transportal techniques have been shown to have better clinical outcome and knee laxity scores as compared to transtibial techniques [7]. The following technique describes a single-bundle hamstring autograft recon-

**Figure 13.** Following debridement of damaged cartilage and microfracture, an injectable collagen scaffold has been

The patient's own hamstrings can be harvested using a 3–4 cm oblique incision placed directly over the palpable 'speed-bumps' that insert into the anteromedial surface of the tibia. Where the speed-bumps are not well-felt, the lowest-most end of the incision should be 2 cm medial and 1 cm inferior to the tibial tubercle. The hamstrings consist of the sartorius, the gracilis, and the semitendinosus and the latter two are harvested. The hamstrings should be harvested with the knee in 90° flexion to allow the tendons to relax and allow for easy identification. Following incision and dissection through subcutaneous fat, the sartorius fascia will be encountered. An incision in line with the skin incision is made in the sartorius fascia and the fascia dissected and peeled away from the tendons. The sartorius fascia will be overlying the terminal tendons of the gracilis and the semitendinosus and will be effectively merged with the tendons at the insertion, so they cannot be properly identified at its insertion. Identification of the tendons should start at the proximal-most end of the incision, where the tendons are still separate. Glistening white tendons should be identified, and from the lowest semitendinosus up. This is because the sartorius may occasionally be mistaken for a The saphenous nerve is in the vicinity during harvest of the hamstrings. The reported incidence of post-operative sensory disturbance is as high as 74–88% as reported in the literature [8, 9]. The infrapatellar branch of the saphenous nerve is also commonly damaged during hamstring harvest. While it is not possible to completely eliminate the risk every time due to anatomical variabilities, steps can be taken to minimize the risk. It has been found that an oblique incision carries a lower risk compared to a vertical incision [10]. After incising the sartorial fascia, dissecting the fascia separate from the tendons is done carefully and in a blunt manner. This is because the saphenous nerve can be closely apposed to the sartorial fascia at this level. Any obvious nervous structure should be preserved. Also, the nerve is also in close proximity with the distal portion of the gracilis tendon. Cutting of bands from the gracilis tendon must be done under direct visualization, and all sartorial and surrounding adhesions must be bluntly freed before stripping the tendon. During closure of the wound, stitching of the fascia must be done with only small needle bites, and the fascia is merely apposed but not bundled tightly together. Using these steps, the author finds a rate of less than 10% of patients reporting persistent post-operative numbness or sensory disturbance in the infrapatellar area of the knee, and perhaps 1–2% of patients reporting saphenous nerve sensory disturbances.

The graft is prepared on the back-table by first removing all remnant muscular attachments. For a quadrupled graft, both ends of the both tendons are whip-stitched and the folded quadrupled graft sized and then kept under tension. After drilling of the femoral tunnel and measurement of the tunnel length (usually femoral tunnel length will be about 40 mm), the appropriate endobutton will be opened and the graft threaded through the endobutton. The intra-articular portion of the quadrupled graft is then stitched together. If a particularly long graft is obtained (e.g. more than 24 cm), each graft can potentially be tripled to produce a sextupled graft. Generally at least 8–9 cm of graft will be a sufficient length for appropriate fixation in both femoral and tibial ends using a femoral endobutton and a tibial interference screw. If a sextupled graft is used, then the whip stitches will only be at one end of the graft. Following threading of the graft through the endobutton, the graft is tripled, and the entire graft stitched together at the loop of the endobutton and throughout the entire graft, to prevent the graft from adjusting within the loop.

Standard positioning for ACL reconstruction is with 2 foot-rests. Following standard arthroscopic evaluation and debridement of remnant ACL tissue, the femoral tunnel is prepared first. Remnant tissue if available on the lateral femoral condyle can be used as a guide to the insertion point of the guide wire. Otherwise, the Resident's Ridge is a reliable landmark which is consistently present in nearly all knees. With the knee in anatomical position, the Ridge is a linear landmark that runs from superior-anterior to inferior-posterior across the lateral femoral condyle, more-or-less dividing the wall of the lateral femoral condyle into an anterior and posterior half. With the knee bent at 90°, the terminology can be confusing, so it is important to only refer to the landmarks based on anatomical terminology. The femoral insertion site of the ACL is in the posterior half of the lateral femoral condyle and slightly superior. Preparation of the wall of the lateral femoral condyle should show the Ridge and the entire wall inferior, posterior and superior to the Ridge. The anatomical landmark is at the halfway point between the Ridge and the posterior cartilage margin, and just slightly (1–2 mm) superior to the halfway point between the inferior and the superior cartilage margins. Proper visualization of the wall is through the anteromedial portal with a 30° lens. With the knee hyperflexed, the guidewire can be first inserted through the accessory anteromedial portal to judge its trajectory and position. The accessory anteromedial portal is more medial to the standard anteromedial portal and is as low as possible without injuring the medial meniscus. This ensures a trajectory of the guidewire exiting the anterolateral femoral cortex. With this method, there is no necessity to perform a notchplasty. The guidewire can be lightly tapped with a mallet to first engage the femoral condyle wall, before being advanced with the drill. With satisfactory guidewire positioning, the lateral cortex is then broken. The length of the tunnel can be measured at this point, following which the guidewire is re-inserted and the appropriate reamer used to create the femoral tunnel to a depth about 5 mm less than the length of the tunnel. For a standard 40 mm femoral tunnel, the 15 mm endobutton is used, giving a 25 mm length of tendon within the tunnel.

Following passage of the graft and flipping of the endobutton, the knee is cycled about 15–20 times while maintaining tension on the graft. This allows even distribution of tension throughout the diameter of the graft and allows stress relaxation. The tibial end is then fixed with an interference screw usually 0.5–1 mm larger than the diameter of the tunnel itself and with the knee in 20° of flexion and a posterior drawer on the tibia. A final check arthroscopy can then be done, assessing the final position of the new graft. The knee can also be brought to full extension and the graft arthroscopically checked to ensure no impingement on the femoral trochlear, though with anatomical positioning of the tunnels, there should be none (**Figure 14**). The wounds are closed in standard fashion followed by a generous subcutaneous

**Figure 14.** With the knee in 90°, the reconstructed ACL graft should appear as a low-lying graft passing from the anterior

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 19

**1.** First 2 weeks: A hinged knee brace locked at 0–30°, worn all the time. Patient to perform

**2.** Second 2 weeks: The brace can be removed while awake and not ambulating, but worn at night and if ambulating. The degree angle need not be adjusted as the patient can perform flexion exercises when the brace is not on. Patient can start to perform prone hang and

**3.** Third 2 weeks: The brace can be removed at night, and worn only during ambulation. Again, the brace angle need not be adjusted. The locked brace will continue to protect the patient's ACL during activities such as ascending/descending stairs or getting in/out of a car. Closed-chain exercises can commence. The brace can be taken off after the third

Meniscal repair methods include all-inside, inside-out, and outside-in techniques. However, with the advent of a range of commercially available products and instruments for all-inside

The author's post-operative rehabilitation protocol consists of the following:

infiltration of long-acting anesthetic.

passive flexion exercises.

**6. Arthroscopic meniscal repair**

2 weeks.

static quadriceps and straight leg raise exercises.

part of the medial tibial eminence to the lateral femoral condyle.

The tibial tunnel position should be centred at a point about 40% of the antero-posterior length of the tibial plateau from the anterior end backwards. Medio-laterally, it should be centred just slightly lateral to the medial tibial intercondylar tubercle. Arthroscopically, the centre of the tibial tunnel should be on the medio-lateral line just traversing the posterior part of the anterior horn of the lateral meniscus, and on the antero-posterior line just traversing slightly lateral to the highest point of the medial tibial intercondylar tubercle. This will ensure the entire graft is situated anterior to the line connecting the highest points of the medial and lateral tibial intercondylar tubercles and is medial enough. This is the anatomical position for a singlebundle reconstruction and will give the best results in terms of anterior drawer and rotational control. With the scope in the anterolateral portal, it is important to assess the tibial tunnel position from both an anterior view and from a lateral view to obtain an accurate judgment of the location. Sometimes, the 70° scope is used to assess the anatomy accurately. The tibial drill guide is inserted through the anteromedial portal and the guidewire inserted through the incision used for harvest of the hamstrings. The tunnel is then reamed and a shaver inserted through the tunnel to clear out debris and smooth the entry and exit edges of the tunnel.

**Figure 14.** With the knee in 90°, the reconstructed ACL graft should appear as a low-lying graft passing from the anterior part of the medial tibial eminence to the lateral femoral condyle.

Following passage of the graft and flipping of the endobutton, the knee is cycled about 15–20 times while maintaining tension on the graft. This allows even distribution of tension throughout the diameter of the graft and allows stress relaxation. The tibial end is then fixed with an interference screw usually 0.5–1 mm larger than the diameter of the tunnel itself and with the knee in 20° of flexion and a posterior drawer on the tibia. A final check arthroscopy can then be done, assessing the final position of the new graft. The knee can also be brought to full extension and the graft arthroscopically checked to ensure no impingement on the femoral trochlear, though with anatomical positioning of the tunnels, there should be none (**Figure 14**). The wounds are closed in standard fashion followed by a generous subcutaneous infiltration of long-acting anesthetic.

The author's post-operative rehabilitation protocol consists of the following:


### **6. Arthroscopic meniscal repair**

Following threading of the graft through the endobutton, the graft is tripled, and the entire graft stitched together at the loop of the endobutton and throughout the entire graft, to pre-

Standard positioning for ACL reconstruction is with 2 foot-rests. Following standard arthroscopic evaluation and debridement of remnant ACL tissue, the femoral tunnel is prepared first. Remnant tissue if available on the lateral femoral condyle can be used as a guide to the insertion point of the guide wire. Otherwise, the Resident's Ridge is a reliable landmark which is consistently present in nearly all knees. With the knee in anatomical position, the Ridge is a linear landmark that runs from superior-anterior to inferior-posterior across the lateral femoral condyle, more-or-less dividing the wall of the lateral femoral condyle into an anterior and posterior half. With the knee bent at 90°, the terminology can be confusing, so it is important to only refer to the landmarks based on anatomical terminology. The femoral insertion site of the ACL is in the posterior half of the lateral femoral condyle and slightly superior. Preparation of the wall of the lateral femoral condyle should show the Ridge and the entire wall inferior, posterior and superior to the Ridge. The anatomical landmark is at the halfway point between the Ridge and the posterior cartilage margin, and just slightly (1–2 mm) superior to the halfway point between the inferior and the superior cartilage margins. Proper visualization of the wall is through the anteromedial portal with a 30° lens. With the knee hyperflexed, the guidewire can be first inserted through the accessory anteromedial portal to judge its trajectory and position. The accessory anteromedial portal is more medial to the standard anteromedial portal and is as low as possible without injuring the medial meniscus. This ensures a trajectory of the guidewire exiting the anterolateral femoral cortex. With this method, there is no necessity to perform a notchplasty. The guidewire can be lightly tapped with a mallet to first engage the femoral condyle wall, before being advanced with the drill. With satisfactory guidewire positioning, the lateral cortex is then broken. The length of the tunnel can be measured at this point, following which the guidewire is re-inserted and the appropriate reamer used to create the femoral tunnel to a depth about 5 mm less than the length of the tunnel. For a standard 40 mm femoral tunnel, the 15 mm endobutton is used,

The tibial tunnel position should be centred at a point about 40% of the antero-posterior length of the tibial plateau from the anterior end backwards. Medio-laterally, it should be centred just slightly lateral to the medial tibial intercondylar tubercle. Arthroscopically, the centre of the tibial tunnel should be on the medio-lateral line just traversing the posterior part of the anterior horn of the lateral meniscus, and on the antero-posterior line just traversing slightly lateral to the highest point of the medial tibial intercondylar tubercle. This will ensure the entire graft is situated anterior to the line connecting the highest points of the medial and lateral tibial intercondylar tubercles and is medial enough. This is the anatomical position for a singlebundle reconstruction and will give the best results in terms of anterior drawer and rotational control. With the scope in the anterolateral portal, it is important to assess the tibial tunnel position from both an anterior view and from a lateral view to obtain an accurate judgment of the location. Sometimes, the 70° scope is used to assess the anatomy accurately. The tibial drill guide is inserted through the anteromedial portal and the guidewire inserted through the incision used for harvest of the hamstrings. The tunnel is then reamed and a shaver inserted through the tunnel to clear out debris and smooth the entry and exit edges of the tunnel.

vent the graft from adjusting within the loop.

18 Recent Advances in Arthroscopic Surgery

giving a 25 mm length of tendon within the tunnel.

Meniscal repair methods include all-inside, inside-out, and outside-in techniques. However, with the advent of a range of commercially available products and instruments for all-inside repair, this technique has become standard practice to treat all meniscal tears wherever possible. Meniscal tears are classified by their location and pattern of tear. Tears affecting the white-white zone, the edge of the meniscus, can be debrided to a stable and smooth edge since this zone is avascular and will not heal well with repair. Tears affecting the white-red zone or the peripheral red-red zone should be repaired wherever possible. An MRI is a prerequisite before surgery to repair the meniscus. It elucidates the location and the likely pattern of tear, but it should be noted that MRI is a static assessment of the meniscus with the knee in an extended position. Significant displacements that occur with the knee in a deep flexion position may not be seen on the MRI [11]. It is therefore important that arthroscopically, an assessment of the stability is made both with a probe and with the knee in varying degrees of flexion. One important pathology to look out for on the MRI is a root tear. The signs of a root tear on the MRI include the 'ghost' sign on the sagittal cut of the root (meniscus root appearing faintly and poorly defined), the truncation sign on the coronal cut (the posterior horn appears to be abruptly truncated and separated from its tibia attachment), and extrusion of the body of the meniscus on the coronal cut, indicating a lateral displacement of the entire meniscus [12]. Root tears should always be repaired as an unrepaired root is grossly unstable and will quickly lead to osteoarthritis.

All-inside fixation devices typically consist of a delivery needle that penetrates the meniscus and deploys fixation tabs behind the capsule. These come with a pre-tied, self-sliding knot that can be pushed downwards onto the meniscus after deployment of the fixation tabs, locking the meniscus in place. The delivery needles are usually curved slightly, giving the surgeon versatility in the direction of the penetration into the meniscus. Vertical mattress sutures have been shown to have higher fixation strength than horizontal mattress sutures. Importantly, these devices are only used for the posterior horn and body of the menisci. Anterior horn tears will need to be repaired with an outside-in technique usually. When using the all-inside devices, the needle itself can be used as a reduction device since there is usually little room to admit another instrument to hold the meniscus in place. For example, for a horizontal flap tear in the posterior horn of the meniscus, the needle can first be used to penetrate the upper flap, and used to bring the upper flap over the lower flap in a reduced position, then penetrated through the lower flap to the deploy the first tab (**Figures 15** and **16**). For buckethandle tears, it is often useful to provisionally reduce the meniscus by using a smooth suture passed through the body of the meniscus using an outside-in needle. The body of the meniscus can be held in place with a grasper while the needle penetrates the body. The suture is passed through the needle and retrieved outside either of the anterior portals. The needle is then passed one more time from outside-in either above or below the meniscal edge, and a lasso passed through and retrieved outside the same portal as the one with the end of the suture. This end of the suture can then be shuttled back outside the knee, and traction applied to provisionally reduce the body of the meniscus. The rest of the meniscus can then be fixed using all-inside fixation.

biological conditions for healing. Another described method is to use a needle to penetrate the tear surfaces, called trephination. When working with very unstable tears, it is useful to use a grasper to hold the meniscus in place while the rasp or needle is used. The grasper can be inserted from an accessory portal on the same side as the meniscus tear. Following abrasion or trephination, the meniscus can be repaired. Sometimes, instead of a tear in the meniscus itself, it is a separation of the meniscus from the capsule, called a menisco-capsular separation (also called a ramp lesion). This will result in abnormal increased mobility of the meniscus and should be repaired as well. Radial tears can be repaired using an arthroscopic suture-passer (for example Arthrex Knee Scorpion) or an all-fixation device (for example Smith & Nephew FastFix 360). The arthroscopic suture-passer is small enough and allows easy passage and retrieval of suture through the meniscus. The surgeon then ties arthroscopic knots to repair the meniscus.

**Figure 16.** Following meniscal repair with all-inside fixation devices closing the cleavage and debridement of the frayed

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 21

**Figure 15.** A cleavage tear of the posterior horn of the medial meniscus.

edges.

Repair of the meniscus will start with an assessment of the location and morphology of tear, in order to guide optimal suture placement. Fibrillated or torn edges in the white-white zone can be debrided to a stable rim. The remaining tear surfaces in the white-red or red-red zones are first abraded using an arthroscopic rasp to create bleeding vascular channels to optimize

**Figure 15.** A cleavage tear of the posterior horn of the medial meniscus.

repair, this technique has become standard practice to treat all meniscal tears wherever possible. Meniscal tears are classified by their location and pattern of tear. Tears affecting the white-white zone, the edge of the meniscus, can be debrided to a stable and smooth edge since this zone is avascular and will not heal well with repair. Tears affecting the white-red zone or the peripheral red-red zone should be repaired wherever possible. An MRI is a prerequisite before surgery to repair the meniscus. It elucidates the location and the likely pattern of tear, but it should be noted that MRI is a static assessment of the meniscus with the knee in an extended position. Significant displacements that occur with the knee in a deep flexion position may not be seen on the MRI [11]. It is therefore important that arthroscopically, an assessment of the stability is made both with a probe and with the knee in varying degrees of flexion. One important pathology to look out for on the MRI is a root tear. The signs of a root tear on the MRI include the 'ghost' sign on the sagittal cut of the root (meniscus root appearing faintly and poorly defined), the truncation sign on the coronal cut (the posterior horn appears to be abruptly truncated and separated from its tibia attachment), and extrusion of the body of the meniscus on the coronal cut, indicating a lateral displacement of the entire meniscus [12]. Root tears should always be repaired as an unrepaired root is grossly unstable

All-inside fixation devices typically consist of a delivery needle that penetrates the meniscus and deploys fixation tabs behind the capsule. These come with a pre-tied, self-sliding knot that can be pushed downwards onto the meniscus after deployment of the fixation tabs, locking the meniscus in place. The delivery needles are usually curved slightly, giving the surgeon versatility in the direction of the penetration into the meniscus. Vertical mattress sutures have been shown to have higher fixation strength than horizontal mattress sutures. Importantly, these devices are only used for the posterior horn and body of the menisci. Anterior horn tears will need to be repaired with an outside-in technique usually. When using the all-inside devices, the needle itself can be used as a reduction device since there is usually little room to admit another instrument to hold the meniscus in place. For example, for a horizontal flap tear in the posterior horn of the meniscus, the needle can first be used to penetrate the upper flap, and used to bring the upper flap over the lower flap in a reduced position, then penetrated through the lower flap to the deploy the first tab (**Figures 15** and **16**). For buckethandle tears, it is often useful to provisionally reduce the meniscus by using a smooth suture passed through the body of the meniscus using an outside-in needle. The body of the meniscus can be held in place with a grasper while the needle penetrates the body. The suture is passed through the needle and retrieved outside either of the anterior portals. The needle is then passed one more time from outside-in either above or below the meniscal edge, and a lasso passed through and retrieved outside the same portal as the one with the end of the suture. This end of the suture can then be shuttled back outside the knee, and traction applied to provisionally reduce the body of the meniscus. The rest of the meniscus can then be fixed

Repair of the meniscus will start with an assessment of the location and morphology of tear, in order to guide optimal suture placement. Fibrillated or torn edges in the white-white zone can be debrided to a stable rim. The remaining tear surfaces in the white-red or red-red zones are first abraded using an arthroscopic rasp to create bleeding vascular channels to optimize

and will quickly lead to osteoarthritis.

20 Recent Advances in Arthroscopic Surgery

using all-inside fixation.

biological conditions for healing. Another described method is to use a needle to penetrate the tear surfaces, called trephination. When working with very unstable tears, it is useful to use a grasper to hold the meniscus in place while the rasp or needle is used. The grasper can be inserted from an accessory portal on the same side as the meniscus tear. Following abrasion or trephination, the meniscus can be repaired. Sometimes, instead of a tear in the meniscus itself, it is a separation of the meniscus from the capsule, called a menisco-capsular separation (also called a ramp lesion). This will result in abnormal increased mobility of the meniscus and should be repaired as well. Radial tears can be repaired using an arthroscopic suture-passer (for example Arthrex Knee Scorpion) or an all-fixation device (for example Smith & Nephew FastFix 360). The arthroscopic suture-passer is small enough and allows easy passage and retrieval of suture through the meniscus. The surgeon then ties arthroscopic knots to repair the meniscus.

Meniscal root tears, as mentioned above, should always be repaired [13]. The attachment site of the root on the tibial plateau should be freshened with a serrated curette or even a motorized burr to create a fresh bleeding surface. Using the ACL tibial drill guide aimer, a transtibial tunnel is created. The undersurface of the root should also be freshened with a rasp. There are different methods of repairing root tears, including using trans-tibial sutures to pull the root down or suture anchors inserted via an accessory posteromedial portal. There are also different ways of suture passage through the root. One commonly used method is cinching the suture, meaning passing the suture through its own loop. However, this often creates fixation only along the edge of the meniscus. The author's preferred method is to insert the suture in a cruciate manner in the root, creating an undersurface area of fixation rather than just an edge of fixation. The dimensions of the cruciate should be slightly larger than the width of the transtibial tunnel, which is usually about 4 mm to admit a suture lasso device to shuttle the root sutures through the tibial tunnel. The sutures can then be tied over a button on the surface of the proximal tibia.

will be out of our visualization once it penetrates the capsule. It is also important to use a trajectory that is away from the central popliteal neurovascular bundle, and to use a curved delivery device that allows the surgeon to direct it away from the area of danger. Also, the penetration depth should be adjusted depending on the size of the patient [14]. For average sized males, a penetration depth of 14 mm can be used quite safely, 16 mm being the distance from the point of penetration on the meniscus to the tip of the device. For slim females, the depth can be adjusted to 12 mm. Keep in mind that penetrating the meniscus and pushing the device through the meniscus will also compress the meniscus towards the capsule, so if the device is entirely pushed through to the pre-set depth limit, the tip of the device may end up even deeper than anticipated. If repairing the lateral meniscus using inside-out methods, a posterolateral incision should be made and the biceps femoris retracted posteriorly to protect the nerve. The common peroneal nerve branches off the sciatic nerve at the distal part of the thigh and runs in between the lateral head of the gastrocnemius and biceps femoris muscles. It follows the biceps muscle distally where it wraps around the fibular neck. Injury to the common peroneal nerve is a debilitating complication causing the patient to develop foot-drop. The prognosis of a neurapraxic injury of the nerve is moderate at best, with 50% achieving full recovery within 6–12 months and 50% never recovering fully. Treatment is essentially

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 23

When performing PCL reconstructions, the proximity of the popliteal neurovascular bundle to the PCL mandates a posteromedial incision with the dissection just along the posterior capsule of the knee. The knee should be at 90° of flexion. The medial head of the gastrocnemius muscle is lifted posteriorly and a blunt trocar used to create a track along the posterior edge of the tibial plateau. When performing this step, the surgeon should maintain intraarticular visualization using the scope and observe the trocar come into view. The PCL is intra-articular at the femoral end and extra-articular at the tibial end, and so debriding the torn PCL will open the posterior capsule already, allowing the trocar to come into the posterior part of the knee. Seeing the trocar come into view indicates the correct placement of the trocar in the posterior part of the knee anterior to the popliteal bundle. This tract can then be dilated and the posterior tissues lifted off with the trocar during PCL tibial tunnel guide-wire drilling. When reaming the tibial tunnel, the terminal reaming of the posterior cortex should

Deep vein thrombosis after a knee arthroscopic surgery remains very uncommon, and it is not routine to anticoagulate patients unless they have predispositions for deep vein thrombosis, such as inherited clotting tendencies, or combinations of factors such as poor mobility, cancer or smoking. The post-tourniquet syndrome is a commoner complication, consisting of numbness of the leg and weakness of the quadriceps following a prolonged period of tourniquet inflation, causing a neurapraxia of the femoral nerve. Neurapraxia of the sciatic nerve with resultant foot-drop is rare. This syndrome is treated symptomatically and is expected to recover fully. It is recommended that the tourniquet should be temporarily let down after about 100 – 120 min of inflation to prevent this complication. Death by pulmonary embolism is very rare but may be a reason for litigation, as are unfortunate situations such as wrong-

supportive with an ankle-foot orthosis.

be strictly done by hand.

sided surgery or retained instruments [15].

### **7. Complications of arthroscopy**

Even though uncommon, every surgeon should be aware of potential complications of arthroscopy and these should be fully discussed with the patient before a decision for surgery is made. Infection remains one of the most feared complication with an incidence rate of 0.1–0.4%, and the most likely period of presentation within the first month after surgery. Where there is a suspicion of an intra-articular infection, aspiration should be performed for an immediate diagnosis through Gram Stain and bacterial cultures. Proven intra-articular infection of the knee should be treated with an open arthrotomy, wash-out and synovectomy. In ACL reconstructions, if the presentation had been fairly acute and treatment fairly expeditious, the graft may be retained. However, for more insidious infections that typically present over a longer time-frame, the graft should be excised and the femoral and tibial tunnels curetted. Infection in ACL reconstructions carries a high risk of a poor outcome with eventual stiffness.

There are several nerves which may potentially be damaged during arthroscopic surgery. When harvesting the hamstrings for ACL reconstruction, the anatomical variation of the saphenous nerve and its infrapatellar branches means that there is a high risk of damage to some of these branches with a resultant numbness or sensory difference in the infrapatellar area. In the literature, sensory nerve damage is very common during hamstring harvest, but the resultant numbness can be minimized using careful dissection and harvesting techniques as described in Section 5 above.

When repairing the lateral meniscus around the body/posterior horn junction using all-inside fixation devices, a potential risk is overpenetration of the needle device, injuring the common peroneal nerve. To minimize this risk, it is important to carefully penetrate the needle device through the meniscus, and ensure the tip penetrates to just immediately outside the capsule. It is important to have a mental awareness of where the tip ends up even though it will be out of our visualization once it penetrates the capsule. It is also important to use a trajectory that is away from the central popliteal neurovascular bundle, and to use a curved delivery device that allows the surgeon to direct it away from the area of danger. Also, the penetration depth should be adjusted depending on the size of the patient [14]. For average sized males, a penetration depth of 14 mm can be used quite safely, 16 mm being the distance from the point of penetration on the meniscus to the tip of the device. For slim females, the depth can be adjusted to 12 mm. Keep in mind that penetrating the meniscus and pushing the device through the meniscus will also compress the meniscus towards the capsule, so if the device is entirely pushed through to the pre-set depth limit, the tip of the device may end up even deeper than anticipated. If repairing the lateral meniscus using inside-out methods, a posterolateral incision should be made and the biceps femoris retracted posteriorly to protect the nerve. The common peroneal nerve branches off the sciatic nerve at the distal part of the thigh and runs in between the lateral head of the gastrocnemius and biceps femoris muscles. It follows the biceps muscle distally where it wraps around the fibular neck. Injury to the common peroneal nerve is a debilitating complication causing the patient to develop foot-drop. The prognosis of a neurapraxic injury of the nerve is moderate at best, with 50% achieving full recovery within 6–12 months and 50% never recovering fully. Treatment is essentially supportive with an ankle-foot orthosis.

Meniscal root tears, as mentioned above, should always be repaired [13]. The attachment site of the root on the tibial plateau should be freshened with a serrated curette or even a motorized burr to create a fresh bleeding surface. Using the ACL tibial drill guide aimer, a transtibial tunnel is created. The undersurface of the root should also be freshened with a rasp. There are different methods of repairing root tears, including using trans-tibial sutures to pull the root down or suture anchors inserted via an accessory posteromedial portal. There are also different ways of suture passage through the root. One commonly used method is cinching the suture, meaning passing the suture through its own loop. However, this often creates fixation only along the edge of the meniscus. The author's preferred method is to insert the suture in a cruciate manner in the root, creating an undersurface area of fixation rather than just an edge of fixation. The dimensions of the cruciate should be slightly larger than the width of the transtibial tunnel, which is usually about 4 mm to admit a suture lasso device to shuttle the root sutures through the tibial tunnel. The sutures can then be tied over a button on the surface

Even though uncommon, every surgeon should be aware of potential complications of arthroscopy and these should be fully discussed with the patient before a decision for surgery is made. Infection remains one of the most feared complication with an incidence rate of 0.1–0.4%, and the most likely period of presentation within the first month after surgery. Where there is a suspicion of an intra-articular infection, aspiration should be performed for an immediate diagnosis through Gram Stain and bacterial cultures. Proven intra-articular infection of the knee should be treated with an open arthrotomy, wash-out and synovectomy. In ACL reconstructions, if the presentation had been fairly acute and treatment fairly expeditious, the graft may be retained. However, for more insidious infections that typically present over a longer time-frame, the graft should be excised and the femoral and tibial tunnels curetted. Infection in ACL reconstructions carries a high risk of a poor outcome with eventual

There are several nerves which may potentially be damaged during arthroscopic surgery. When harvesting the hamstrings for ACL reconstruction, the anatomical variation of the saphenous nerve and its infrapatellar branches means that there is a high risk of damage to some of these branches with a resultant numbness or sensory difference in the infrapatellar area. In the literature, sensory nerve damage is very common during hamstring harvest, but the resultant numbness can be minimized using careful dissection and harvesting techniques

When repairing the lateral meniscus around the body/posterior horn junction using all-inside fixation devices, a potential risk is overpenetration of the needle device, injuring the common peroneal nerve. To minimize this risk, it is important to carefully penetrate the needle device through the meniscus, and ensure the tip penetrates to just immediately outside the capsule. It is important to have a mental awareness of where the tip ends up even though it

of the proximal tibia.

22 Recent Advances in Arthroscopic Surgery

stiffness.

as described in Section 5 above.

**7. Complications of arthroscopy**

When performing PCL reconstructions, the proximity of the popliteal neurovascular bundle to the PCL mandates a posteromedial incision with the dissection just along the posterior capsule of the knee. The knee should be at 90° of flexion. The medial head of the gastrocnemius muscle is lifted posteriorly and a blunt trocar used to create a track along the posterior edge of the tibial plateau. When performing this step, the surgeon should maintain intraarticular visualization using the scope and observe the trocar come into view. The PCL is intra-articular at the femoral end and extra-articular at the tibial end, and so debriding the torn PCL will open the posterior capsule already, allowing the trocar to come into the posterior part of the knee. Seeing the trocar come into view indicates the correct placement of the trocar in the posterior part of the knee anterior to the popliteal bundle. This tract can then be dilated and the posterior tissues lifted off with the trocar during PCL tibial tunnel guide-wire drilling. When reaming the tibial tunnel, the terminal reaming of the posterior cortex should be strictly done by hand.

Deep vein thrombosis after a knee arthroscopic surgery remains very uncommon, and it is not routine to anticoagulate patients unless they have predispositions for deep vein thrombosis, such as inherited clotting tendencies, or combinations of factors such as poor mobility, cancer or smoking. The post-tourniquet syndrome is a commoner complication, consisting of numbness of the leg and weakness of the quadriceps following a prolonged period of tourniquet inflation, causing a neurapraxia of the femoral nerve. Neurapraxia of the sciatic nerve with resultant foot-drop is rare. This syndrome is treated symptomatically and is expected to recover fully. It is recommended that the tourniquet should be temporarily let down after about 100 – 120 min of inflation to prevent this complication. Death by pulmonary embolism is very rare but may be a reason for litigation, as are unfortunate situations such as wrongsided surgery or retained instruments [15].

### **8. Conclusion**

Knee arthroscopy is a vital skill for all orthopedic surgeons to have. This chapter describes the essential techniques required of an arthroscopist. The keys to technical success are appropriate pre-operative planning and thoughtful execution. To interpret the anatomy of intraarticular pathology, the arthroscopist should correlate what he views through the scope with a mental overview of normal knee anatomy.

[5] Oussedik S, Tsitskaris K, Parker D. Treatment of articular cartilage lesions of the knee by microfracture or autologous chondrocyte implantation: A systematic review. Arthros-

Successful Knee Arthroscopy: Techniques http://dx.doi.org/10.5772/intechopen.79268 25

[6] Pellegrino M, Trinchese E, Bisaccia M, et al. Long-term outcome of grade III and IV chondral injuries of the knee treated with Steadman microfracture technique. Clinical Cases in Mineral and Bone Metabolism. 2016;**13**:237-240. DOI: 10.11138/ccmbm/2016.13.3.237

[7] Ro KH, Kim HJ, Lee DH. The transportal technique shows better clinical results than the transtibial techniques for single-bundle anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.10.1007/s00167-017-4786-1

[8] Sanders B, Rolf R, McClelland W, Xerogeanes J. Prevalence of saphenous nerve injury after autogenous hamstring harvest: An anatomic and clinical study of sartorial branch

[9] Kjaergaard J, Fauno LZ, Fauno P. Sensibility loss after ACL reconstruction with ham-

[10] Grassi A, Perdisa F, Samuelsson K, Svantesson E, Romagnoli M, Raggi F, Gaziano T, Mosca M, Ayeni O, Zaffagnini S. Association between incision technique for hamstring tendon harvest in anterior cruciate ligament reconstruction and the risk of injury to the infra-patellar branch of the saphenous nerve: A meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-4858-x [Epub ahead of print]

[11] Masuda S, Furumatsu T, Okazaki Y, Kodama Y, Hino T, Kamatsuki Y, Miyazawa S, Ozaki T. Medical meniscus posterior root tear induces pathological posterior extrusion of the meniscus in the knee-flexed position: An open magnetic resonance imaging analysis. Orthopaedics & Traumatology, Surgery & Research. 2018. DOI: 10.1016/j.

[12] Choi SH, Bae S, Ji SK, Chang MJ. The MRI findings of meniscal root tear of the medial meniscus: Emphasis on coronal, sagittal and axial images. Knee Surgery, Sports Trau-

[13] LaPrade RF. Editorial Commentary: We know we need to fix knee meniscal radial root tears-but how best to perform the repairs? Arthroscopy. 2018;**34**:1069-1071. DOI:

[14] Abouheif MM, Shibuya H, Niimoto T, et al. Determination of the safe penetration depth during all-inside meniscal repair of the posterior part of the lateral meniscus using the fast-fix suture repair system. Knee Surgery, Sports Traumatology, Arthroscopy. 2011;

[15] Shah KN, Eltorai AEM, Perera S, Durand WM, Shantharam G, Owens BD, Daniels AH. Medical malpractice litigation following arthroscopic surgery. Arthroscopy. 2018. DOI:

string graft. International Journal of Sports Medicine. 2008;**29**:507-511

copy. 2015;**31**:731-744. DOI: 10.1016/j.arthro.2014.11.023

[Epub ahead of print]

injury. Arthroscopy. 2007;**23**:956-963

ostr.2018.02.012 [Epub ahead of print]

matology, Arthroscopy. 2012;**20**:2098-2103

**19**:1868-1875. DOI: 10.1007/s00167-011-1489-x

10.1016/j.arthro.2018.02.035 [Epub ahead of print]

10.1016/j.arthro.2017.11.009

### **Conflict of interest**

The author has no conflicts of interest associated with any of the medical devices mentioned in this chapter.

### **Author details**

Chia-Liang Ang1,2,3\*

\*Address all correspondence to: med80199@yahoo.com

1 Royal College of Surgeons, Edinburgh, UK

2 American College of Surgeons, USA

3 Island Orthopaedic Consultants Pte Ltd, Singapore

### **References**


[5] Oussedik S, Tsitskaris K, Parker D. Treatment of articular cartilage lesions of the knee by microfracture or autologous chondrocyte implantation: A systematic review. Arthroscopy. 2015;**31**:731-744. DOI: 10.1016/j.arthro.2014.11.023

**8. Conclusion**

24 Recent Advances in Arthroscopic Surgery

**Conflict of interest**

in this chapter.

**Author details**

Chia-Liang Ang1,2,3\*

**References**

2017;**31**:S12-S13

s00167-012-2128-x

DOI: 10.1016/j.csm.2017.12.008

a mental overview of normal knee anatomy.

\*Address all correspondence to: med80199@yahoo.com

3 Island Orthopaedic Consultants Pte Ltd, Singapore

2001;**17**:532-535. DOI: 10.1053/jars.2001.24058

1 Royal College of Surgeons, Edinburgh, UK

2 American College of Surgeons, USA

Knee arthroscopy is a vital skill for all orthopedic surgeons to have. This chapter describes the essential techniques required of an arthroscopist. The keys to technical success are appropriate pre-operative planning and thoughtful execution. To interpret the anatomy of intraarticular pathology, the arthroscopist should correlate what he views through the scope with

The author has no conflicts of interest associated with any of the medical devices mentioned

[1] Kieser CW, Jackson RW. Severin Nordentoft: The first arthroscopist. Arthroscopy.

[2] Egol KA, Cantlon M, Fisher N, Broder K, Reisgo A. Percutaneous repair of a Schatzker III tibial plateau fracture assisted by arthroscopy. Journal of Orthopaedic Trauma.

[3] Fakioglu O, Ozsoy MH, Ozdemir HM, Yigit H, Cavusoglu AT, Lobenhoffer P. Percutaneous medial collateral ligament release in arthroscopic medial meniscectomy in tight knees. Knee Surgery, Sports Traumatology, Arthroscopy. 2013;**21**:1540-1545. DOI: 10.1007/

[4] Welton KL, Logterman S, Bartley JH, Vidal AF, McCarty EC. Knee cartilage repair and restoration: Common problems and solutions. Clinics in Sports Medicine. 2018;**37**:307-330.


**Chapter 2**

**Provisional chapter**

**Single-Bundle Anterior Cruciate Ligament**

**Single-Bundle Anterior Cruciate Ligament** 

DOI: 10.5772/intechopen.77338

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures performed in orthopedics. The research has focused extensively on surgical technique factors like tunnel position, graft choices, fixation methods, and rehabilitation protocols following surgery. The advantages and disadvantages of each graft option shall help in deciding the correct graft in an individual case. A thorough understanding of anatomy and biomechanics of normal ACL has improved the understanding of complexities of knee joint stabilization over the preceding decades. The chapter shall discuss in detail about the anatomy, biomechanics, and surgical techniques along with postoperative

**Keywords:** anterior cruciate ligament, injury, repair, ACL rehabilitation, preoperative

Anterior cruciate ligament (ACL) is the primary stabilizer for pivotal activities of the knee. In the early nineteenth century, Hay Groves and Ivor Palmer advocated repair of ACL [1]. However, the high rate of failure after repair shifted the focus to reconstruction of ACL. Macintosh advocated extra-articular reconstruction of ACL which was subsequently replaced by intra-articular approach popularized by Erikson [2, 3]. The choice of graft also shifted from patellar tendon to semitendinosus over the years [4, 5]. There has been marked improvement in surgical procedure with change from open to arthroscopic procedure.

Similarly the pain management has improved significantly since then.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Kavin Khatri, Darsh Goyal and Deepak Bansal

Kavin Khatri, Darsh Goyal and Deepak Bansal

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

rehabilitation protocol in current perspective.

rehabilitation, postoperative rehabilitation

http://dx.doi.org/10.5772/intechopen.77338

**Reconstruction**

**Abstract**

**1. Introduction**

**Reconstruction**

#### **Single-Bundle Anterior Cruciate Ligament Reconstruction Single-Bundle Anterior Cruciate Ligament Reconstruction**

DOI: 10.5772/intechopen.77338

Kavin Khatri, Darsh Goyal and Deepak Bansal Kavin Khatri, Darsh Goyal and Deepak Bansal

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.77338

#### **Abstract**

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures performed in orthopedics. The research has focused extensively on surgical technique factors like tunnel position, graft choices, fixation methods, and rehabilitation protocols following surgery. The advantages and disadvantages of each graft option shall help in deciding the correct graft in an individual case. A thorough understanding of anatomy and biomechanics of normal ACL has improved the understanding of complexities of knee joint stabilization over the preceding decades. The chapter shall discuss in detail about the anatomy, biomechanics, and surgical techniques along with postoperative rehabilitation protocol in current perspective.

**Keywords:** anterior cruciate ligament, injury, repair, ACL rehabilitation, preoperative rehabilitation, postoperative rehabilitation

### **1. Introduction**

Anterior cruciate ligament (ACL) is the primary stabilizer for pivotal activities of the knee. In the early nineteenth century, Hay Groves and Ivor Palmer advocated repair of ACL [1]. However, the high rate of failure after repair shifted the focus to reconstruction of ACL. Macintosh advocated extra-articular reconstruction of ACL which was subsequently replaced by intra-articular approach popularized by Erikson [2, 3]. The choice of graft also shifted from patellar tendon to semitendinosus over the years [4, 5]. There has been marked improvement in surgical procedure with change from open to arthroscopic procedure. Similarly the pain management has improved significantly since then.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **2. Anatomy**

The major reason for the failure of ACL reconstruction is the improper placement of tunnel either femoral of tibial. So, it is imperative to know about the natural anatomy of the ACL insertion over the tibia and femur. It is an intra-articular but extrasynovial ligament of knee providing primary constraint to the anterior translation of the tibia and secondary stabilizer to varus and valgus stress to the knee. It comprises type I collagen peptide and viscoelastic properties similar to other ligaments in the body.

**3. Biomechanics**

knee biomechanics.

**4. Mechanism of injury**

and anterior cruciate ligament.

**5.2. Physical examination**

**5. Diagnosis**

**5.1. History**

*5.2.1. Swelling*

suspected.

strings to prevent the anterior subluxation.

femur, the injury to ACL is sometimes missed [16].

The tensile strength of native ACL has been estimated to be within the range of 1725 ± 269 N [12]. ACL was initially thought be subjected to isometric stresses throughout the range of motion; however, biomechanical studies demonstrated that the ACL is subjected to differential stresses in movement of the knee [13]. The anteromedial bundle experiences maximum stress in flexion, while posterolateral bundle experiences maximum stress in extension [14]. The posterolateral bundle bears the majority of the stress during knee motion. The singlebundle ACL reconstruction had stressed upon the restoration of anteromedial bundle leaving behind the posterolateral reconstruction [15]. Consequently, it was noticed that there were experiences of rotational instability and persistent pain in almost 31% cases. There has been now shift in focus from single-bundle to double-bundle ACL reconstruction improving the

Single-Bundle Anterior Cruciate Ligament Reconstruction

http://dx.doi.org/10.5772/intechopen.77338

29

In majority of the cases, the flexed knee is subjected to rotational stress leading to ACL injury. The contraction of quadriceps leads to subluxation of the tibia anteriorly with failure of ham-

In contact sports like football and hockey, the direct blow from the lateral aspect of the knee in a flexed and externally rotated position leads to tear in medial collateral ligament (MCL)

The athlete gives a history of twisting injury to knee with popping sensation. There is associated swelling and pain. There is sensation giving away of the knee with respect to body. There are marked variations in the presenting symptoms ranging from mild pain and swelling to inability to bear weight. In the presence of associated injuries like fracture of the tibial shaft or

There is swelling of the knee associated with the ACL injury due to hemarthrosis. The swelling might take some time before manifesting itself. The knee can be aspirated in selected cases of severe knee pain. If there are fat globules in the aspirate, then the intra-articular fracture is

It comprises two bundles, i.e., anteromedial bundle and posterolateral bundle (**Figure 1**). The anteromedial bundle is tightened in 60 or more degrees of flexion, while posterolateral bundle is tight in extension. In extension both bundles are in parallel orientation along the sagittal plane, whereas in flexion of the knee, the insertion of posterolateral bundle moves anteriorly, and they appeared crossed [7, 8].

The names of the two ACL bundles are based upon the relationship between the two at the insertion point on the tibia. Both bundles originate from the posteromedial aspect of lateral femoral condyle and insert over the tibia just anterior to the intercondylar eminence. The diameter of both bundles varies from 7 to 17 mm, while the length of anteromedial bundle is slightly longer than posterolateral bundle measuring approximately between 28 and 38 mm [9, 10]. The cross section of the ACL bundle in midsubstance cross section varies from 36 to 44 mm<sup>2</sup> .

The blood supply of ACL is primarily from middle geniculate artery which is a branch of popliteal artery. Inferomedial and inferolateral genicular arteries supply the ACL through anterior fat pad. ACL receives nerve fibers for proprioception through a branch of posterior tibial nerve [11].

**Figure 1.** Distal femoral condyle showing the two bundles (anteromedial [AM] and posterolateral [PL] bundles) of the anterior cruciate ligament (reprinted with permission from Ref. [6]).

### **3. Biomechanics**

**2. Anatomy**

28 Recent Advances in Arthroscopic Surgery

properties similar to other ligaments in the body.

and they appeared crossed [7, 8].

tibial nerve [11].

The major reason for the failure of ACL reconstruction is the improper placement of tunnel either femoral of tibial. So, it is imperative to know about the natural anatomy of the ACL insertion over the tibia and femur. It is an intra-articular but extrasynovial ligament of knee providing primary constraint to the anterior translation of the tibia and secondary stabilizer to varus and valgus stress to the knee. It comprises type I collagen peptide and viscoelastic

It comprises two bundles, i.e., anteromedial bundle and posterolateral bundle (**Figure 1**). The anteromedial bundle is tightened in 60 or more degrees of flexion, while posterolateral bundle is tight in extension. In extension both bundles are in parallel orientation along the sagittal plane, whereas in flexion of the knee, the insertion of posterolateral bundle moves anteriorly,

The names of the two ACL bundles are based upon the relationship between the two at the insertion point on the tibia. Both bundles originate from the posteromedial aspect of lateral femoral condyle and insert over the tibia just anterior to the intercondylar eminence. The diameter of both bundles varies from 7 to 17 mm, while the length of anteromedial bundle is slightly longer than posterolateral bundle measuring approximately between 28 and 38 mm [9, 10]. The cross section of the ACL bundle in midsubstance cross section varies from 36 to 44 mm<sup>2</sup>

The blood supply of ACL is primarily from middle geniculate artery which is a branch of popliteal artery. Inferomedial and inferolateral genicular arteries supply the ACL through anterior fat pad. ACL receives nerve fibers for proprioception through a branch of posterior

**Figure 1.** Distal femoral condyle showing the two bundles (anteromedial [AM] and posterolateral [PL] bundles) of the

anterior cruciate ligament (reprinted with permission from Ref. [6]).

.

The tensile strength of native ACL has been estimated to be within the range of 1725 ± 269 N [12]. ACL was initially thought be subjected to isometric stresses throughout the range of motion; however, biomechanical studies demonstrated that the ACL is subjected to differential stresses in movement of the knee [13]. The anteromedial bundle experiences maximum stress in flexion, while posterolateral bundle experiences maximum stress in extension [14]. The posterolateral bundle bears the majority of the stress during knee motion. The singlebundle ACL reconstruction had stressed upon the restoration of anteromedial bundle leaving behind the posterolateral reconstruction [15]. Consequently, it was noticed that there were experiences of rotational instability and persistent pain in almost 31% cases. There has been now shift in focus from single-bundle to double-bundle ACL reconstruction improving the knee biomechanics.

### **4. Mechanism of injury**

In majority of the cases, the flexed knee is subjected to rotational stress leading to ACL injury. The contraction of quadriceps leads to subluxation of the tibia anteriorly with failure of hamstrings to prevent the anterior subluxation.

In contact sports like football and hockey, the direct blow from the lateral aspect of the knee in a flexed and externally rotated position leads to tear in medial collateral ligament (MCL) and anterior cruciate ligament.

### **5. Diagnosis**

### **5.1. History**

The athlete gives a history of twisting injury to knee with popping sensation. There is associated swelling and pain. There is sensation giving away of the knee with respect to body. There are marked variations in the presenting symptoms ranging from mild pain and swelling to inability to bear weight. In the presence of associated injuries like fracture of the tibial shaft or femur, the injury to ACL is sometimes missed [16].

#### **5.2. Physical examination**

#### *5.2.1. Swelling*

There is swelling of the knee associated with the ACL injury due to hemarthrosis. The swelling might take some time before manifesting itself. The knee can be aspirated in selected cases of severe knee pain. If there are fat globules in the aspirate, then the intra-articular fracture is suspected.

### *5.2.2. Joint line tenderness*

Both medial and lateral knee joint line should be palpated to assess the injury to medial and lateral meniscus. There is an associated meniscal injury in up to 50% of cases. The lateral meniscal tear is more common than medial meniscus tear. McMurray's test is difficult to perform in cases of acute knee injuries due to limitation in flexion.

over the patella, and the other is placed over the tibial tubercle. The arthrometer is secured to the leg with Velcro straps. The anteroposterior translation is measured by relative motion between sensory pads. When the examiner applies anterior force through handle, a tone is heard at 67, 89 and 133 N. The readings are recorded and evaluated. A side-to-side difference of less than 3 mm at 67 N and maximum force is considered normal. The side-to-side differ-

Single-Bundle Anterior Cruciate Ligament Reconstruction

http://dx.doi.org/10.5772/intechopen.77338

31

The movement of the knee is compared with the uninjured knee. The loss of extension is seen in cases with associated bucket handle tear of meniscus or torn fragments of ligament

The injured knee is given varus and valgus stress at 0 and 30° of flexion. The opening of medial or lateral joint space is graded from zero to three depending upon the amount of opening noticed on stress. Grade I injury is mild opening of less than 5 mm, grade II is opening

It is important to document associated PCL and posterolateral corner injuries as the influence

It is imperative to document injures to neurovascular injuries though they are rarely associ-

Anteroposterior and lateral radiographs of the knee are carried out to detect the bony avul-

It is used to detect the suspected tibial plateau fracture that may be associated with ACL injury.

In acute setting the hemarthrosis may mask the ACL and meniscal injuries and sometimes even the minor injuries to ACL present as significant strains. It may detect the associated bone bruises and other ligament injuries. Generally the MRI examination should be delayed by

ence is more than 5 mm and is considered diagnostic of an ACL tear.

between 5 and 10 mm, and grade III is opening of more than 15 mm.

sions, osteochondral fractures, and tibial plateau fractures.

*5.2.8. Range of motion*

impinging anteriorly.

*5.2.9. Assessment of collateral ligaments*

*5.2.10. Associated ligament injuries*

of the management of ACL injury.

ated with isolated ligament injuries.

*5.2.11. Neurovascular assessment*

*5.3.2. Computerized tomography*

*5.3.3. Magnetic resonance imaging*

**5.3. Imaging**

*5.3.1. Radiographs*

### *5.2.3. Lachman test*

It is the definitive test to detect the ACL injury. The knee is positioned in 20–30° of flexion. One hand is placed over the thigh to hold it firmly, and another hand is positioned such that the thumb is over the tibial tubercle and fingers across the calf region. The tibia is pulled forward with the lower hand placed over the tibia, and degree of anterior tibial translation is noted. The anterior displacement of the tibia by less than 5 mm is graded as 1+, between 5 and 10 mm as 2+, and more than 10 mm as 3+. Practically the firm end point indicates no injury, while soft end point indicates ACL injury.

### *5.2.4. Pivot shift test*

It is a more consistent test to detect the ACL injury. The patient lies supine with legs extended. The examiner holds the heel of the involved leg and with opposite hand holding the leg just distal to the knee applies a valgus stress and an axial load while internally rotating the tibia when moving from full extension to flexion. A positive test is indicated by tibial subluxation with femoral rotation followed by reduction of the tibia at 30–40° of flexion.

#### *5.2.5. Anterior drawer test*

This test is usually carried out in chronic ACL injuries. The knee is bent at 90°, and both hands are kept over the proximal tibia giving an anteriorly directed pressure to look for anterior subluxation of the tibia. Positive test is indicated by soft end point with anterior subluxation of the tibia. Before performing the test, it is mandatory to rule out posterior cruciate ligament (PCL) injury by noting the anterior step off of the tibia with respect to femoral condyle.

#### *5.2.6. Active quadriceps test*

The anterior subluxation of the tibia on active contraction of quadriceps is indicative of ACLdeficit knee. The active quadriceps contraction is generally avoided in recently constructed ACL to prevent excessive pressure over the graft.

#### *5.2.7. KT-1000 arthrometer*

It is used to measure anterior and posterior translation of the tibia with respect to the femur. It is used to quantify the amount of anteroposterior translation of the tibia in ACL injury. The patient is placed in supine position with thighs supported with bolster keeping the knee in approximately 30° of flexion. The arthrometer has two sensing pads: one is positioned over the patella, and the other is placed over the tibial tubercle. The arthrometer is secured to the leg with Velcro straps. The anteroposterior translation is measured by relative motion between sensory pads. When the examiner applies anterior force through handle, a tone is heard at 67, 89 and 133 N. The readings are recorded and evaluated. A side-to-side difference of less than 3 mm at 67 N and maximum force is considered normal. The side-to-side difference is more than 5 mm and is considered diagnostic of an ACL tear.

### *5.2.8. Range of motion*

*5.2.2. Joint line tenderness*

30 Recent Advances in Arthroscopic Surgery

*5.2.3. Lachman test*

*5.2.4. Pivot shift test*

*5.2.5. Anterior drawer test*

*5.2.6. Active quadriceps test*

*5.2.7. KT-1000 arthrometer*

ACL to prevent excessive pressure over the graft.

Both medial and lateral knee joint line should be palpated to assess the injury to medial and lateral meniscus. There is an associated meniscal injury in up to 50% of cases. The lateral meniscal tear is more common than medial meniscus tear. McMurray's test is difficult to per-

It is the definitive test to detect the ACL injury. The knee is positioned in 20–30° of flexion. One hand is placed over the thigh to hold it firmly, and another hand is positioned such that the thumb is over the tibial tubercle and fingers across the calf region. The tibia is pulled forward with the lower hand placed over the tibia, and degree of anterior tibial translation is noted. The anterior displacement of the tibia by less than 5 mm is graded as 1+, between 5 and 10 mm as 2+, and more than 10 mm as 3+. Practically the firm end point indicates no injury,

It is a more consistent test to detect the ACL injury. The patient lies supine with legs extended. The examiner holds the heel of the involved leg and with opposite hand holding the leg just distal to the knee applies a valgus stress and an axial load while internally rotating the tibia when moving from full extension to flexion. A positive test is indicated by tibial subluxation

This test is usually carried out in chronic ACL injuries. The knee is bent at 90°, and both hands are kept over the proximal tibia giving an anteriorly directed pressure to look for anterior subluxation of the tibia. Positive test is indicated by soft end point with anterior subluxation of the tibia. Before performing the test, it is mandatory to rule out posterior cruciate ligament (PCL) injury by noting the anterior step off of the tibia with respect to femoral condyle.

The anterior subluxation of the tibia on active contraction of quadriceps is indicative of ACLdeficit knee. The active quadriceps contraction is generally avoided in recently constructed

It is used to measure anterior and posterior translation of the tibia with respect to the femur. It is used to quantify the amount of anteroposterior translation of the tibia in ACL injury. The patient is placed in supine position with thighs supported with bolster keeping the knee in approximately 30° of flexion. The arthrometer has two sensing pads: one is positioned

with femoral rotation followed by reduction of the tibia at 30–40° of flexion.

form in cases of acute knee injuries due to limitation in flexion.

while soft end point indicates ACL injury.

The movement of the knee is compared with the uninjured knee. The loss of extension is seen in cases with associated bucket handle tear of meniscus or torn fragments of ligament impinging anteriorly.

### *5.2.9. Assessment of collateral ligaments*

The injured knee is given varus and valgus stress at 0 and 30° of flexion. The opening of medial or lateral joint space is graded from zero to three depending upon the amount of opening noticed on stress. Grade I injury is mild opening of less than 5 mm, grade II is opening between 5 and 10 mm, and grade III is opening of more than 15 mm.

### *5.2.10. Associated ligament injuries*

It is important to document associated PCL and posterolateral corner injuries as the influence of the management of ACL injury.

### *5.2.11. Neurovascular assessment*

It is imperative to document injures to neurovascular injuries though they are rarely associated with isolated ligament injuries.

#### **5.3. Imaging**

#### *5.3.1. Radiographs*

Anteroposterior and lateral radiographs of the knee are carried out to detect the bony avulsions, osteochondral fractures, and tibial plateau fractures.

#### *5.3.2. Computerized tomography*

It is used to detect the suspected tibial plateau fracture that may be associated with ACL injury.

#### *5.3.3. Magnetic resonance imaging*

In acute setting the hemarthrosis may mask the ACL and meniscal injuries and sometimes even the minor injuries to ACL present as significant strains. It may detect the associated bone bruises and other ligament injuries. Generally the MRI examination should be delayed by 2–3 weeks for correct assessment of ACL injury. However, it is important to note that a good clinical examination is more informative and useful that an MRI to assess knee ligamentous injury (**Figure 2**).

*5.4.1. Age of patient*

*5.4.2. Activity level*

of the same level.

*5.4.3. Degree of instability*

ful surgical reconstruction are good.

healing of associated meniscocapsulolabral tears

**c.** Range-of-motion exercises to regain the movement of the knee

till the swelling subsides, and good range of motion is achieved at the knee.

**b.** Cryotherapy to reduce the swelling and pain

**5.5. Nonoperative management**

**5.6. Operative management**

*5.6.2. Graft selection*

*5.6.1. Timing of operative intervention*

surgeon's experience, and preference.

The older patients are given the option of nonoperative treatment with lifestyle modification.

Single-Bundle Anterior Cruciate Ligament Reconstruction

http://dx.doi.org/10.5772/intechopen.77338

33

The sportsperson shall require operative treatment in order to return back to sports activity

If side-to-side difference on KT-1000 arthrometer is more than 7 mm, then chances of success-

**a.** The use of extension splints and crutches for mobilization in early ACL injury as it allows the

**d.** Progressive strengthening exercises to regain tone of the quadriceps and hamstrings

There is controversy over the timing of repair. Shelbourne had advised wait period of 3 weeks before reconstruction. He advocated that there are high chances of knee stiffness and loss of range of motion if operative procedure is carried out in acute phase [19]. However, Pinczweski reported good results with early reconstruction of ACL [20]. The general consensus is to wait

The various grafts available for ACL reconstruction are patellar tendon bone graft, hamstring graft, allograft, and synthetic tapes. The choice of graft depends upon the individual case,

In the 1970s, Erikson popularized the patellar tendon bone (PTB) as the graft for ACL reconstruction. It was the popular choice till the late 1990s. However, due to morbidity associated with the PTB, the focus was shifted to other grafts like hamstring graft, synthetic graft, allografts, etc. Fowler and Rosenberg popularized the use of hamstring graft. Initially there were apprehension about the strength of hamstring graft in comparison to PTB, but biomechanical testing and the use of newer fixation techniques like endobutton installed confidence

Young patients involved in sports activities are subjected to ACL reconstruction.

### *5.3.4. Examination under anesthesia*

The patient should be examined under anesthesia to reconfirm the findings of previous examinations. Sometimes due to spasm of muscles and pain, the laxity of the knee may be graded on a lower scale; hence, examination under anesthesia is important to assess the ligamentous injuries.

### *5.3.5. Diagnostic arthroscopy*

Sometimes the findings of the MRI and clinical examination are equivocal, and diagnostic arthroscopy is carried out to look for pathology. In few cases the MRI findings may be falsely positive which can be ascertained on diagnostic arthroscopy [18].

#### **5.4. Treatment decision**

The treatment of ACL should be individualized to the patient. The two options in ACL tear are:


Various factors should be considered before opting for operative or nonoperative treatment.

**Figure 2.** Signs of anterior cruciate ligament tear: (A) midsubstance discontinuity (white arrow heads), residual stump of ACL on tibial (white arrow), and femoral side (white asterisk); (B) complete resorption of ACL fibers and buckling of posterior cruciate ligament (PCL); (C) some fibers are shown in continuity (white arrows) suggestive of partial ACL tear (reprinted with permissions from Ref. [17]).

### *5.4.1. Age of patient*

2–3 weeks for correct assessment of ACL injury. However, it is important to note that a good clinical examination is more informative and useful that an MRI to assess knee ligamentous

The patient should be examined under anesthesia to reconfirm the findings of previous examinations. Sometimes due to spasm of muscles and pain, the laxity of the knee may be graded on a lower scale; hence, examination under anesthesia is important to assess the ligamentous

Sometimes the findings of the MRI and clinical examination are equivocal, and diagnostic arthroscopy is carried out to look for pathology. In few cases the MRI findings may be falsely

The treatment of ACL should be individualized to the patient. The two options in ACL tear are:

**a.** Activity modification: the patient can opt for sports like cycling or swimming from contact sports. If there are no giving away episodes, then he can opt for conservative treatment. **b.** ACL reconstruction: in order to prevent early degenerative arthritis and return to previ-

Various factors should be considered before opting for operative or nonoperative treatment.

**Figure 2.** Signs of anterior cruciate ligament tear: (A) midsubstance discontinuity (white arrow heads), residual stump of ACL on tibial (white arrow), and femoral side (white asterisk); (B) complete resorption of ACL fibers and buckling of posterior cruciate ligament (PCL); (C) some fibers are shown in continuity (white arrows) suggestive of partial ACL tear

ous activity level, the patient is advised to undergo ACL reconstruction.

positive which can be ascertained on diagnostic arthroscopy [18].

injury (**Figure 2**).

injuries.

*5.3.4. Examination under anesthesia*

32 Recent Advances in Arthroscopic Surgery

*5.3.5. Diagnostic arthroscopy*

**5.4. Treatment decision**

(reprinted with permissions from Ref. [17]).

The older patients are given the option of nonoperative treatment with lifestyle modification. Young patients involved in sports activities are subjected to ACL reconstruction.

### *5.4.2. Activity level*

The sportsperson shall require operative treatment in order to return back to sports activity of the same level.

#### *5.4.3. Degree of instability*

If side-to-side difference on KT-1000 arthrometer is more than 7 mm, then chances of successful surgical reconstruction are good.

#### **5.5. Nonoperative management**


#### **5.6. Operative management**

### *5.6.1. Timing of operative intervention*

There is controversy over the timing of repair. Shelbourne had advised wait period of 3 weeks before reconstruction. He advocated that there are high chances of knee stiffness and loss of range of motion if operative procedure is carried out in acute phase [19]. However, Pinczweski reported good results with early reconstruction of ACL [20]. The general consensus is to wait till the swelling subsides, and good range of motion is achieved at the knee.

#### *5.6.2. Graft selection*

The various grafts available for ACL reconstruction are patellar tendon bone graft, hamstring graft, allograft, and synthetic tapes. The choice of graft depends upon the individual case, surgeon's experience, and preference.

In the 1970s, Erikson popularized the patellar tendon bone (PTB) as the graft for ACL reconstruction. It was the popular choice till the late 1990s. However, due to morbidity associated with the PTB, the focus was shifted to other grafts like hamstring graft, synthetic graft, allografts, etc. Fowler and Rosenberg popularized the use of hamstring graft. Initially there were apprehension about the strength of hamstring graft in comparison to PTB, but biomechanical testing and the use of newer fixation techniques like endobutton installed confidence in minds of surgeons opting for it. The success of the reconstruction depends upon various factors like patient selection, surgical technique including correct tunnel placement, rehabilitation, and other associated ligamentous injuries.

*5.6.2.1.4. Contraindications for the use of PTB graft*

upon.

vate the pain.

*5.6.2.2. Hamstring graft*

*5.6.2.2.2. Disadvantages*

hamstrings.

*5.6.2.4. Allograft*

*5.6.2.4.1. Advantages*

*5.6.2.4.2. Disadvantages*

**a.** There is risk of disease transmission.

**b.** It takes a much longer time than autograft to heal.

**c.** The incidence of failure with allograft is higher than autograft.

*5.6.2.3. Central quadriceps tendon*

the weakness is to a minimal extent.

**c.** Harvesting of graft can be difficult at times.

*5.6.2.2.1. Advantage*

**c.** Osgood-Schlatter disease.

**a.** Small patellar tendon: if the width of the patellar tendon is less than 25 mm, then harvesting the patellar tendon should be avoided, and another source is looked

Single-Bundle Anterior Cruciate Ligament Reconstruction

http://dx.doi.org/10.5772/intechopen.77338

35

**b.** Preexisting patellofemoral pain: it is advisable not to go for PTB if there is history of patellofemoral pain. There may be associated chondromalacia of patella which might aggra-

**a.** Weakness of internal rotation of the tibia is associated with hamstring retrieval; however,

**d.** Sometimes during harvesting of graft, there may occur premature amputation of the

**e.** It takes longer to heal with hamstring graft, i.e., approximately 10–12 weeks.

It can be harvested with minimal morbidity and used with interference screws.

As there is no need to harvest the graft, the surgical time is greatly reduced.

The principal advantage of hamstring graft is minimal donor site morbidity.

**b.** Injury to the saphenous though rare but has been reported with it.

### *5.6.2.1. Patellar tendon*

It is considered as the gold strand in terms of graft for ACL reconstruction. There are advantages and disadvantages associated with this use of this graft.

#### *5.6.2.1.1. Advantages*


#### *5.6.2.1.2. Disadvantages*


#### *5.6.2.1.3. Indications for the use of PTB graft for ACL reconstruction*

The ideal patient for this graft is young athlete who would like to continue in contact sports for a longer time. The elder individuals can also be advised to undergo ACL reconstruction but with a caution that they had to undergo aggressive physiotherapy following reconstruction procedure.

### *5.6.2.1.4. Contraindications for the use of PTB graft*


### *5.6.2.2. Hamstring graft*

### *5.6.2.2.1. Advantage*

in minds of surgeons opting for it. The success of the reconstruction depends upon various factors like patient selection, surgical technique including correct tunnel placement, rehabili-

It is considered as the gold strand in terms of graft for ACL reconstruction. There are advan-

**a.** Harvest site morbidity: the common long-term problem is kneeling pain experienced with it. It was due to graft site morbidity that many surgeons had switched to hamstring

**b.** Anterior knee pain: injury to infrapatellar branch of the saphenous nerve can produce

**e.** Patella fracture: the cases of intraoperative patella fracture have been reported in patients when the graft was harvested with osteotome instead of saw. Sometimes the fractures are detected in late postoperative period due to overrun of saw. The stress risers that go beyond the limit of bone block should be avoided. The proximal saw cuts should prefer-

**g.** Patellar tendonitis: it leads to pain in some cases; however, it subsides by the end of the

**h.** Quadriceps weakness: inadequate participation in the rehabilitation program can result

The ideal patient for this graft is young athlete who would like to continue in contact sports for a longer time. The elder individuals can also be advised to undergo ACL reconstruction but with a caution that they had to undergo aggressive physiotherapy following reconstruc-

anterior knee pain. It may also be due to patellofemoral syndrome.

ably be boat shaped to avoid the stress riser formation.

*5.6.2.1.3. Indications for the use of PTB graft for ACL reconstruction*

tation, and other associated ligamentous injuries.

**a.** Early bone-to-bone healing at 6 weeks

**b.** Consistent size and shape of graft

**c.** Late patellar tendon rupture.

**f.** Late chondromalacia of patella.

in quadriceps weakness.

**d.** Loss of range of motion.

tages and disadvantages associated with this use of this graft.

*5.6.2.1. Patellar tendon*

34 Recent Advances in Arthroscopic Surgery

*5.6.2.1.1. Advantages*

**c.** Ease of harvest

tendons.

first year.

tion procedure.

*5.6.2.1.2. Disadvantages*

The principal advantage of hamstring graft is minimal donor site morbidity.

#### *5.6.2.2.2. Disadvantages*


### *5.6.2.3. Central quadriceps tendon*

It can be harvested with minimal morbidity and used with interference screws.

#### *5.6.2.4. Allograft*

#### *5.6.2.4.1. Advantages*

As there is no need to harvest the graft, the surgical time is greatly reduced.

#### *5.6.2.4.2. Disadvantages*


### *5.6.2.5. Synthetic graft*

### *5.6.2.5.1. Advantages*


### *5.6.2.5.2. Disadvantages*


### *5.6.3. Surgical technique with harvesting of hamstring graft*

A 3-cm-long skin incision is given 1 cm medial to the tibial tubercle. Subcutaneous fat and fascia are incised along the line of skin incision. The superior border of pes anserinus is palpated, and the overlying fascia is incised. A curved artery is used to lift up the semitendinosus along with gracilis. The distal end of the tendon is stripped off from the tibia, and the free end of the tendons is held with Kocher. Each tendon is individually freed from the bands that attach it to the gastrocnemius. It is imperative to remove all the bands as passage of tendon stripper may inadvertently cut the tendon short. The length of the tendon usually obtained is approximately 28–30 cm. While harvesting tendon, it is advisable to keep the free end of the tendon in tension and move the tendon stripper with gentle push.

position in right knee (2 o'clock in left knee) mimics the anatomic center of posterolateral bundle of native ACL (**Figure 3**). The remnants of the torn ACL also help in placement of femoral tunnel. The mean distance between the centers of the two bundles was 6.2 mm. The distance from the center of the anteromedial bundle to the center of the femoral tunnel and the center of the posterolateral bundle to the center of the femoral tunnel was 4.2 and 4.1 mm, respectively. The placement of 7-mm offset reamer and creating a tunnel with the help of 10 mm reamer approximately reaches a midpoint between anteromedial bundle and

Single-Bundle Anterior Cruciate Ligament Reconstruction

http://dx.doi.org/10.5772/intechopen.77338

37

The graft is then passed with the help of passer sutures through femoral and tibial tunnel. The various fixation methods used to fix femoral side of the graft are transfixation screws, endobutton, and tight rope. The tibial end of the graft can be fixed with the help of titanium or bioscrew or bone staples. Before fixing the graft, the knee should be flexed by approximately

**Figure 3.** Diagram showing clock face superimposed on a coronal image of a right knee. It helps in coronal plane

orientation in arthroscopy (reprinted with permission from Ref. [21]).

anterolateral bundle.

20° in order to avoid fixation of a loose graft.

The harvested tendon is taken over to the back table, and graft is freed from the muscle attached. The free ends of the tendons are whipstitched with no. 2 ethibond. Both tendons, i.e., semitendinosus and gracilis, are quadrupled. The width and length of the tendons are measured. A stitched is applied at 3 cm from the free end of the graft as minimum desired length of the graft in the tunnels (femoral and tibial) is 3 cm.

The femoral notch area, tibial attachment, and femoral attachment of ACL are cleared of loose tissue with the help of shaver and cautery.

Next the focus is shifted to creation of tibial tunnel. Tibial zig is set at 55–60° and introduced from the anteromedial portal. The tip of the zig is positioned approximately 7 mm anterior to PCL insertion, in line with posterior border of lateral meniscus and 5 mm lateral to the medial tibial spine. Externally the tibial zig is positioned approximately 2 cm medial to the tibial tuberosity and 4 cm below the joint line. A guide wire is then introduced through tibial zig and passed across the proximal tibia till the tip of tibial zig. Sequential reaming is carried out for passage of graft.

The femoral tunnel placement is another important aspect of ACL reconstruction. The ACL foot print can be appreciated on the medial aspect of lateral femoral condyle. The femoral notch is assumed at 12 o'clock position; hence, the femoral tunnel approaching 10 o'clock position in right knee (2 o'clock in left knee) mimics the anatomic center of posterolateral bundle of native ACL (**Figure 3**). The remnants of the torn ACL also help in placement of femoral tunnel. The mean distance between the centers of the two bundles was 6.2 mm. The distance from the center of the anteromedial bundle to the center of the femoral tunnel and the center of the posterolateral bundle to the center of the femoral tunnel was 4.2 and 4.1 mm, respectively. The placement of 7-mm offset reamer and creating a tunnel with the help of 10 mm reamer approximately reaches a midpoint between anteromedial bundle and anterolateral bundle.

*5.6.2.5. Synthetic graft*

36 Recent Advances in Arthroscopic Surgery

*5.6.2.5.1. Advantages*

*5.6.2.5.2. Disadvantages*

**a.** There is no graft site morbidity.

**c.** There is no risk of disease transmission.

**a.** There are high chances of failure with it.

**b.** The graft is strong from the time of initial implantation itself.

**b.** Sometimes there is synovitis seen with the use of synthetic graft.

tendon in tension and move the tendon stripper with gentle push.

length of the graft in the tunnels (femoral and tibial) is 3 cm.

tissue with the help of shaver and cautery.

out for passage of graft.

A 3-cm-long skin incision is given 1 cm medial to the tibial tubercle. Subcutaneous fat and fascia are incised along the line of skin incision. The superior border of pes anserinus is palpated, and the overlying fascia is incised. A curved artery is used to lift up the semitendinosus along with gracilis. The distal end of the tendon is stripped off from the tibia, and the free end of the tendons is held with Kocher. Each tendon is individually freed from the bands that attach it to the gastrocnemius. It is imperative to remove all the bands as passage of tendon stripper may inadvertently cut the tendon short. The length of the tendon usually obtained is approximately 28–30 cm. While harvesting tendon, it is advisable to keep the free end of the

The harvested tendon is taken over to the back table, and graft is freed from the muscle attached. The free ends of the tendons are whipstitched with no. 2 ethibond. Both tendons, i.e., semitendinosus and gracilis, are quadrupled. The width and length of the tendons are measured. A stitched is applied at 3 cm from the free end of the graft as minimum desired

The femoral notch area, tibial attachment, and femoral attachment of ACL are cleared of loose

Next the focus is shifted to creation of tibial tunnel. Tibial zig is set at 55–60° and introduced from the anteromedial portal. The tip of the zig is positioned approximately 7 mm anterior to PCL insertion, in line with posterior border of lateral meniscus and 5 mm lateral to the medial tibial spine. Externally the tibial zig is positioned approximately 2 cm medial to the tibial tuberosity and 4 cm below the joint line. A guide wire is then introduced through tibial zig and passed across the proximal tibia till the tip of tibial zig. Sequential reaming is carried

The femoral tunnel placement is another important aspect of ACL reconstruction. The ACL foot print can be appreciated on the medial aspect of lateral femoral condyle. The femoral notch is assumed at 12 o'clock position; hence, the femoral tunnel approaching 10 o'clock

*5.6.3. Surgical technique with harvesting of hamstring graft*

The graft is then passed with the help of passer sutures through femoral and tibial tunnel. The various fixation methods used to fix femoral side of the graft are transfixation screws, endobutton, and tight rope. The tibial end of the graft can be fixed with the help of titanium or bioscrew or bone staples. Before fixing the graft, the knee should be flexed by approximately 20° in order to avoid fixation of a loose graft.

**Figure 3.** Diagram showing clock face superimposed on a coronal image of a right knee. It helps in coronal plane orientation in arthroscopy (reprinted with permission from Ref. [21]).

The stability of the graft should be checked with the help of probe and anterior drawer test. The wound is closed in layers, and a knee immobilizer is applied.

**g.** Posterior blowout of femoral tunnel: in case of posterior wall blow out, the method of femoral fixation should be changed to endobutton or cortical fixation techniques. The posterior wall blow out can be prevented with accurate positioning of the femoral zig before drilling the femoral tunnel. It is preferable to flex the knee beyond 90° to create a longer

Single-Bundle Anterior Cruciate Ligament Reconstruction

http://dx.doi.org/10.5772/intechopen.77338

39

**h.** Loss of fixation: in case of tibial fixation, use a screw of the same or one size larger to achieve good purchase and avoid loss of fixation. This complication can be avoided with the appropriate measuring of the tunnel width and drilling it according to the graft width.

**j.** Arthrofibrosis: in cases where the patients do not follow the postoperative rehabilitation protocol, there are high chances of knee stiffness and loss of motion. Regular physiother-

**k.** Residual or recurrent instability: sometimes there could be failure of fixation or tunnel widening (femoral or tibial) leading to sense of instability. Thorough workup should be

The functional outcome of the ACL reconstruction should be done with the help of measurement scales like international knee documentation committee form (IKDC), Oxford Knee Score (OKS), etc. [22]. However, the practice of outcome assessment is followed up in very few cases by authors. If the outcome assessment is carried out on these scales, then the interpretation of results can be done easily by others. Due to complexity of these forms, the authors generally avoid these methodologies. We should strive to from a universally acceptable and easily reproducible scoring system so that the results can be

Anterior cruciate ligament is now increasing being treated operatively with good functional results. The choice of graft has shifted from patellar tendon bone to hamstring graft over the years. There are several other graft choices; however, the preference depends upon the surgeon and patient. The more important issue in ACL reconstruction is the correct placement of tunnels. The modern zigs and fluoroscopy help in correct tunnel formations and hence graft placement. The assessment of the functional outcome should be done by both subjective and

I acknowledge the support from Dr. Darsh Goyal and Dr. Deepak Bansal for their support in

**i.** Patellar fracture: it can occur intraoperatively and in late postoperative period.

femoral tunnel and prevent posterior wall blow out.

apy sessions can prevent this complication.

**5.7. Outcome assessment**

interpreted with ease.

objective measurement scales.

preparation of the manuscript.

**Acknowledgements**

**5.8. Conclusion**

carried out to ascertain the cause of residual instability.

### *5.6.4. Postoperative rehabilitation protocol*

The compressive stockings are applied over the limb to reduce the swelling, and cold fomentation at regular intervals is advised to the patient. Continuous passive motion (CPM) machine helps in regaining range of motion in the operated limb. The patient is allowed partial weight bearing with crutches and extension splint. The physiotherapy protocol including closed chain exercises is started immediately in the postoperative period.

The goal within 2 weeks is to achieve full extension, minimize swelling, and achieve 90° of flexion. Subsequently after 2 weeks, increase the knee flexion up to 135°, and increase the tone of the quadriceps along with hamstrings. At the end of 6 weeks, full movement of the knee is achieved along with full weight bearing with extension splint. At the end of 2 months, full weight bearing is allowed along with full functional activities like cycling, jogging, etc. At the end of 3 months, the goal is to achieve adequate hamstring and quadriceps strength along with proprioception with the help of balance board exercises. Light sports activities are allowed at the end of 4 months, and return to contact sports is permitted at the end of 6 months.

#### *5.6.5. Complications*

Every surgical procedure inherits the risk of complications so is the case with ACL reconstruction. Various factors have been implicated which lead to complications. Some of the factors are discussed below:


#### **5.7. Outcome assessment**

The stability of the graft should be checked with the help of probe and anterior drawer test.

The compressive stockings are applied over the limb to reduce the swelling, and cold fomentation at regular intervals is advised to the patient. Continuous passive motion (CPM) machine helps in regaining range of motion in the operated limb. The patient is allowed partial weight bearing with crutches and extension splint. The physiotherapy protocol including closed

The goal within 2 weeks is to achieve full extension, minimize swelling, and achieve 90° of flexion. Subsequently after 2 weeks, increase the knee flexion up to 135°, and increase the tone of the quadriceps along with hamstrings. At the end of 6 weeks, full movement of the knee is achieved along with full weight bearing with extension splint. At the end of 2 months, full weight bearing is allowed along with full functional activities like cycling, jogging, etc. At the end of 3 months, the goal is to achieve adequate hamstring and quadriceps strength along with proprioception with the help of balance board exercises. Light sports activities are allowed at

the end of 4 months, and return to contact sports is permitted at the end of 6 months.

Every surgical procedure inherits the risk of complications so is the case with ACL reconstruction. Various factors have been implicated which lead to complications. Some of the factors

**a.** Patient selection: there are high chances of failure in cases where the patient returns to

**b.** Anterior knee pain: the patellar tendon bone graft should be avoided in cases with preop-

**c.** Timing of operation: the operative procedure should be delayed by few days in cases of

**d.** Fracture of bone plug in the case of PTB graft: with careful harvesting of the graft, this complication can be avoided. It is advisable to harvest graft with the help of saw rather than osteotome. In the case of fracture of bony plug of the PTB graft, the ends of the tendon

**e.** Dropped graft: in case the graft falls on the floor while preparation or shifting from trolley, then the option is to harvest another graft or wash the dropped graft multiple times with chlorhexidine solution and normal saline. The graft should be prepared on a separate

**f.** Tibial or femoral tunnel malposition: the earlier tunnel can be plugged with bone graft and new tunnel can be created. The complication can be avoided by looking for the tunnel

sports activity too early without following proper rehabilitation protocols.

can be reversed, and the free end can be fixed with large bioscrew.

swelling or limited range of motion of the knee.

workstation in order to avoid falling of the graft.

positions with fluoroscopy.

The wound is closed in layers, and a knee immobilizer is applied.

chain exercises is started immediately in the postoperative period.

*5.6.4. Postoperative rehabilitation protocol*

38 Recent Advances in Arthroscopic Surgery

*5.6.5. Complications*

are discussed below:

erative knee pain.

The functional outcome of the ACL reconstruction should be done with the help of measurement scales like international knee documentation committee form (IKDC), Oxford Knee Score (OKS), etc. [22]. However, the practice of outcome assessment is followed up in very few cases by authors. If the outcome assessment is carried out on these scales, then the interpretation of results can be done easily by others. Due to complexity of these forms, the authors generally avoid these methodologies. We should strive to from a universally acceptable and easily reproducible scoring system so that the results can be interpreted with ease.

#### **5.8. Conclusion**

Anterior cruciate ligament is now increasing being treated operatively with good functional results. The choice of graft has shifted from patellar tendon bone to hamstring graft over the years. There are several other graft choices; however, the preference depends upon the surgeon and patient. The more important issue in ACL reconstruction is the correct placement of tunnels. The modern zigs and fluoroscopy help in correct tunnel formations and hence graft placement. The assessment of the functional outcome should be done by both subjective and objective measurement scales.

### **Acknowledgements**

I acknowledge the support from Dr. Darsh Goyal and Dr. Deepak Bansal for their support in preparation of the manuscript.

### **Conflict of interest**

There is no conflict of interest in preparation of this chapter.

### **Author details**

Kavin Khatri<sup>1</sup> \*, Darsh Goyal2 and Deepak Bansal<sup>3</sup>

\*Address all correspondence to: kavinkhatri84@gmail.com

1 Guru Gobind Medical College and Hospital, Faridkot, India

2 Sports Injury Centre, New Delhi, India

3 AIMC Bassi Hospital, Ludhiana, India

### **References**

[1] Groves EWH. Operation for repair of the crucial ligaments. Clinical Orthopaedics and Related Research. 1980;**147**:4-6

[9] Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. Journal of Bone and Joint Surgery. British Volume (London).

Single-Bundle Anterior Cruciate Ligament Reconstruction

http://dx.doi.org/10.5772/intechopen.77338

41

[10] Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clinical Orthopaedics and Related Research.

[11] Georgoulis AD, Pappa L, Moebius U, et al. The presence of proprioceptive mechanoreceptors in the remnants of the ruptured ACL as a possible source of reinnervation of the ACL autograft. Knee Surgery, Sports Traumatology, Arthroscopy. 2001;**9**:364-368 [12] Noyes FR, Butler DL, Grood ES, Aernicke RF, Hefzy MS. Biomechanical analysis of human ligament grafts used in knee ligament repairs and reconstructions. Journal of

[13] Hefzy MS, Grood ES. Sensitivity of insertion locations on length patterns of anterior cruciate ligament fibers. Journal of Biomechanical Engineering. 1986;**108**:73-82

[14] Sakane M, Fox J, Woo SL, Livesay GA, Li G, Fu FH. In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. Journal of Orthopaedic

[15] Devgan A, Singh A, Gogna P, Singla R, Magu NK, Mukhopadhyay R.Arthroscopic anatomical double bundle anterior cruciate ligament reconstruction: A prospective longitudinal study. Indian Journal of Orthopaedics. 2015;**49**(2):136-142. DOI: 10.4103/0019-5413.152406

[16] Stevens K, Dragoo J. Anterior cruciate ligament tears and associated injuries. Topics in

[17] Ng WHA, Griffith JF, Hung EHY, Paunipagar B, Law BKY, Yung PSH.Imaging of the anterior cruciate ligament. World Journal of Orthopedics. 2011;**2**(8):75-84. DOI: 10.5312/wjo.v2.i8.75

[18] De Smet A, Nathan D, Graf B, Haaland B, Fine J. Clinical and MRI findings associated with false-positive knee MR diagnoses of medial meniscal tears. American Journal of

[19] Shelbourne KD. JG. Patient selection for anterior cruciate ligament reconstruction.

[20] Pinczewski L, Lyman J, Salmon L, Russell V, Roe J, Linklater J. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: A controlled, prospective trial. Scandinavian Journal of Medicine & Science in

[21] Rue JH, Busam ML, Bach Jr BR. Hybrid single-bundle anterior cruciate ligament reconstruction technique using a transtibial drilled femoral tunnel. Techniques in Knee

[22] Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of patients about total hip replacement. Journal of Bone and Joint Surgery. British Volume (London).

Bone and Joint Surgery. British Volume (London). 1984;**66**:344-352

1985;**67**:257-262

1975;**106**:216-231

Research. 1997;**15**:285-293

Roentgenology. 2008;**191**(1):93-99

Sports. 2007;**17**(5):611-619

Surgery. 2008;**7**:107-114

1998;**80**(1):63-69

Magnetic Resonance Imaging. 2006;**17**(5):347-362

Operative Techniques in Sports Medicine. 1993;**1**(7):16-18


[9] Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. Journal of Bone and Joint Surgery. British Volume (London). 1985;**67**:257-262

**Conflict of interest**

40 Recent Advances in Arthroscopic Surgery

**Author details**

Kavin Khatri<sup>1</sup>

**References**

There is no conflict of interest in preparation of this chapter.

\*Address all correspondence to: kavinkhatri84@gmail.com

1 Guru Gobind Medical College and Hospital, Faridkot, India

and Deepak Bansal<sup>3</sup>

[1] Groves EWH. Operation for repair of the crucial ligaments. Clinical Orthopaedics and

[2] Bertoia JT, Urovitz EP, Richards RR, et al. Anterior cruciate reconstruction using the MacIntosh lateral-substitution over-the top repair. The Journal of Bone and Joint Sur-

[3] Erikson E. Reconstruction of the anterior cruciate ligament. Orthopedic Clinics of North

[4] Lipscomb AB, Jonhston RK, Synder RB, Warburton MJ, Gilbert PP. Evaluation of hamstring strength following use of semitendinosus and gracilis tendons to reconstruct the anterior cruciate ligament. The American Journal of Sports Medicine. 1982;**10**:340-342.

[5] Martin SD, Martin TL, Brown CH. Anterior cruciate ligament fixation. Orthopedic Clinics of North America. 2002;**33**:685-696. DOI: 10.1016/S0030-5898(02)00023-8

[6] Rue JP, Lewis PB, Parameswaran AD, Bach BR Jr. Single bundle anterior cruciate ligament reconstruction: Technique overview and comprehensive review of results. The

[7] Gabriel MT, Wong EK, Woo SL, Yogi M, Debski RE. Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. Journal of Orthopaedic

[8] Buoncristiani AM, Tjoumakaris FP, Starman JS, Ferretti M, Fu FH. Anatomic doublebundle anterior cruciate ligament reconstruction. Arthroscopy. 2006;**22**:1000-1006

Journal of Bone and Joint Surgery. American Volume. 2008;**90**(Suppl 4):67-74

\*, Darsh Goyal2

2 Sports Injury Centre, New Delhi, India

3 AIMC Bassi Hospital, Ludhiana, India

Related Research. 1980;**147**:4-6

America. 1976;**7**:167-179

Research. 2004;**22**:85-89

DOI: 10.1177/036354658201000603

gery. American Volume. 1985;**67**:1183-1188


**Chapter 3**

**Provisional chapter**

**Anatomic Single-Bundle ACL Reconstruction with**

**Anatomic Single-Bundle ACL Reconstruction with** 

DOI: 10.5772/intechopen.76577

Anterior cruciate ligament (ACL) injury is the common ligamentous injury of the knees. An ACL reconstruction is the procedure that has been proven to improve knee stability and functional outcomes and may prevent the osteoarthritic changes and subsequent meniscal injuries. The ACL reconstruction techniques have been developed in various ways. Anatomical single-bundle ACL reconstruction with remnant augmentation technique is the optimal reconstruction procedure. It may improve the clinical outcomes of biological healing, preserve the proprioceptive function, and has shown less tibial tunnel widening postoperatively. This chapter presents the step-by-step technique of an anatomical single-bundle ACL reconstruction, indication and contraindication for surgery, the preferred graft choice, fixation methods, pearls and pitfalls of the procedure, and postoperative rehabilitation. The review of literatures about the remnant preserving ACL

**Keywords:** ACL reconstruction, remnant augmentation, anatomic single-bundle,

Anterior cruciate ligament (ACL) injury is the common ligamentous injury of the knees, especially in active, healthy patients. An ACL reconstruction is the procedure that has been proven to improve knee stability and functional outcomes. Although there have been no clear benefits and prevention of osteoarthritic changes following ACL reconstruction [1, 2], some studies have proven that this operative procedure can prevent these changes and subsequent menis-

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

**Remnant Augmentation Technique**

**Remnant Augmentation Technique**

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

reconstruction is also discussed in this chapter.

preserving, the ACL remnant.

http://dx.doi.org/10.5772/intechopen.76577

Adinun Apivatgaroon

Adinun Apivatgaroon

**Abstract**

**1. Introduction**

cal injuries [3, 4].

#### **Anatomic Single-Bundle ACL Reconstruction with Remnant Augmentation Technique Anatomic Single-Bundle ACL Reconstruction with Remnant Augmentation Technique**

DOI: 10.5772/intechopen.76577

#### Adinun Apivatgaroon Adinun Apivatgaroon

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76577

#### **Abstract**

Anterior cruciate ligament (ACL) injury is the common ligamentous injury of the knees. An ACL reconstruction is the procedure that has been proven to improve knee stability and functional outcomes and may prevent the osteoarthritic changes and subsequent meniscal injuries. The ACL reconstruction techniques have been developed in various ways. Anatomical single-bundle ACL reconstruction with remnant augmentation technique is the optimal reconstruction procedure. It may improve the clinical outcomes of biological healing, preserve the proprioceptive function, and has shown less tibial tunnel widening postoperatively. This chapter presents the step-by-step technique of an anatomical single-bundle ACL reconstruction, indication and contraindication for surgery, the preferred graft choice, fixation methods, pearls and pitfalls of the procedure, and postoperative rehabilitation. The review of literatures about the remnant preserving ACL reconstruction is also discussed in this chapter.

**Keywords:** ACL reconstruction, remnant augmentation, anatomic single-bundle, preserving, the ACL remnant.

### **1. Introduction**

Anterior cruciate ligament (ACL) injury is the common ligamentous injury of the knees, especially in active, healthy patients. An ACL reconstruction is the procedure that has been proven to improve knee stability and functional outcomes. Although there have been no clear benefits and prevention of osteoarthritic changes following ACL reconstruction [1, 2], some studies have proven that this operative procedure can prevent these changes and subsequent meniscal injuries [3, 4].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The ACL reconstruction techniques have been developed in various ways. These include single-bundle reconstruction, double-bundle reconstruction, selective bundle reconstruction, single-bundle reconstruction with remnant preservation, and double-bundle reconstruction with remnant preservation. With so many techniques, there has yet to be determined as to what is the best technique that provides the greatest stability and preserves knee functions (proprioceptive sensation, range of motion).

This chapter presents one optional ACL reconstruction technique that uses anatomic singlebundle anterior cruciate reconstruction with remnant augmentation. This technique is simple, has shown improved knee stability, may preserve the proprioceptive function, may accelerate cellular proliferation and revascularization of the grafted tendon, and has shown a lower incidence of tibial tunnel enlargement postoperatively.

### **2. The anatomic single-bundle anterior cruciate ligament reconstruction with remnant augmentation**

The functional ACL bundles consist of two parts that include the anteromedial (AM) and the posterolateral (PL) bundles. The anatomical placement of the reconstructed ACL graft has similar forces as compared to the native ACL [5]. The different techniques for ACL reconstruction aim to perform as near a normal anatomic reconstruction as possible. The double-bundle reconstruction technique has become the more popular procedure. However, the doublebundle technique is more technically demanding and more costly and has limited evidence of superior results when compared with the single-bundle reconstruction technique [6]. The centrally placed anatomic single-bundle ACL reconstruction is the common operative procedure and has been proven to restore normal knee function [7, 8].

of the proprioceptive function of the knee, and (4) development of a lower incidence of tunnel

**Figure 1.** Arthroscopic view of the left knee from the anterolateral viewing portal. The ACL remnant was found and

Anatomic Single-Bundle ACL Reconstruction with Remnant…

http://dx.doi.org/10.5772/intechopen.76577

45

pulled with an arthroscopic probe during the arthroscopic ACL reconstruction surgery.

The ACL reconstruction with remnant augmentation has been developed in various ways.

**1.** Selective single-bundle reconstruction of the isolated ruptured bundle (AM or PL bundle): this technique is performed if the intact bundle remains attached at its anatomical origin. **2.** Anatomic center, single-bundle reconstruction with remnant-preserving technique: this technique is indicated if both ACL bundles are completely torn but retain the ACL rem-

**3.** Anatomic double-bundle reconstruction with remnant-preserving technique: this technique might be indicated as in the anatomic center single-bundle reconstruction but has a

A prospective, randomized controlled trial (RCTs) study [13] was evaluated in two groups. There were 45 patients with remnant-preserving ACL reconstruction, and these were compared with 45 patients who underwent a standard ACL reconstruction. Proprioception measurements were evaluated using a passive angle reproduction test with the Biodex detector (Shirley, New York) in 80 patients preoperatively and at the last follow-up appointment. There were no differences seen between both groups at the final follow-up (mean ± SD,

A systematic review of clinical outcomes of remnant-preserving augmentation ACL reconstruction [14] evaluated 13 studies including five RCTs, six case studies, and two retrospective cohort studies. The patients were 14–62 years of age and were treated with various

near normal ACL and may provide more stability of the reconstructed knee.

degree = 3.6 ± 1.8 in preservation group and 3.9 ± 2.2 in standard group, p = 0.739).

widening postoperatively.

nant in a nonanatomical position.

Some of these include:

The ACL remnants are often found during arthroscopic ACL reconstruction of the knee (**Figure 1**). A previous study reported that the mechanoreceptors that are found in the ACL remnant may contribute to the proprioception of the knee [9] and provide some biomechanical stability of the knee [10]. An immunohistochemical study [11] on the morphology and the quantity of mechanoreceptors in 40 ACL reconstruction patients shows that the time from injury to surgery was negatively correlated with the number of total mechanoreceptors (r = −0.52, p < 0.01). This study emphasizes the role of the ACL stump or ACL remnant that has a role in the preservation of proprioceptive functions of the knee.

The ACL remnant is the tissue bridge between the tibia and either the posterior cruciate ligament (PCL) or the intercondylar notch. This remnant tissue maybe developed from the synovial scar, the remnant of the ACL, and the partial rupturing of the anteromedial (AM) or posterolateral ACL bundles. Although the injured knee has the remnant of the ACL, this remnant is often in an abnormal position and could not have the normal biomechanical functions identical to an intact ACL.

The remnant-preserving technique in ACL reconstruction was introduced in 1992 [12]. This procedure has theoretical advantages that include (1) possible promotion of the revascularization and the synovial coverage of the graft, (2) improvement of knee stability, (3) preservation

The ACL reconstruction techniques have been developed in various ways. These include single-bundle reconstruction, double-bundle reconstruction, selective bundle reconstruction, single-bundle reconstruction with remnant preservation, and double-bundle reconstruction with remnant preservation. With so many techniques, there has yet to be determined as to what is the best technique that provides the greatest stability and preserves knee functions

This chapter presents one optional ACL reconstruction technique that uses anatomic singlebundle anterior cruciate reconstruction with remnant augmentation. This technique is simple, has shown improved knee stability, may preserve the proprioceptive function, may accelerate cellular proliferation and revascularization of the grafted tendon, and has shown a lower

The functional ACL bundles consist of two parts that include the anteromedial (AM) and the posterolateral (PL) bundles. The anatomical placement of the reconstructed ACL graft has similar forces as compared to the native ACL [5]. The different techniques for ACL reconstruction aim to perform as near a normal anatomic reconstruction as possible. The double-bundle reconstruction technique has become the more popular procedure. However, the doublebundle technique is more technically demanding and more costly and has limited evidence of superior results when compared with the single-bundle reconstruction technique [6]. The centrally placed anatomic single-bundle ACL reconstruction is the common operative proce-

The ACL remnants are often found during arthroscopic ACL reconstruction of the knee (**Figure 1**). A previous study reported that the mechanoreceptors that are found in the ACL remnant may contribute to the proprioception of the knee [9] and provide some biomechanical stability of the knee [10]. An immunohistochemical study [11] on the morphology and the quantity of mechanoreceptors in 40 ACL reconstruction patients shows that the time from injury to surgery was negatively correlated with the number of total mechanoreceptors (r = −0.52, p < 0.01). This study emphasizes the role of the ACL stump or ACL remnant that has

The ACL remnant is the tissue bridge between the tibia and either the posterior cruciate ligament (PCL) or the intercondylar notch. This remnant tissue maybe developed from the synovial scar, the remnant of the ACL, and the partial rupturing of the anteromedial (AM) or posterolateral ACL bundles. Although the injured knee has the remnant of the ACL, this remnant is often in an abnormal position and could not have the normal biomechanical func-

The remnant-preserving technique in ACL reconstruction was introduced in 1992 [12]. This procedure has theoretical advantages that include (1) possible promotion of the revascularization and the synovial coverage of the graft, (2) improvement of knee stability, (3) preservation

(proprioceptive sensation, range of motion).

44 Recent Advances in Arthroscopic Surgery

incidence of tibial tunnel enlargement postoperatively.

**reconstruction with remnant augmentation**

**2. The anatomic single-bundle anterior cruciate ligament** 

dure and has been proven to restore normal knee function [7, 8].

a role in the preservation of proprioceptive functions of the knee.

tions identical to an intact ACL.

**Figure 1.** Arthroscopic view of the left knee from the anterolateral viewing portal. The ACL remnant was found and pulled with an arthroscopic probe during the arthroscopic ACL reconstruction surgery.

of the proprioceptive function of the knee, and (4) development of a lower incidence of tunnel widening postoperatively.

The ACL reconstruction with remnant augmentation has been developed in various ways. Some of these include:


A prospective, randomized controlled trial (RCTs) study [13] was evaluated in two groups. There were 45 patients with remnant-preserving ACL reconstruction, and these were compared with 45 patients who underwent a standard ACL reconstruction. Proprioception measurements were evaluated using a passive angle reproduction test with the Biodex detector (Shirley, New York) in 80 patients preoperatively and at the last follow-up appointment. There were no differences seen between both groups at the final follow-up (mean ± SD, degree = 3.6 ± 1.8 in preservation group and 3.9 ± 2.2 in standard group, p = 0.739).

A systematic review of clinical outcomes of remnant-preserving augmentation ACL reconstruction [14] evaluated 13 studies including five RCTs, six case studies, and two retrospective cohort studies. The patients were 14–62 years of age and were treated with various surgical techniques (the selective single-bundle reconstruction, remnant-tensioning technique, or remnant-sparing technique) using various types of grafts. The results showed that only two of the nine studies had exhibited a small significant side-to-side difference in the remnant-preserving groups. In the standard technique group, only 1 of 13 studies showed significant higher Lysholm scores in the remnant-preserving groups. Two of 13 studies showed significantly less tibial tunnel enlargement in the remnant-preserving groups. There were no significant reported complications in both groups (including the development of cyclops lesions).

osteotomy is indicated. The patients are evaluated for knee instability, with special attention to the anterior laxity using the anterior drawer, Lachman's test, and the pivot shift tests. The preoperative knee laxity was not an indicator of either the presence or lack of the presence of the ACL remnant. Associated knee pathologies such as ligamentous tears, meniscus lesions, or cartilage lesions are evaluated preoperatively. Magnetic resonance imaging (MRI) of the affected knee is obtained to evaluate the condition and associated pathologies

Anatomic Single-Bundle ACL Reconstruction with Remnant…

http://dx.doi.org/10.5772/intechopen.76577

47

The patient is positioned supine with the operative knee flexed to approximately 90°. The procedure is done under spinal or general anesthesia depending on the patients' preference. The affected knee is draped and freely prepped from the proximal thigh to the foot. An arthroscopic examination is performed using standard anterolateral viewing and a standard anteromedial working portal (**Figure 3**). After cleaning the obstacles of fatty tissue and the ligamentum mucosum in the tibiofemoral compartment, the torn ACL and the ACL remnant are identified. Both menisci are then evaluated, and then the menisci are repaired or resected

A quadruple semitendinosus autograft is harvested and prepared from the affected knee. The quadruple autograft length should be more than 6.5 cm, and the graft's diameter should be at least 7.5 mm. If the semitendinosus autograft is inadequate in size, an additional double or triple autogenous gracilis is also harvested. The EndoButton (Smith & Nephew, Andover, MA) is used for the graft's fixation point at the femoral side, and an interference screw (Smith & Nephew) is used for tibial fixation of the graft. Keeping in mind that the anatomic position of the tunnel is more important than the obstacle remnant of the ACL tissue, the femoral tunnel is created using a transportal technique from a standard anteromedial portal (**Figure 4**).

**Figure 2.** Preoperative MRI of the patient with ACL deficiency of the left knee reveals the increased signal intensity in the ACL fibers with the presence of a loose ACL remnant (yellow asterisk, \*). The hypersignal of the lateral tibial plateau

of the ACL (**Figure 2**).

depending on the conditions found.

is represented by a valgus-impacted injury with bone bruise.

The meta-analysis of the clinical outcomes of single-bundle ACL reconstruction with and without remnant preservation [15] in 6 RCTs, 378 patients (190 remnant-preserving patients, and 188 standard ACL reconstructions) had shown no significant differences in anterior stability, the pivot shift test, knee function scores, and the development of cyclops lesions. However, two RCTs from the remnant-preserving group had a lower percentage of tibial tunnel enlargement (obvious heterogeneity, p = 0.067, I2 = 70.3%). The percentage of tibial tunnel enlargement was 6.6 ± 0.8% vs. 2.4 ± 0.3% in one study and 34 ± 8.9% vs. 25.7 ± 6.7% in another study with significantly different results.

The study of the clinical outcomes with an arthroscopic reevaluation following ACL augmentation [16] in 216 patients with a mean age of 25 years (73 patients with single-bundle ACL augmentation, 82 of double-bundle reconstruction, and 61 of single-bundle reconstruction) had shown significantly better synovial coverage of the graft in the augmentation group (good 82%, fair 14%, poor 4%, p = 0.039). The side-to-side differences measured with the KT-2000 arthrometer were significantly better in the augmentation group than in the single-bundle reconstruction group (0.4 mm [−3.3 to 2.9] vs. 1.3 mm [−2.7 to 3.9], p = 0.013). Moreover, in the 62 patients who were with adequate synovial coverage had revealed significant improvement of the knee proprioception in three quarter motion measurements.

From previous studies, ACL reconstruction with remnant augmentation has shown comparable results with the standard ACL reconstruction. Although ACL reconstruction with remnant augmentation may not has proven to provide the benefits in terms of stability improvement, graft healing, proprioceptive functions, and clinical outcomes, this technique has significantly less tibial tunnel widening postoperatively and no greater incidence of complications. These complications include the occurrence of the cyclops lesions.

### **2.1. Surgical technique**

This chapter shows the technique of anatomic center, single-bundle ACL reconstruction with remnant augmentation. Indications for this surgery are active patients with clinical instability from an ACL-deficient knee. The patients must have normal alignment of the lower extremity, have no advanced knee osteoarthritic changes, and should have good knee range of motion preoperatively (more than 90° arch of motion). Obvious knee stiffness, active infection, or the patients with skeletal immaturity are relative contraindications for this procedure. If the patients have a significant malalignment of the knee, corrective osteotomy is indicated. The patients are evaluated for knee instability, with special attention to the anterior laxity using the anterior drawer, Lachman's test, and the pivot shift tests. The preoperative knee laxity was not an indicator of either the presence or lack of the presence of the ACL remnant. Associated knee pathologies such as ligamentous tears, meniscus lesions, or cartilage lesions are evaluated preoperatively. Magnetic resonance imaging (MRI) of the affected knee is obtained to evaluate the condition and associated pathologies of the ACL (**Figure 2**).

surgical techniques (the selective single-bundle reconstruction, remnant-tensioning technique, or remnant-sparing technique) using various types of grafts. The results showed that only two of the nine studies had exhibited a small significant side-to-side difference in the remnant-preserving groups. In the standard technique group, only 1 of 13 studies showed significant higher Lysholm scores in the remnant-preserving groups. Two of 13 studies showed significantly less tibial tunnel enlargement in the remnant-preserving groups. There were no significant reported complications in both groups (including the development of

The meta-analysis of the clinical outcomes of single-bundle ACL reconstruction with and without remnant preservation [15] in 6 RCTs, 378 patients (190 remnant-preserving patients, and 188 standard ACL reconstructions) had shown no significant differences in anterior stability, the pivot shift test, knee function scores, and the development of cyclops lesions. However, two RCTs from the remnant-preserving group had a lower percentage of tibial tunnel enlargement (obvious heterogeneity, p = 0.067, I2 = 70.3%). The percentage of tibial tunnel enlargement was 6.6 ± 0.8% vs. 2.4 ± 0.3% in one study and 34 ± 8.9% vs. 25.7 ± 6.7% in another

The study of the clinical outcomes with an arthroscopic reevaluation following ACL augmentation [16] in 216 patients with a mean age of 25 years (73 patients with single-bundle ACL augmentation, 82 of double-bundle reconstruction, and 61 of single-bundle reconstruction) had shown significantly better synovial coverage of the graft in the augmentation group (good 82%, fair 14%, poor 4%, p = 0.039). The side-to-side differences measured with the KT-2000 arthrometer were significantly better in the augmentation group than in the single-bundle reconstruction group (0.4 mm [−3.3 to 2.9] vs. 1.3 mm [−2.7 to 3.9], p = 0.013). Moreover, in the 62 patients who were with adequate synovial coverage had revealed significant improvement of the knee proprioception in three quarter motion

From previous studies, ACL reconstruction with remnant augmentation has shown comparable results with the standard ACL reconstruction. Although ACL reconstruction with remnant augmentation may not has proven to provide the benefits in terms of stability improvement, graft healing, proprioceptive functions, and clinical outcomes, this technique has significantly less tibial tunnel widening postoperatively and no greater incidence of complications. These

This chapter shows the technique of anatomic center, single-bundle ACL reconstruction with remnant augmentation. Indications for this surgery are active patients with clinical instability from an ACL-deficient knee. The patients must have normal alignment of the lower extremity, have no advanced knee osteoarthritic changes, and should have good knee range of motion preoperatively (more than 90° arch of motion). Obvious knee stiffness, active infection, or the patients with skeletal immaturity are relative contraindications for this procedure. If the patients have a significant malalignment of the knee, corrective

complications include the occurrence of the cyclops lesions.

cyclops lesions).

46 Recent Advances in Arthroscopic Surgery

measurements.

**2.1. Surgical technique**

study with significantly different results.

The patient is positioned supine with the operative knee flexed to approximately 90°. The procedure is done under spinal or general anesthesia depending on the patients' preference. The affected knee is draped and freely prepped from the proximal thigh to the foot. An arthroscopic examination is performed using standard anterolateral viewing and a standard anteromedial working portal (**Figure 3**). After cleaning the obstacles of fatty tissue and the ligamentum mucosum in the tibiofemoral compartment, the torn ACL and the ACL remnant are identified. Both menisci are then evaluated, and then the menisci are repaired or resected depending on the conditions found.

A quadruple semitendinosus autograft is harvested and prepared from the affected knee. The quadruple autograft length should be more than 6.5 cm, and the graft's diameter should be at least 7.5 mm. If the semitendinosus autograft is inadequate in size, an additional double or triple autogenous gracilis is also harvested. The EndoButton (Smith & Nephew, Andover, MA) is used for the graft's fixation point at the femoral side, and an interference screw (Smith & Nephew) is used for tibial fixation of the graft. Keeping in mind that the anatomic position of the tunnel is more important than the obstacle remnant of the ACL tissue, the femoral tunnel is created using a transportal technique from a standard anteromedial portal (**Figure 4**).

**Figure 2.** Preoperative MRI of the patient with ACL deficiency of the left knee reveals the increased signal intensity in the ACL fibers with the presence of a loose ACL remnant (yellow asterisk, \*). The hypersignal of the lateral tibial plateau is represented by a valgus-impacted injury with bone bruise.

The medial femoral condyle is carefully protected during the creation of the femoral tunnel to avoid an iatrogenic cartilage injury [17]. The graft should be inserted within the femoral tunnel, and it should be at least 15 mm in length. Next, the tibial footprint of the ACL is identified. In this step, the ACL remnant at the tibial footprint often needs to be partially removed until obtaining the appropriated tibial footprint. The tibial tunnel is then created using a transtibial ACL guide pin (Acufex Director Drill Guide, Smith & Nephew) that is then inserted from a standard anteromedial working portal (**Figure 5**). If the position of the guide pin is not positioned through the center of the tibial footprint, an increment reamer is used to adjust the

Anatomic Single-Bundle ACL Reconstruction with Remnant…

http://dx.doi.org/10.5772/intechopen.76577

49

After creating the femoral and tibial tunnels, the prepared autograft is passed from the anteromedial tibial cavity through the tibia and into the lateral intercondylar notch of the femur. The EndoButton is tested for possible dislodgement of the femoral cortex. Pretensioning of the ACL graft is performed, and the knee's motion is checked to evaluate of the graft position and the presence of an impingement (**Figure 6**). The ACL graft is then fixated at the tibia with an appropriately sized interference screw positioned eccentrically under adequate ACL graft tension in a position of nearly full extension of the operative knee (**Figure 7**). Postoperative radiographs are taken to evaluate the positioning of the implants and the femoral and the tibial tunnel positions (**Figure 8**). **Figure 9** represents the stepby-step process of a remnant-preserving ACL reconstruction of a 26-year-old woman with

**Figure 5.** Arthroscopic view of the left knee from the anterolateral viewing portal. After identifying the ACL tibial footprint, a tibial tunnel is created with the use of a transtibial, ACL guide pin (Acufex Director Drill Guide, Smith &

position of the guide pin [18].

injury to her left knee.

Nephew) inserted from the anteromedial portal.

**Figure 3.** Patient positioning and placement of portals; the pictures show the positioning, preparation, and arthroscopic portals for arthroscopic ACL reconstruction of the left knee (AM, anteromedial portal; AL, anterolateral portal).

**Figure 4.** Arthroscopic view of the left knee from anterolateral viewing portal. After identifying the ACL femoral footprint, the femoral tunnel is created using the transportal technique from a standard anteromedial portal.

The medial femoral condyle is carefully protected during the creation of the femoral tunnel to avoid an iatrogenic cartilage injury [17]. The graft should be inserted within the femoral tunnel, and it should be at least 15 mm in length. Next, the tibial footprint of the ACL is identified. In this step, the ACL remnant at the tibial footprint often needs to be partially removed until obtaining the appropriated tibial footprint. The tibial tunnel is then created using a transtibial ACL guide pin (Acufex Director Drill Guide, Smith & Nephew) that is then inserted from a standard anteromedial working portal (**Figure 5**). If the position of the guide pin is not positioned through the center of the tibial footprint, an increment reamer is used to adjust the position of the guide pin [18].

After creating the femoral and tibial tunnels, the prepared autograft is passed from the anteromedial tibial cavity through the tibia and into the lateral intercondylar notch of the femur. The EndoButton is tested for possible dislodgement of the femoral cortex. Pretensioning of the ACL graft is performed, and the knee's motion is checked to evaluate of the graft position and the presence of an impingement (**Figure 6**). The ACL graft is then fixated at the tibia with an appropriately sized interference screw positioned eccentrically under adequate ACL graft tension in a position of nearly full extension of the operative knee (**Figure 7**). Postoperative radiographs are taken to evaluate the positioning of the implants and the femoral and the tibial tunnel positions (**Figure 8**). **Figure 9** represents the stepby-step process of a remnant-preserving ACL reconstruction of a 26-year-old woman with injury to her left knee.

**Figure 3.** Patient positioning and placement of portals; the pictures show the positioning, preparation, and arthroscopic portals for arthroscopic ACL reconstruction of the left knee (AM, anteromedial portal; AL, anterolateral portal).

48 Recent Advances in Arthroscopic Surgery

**Figure 4.** Arthroscopic view of the left knee from anterolateral viewing portal. After identifying the ACL femoral

footprint, the femoral tunnel is created using the transportal technique from a standard anteromedial portal.

**Figure 5.** Arthroscopic view of the left knee from the anterolateral viewing portal. After identifying the ACL tibial footprint, a tibial tunnel is created with the use of a transtibial, ACL guide pin (Acufex Director Drill Guide, Smith & Nephew) inserted from the anteromedial portal.

**Figure 6.** Arthroscopic view of the left knee from anterolateral viewing portal. The reconstructed ACL graft and positioning and impingement in full knee extension are checked.

**2.2. Postoperative rehabilitation**

EndoButton and the bony tunnels.

**2.3. Pearls and pitfalls**

ties are allowed 10–12 months following the surgery.

more advantages as have been discussed previously.

The pearls and pitfalls of this procedure are shown in **Table 1**.

A small tubular drain is placed in the intra-articular area for 24 h postoperatively. An early range of motion exercises of the affected knee are encouraged as soon as possible with no limitations in knee flexion postoperatively. No knee braces or immobilization prosthetics are used. The patients can ambulate with crutches, and they are able to bear weight on the affected limb at approximately 10% of normal in the cases that had cartilage procedures done (microfracture or mosaicplasty). Approximately 50% of normal weight-bearing in the cases with meniscal repair and full weight-bearing as tolerated in cases with only ACL reconstructive surgery.

**Figure 8.** Postoperative radiographs of the left knee in anteroposterior and lateral views reveal the position of the

Anatomic Single-Bundle ACL Reconstruction with Remnant…

http://dx.doi.org/10.5772/intechopen.76577

51

The stitches are removed 10–14 days postoperatively. Active quadriceps contraction exercises are allowed at the earliest possible time frame. Light sports activities such as jogging, swimming, and bicycling will be allowed 4 months postoperatively. Return to contact sports activi-

This technique is simple and processes in the same steps of a standard anatomic single-bundle ACL reconstruction. The difference is only of the preservation of the ACL remnant to get

**Figure 7.** Arthroscopic view of the left knee from anterolateral viewing portal. Following fixation of the ACL graft, the graft, and the remnant appears to be a stable ACL reconstruct.

**Figure 8.** Postoperative radiographs of the left knee in anteroposterior and lateral views reveal the position of the EndoButton and the bony tunnels.

### **2.2. Postoperative rehabilitation**

A small tubular drain is placed in the intra-articular area for 24 h postoperatively. An early range of motion exercises of the affected knee are encouraged as soon as possible with no limitations in knee flexion postoperatively. No knee braces or immobilization prosthetics are used. The patients can ambulate with crutches, and they are able to bear weight on the affected limb at approximately 10% of normal in the cases that had cartilage procedures done (microfracture or mosaicplasty). Approximately 50% of normal weight-bearing in the cases with meniscal repair and full weight-bearing as tolerated in cases with only ACL reconstructive surgery.

The stitches are removed 10–14 days postoperatively. Active quadriceps contraction exercises are allowed at the earliest possible time frame. Light sports activities such as jogging, swimming, and bicycling will be allowed 4 months postoperatively. Return to contact sports activities are allowed 10–12 months following the surgery.

### **2.3. Pearls and pitfalls**

**Figure 7.** Arthroscopic view of the left knee from anterolateral viewing portal. Following fixation of the ACL graft, the

**Figure 6.** Arthroscopic view of the left knee from anterolateral viewing portal. The reconstructed ACL graft and

graft, and the remnant appears to be a stable ACL reconstruct.

positioning and impingement in full knee extension are checked.

50 Recent Advances in Arthroscopic Surgery

This technique is simple and processes in the same steps of a standard anatomic single-bundle ACL reconstruction. The difference is only of the preservation of the ACL remnant to get more advantages as have been discussed previously.

The pearls and pitfalls of this procedure are shown in **Table 1**.

**3. Conclusion(s)**

of cyclops lesions.

**Acknowledgements**

**Conflict of interest**

**Author details**

**References**

Adinun Apivatgaroon

Epub April 9, 2015

There is no support funding for the publication.

The author declares that no conflicts of interest exist.

Address all correspondence to: adino\_ball@yahoo.com

Department of Orthopaedics, Thammasat University, Pathum Thani, Thailand

[1] Tsoukas D, Fotopoulos V, Basdekis G, Makridis KG. No difference in osteoarthritis after surgical and non-surgical treatment of ACL-injured knees after 10 years. Knee Surgery, Sports Traumatology, Arthroscopy. 2016;**24**(9):2953-2959. DOI: 10.1007/s00167-015-3593-9.

[2] Monk AP, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ. Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database of

[3] Sanders TL, Kremers HM, Bryan AJ, Fruth KM, Larson DR, Pareek A, Levy BA, Stuart MJ, Dahm DL, Krych AJ. Is anterior cruciate ligament reconstruction effective in preventing secondary meniscal tears and osteoarthritis? The American Journal of Sports Medicine. 2016;**44**(7):1699-1707. DOI: 10.1177/0363546516634325. Epub 2016 Mar 8

Systematic Reviews. 2016;**4**:CD011166. DOI: 10.1002/14651858.CD011166.pub2

The anatomical single-bundle ACL reconstruction with remnant augmentation or preservation is the optional reconstruction technique that has shown comparable results with standard ACL reconstruction. This technique has theoretical advantages in the improvement of the stability of the knee, promotion of graft healing, preservation of the proprioceptive functions, and resulting good to excellent clinical outcomes. Although the studies have shown no significant benefits, this technique has a significantly lower incidence of tibial tunnel widening postoperatively and has exhibited no additional complications, including the occurrence

Anatomic Single-Bundle ACL Reconstruction with Remnant…

http://dx.doi.org/10.5772/intechopen.76577

53

**Figure 9.** Arthroscopic images of a 26-year-old woman with left knee injury. The ACL remnant is observed arthroscopically. The step-by-step technique of a remnant-preserving ACL reconstruction is shown.


**Table 1.** The pearls and pitfalls of the anatomic single-bundle ACL reconstruction with remnant augmentation technique.

### **3. Conclusion(s)**

The anatomical single-bundle ACL reconstruction with remnant augmentation or preservation is the optional reconstruction technique that has shown comparable results with standard ACL reconstruction. This technique has theoretical advantages in the improvement of the stability of the knee, promotion of graft healing, preservation of the proprioceptive functions, and resulting good to excellent clinical outcomes. Although the studies have shown no significant benefits, this technique has a significantly lower incidence of tibial tunnel widening postoperatively and has exhibited no additional complications, including the occurrence of cyclops lesions.

### **Acknowledgements**

There is no support funding for the publication.

### **Conflict of interest**

The author declares that no conflicts of interest exist.

### **Author details**

Adinun Apivatgaroon

Address all correspondence to: adino\_ball@yahoo.com

Department of Orthopaedics, Thammasat University, Pathum Thani, Thailand

### **References**

**Pearls Pitfalls**

Clear identification of the center of both, the femoral and tibial

The appropriate graft position should be of greater concern than remnant preservation without anatomical graft placement

Most of the anterior tibial footprint stump of the ACL remnant should be removed to prevent anterior impingement of the graft

or tissue (cyclops lesion) during full knee extension

footprints using bony ridges as reference

**Table 1.** The pearls and pitfalls of the anatomic single-bundle ACL reconstruction with remnant augmentation technique.

**Figure 9.** Arthroscopic images of a 26-year-old woman with left knee injury. The ACL remnant is observed

arthroscopically. The step-by-step technique of a remnant-preserving ACL reconstruction is shown.

Simple, needs minimal technical demand as compared with the standard anatomic single-

52 Recent Advances in Arthroscopic Surgery

Some studies have reported achievement of greater knee stability and better proprioceptive

The RCTs show that the remnant-preserving ACL reconstruction has less tibial tunnel widening

Strict postoperative care is the key to obtaining

bundle ACL reconstruction

functions

postoperatively

good results


[4] Mihelic R, Jurdana H, Jotanovic Z, Madjarevic T, Tudor A. Long-term results of anterior cruciate ligament reconstruction: A comparison with non-operative treatment with a follow-up of 17-20 years. International Orthopaedics. 2011;**35**:1093-1097

[15] Tie K, Chen L, Hu D, Wang H. The difference in clinical outcome of single-bundle anterior cruciate ligament reconstructions with and without remnant preservation: A metaanalysis. The Knee. 2016;**23**(4):566-574. DOI: 10.1016/j.knee.2015.07.010. Epub May 17,

Anatomic Single-Bundle ACL Reconstruction with Remnant…

http://dx.doi.org/10.5772/intechopen.76577

55

[16] Nakamae A, Ochi M, Deie M, Adachi N, Shibuya H, Ohkawa S, Hirata K. Clinical outcomes of second-look arthroscopic evaluation after anterior cruciate ligament augmentation: Comparison with single- and double-bundle reconstruction. Bone and Joint

[17] Chuaychoosakoon C, Duangnumsawang Y, Apivatgaroon A. Prevention of medial femoral condyle injury by using a slotted cannula in anterior cruciate ligament reconstruc-

[18] Apivatgaroon A, Chernchujit B. A surgical trick for adjusting an inaccurate guide pin to the center of the tibial footprint in anatomic single-bundle anterior cruciate ligament

2016. Review

Journal. 2014;**96-B**(10):1325-1332

tion. Arthroscopy Techniques. 2017;**6**(5):e1639-e1643

reconstruction. Arthroscopy Techniques. 2014;**3**(2):e275-e277


[15] Tie K, Chen L, Hu D, Wang H. The difference in clinical outcome of single-bundle anterior cruciate ligament reconstructions with and without remnant preservation: A metaanalysis. The Knee. 2016;**23**(4):566-574. DOI: 10.1016/j.knee.2015.07.010. Epub May 17, 2016. Review

[4] Mihelic R, Jurdana H, Jotanovic Z, Madjarevic T, Tudor A. Long-term results of anterior cruciate ligament reconstruction: A comparison with non-operative treatment with a

[5] Kato Y, Ingham SJ, Kramer S, et al. Effect of tunnel position for anatomic single bundle ACL reconstruction on knee biomechanics in a porcine model. Knee Surgery, Sports

[6] Tiamklang T, Sumanont S, Foocharoen T, Laopaiboon M. Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults. Cochrane Database of Systematic Reviews. 2012;**11**:CD008413. DOI: 10.1002/14651858.CD008413.

[7] Ho JY, Gardiner A, Shah V, et al. Equal kinematics between central anatomic singlebundle and double-bundle anterior cruciate ligament reconstructions. Arthroscopy.

[8] Kanaya A, Ochi M, Deie M, et al. Intraoperative evaluation of anteroposterior and rotational stabilities in anterior cruciate ligament reconstruction: Lower femoral tunnel placed single-bundle versus double-bundle reconstruction. Knee Surgery, Sports

[9] Adachi N, Ochi M, Uchino Y, Iwasa J, Ryoke K, Kuriwaka M. Contribution of mechanoreceptors in the anterior cruciate ligament to the joint position sense knee. Acta

[10] Nakamae A, Ochi M, Deie M, Adachi N, Kanaya A, Nishimori M, Nakasa T.Biomechanical function of anterior cruciate ligament remnants: How long do they contribute to knee stability after injury in patients with complete tears? Arthroscopy. 2010;**26**:1577-1585 [11] Gao F, Zhou J, He C, Ding J, Lou Z, Xie Q, Li H, Li F, Li G. A morphologic and quantitative study of mechanoreceptors in the remnant stump of the human anterior cruciate ligament. Arthroscopy. 2016;**32**(2):273-280. DOI: 10.1016/j.arthro.2015.07.010. Epub

[12] Kazusa H, Nakamae A, Ochi M. Augmentation technique for anterior cruciate ligament injury. Clinics in Sports Medicine. 2013;**32**(1):127-140. DOI: 10.1016/j.csm.2012.08.012.

[13] Hong L, Li X, Zhang H, Liu X, Zhang J, Shen JW, Feng H. Anterior cruciate ligament reconstruction with remnant preservation: A prospective, randomized controlled study. The American Journal of Sports Medicine. 2012;**40**(12):2747-2755. DOI:

[14] Hu J, Qu J, Xu D, Zhang T, Zhou J, Lu H. Clinical outcomes of remnant preserving augmentation in anterior cruciate ligament reconstruction: A systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2014;**22**(9):1976-1985. DOI: 10.1007/s00167-

follow-up of 17-20 years. International Orthopaedics. 2011;**35**:1093-1097

Traumatology, Arthroscopy. 2010;**18**:2-10

Traumatology, Arthroscopy. 2009;**17**:907-913

Orthopaedica Scandinavica. 2002;**73**:330-334

pub2

2009;**25**:464-472

54 Recent Advances in Arthroscopic Surgery

October 1, 2015

Epub September 23, 2012. Review

10.1177/0363546512461481. Epub October 17, 2012

013-2749-8. Epub November 2, 2013. Review


**Chapter 4**

**Provisional chapter**

**Office-Based Small Bore Needle Arthroscopy of the**

**Office-Based Small Bore Needle Arthroscopy of the** 

Advanced imaging, such as MRI, can sometimes provide inconclusive results with knee pathology, leaving both patients and providers with a diagnostic challenge. In-office arthroscopy is a newer, low-risk, diagnostic procedure that allows the physician to use a small bore needle arthroscope to view the intra-articular anatomy of the joint. The patient and provider are provided with immediate results of the pathology found. This prevents having to undergo repeat imaging, which can be a costly, time-consuming, and inconclusive process. Ideal indications are patients who are claustrophobic, have previously undergone meniscal or chondral surgery, or whose MRI results are inconclusive. This chapter will review the background, indications, technique, and risks of this novel

Arthroscopy is currently the gold standard for diagnosing intra-articular knee pathology. While arthroscopy does allow surgeons to see within the finite pathologic area, magnetic resonance imaging (MRI) serves as a less invasive tool to diagnose injuries within the knee. MRI currently serves as the leading imaging tool to diagnose intra-articular injuries; however, studies have questioned its accuracy. Objective measures of test performance generally include, but are not limited to, sensitivity, specificity, accuracy and predictive values. To diagnose a complete anterior cruciate ligament (ACL) tear, studies show MRI to have sensitivity, specificity, accuracy and negative predictive value (NPV) of 90.9, 84.6, 88.6, and

**Keywords:** knee arthroscopy, in-office, magnetic resonance imaging

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.76757

Kyle Williams, Kelly Scott, Donald Dulle III and

Kyle Williams, Kelly Scott, Donald Dulle III and

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76757

**Knee**

**Knee**

Anikar Chhabra

Anikar Chhabra

**Abstract**

procedure.

**1. Introduction**

#### **Office-Based Small Bore Needle Arthroscopy of the Knee Office-Based Small Bore Needle Arthroscopy of the Knee**

DOI: 10.5772/intechopen.76757

Kyle Williams, Kelly Scott, Donald Dulle III and Anikar Chhabra Kyle Williams, Kelly Scott, Donald Dulle III and Anikar Chhabra

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76757

#### **Abstract**

Advanced imaging, such as MRI, can sometimes provide inconclusive results with knee pathology, leaving both patients and providers with a diagnostic challenge. In-office arthroscopy is a newer, low-risk, diagnostic procedure that allows the physician to use a small bore needle arthroscope to view the intra-articular anatomy of the joint. The patient and provider are provided with immediate results of the pathology found. This prevents having to undergo repeat imaging, which can be a costly, time-consuming, and inconclusive process. Ideal indications are patients who are claustrophobic, have previously undergone meniscal or chondral surgery, or whose MRI results are inconclusive. This chapter will review the background, indications, technique, and risks of this novel procedure.

**Keywords:** knee arthroscopy, in-office, magnetic resonance imaging

#### **1. Introduction**

Arthroscopy is currently the gold standard for diagnosing intra-articular knee pathology. While arthroscopy does allow surgeons to see within the finite pathologic area, magnetic resonance imaging (MRI) serves as a less invasive tool to diagnose injuries within the knee. MRI currently serves as the leading imaging tool to diagnose intra-articular injuries; however, studies have questioned its accuracy. Objective measures of test performance generally include, but are not limited to, sensitivity, specificity, accuracy and predictive values. To diagnose a complete anterior cruciate ligament (ACL) tear, studies show MRI to have sensitivity, specificity, accuracy and negative predictive value (NPV) of 90.9, 84.6, 88.6, and

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

84.6% respectively [1, 2]. Furthermore, the sensitivity, specificity, accuracy, and NPV of MRI to detect medial meniscus pathology was 100, 52.6, 64 and 100%, respectively, while detection of lateral meniscus pathology was 55.6, 83.3, 75.8 and 83.3%, respectively [1, 2]. MRI's objective measures of test performance are not perfect by any means, leading experts to question its overall reliability [3], while also seeking a superior method.

While arthroscopy is considered the gold standard for diagnosing and treating pathology of the knee, any type of surgical procedure, especially one that requires general anesthesia, presents risks that must be weighed alongside the benefits of the procedure. Arthroscopic procedures have been shown to have 30-day readmission rates of 0.92% for reasons including surgical site infections, deep venous thrombosis, pulmonary embolism, and postoperative ailments [4]. Although this percentage is low, complications do still exist. New technology geared toward obviating diagnostic arthroscopies may allow for similar diagnostic outcomes while also eliminating the surgical risk. New technology, namely mi-eye 2 (Trice Medical) has allowed physicians to perform in-office diagnostic arthroscopies.

> the patella, can be marked and used as well (**Figure 3**). If further evaluation of the patellofemoral joint is necessary, standard supero-lateral or supero-medial portals can be used. Once the intended portal sites are marked, the skin is prepped in a sterile fashion and 2 cc of 0.2% lidocaine

> **Figure 3.** Portal sites. Anterolateral, anteromedial and transpatellar portal sites are marked, sterilized, and anesthetized. Additionally, superolateral and superomedial sites can be used for a more thorough visualization of the patellofemoral

joint.

**Figure 2.** Patient set-up. The patient is set up with the knee at 90° in a comfortable position. This picture demonstrates

Office-Based Small Bore Needle Arthroscopy of the Knee

http://dx.doi.org/10.5772/intechopen.76757

59

the patient in a supine position. Alternatively, the patient can be positioned sitting with the knee bent to 90°.

### **2. Technique**

The mi-eye 2™ received FDA 501(k) clearance in October 2016 for in-office diagnostic arthroscopy use (**Figure 1**). The device itself consists of a 14-gauge needle, through which the arthroscope is placed. The arthroscope is a 2.26 mm, 0° camera, which allows a 120° field of view and 5–35 mm depth of view with autofocus capability. The light source and the display monitor are also included in the packaging.

The patient should be placed in a comfortable position during the procedure; the knee should be in 90° of flexion, which can be done in a seated position or supine position with a bump under the patient's heel (**Figure 2**). Landmarks are then palpated and marked, including the medial, lateral, and inferior borders of the patella as well as the patellar tendon. The standard medial and lateral portals are marked 0.5 cm inferior to the inferior pole of the patella, just medial or lateral to the patellar tendon; a trans-patellar tendon portal, located 1 cm inferior to the inferior pole of

**Figure 1.** Device. The mi-eye 2 device from trice medical, which includes the tablet and disposable probe. The needle sheath is retracted by pushing back on button found on superior portion of device.

84.6% respectively [1, 2]. Furthermore, the sensitivity, specificity, accuracy, and NPV of MRI to detect medial meniscus pathology was 100, 52.6, 64 and 100%, respectively, while detection of lateral meniscus pathology was 55.6, 83.3, 75.8 and 83.3%, respectively [1, 2]. MRI's objective measures of test performance are not perfect by any means, leading experts to question

While arthroscopy is considered the gold standard for diagnosing and treating pathology of the knee, any type of surgical procedure, especially one that requires general anesthesia, presents risks that must be weighed alongside the benefits of the procedure. Arthroscopic procedures have been shown to have 30-day readmission rates of 0.92% for reasons including surgical site infections, deep venous thrombosis, pulmonary embolism, and postoperative ailments [4]. Although this percentage is low, complications do still exist. New technology geared toward obviating diagnostic arthroscopies may allow for similar diagnostic outcomes while also eliminating the surgical risk. New technology, namely mi-eye 2 (Trice Medical) has

The mi-eye 2™ received FDA 501(k) clearance in October 2016 for in-office diagnostic arthroscopy use (**Figure 1**). The device itself consists of a 14-gauge needle, through which the arthroscope is placed. The arthroscope is a 2.26 mm, 0° camera, which allows a 120° field of view and 5–35 mm depth of view with autofocus capability. The light source and the display moni-

The patient should be placed in a comfortable position during the procedure; the knee should be in 90° of flexion, which can be done in a seated position or supine position with a bump under the patient's heel (**Figure 2**). Landmarks are then palpated and marked, including the medial, lateral, and inferior borders of the patella as well as the patellar tendon. The standard medial and lateral portals are marked 0.5 cm inferior to the inferior pole of the patella, just medial or lateral to the patellar tendon; a trans-patellar tendon portal, located 1 cm inferior to the inferior pole of

**Figure 1.** Device. The mi-eye 2 device from trice medical, which includes the tablet and disposable probe. The needle

sheath is retracted by pushing back on button found on superior portion of device.

its overall reliability [3], while also seeking a superior method.

allowed physicians to perform in-office diagnostic arthroscopies.

**2. Technique**

58 Recent Advances in Arthroscopic Surgery

tor are also included in the packaging.

**Figure 2.** Patient set-up. The patient is set up with the knee at 90° in a comfortable position. This picture demonstrates the patient in a supine position. Alternatively, the patient can be positioned sitting with the knee bent to 90°.

the patella, can be marked and used as well (**Figure 3**). If further evaluation of the patellofemoral joint is necessary, standard supero-lateral or supero-medial portals can be used. Once the intended portal sites are marked, the skin is prepped in a sterile fashion and 2 cc of 0.2% lidocaine

**Figure 3.** Portal sites. Anterolateral, anteromedial and transpatellar portal sites are marked, sterilized, and anesthetized. Additionally, superolateral and superomedial sites can be used for a more thorough visualization of the patellofemoral joint.

without epinephrine is used to anesthetize the skin directly over each portal sites. An additional 20 cc of 0.2% lidocaine without epinephrine is injected intra-articularly. Allow approximately 10 minutes for the analgesia to take full effect. The skin is then sterily prepped a second time, prior to insertion of the mi-eye 2™ probe into the knee joint.

Multiple syringes of sterile saline are at hand and ready to inject into the knee joint through the mi-eye 2™ probe to obtain adequate distension for visualization; varying amounts of saline are needed but often times do not exceed 150 cc. The mi-eye 2™ is removed from its sterile packaging. The first syringe of saline (we recommend using 10 cc syringes to better control the probe) is attached to the stopcock and the probe connector is removed and handed to the assistant to be plugged into the tablet. The probe is then inserted into the medial or lateral portal sites, making sure to aim toward the notch to avoid damage to the cartilage or menisci. Once the capsule is entered, the retraction button is depressed and the needle is retracted; this will expose the probe optics. The stopcock should be opened a ¼ turn to allow for injection of saline. Slowly inject saline to distend the capsule and fill the joint to allow for adequate visualization. Bursts of fluid will be required to push away soft tissue and allow for visualization at various times during the procedure. A diagnostic arthroscopy is performed in a step-wise fashion, visualizing each compartment (medial, lateral and patellofemoral) (**Figures 4**–**6**), the notch (**Figure 7**), and the gutters. Certain maneuvers, including slight varus and valgus stresses, may be employed to visualize desired structures. Images and live video can be saved to the tablet device as needed.

After completion of the arthroscopy, the fluid in the joint can be aspirated through the same stopcock using multiple 50 cc syringes. The probe is then removed from the joint, and a compressive dressing, such as an Ace Wrap, should be applied to the knee. The images and video saved to the portal can then be reviewed with the patient immediately following the procedure. Given the minimal procedure and early mobilization, no deep venous thrombosis prophylaxis is warranted.

**Figure 5.** a) Knee position in the Figure of Four Position to gain access to the Lateral Compartment of the Knee b) Visualization of the Lateral Meniscus and the Lateral Chondral Surfaces using the in-office arthroscopy system.

Office-Based Small Bore Needle Arthroscopy of the Knee

http://dx.doi.org/10.5772/intechopen.76757

61

**Figure 4.** Medial knee compartment. Visualization of the medial meniscus and medial chondral surfaces using the

without epinephrine is used to anesthetize the skin directly over each portal sites. An additional 20 cc of 0.2% lidocaine without epinephrine is injected intra-articularly. Allow approximately 10 minutes for the analgesia to take full effect. The skin is then sterily prepped a second time,

Multiple syringes of sterile saline are at hand and ready to inject into the knee joint through the mi-eye 2™ probe to obtain adequate distension for visualization; varying amounts of saline are needed but often times do not exceed 150 cc. The mi-eye 2™ is removed from its sterile packaging. The first syringe of saline (we recommend using 10 cc syringes to better control the probe) is attached to the stopcock and the probe connector is removed and handed to the assistant to be plugged into the tablet. The probe is then inserted into the medial or lateral portal sites, making sure to aim toward the notch to avoid damage to the cartilage or menisci. Once the capsule is entered, the retraction button is depressed and the needle is retracted; this will expose the probe optics. The stopcock should be opened a ¼ turn to allow for injection of saline. Slowly inject saline to distend the capsule and fill the joint to allow for adequate visualization. Bursts of fluid will be required to push away soft tissue and allow for visualization at various times during the procedure. A diagnostic arthroscopy is performed in a step-wise fashion, visualizing each compartment (medial, lateral and patellofemoral) (**Figures 4**–**6**), the notch (**Figure 7**), and the gutters. Certain maneuvers, including slight varus and valgus stresses, may be employed to visualize desired structures. Images and live video can be saved to the tablet device as needed.

prior to insertion of the mi-eye 2™ probe into the knee joint.

in-office arthroscopy system.

60 Recent Advances in Arthroscopic Surgery

**Figure 5.** a) Knee position in the Figure of Four Position to gain access to the Lateral Compartment of the Knee b) Visualization of the Lateral Meniscus and the Lateral Chondral Surfaces using the in-office arthroscopy system.

After completion of the arthroscopy, the fluid in the joint can be aspirated through the same stopcock using multiple 50 cc syringes. The probe is then removed from the joint, and a compressive dressing, such as an Ace Wrap, should be applied to the knee. The images and video saved to the portal can then be reviewed with the patient immediately following the procedure. Given the minimal procedure and early mobilization, no deep venous thrombosis prophylaxis is warranted.

the out the knee. Additionally, visualization can be difficult in patients who have had mul-

Office-Based Small Bore Needle Arthroscopy of the Knee

http://dx.doi.org/10.5772/intechopen.76757

63

While in office arthroscopy negates the anesthetic risk and greatly minimizes DVT and infection risks associated with intraoperative arthroscopy, there are limitations associated with its use. First, the surgeon must feel comfortable with the instruments, particularly the 0° scope, which may be unfamiliar. The 0° scope is used because the optics do not allow for the more commonly used 30° scope; however, the development of the 30° scope is in progress. Second, while direct visualization of intraarticular pathology is possible, the images are not as clear as

In-office arthroscopy has been available since the early 1990s, yet, over the years, this technology has evolved, allowing for high quality intra-articular images to be obtained in an office setting [5, 6]. Historically, MRI has been used to diagnose a variety of intra-articular pathologies, due to its superiority to other imaging studies in identifying chondral, ligamentous and meniscal pathologies; reported accuracy rates hover around 90% [7, 8]. While imaging studies often play a substantial role in the decision to treat a patient conservatively or surgically, these studies are not perfect and can sometimes miss, under-diagnose, or overdiagnose intra-articular knee pathologies [8–10]. In-office arthroscopy allows the physician to directly visualize the knee through high-quality, real-time images. In an unpublished, current study, the accuracy of in-office arthroscopy in comparison to MRI is 91.5 versus 61.3% for all

In addition to the accurate diagnostic potential, in-office arthroscopy provides further benefits to both the patient and the physician. The patient, who is seeking a medical opinion, can receive not only a more definitive and accurate answer regarding the nature of their pathology but this diagnosis can eliminate a possibly unnecessary diagnostic arthroscopy performed in the operating room under general anesthesia. The physician, who is providing a medical opinion, can be more definitive in their diagnosis of intra-articular pathology, leading to a more definitive and accurate treatment plan. In-office arthroscopy is a purely diagnostic tool;

The risk associated with in-office arthroscopy, as compared to diagnostic arthroscopy, is minimal. Diagnostic arthroscopy requires patients to undergo general anesthesia, adding both risk and cost to the patient, while in-office arthroscopy uses local anesthetic. Furthermore, both procedures allow patients to go home the same day, yet the time constraint of in-office arthroscopy is significantly decreased, since a diagnostic arthroscopy requires more time due to preoperative evaluation, anesthetic induction, the procedure itself, and time in the post-

simple procedures, like loose body removal, are not yet possible.

tiple surgical procedures resulting in significant synovial scarring.

**4. Risks/limitations**

an operative arthroscopy.

**5. Discussion**

pathologies [11].

anesthesia care unit after surgery.

**Figure 6.** Patellofemoral knee compartment. Visualization of the patella and the trochlear chondral surfaces from the anterolateral portal using the in-office arthroscopy system.

**Figure 7.** The notch. Visualization of the anterior Cruciate ligament in the notch using the in-office arthroscopy system.

### **3. Indications and contraindications**

Indications for diagnostic in office arthroscopy include patients who cannot undergo an MRI for medical or personal reasons or patients who have undergone prior arthroscopic procedures and subsequently have an inconclusive MRI. In addition, patients who are potential candidates for a meniscal transplant, osteochondral allograft, or a unicompartmental knee arthroplasty (UKA) can undergo this in office procedure to better characterize current pathology as well as aid in the preparation of a definitive treatment plan. The main contraindication to the procedure are patients with acute hemarthrosis, due to the inability to adequately flush the out the knee. Additionally, visualization can be difficult in patients who have had multiple surgical procedures resulting in significant synovial scarring.

### **4. Risks/limitations**

While in office arthroscopy negates the anesthetic risk and greatly minimizes DVT and infection risks associated with intraoperative arthroscopy, there are limitations associated with its use. First, the surgeon must feel comfortable with the instruments, particularly the 0° scope, which may be unfamiliar. The 0° scope is used because the optics do not allow for the more commonly used 30° scope; however, the development of the 30° scope is in progress. Second, while direct visualization of intraarticular pathology is possible, the images are not as clear as an operative arthroscopy.

### **5. Discussion**

**3. Indications and contraindications**

anterolateral portal using the in-office arthroscopy system.

62 Recent Advances in Arthroscopic Surgery

Indications for diagnostic in office arthroscopy include patients who cannot undergo an MRI for medical or personal reasons or patients who have undergone prior arthroscopic procedures and subsequently have an inconclusive MRI. In addition, patients who are potential candidates for a meniscal transplant, osteochondral allograft, or a unicompartmental knee arthroplasty (UKA) can undergo this in office procedure to better characterize current pathology as well as aid in the preparation of a definitive treatment plan. The main contraindication to the procedure are patients with acute hemarthrosis, due to the inability to adequately flush

**Figure 7.** The notch. Visualization of the anterior Cruciate ligament in the notch using the in-office arthroscopy system.

**Figure 6.** Patellofemoral knee compartment. Visualization of the patella and the trochlear chondral surfaces from the

In-office arthroscopy has been available since the early 1990s, yet, over the years, this technology has evolved, allowing for high quality intra-articular images to be obtained in an office setting [5, 6]. Historically, MRI has been used to diagnose a variety of intra-articular pathologies, due to its superiority to other imaging studies in identifying chondral, ligamentous and meniscal pathologies; reported accuracy rates hover around 90% [7, 8]. While imaging studies often play a substantial role in the decision to treat a patient conservatively or surgically, these studies are not perfect and can sometimes miss, under-diagnose, or overdiagnose intra-articular knee pathologies [8–10]. In-office arthroscopy allows the physician to directly visualize the knee through high-quality, real-time images. In an unpublished, current study, the accuracy of in-office arthroscopy in comparison to MRI is 91.5 versus 61.3% for all pathologies [11].

In addition to the accurate diagnostic potential, in-office arthroscopy provides further benefits to both the patient and the physician. The patient, who is seeking a medical opinion, can receive not only a more definitive and accurate answer regarding the nature of their pathology but this diagnosis can eliminate a possibly unnecessary diagnostic arthroscopy performed in the operating room under general anesthesia. The physician, who is providing a medical opinion, can be more definitive in their diagnosis of intra-articular pathology, leading to a more definitive and accurate treatment plan. In-office arthroscopy is a purely diagnostic tool; simple procedures, like loose body removal, are not yet possible.

The risk associated with in-office arthroscopy, as compared to diagnostic arthroscopy, is minimal. Diagnostic arthroscopy requires patients to undergo general anesthesia, adding both risk and cost to the patient, while in-office arthroscopy uses local anesthetic. Furthermore, both procedures allow patients to go home the same day, yet the time constraint of in-office arthroscopy is significantly decreased, since a diagnostic arthroscopy requires more time due to preoperative evaluation, anesthetic induction, the procedure itself, and time in the postanesthesia care unit after surgery.


**References**

1992;**8**(3):320-326

2011;**39**:1557-1568

DOI: 10.12788/ajo.2018.0007

Health Services Research. 2014;**14**:203

ation. 1993;**89**(7):329-331

[1] Laoruengthana A, Jarusriwann A. Sensitivity and specificity of magnetic resonance imaging for knee injury and clinical application for the Naresuan University Hospital.

Office-Based Small Bore Needle Arthroscopy of the Knee

http://dx.doi.org/10.5772/intechopen.76757

65

[2] Panigrahi R, Priyadarshi A, Palo N, Marandi H, Agrawalla DK, Biswal MR. Correlation of clinical examination, MRI and arthroscopy findings in Menisco-Cruciate injuries of the knee: A prospective diagnostic study. Archives of Trauma Research. 2016;**6**(1):e30364

[3] Hoyt M, Goodemote P, Morton J. How accurate is an MRI at diagnosing injured knee

[4] Westermann RW, Pugely AJ, Ries Z, Amendola A, Martin CT, Gao Y, Wolf BR. Causes and predictors of 30-day readmission after shoulder and knee arthroscopy: An analysis

[5] Halbrecht JL, Jackson DW. Office arthroscopy: A diagnostic alternative. Arthroscopy.

[6] Yates JW. Diagnostic office arthroscopy. Journal of the South Carolina Medical Associ-

[7] Phelan N, Rowland P, Galvin R, et al. A systematic review and meta-analysis of the diagnostic accuracy of MRI for suspected ACL and meniscal tears of the knee. Knee Surgery,

[8] Quatman CE, Hettrich CM, Schmitt LC, et al. The clinical utility and diagnostic performance of magnetic resonance imaging for identification of early and advanced knee osteoarthritis: A systematic review. The American Journal of Sports Medicine.

[9] Gomoll AH, Yoshioka H, Watanabe A, et al. Preoperative management of cartilage

[10] Figueroa D, Calvo R, Vaisman A, et al. Knee chondral lesions: Incidence and correlation between arthroscopic and magnetic resonance findings. Arthroscopy. 2007;**23**:312-315

[11] Deirmengian CA, Dines JS, Vernace JV, Schwartz MS, Creighton A, Gladstone JN. Use of a small-bore needle arthroscope to diagnose intra-articular knee pathology: Comparison with magnetic resonance imaging. American Journal of Orthopedics. 2018 Feb;**47**(2).

[12] Voight JD, Mosier M, Huber B. In-office diagnostic arthroscopy for knee and shoulder intra-articular injuries its potential impact on cost savings in the United States. BMC

defects by MRI underestimates lesion size. Cartilage. 2011;**2**(4):389-393

Journal of the Medical Association of Thailand. 2012;**95**(Suppl 10):S151-S157

ligaments? The Journal of Family Practice. 2010;**59**(2):118-120

of 15,167 cases. Arthroscopy. 2015;**31**(6):1035-1040

Sports Traumatology, Arthroscopy. 2016;**24**:1525-1539

**Table 1.** Advantages and disadvantages of in-office arthroscopy.

The potential cost savings associated with in-office arthroscopy is also worth noting. Studies have shown that in-office arthroscopy procedures are responsible for a net \$151 million per year in cost savings while being used over MRI [12]. Furthermore, the avoidance of unnecessary future surgical procedures has the potential for cost saving, yet this topic has not yet been critically analyzed. Although the procedure in novel, it appears that insurances are reimbursing for the diagnostic arthroscopy code. Advantages and disadvantages of in-office arthroscopy are listed in **Table 1**.

While in-office arthroscopy is not required in every patient presenting with symptoms of knee pain, its use in specific situations can greatly improve and expedite patient care, as well as save patients the cost and morbidity of an unnecessary procedure. In-office arthroscopy offers the surgeon another diagnostic tool that can be valuable in a multitude of clinical settings.

### **Conflict of interest**

The authors have no conflict of interest or financial interest regarding this product.

### **Financial disclosures**

Anikar Chhabra, MD MS: Arthrex Consultant.

### **Author details**

Kyle Williams1 , Kelly Scott<sup>2</sup> , Donald Dulle III2 and Anikar Chhabra2 \*


### **References**

The potential cost savings associated with in-office arthroscopy is also worth noting. Studies have shown that in-office arthroscopy procedures are responsible for a net \$151 million per year in cost savings while being used over MRI [12]. Furthermore, the avoidance of unnecessary future surgical procedures has the potential for cost saving, yet this topic has not yet been critically analyzed. Although the procedure in novel, it appears that insurances are reimbursing for the diagnostic arthroscopy code. Advantages and disadvantages of in-office arthroscopy are listed in **Table 1**. While in-office arthroscopy is not required in every patient presenting with symptoms of knee pain, its use in specific situations can greatly improve and expedite patient care, as well as save patients the cost and morbidity of an unnecessary procedure. In-office arthroscopy offers the surgeon another diagnostic tool that can be valuable in a multitude of clinical settings.

**Advantages Disadvantages**

Can be used when MRI contraindicated due to medical

**Table 1.** Advantages and disadvantages of in-office arthroscopy.

reasons, claustrophobia

Cost effective Cost savings

Allows visualization of prior repair

64 Recent Advances in Arthroscopic Surgery

Minimal risk (compared to standard arthroscopy) Surgeon unfamiliarity using 0° scope

No risk of anesthesia Visualization not as clear (compared to standard

Improved accuracy (compared to MRI) Scar tissue from prior surgeries limits excursion of

arthroscopy)

flush out knee)

small-bore needle

Contraindicated with acute hemarthrosis (unable to

The authors have no conflict of interest or financial interest regarding this product.

, Donald Dulle III2

2 Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, United States

\*Address all correspondence to: chhabra.anikar@mayo.edu

and Anikar Chhabra2

\*

**Conflict of interest**

**Financial disclosures**

**Author details**

Kyle Williams1

Anikar Chhabra, MD MS: Arthrex Consultant.

, Kelly Scott<sup>2</sup>

1 Arizona State University, United States


**Chapter 5**

**Provisional chapter**

**Arthroscopic Technique to Treat Articular Cartilage**

**Arthroscopic Technique to Treat Articular Cartilage** 

Cartilage lesions are frequent in routine knee arthroscopy (63%). Among these injuries, 11–23% are located in patella and 6–15% in the trochlea. Treatment of cartilage lesions in patellofemoral joint (PFJ) represents a challenge because of its complex access, high axial loading, and shearing forces. These factors explain the 7% of good results in the PFJ versus 90% in femoral condyles for autologous chondrocyte implantation (ACI). Microfracture (MF) as the first line of treatment has revealed limited hyaline-like cartilage formation in comparison to ACI. This fibrocartilage deteriorates with the time resulting in inferior biomechanical properties. Important issues that enhance the results of cartilage repair procedures in PFJ are associated with the restoration of the joint balance as unloading/realigning techniques. In the literature, there is no description of any convenient *arthroscopic technique* for ACI. The reported techniques usually require to set up the patient in prone position to perform the arthroscopy making it difficult to treat associated knee malalignment or instability. Others are open techniques with more risk of morbidities, pain, and complications and longer recovery time. In this chapter, we will describe a novel all-arthroscopic technique to treat cartilage lesions in the patella that permits the correction and treatment of associated lesions in the same patient position. **Keywords:** cartilage lesions, patellofemoral joint, arthroscopic treatment, autologous

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

The patella is the biggest sesamoid bone in the body. The main functions of the patella are to direct forces of the quadriceps and to protect the deeper knee joint and the quadriceps tendon

DOI: 10.5772/intechopen.76617

**Lesions in the Patellofemoral Joint**

**Lesions in the Patellofemoral Joint**

Anell Olivos-Meza, Antonio Madrazo-Ibarra and

Anell Olivos-Meza, Antonio Madrazo-Ibarra and

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Clemente Ibarra Ponce de León

Clemente Ibarra Ponce de León

http://dx.doi.org/10.5772/intechopen.76617

chondrocyte implantation, knee

**1. Introduction**

**Abstract**

#### **Arthroscopic Technique to Treat Articular Cartilage Lesions in the Patellofemoral Joint Arthroscopic Technique to Treat Articular Cartilage Lesions in the Patellofemoral Joint**

DOI: 10.5772/intechopen.76617

Anell Olivos-Meza, Antonio Madrazo-Ibarra and Clemente Ibarra Ponce de León Anell Olivos-Meza, Antonio Madrazo-Ibarra and Clemente Ibarra Ponce de León

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76617

#### **Abstract**

Cartilage lesions are frequent in routine knee arthroscopy (63%). Among these injuries, 11–23% are located in patella and 6–15% in the trochlea. Treatment of cartilage lesions in patellofemoral joint (PFJ) represents a challenge because of its complex access, high axial loading, and shearing forces. These factors explain the 7% of good results in the PFJ versus 90% in femoral condyles for autologous chondrocyte implantation (ACI). Microfracture (MF) as the first line of treatment has revealed limited hyaline-like cartilage formation in comparison to ACI. This fibrocartilage deteriorates with the time resulting in inferior biomechanical properties. Important issues that enhance the results of cartilage repair procedures in PFJ are associated with the restoration of the joint balance as unloading/realigning techniques. In the literature, there is no description of any convenient *arthroscopic technique* for ACI. The reported techniques usually require to set up the patient in prone position to perform the arthroscopy making it difficult to treat associated knee malalignment or instability. Others are open techniques with more risk of morbidities, pain, and complications and longer recovery time. In this chapter, we will describe a novel all-arthroscopic technique to treat cartilage lesions in the patella that permits the correction and treatment of associated lesions in the same patient position.

**Keywords:** cartilage lesions, patellofemoral joint, arthroscopic treatment, autologous chondrocyte implantation, knee

### **1. Introduction**

The patella is the biggest sesamoid bone in the body. The main functions of the patella are to direct forces of the quadriceps and to protect the deeper knee joint and the quadriceps tendon

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

from frictional forces [1, 2]. Posteriorly the patella is covered by a thick hyaline cartilage which decreases friction in the PFJ and allows a correct and smooth flexion of the knee. The patella contact area changes when knee flexion increases showing maximum contact between 60 and 90° of flexion.

statistically significant improvement in patients treated with isolated ACI on the basis of several functional scoring systems as well as a 71% satisfaction rate in patients [16]. In a followup by Brittberg et al., 81% of the patients had good to excellent results at 2 years and 83% at

Arthroscopic Technique to Treat Articular Cartilage Lesions in the Patellofemoral Joint

http://dx.doi.org/10.5772/intechopen.76617

69

ACI performed in conjunction with anteromedialization (AM) of the patella for the correction of malalignment has shown better results with significant improvements in functional and

As with most orthopedic procedures, less invasive procedures such as arthroscopy are being preferred because of the decreased associated comorbidity and the accelerated postoperative rehabilitation for earlier return to full physical function [18]. Biant et al. found that the viability of cells in ACI technique was 16 times higher for open approach-delivered implants than those delivered arthroscopically. However, no clinical outcomes were evaluated since it was a cadaveric experiment [19]. On the other hand, Edwards et al. showed that patients with arthroscopic ACI required a significantly shorter hospital stay after their procedure and presented fewer post-surgery complications than those who underwent ACI performed through

Recent advances in our understanding of focal chondral lesions, surgical techniques, and surgical technology have provided a new array of treatment options for symptomatic patients with cartilage lesions of the PFJ. The aim of the present chapter is to describe a surgical proce-

Before implantation surgery, a knee arthroscopy was performed for biopsy. Two to three osteochondral cylinders of 4-mm diameter were taken from a non-weight-bearing area of the knee (**Figure 1**). Samples were processed in the laboratory for chondrocyte isolation, in vitro expansion, and cell-polymer construct formation as Masri et al. described [21]. In a second

After regional anesthesia the patient was settled in supine position; the knee was prepared and draped in a conventional manner. A tourniquet was placed around the proximal thigh, although normally it was not insufflated. A conventional longitudinal anterolateral portal was established for arthroscopic examination of the knee joint using a superolateral portal for irrigation. The articular cartilage injury was identified, measured, and prepared for construct

Cartilage lesion was measured and debrided to leave stable walls (**Figure 2A**). When the lesion was in the medial trochlea, an oblique anteromedial portal was established over the lesion to have perpendicular access. If the lesion was on the lateral trochlea, the anterolateral portal was extended proximally or distally to allow perpendicular access. A 2-mm hole

arthroscopic procedure, the constructs with cultured chondrocytes were implanted.

5–11-year follow-up [17].

satisfaction outcomes [16].

a mini-open arthrotomy [20].

implantation.

dure for the arthroscopic ACI in the patellofemoral joint.

**2. Arthroscopic chondrocyte implantation in the PFJ**

**2.1. Arthroscopic chondrocyte implantation in the trochlea**

The patellofemoral pain syndrome is very common in the general population. It is often seen in young people with high physical activity level in both competitive and recreational sports. Patellar malalignment and instability with or without articular cartilage lesions (ACL) are usually the source of pain. Repetitive microtrauma as well as acute severe trauma can lead to damage of the articular cartilage of the patella and when those lesions are not treated produces severe pain, disability, and poor quality of life. The accurate detection and treatment of ACL are essential for the proper function of the knee. However, when those lesions are left untreated, it can alter normal distribution of weight-bearing forces and may lead the development of early osteoarthritis (OA) [3].

Articular cartilage injuries are commonly found in knee arthroscopies (61–63%). The majority of these lesions are found in the medial femoral condyle (58%), while chondral lesions affecting the patella are the second most common (11%) location [4, 5]. Hielle et al. found that 17% of patients having arthroscopy had an articular cartilage injury located in the patella or trochlea [4]. Nomura et al. also found 35 patients with severe articular cartilage injuries in the patella out of 37 patients with a first-time acute patellar dislocation [6]. Articular cartilage lesions of the PFJ can be especially challenging because of the complex biomechanical environment and the significant forces experienced within this compartment during weightbearing activity. Given the poor intrinsic capacity of cartilage to heal, surgical intervention is often necessary for symptomatic relief.

Basic nonsurgical management is recommended as an initial treatment modality to treat chondral lesion of patellofemoral joint for at least 6 months [7]. This option is recommended for patients without significant pain and without mechanical symptoms. Anti-inflammatory medications, activity modification, weight loss, and muscle strengthening have been shown to improve pain [8, 9]. However, surgical management is recommended when symptoms are persistent despite the nonsurgical treatment and when the function is limited by symptoms. Surgical options depend on the lesion size, depth, location, and status of the underlying subchondral bone. Microfracture, ACI, DeNovo juvenile chondrocyte implantation, osteochondral autograft transfer, and osteochondral allograft transplantation are considered cartilage restoration procedures for PFJ.

Autologous chondrocyte implantation is currently the preferred and most effective procedure in the management ACL. Microfractures have shown great short-term results for well-contained lesions less than 2 cm2 ; however, 47–80% of patients have shown functional deterioration between 18 and 36 months after microfracture technique. Some authors attribute this decline to incomplete defect filling and poor integration with the surrounding normal cartilage as well as an inferior capacity of the fibrocartilage to resist articular stress [10–14]. ACI is considered a first-line surgical treatment in large lesions (>4 cm<sup>2</sup> ) and in secondary treatment for patients with persistent symptoms following treatment with another procedure [15]. However, outcomes of ACI in PFJ have shown mixed results. Pascual-Garrido et al. reported a statistically significant improvement in patients treated with isolated ACI on the basis of several functional scoring systems as well as a 71% satisfaction rate in patients [16]. In a followup by Brittberg et al., 81% of the patients had good to excellent results at 2 years and 83% at 5–11-year follow-up [17].

ACI performed in conjunction with anteromedialization (AM) of the patella for the correction of malalignment has shown better results with significant improvements in functional and satisfaction outcomes [16].

As with most orthopedic procedures, less invasive procedures such as arthroscopy are being preferred because of the decreased associated comorbidity and the accelerated postoperative rehabilitation for earlier return to full physical function [18]. Biant et al. found that the viability of cells in ACI technique was 16 times higher for open approach-delivered implants than those delivered arthroscopically. However, no clinical outcomes were evaluated since it was a cadaveric experiment [19]. On the other hand, Edwards et al. showed that patients with arthroscopic ACI required a significantly shorter hospital stay after their procedure and presented fewer post-surgery complications than those who underwent ACI performed through a mini-open arthrotomy [20].

Recent advances in our understanding of focal chondral lesions, surgical techniques, and surgical technology have provided a new array of treatment options for symptomatic patients with cartilage lesions of the PFJ. The aim of the present chapter is to describe a surgical procedure for the arthroscopic ACI in the patellofemoral joint.

### **2. Arthroscopic chondrocyte implantation in the PFJ**

from frictional forces [1, 2]. Posteriorly the patella is covered by a thick hyaline cartilage which decreases friction in the PFJ and allows a correct and smooth flexion of the knee. The patella contact area changes when knee flexion increases showing maximum contact between

The patellofemoral pain syndrome is very common in the general population. It is often seen in young people with high physical activity level in both competitive and recreational sports. Patellar malalignment and instability with or without articular cartilage lesions (ACL) are usually the source of pain. Repetitive microtrauma as well as acute severe trauma can lead to damage of the articular cartilage of the patella and when those lesions are not treated produces severe pain, disability, and poor quality of life. The accurate detection and treatment of ACL are essential for the proper function of the knee. However, when those lesions are left untreated, it can alter normal distribution of weight-bearing forces and may lead the develop-

Articular cartilage injuries are commonly found in knee arthroscopies (61–63%). The majority of these lesions are found in the medial femoral condyle (58%), while chondral lesions affecting the patella are the second most common (11%) location [4, 5]. Hielle et al. found that 17% of patients having arthroscopy had an articular cartilage injury located in the patella or trochlea [4]. Nomura et al. also found 35 patients with severe articular cartilage injuries in the patella out of 37 patients with a first-time acute patellar dislocation [6]. Articular cartilage lesions of the PFJ can be especially challenging because of the complex biomechanical environment and the significant forces experienced within this compartment during weightbearing activity. Given the poor intrinsic capacity of cartilage to heal, surgical intervention is

Basic nonsurgical management is recommended as an initial treatment modality to treat chondral lesion of patellofemoral joint for at least 6 months [7]. This option is recommended for patients without significant pain and without mechanical symptoms. Anti-inflammatory medications, activity modification, weight loss, and muscle strengthening have been shown to improve pain [8, 9]. However, surgical management is recommended when symptoms are persistent despite the nonsurgical treatment and when the function is limited by symptoms. Surgical options depend on the lesion size, depth, location, and status of the underlying subchondral bone. Microfracture, ACI, DeNovo juvenile chondrocyte implantation, osteochondral autograft transfer, and osteochondral allograft transplantation are considered cartilage

Autologous chondrocyte implantation is currently the preferred and most effective procedure in the management ACL. Microfractures have shown great short-term results for well-con-

tion between 18 and 36 months after microfracture technique. Some authors attribute this decline to incomplete defect filling and poor integration with the surrounding normal cartilage as well as an inferior capacity of the fibrocartilage to resist articular stress [10–14]. ACI

ment for patients with persistent symptoms following treatment with another procedure [15]. However, outcomes of ACI in PFJ have shown mixed results. Pascual-Garrido et al. reported a

is considered a first-line surgical treatment in large lesions (>4 cm<sup>2</sup>

; however, 47–80% of patients have shown functional deteriora-

) and in secondary treat-

60 and 90° of flexion.

68 Recent Advances in Arthroscopic Surgery

ment of early osteoarthritis (OA) [3].

often necessary for symptomatic relief.

restoration procedures for PFJ.

tained lesions less than 2 cm2

Before implantation surgery, a knee arthroscopy was performed for biopsy. Two to three osteochondral cylinders of 4-mm diameter were taken from a non-weight-bearing area of the knee (**Figure 1**). Samples were processed in the laboratory for chondrocyte isolation, in vitro expansion, and cell-polymer construct formation as Masri et al. described [21]. In a second arthroscopic procedure, the constructs with cultured chondrocytes were implanted.

After regional anesthesia the patient was settled in supine position; the knee was prepared and draped in a conventional manner. A tourniquet was placed around the proximal thigh, although normally it was not insufflated. A conventional longitudinal anterolateral portal was established for arthroscopic examination of the knee joint using a superolateral portal for irrigation. The articular cartilage injury was identified, measured, and prepared for construct implantation.

### **2.1. Arthroscopic chondrocyte implantation in the trochlea**

Cartilage lesion was measured and debrided to leave stable walls (**Figure 2A**). When the lesion was in the medial trochlea, an oblique anteromedial portal was established over the lesion to have perpendicular access. If the lesion was on the lateral trochlea, the anterolateral portal was extended proximally or distally to allow perpendicular access. A 2-mm hole

through the portal directly over the lesion, and the sutures from the anchor were pulled outside the joint through an arthroscopic cannula (**Figure 2E**). The anchor sutures were passed in the construct through two needles (20 G × 32 mm); the construct was slide into the joint to place it in the bottom of the cartilage lesion. A self-locking arthroscopic sliding knot was used to fix the implant (**Figure 2F**). Once the construct was sitting in place at the bottom of the lesion, the knot was tightened by pulling on the wrapping limb of the suture, and two additional half-hitch knots were tied with the assistance of a knot pusher. The sutures were then cut flush to the knot and the cannula was retrieved. Stability of the implant was then tested with the probe, and the knee was taken through a range of motion to verify the stability and

Arthroscopic Technique to Treat Articular Cartilage Lesions in the Patellofemoral Joint

http://dx.doi.org/10.5772/intechopen.76617

71

Implantation of constructs in patella is performed with the use of an anterior cruciate ligament tibial guide (ACUFEX; Smith-nephew, Andover, MA) with different grades of angula-

The cartilage lesion is identified, measured, and debrided. The tibial guide is introduced either through medial or lateral portal to have easy access to the lesion (**Figure 3A**). Using the elbow aimer of the tibial guide, the angle was adjusted depending on the better position of the tip over the center of the lesion (**Figure 3D**). Two holes are drilled with a cable wire (Kirschner 0.062″) from the anterior cortex of the patella to the subchondral bone (**Figure 3B** and **E**); the holes are placed in the center of every 10 mm of cartilage lesion. The cable wires

**Figure 3.** Arthroscopic chondrocyte implantation in patella. (A and D) The ACL tibial guide is introduced by the portal that permits better position to the center of the lesion. (B and E) Two holes are drilling from the anterior cortex of the patella to the subchondral bone at the center of the lesion. (C and F) An anterior skin incision is made over the patella; deep direction is necessary to visualize the entrance of both cable wires. Cable wires are removed with the drill, and a

tion. Standard arthroscopy evaluation is done to evaluate additional lesions.

permanence of the implant at the repair site.

**2.2. Arthroscopic chondrocyte implantation in patella**

chia passer is inserted in every hole until it is visible into the joint space.

**Figure 1.** Osteochondral biopsy harvesting. (A) An osteochondral harvester (COR; DePuy Mitek, Raynham, MA) was used to get one to three 4-mm diameter biopsies in a non-weight-bearing area adjacent to the intercondylar notch (B and C).

**Figure 2.** Matrix chondrocyte implantation in trochlear lesions. (A) Cartilage lesion is measured and debrided with a curette to leave stable walls. (B–D) A 1.7-mm hole was made in the center the lesion, and an absorbable anchor charged with 0-PDS suture is inserted. (E) The implant is fixed with self-locking arthroscopic sliding knot and two or three additional half-hitch knots.

was made in the center of every centimeter of cartilage lesion. An absorbable 1.9-mm anchor (MINILOK, Depuy Synthes Mitek, Raynham, MA) with 0-PDS suture (Ethicon, Somerville, NJ) was inserted through the anteromedial or anterolateral portal (**Figure 2B**–**D**). The cellscaffold disk was prepared on the side table. An 8-mm transparent cannula was then inserted through the portal directly over the lesion, and the sutures from the anchor were pulled outside the joint through an arthroscopic cannula (**Figure 2E**). The anchor sutures were passed in the construct through two needles (20 G × 32 mm); the construct was slide into the joint to place it in the bottom of the cartilage lesion. A self-locking arthroscopic sliding knot was used to fix the implant (**Figure 2F**). Once the construct was sitting in place at the bottom of the lesion, the knot was tightened by pulling on the wrapping limb of the suture, and two additional half-hitch knots were tied with the assistance of a knot pusher. The sutures were then cut flush to the knot and the cannula was retrieved. Stability of the implant was then tested with the probe, and the knee was taken through a range of motion to verify the stability and permanence of the implant at the repair site.

#### **2.2. Arthroscopic chondrocyte implantation in patella**

was made in the center of every centimeter of cartilage lesion. An absorbable 1.9-mm anchor (MINILOK, Depuy Synthes Mitek, Raynham, MA) with 0-PDS suture (Ethicon, Somerville, NJ) was inserted through the anteromedial or anterolateral portal (**Figure 2B**–**D**). The cellscaffold disk was prepared on the side table. An 8-mm transparent cannula was then inserted

**Figure 2.** Matrix chondrocyte implantation in trochlear lesions. (A) Cartilage lesion is measured and debrided with a curette to leave stable walls. (B–D) A 1.7-mm hole was made in the center the lesion, and an absorbable anchor charged with 0-PDS suture is inserted. (E) The implant is fixed with self-locking arthroscopic sliding knot and two or three

**Figure 1.** Osteochondral biopsy harvesting. (A) An osteochondral harvester (COR; DePuy Mitek, Raynham, MA) was used to get one to three 4-mm diameter biopsies in a non-weight-bearing area adjacent to the intercondylar notch (B

and C).

70 Recent Advances in Arthroscopic Surgery

additional half-hitch knots.

Implantation of constructs in patella is performed with the use of an anterior cruciate ligament tibial guide (ACUFEX; Smith-nephew, Andover, MA) with different grades of angulation. Standard arthroscopy evaluation is done to evaluate additional lesions.

The cartilage lesion is identified, measured, and debrided. The tibial guide is introduced either through medial or lateral portal to have easy access to the lesion (**Figure 3A**). Using the elbow aimer of the tibial guide, the angle was adjusted depending on the better position of the tip over the center of the lesion (**Figure 3D**). Two holes are drilled with a cable wire (Kirschner 0.062″) from the anterior cortex of the patella to the subchondral bone (**Figure 3B** and **E**); the holes are placed in the center of every 10 mm of cartilage lesion. The cable wires

**Figure 3.** Arthroscopic chondrocyte implantation in patella. (A and D) The ACL tibial guide is introduced by the portal that permits better position to the center of the lesion. (B and E) Two holes are drilling from the anterior cortex of the patella to the subchondral bone at the center of the lesion. (C and F) An anterior skin incision is made over the patella; deep direction is necessary to visualize the entrance of both cable wires. Cable wires are removed with the drill, and a chia passer is inserted in every hole until it is visible into the joint space.

In the back table, the construct was prepared before using two percutaneous needles (20 G × 32 mm) that were inserted in the center (**Figure 4A**). One 0-PDS suture is folded, and its ends are passed in the construct through the needle tips (**Figure 4B** and **C**). Once PDS is placed in

Arthroscopic Technique to Treat Articular Cartilage Lesions in the Patellofemoral Joint

http://dx.doi.org/10.5772/intechopen.76617

73

A 10 mm cannula is placed in the chosen portal where the chia passers were grabbed; every end of the 0-PDS suture with the construct is introduced in the loop of the wire passer and then pulled to introduce the construct into the joint (**Figure 4D**). Once the construct is placed in the bottom of the lesion (**Figure 5A**), a non-sliding knot was performed and tied over the anterior cortex of the patella outside the joint (**Figure 5B**). Steps are repeated if more than one construct is needed. Portals and accessory incision are closed in the tradi-

Arthroscopic autologous chondrocyte implantation in the PFJ is a reproducible and safety technique that permits the early recovery of the patient and the treatment of concomitant

• The described technique is recommended for focal cartilage lesions with healthy and stable

• During the lesion debridement, it is necessary to leave stable walls of normal cartilage and

• Correction of associated lesions as instability or malalignment is mandatory to enhance

This work was supported by the Mexican Council of Science (CONACyT) Grant SALUD-PDCPN-2013-2101-215138 and Technology, Science, and Innovation Secretary Grants SECITI

The authors declare that there is no conflict of interest with respect to the research, author-

the center of the construct, needles are removed.

lesions as patellar realignment and/or ligament reconstruction.

better results in the treatment of cartilage lesions of PFJ.

tional manner.

**3. Conclusion**

**3.1. Take-home points**

cartilage around the lesion.

take out the calcified layer.

**Acknowledgements**

**Conflict of interest**

079 BIS/2013 and SECITI/INR/GOB-25/2013.

ship, and/or publication of this chapter.

**Figure 4.** Preparation of the chondrocytes construct with a 0-PDS suture. (A) Two needles (20 G × 32 mm) are inserted in the center of the construct leaving 2 mm of distance. (B and C) The ends of 0-PDS are passed tin the through the needles. (D) Once the PDS is placed in position, needles are removed, the ends of the PDS are introduced in the loop of every chia passer, and the construct is pulled slowly through a 10-mm cannula.

are left in place, while the tibial guide is removed from the joint. A 15-mm skin incision is performed anterior to the patella connecting the two cable wires (**Figure 3C**). Deep dissection is performed until the periosteum to identify the cable wires; then those are removed with the drill, and a wire passer (CHIA PERCPASSER, Suture Passer Depuy Synthes Mitek, Raynham, MA) is inserted in every hole from anterior cortex of the patella to the inside until the chips are visible and accessible into the joint space by the scope (**Figure 3F**). The chia tip is advanced into the joint and is grabbed with a grasper from either medial or lateral portals.

**Figure 5.** Fixation of the construct. (A and B) Once the construct is placed in the bottom of the lesion, three to four sliding knots are tied over the anterior cortex of the patella. Notice that different to trochlear implantation in patellar technique the knots are out of the articular space.

In the back table, the construct was prepared before using two percutaneous needles (20 G × 32 mm) that were inserted in the center (**Figure 4A**). One 0-PDS suture is folded, and its ends are passed in the construct through the needle tips (**Figure 4B** and **C**). Once PDS is placed in the center of the construct, needles are removed.

A 10 mm cannula is placed in the chosen portal where the chia passers were grabbed; every end of the 0-PDS suture with the construct is introduced in the loop of the wire passer and then pulled to introduce the construct into the joint (**Figure 4D**). Once the construct is placed in the bottom of the lesion (**Figure 5A**), a non-sliding knot was performed and tied over the anterior cortex of the patella outside the joint (**Figure 5B**). Steps are repeated if more than one construct is needed. Portals and accessory incision are closed in the traditional manner.

### **3. Conclusion**

Arthroscopic autologous chondrocyte implantation in the PFJ is a reproducible and safety technique that permits the early recovery of the patient and the treatment of concomitant lesions as patellar realignment and/or ligament reconstruction.

### **3.1. Take-home points**

are left in place, while the tibial guide is removed from the joint. A 15-mm skin incision is performed anterior to the patella connecting the two cable wires (**Figure 3C**). Deep dissection is performed until the periosteum to identify the cable wires; then those are removed with the drill, and a wire passer (CHIA PERCPASSER, Suture Passer Depuy Synthes Mitek, Raynham, MA) is inserted in every hole from anterior cortex of the patella to the inside until the chips are visible and accessible into the joint space by the scope (**Figure 3F**). The chia tip is advanced

**Figure 4.** Preparation of the chondrocytes construct with a 0-PDS suture. (A) Two needles (20 G × 32 mm) are inserted in the center of the construct leaving 2 mm of distance. (B and C) The ends of 0-PDS are passed tin the through the needles. (D) Once the PDS is placed in position, needles are removed, the ends of the PDS are introduced in the loop of every chia

**Figure 5.** Fixation of the construct. (A and B) Once the construct is placed in the bottom of the lesion, three to four sliding knots are tied over the anterior cortex of the patella. Notice that different to trochlear implantation in patellar technique

the knots are out of the articular space.

into the joint and is grabbed with a grasper from either medial or lateral portals.

passer, and the construct is pulled slowly through a 10-mm cannula.

72 Recent Advances in Arthroscopic Surgery


### **Acknowledgements**

This work was supported by the Mexican Council of Science (CONACyT) Grant SALUD-PDCPN-2013-2101-215138 and Technology, Science, and Innovation Secretary Grants SECITI 079 BIS/2013 and SECITI/INR/GOB-25/2013.

### **Conflict of interest**

The authors declare that there is no conflict of interest with respect to the research, authorship, and/or publication of this chapter.

### **A. Appendices and nomenclature**

#### **Indications for proposed technique in PFJ cartilage lesions**


**References**

[1] Fox AJSA, Wanivenhaus FF, Rodeo SAS. The basic science of the patella: Structure, com-

Arthroscopic Technique to Treat Articular Cartilage Lesions in the Patellofemoral Joint

http://dx.doi.org/10.5772/intechopen.76617

75

[2] Tecklenburg KK, Dejour DD, Hoser CC, et al. Bony and cartilaginous anatomy of the patellofemoral joint. Knee Surgery, Sports Traumatology, Arthroscopy. 2006;**14**(3):235-240 [3] Insall JJ, Falvo KAK, Wise DWD. Chondromalacia patellae. A prospective study. The

[4] Hjelle K, Solheim E, Strand T, et al. Articular cartilage defects in 1,000 knee arthrosco-

[5] Widuchowski WW, Widuchowski JJ, Trzaska TT. Articular cartilage defects: Study of

[6] Nomura E, Inoue M, Kurimura M. Chondral and osteochondral injuries associated with

[7] Kramer K. Management of patellar and trochlear chondral injuries. Operative Techniques

[8] Strauss EJE, Fonseca LEL, Shah MRM, et al. Management of focal cartilage defects in the

[9] Chiu JKWJ, Wong Y-MY, Yung PSHP, et al. The effects of quadriceps strengthening on pain, function, and patellofemoral joint contact area in persons with patellofemoral pain. American Journal of Physical Medicine & Rehabilitation. 2012;**91**(2):98-106. Illustrates important non-operative modalities for the treatment of patellofemoral chon-

[10] Mithoefer K, McAdams T, Williams RJ, et al. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: An evidence-based systematic analysis. The American Journal of Sports Medicine. 2009;**37**(10):2053-2063. This study shows evidence as to the efficacy of microfracture as a modality of treatment for chondral lesions

[11] Kreuz PC, Erggelet C, Steinwachs MR, et al. Is microfracture of chondral defects in the knee associated with different results in patients aged 40 years or younger? Arthroscopy.

[12] Williams RJR, Harnly HWH. Microfracture: Indications, technique, and results. Instruc-

[13] Frisbie DDD, Trotter GWG, Powers BEB, et al. Arthroscopic subchondral bone plate microfracture technique augments healing of large chondral defects in the radial carpal bone and medial femoral condyle of horses. Veterinary Surgery. 1999;**28**(4):242-255 [14] Gudas RR, Kalesinskas RJR, Kimtys VV, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment

knee—Is ACI the answer? CORD Conference Proceedings. 2011;**69**(1):63-72

position, and function. The Journal of Knee Surgery. 2012;**25**(2):127-141

Journal of Bone and Joint Surgery. American Volume. 1976;**58**(1):1-8

25,124 knee arthroscopies. The Knee. 2007;**14**(3):177-182

acute patellar dislocation. Arthroscopy. 2003;**19**(7):717-721

pies. Arthroscopy. 2002;**18**(7):730-734

in Orthopaedics. 2007;**17**(4):10-10

dral defects

about the knee

2006;**22**(11):7-7

tional Course Lectures. 2007;**56**:419-428

#### **Postoperative management and rehabilitation**


#### **Important considerations**

Surgical treatment for cartilage lesions in PFJ is recommended when patient has persistent symptoms despite conservative treatment

Satisfactory results are reported in the treatment of isolated cartilage lesions in the patella with ACI (65%); however, when ACI was combined with unloading tibial tubercle osteotomy (AMZ), better results are found (85%)

Clinically both microfracture and autologous chondrocyte implantation improve significantly over time after treatment. However, studies have demonstrated that quantitative assessment with T2-mapping in ACI is more similar to native cartilage than microfracture after 12 months.

### **Author details**

Anell Olivos-Meza<sup>1</sup> , Antonio Madrazo-Ibarra<sup>1</sup> and Clemente Ibarra Ponce de León<sup>2</sup> \*

\*Address all correspondence to: cibarra.corresponding@hotmail.com

1 Orthopedic Sports Medicine and Arthroscopy Service, Instituto Nacional de Rehabilitación, Mexico City, Mexico

2 Instituto Nacional de Rehabilitación, Mexico City, Mexico

### **References**

**A. Appendices and nomenclature**

74 Recent Advances in Arthroscopic Surgery

Focal lesion medial facet + patellar dislocation + lateral

Focal lesion lateral facet + lateral patellar inclination +

**Indications for proposed technique in PFJ cartilage lesions**

**Lesion Technique**

**Postoperative management and rehabilitation**

**Stage Week Process Indication**

Remodeling 24–48 Cartilage hardens Perform ADL

similar to native cartilage than microfracture after 12 months.

Cellular proliferation 4–6 Chondrocyte stimulation Continuous passive motion (6–8 h a day)

Focal lesion medial facet + patellar dislocation Arthroscopic ACI + MPFL reconstruction

Focal lesion lateral facet + lateral patellar inclination Arthroscopic ACI + lateral retinacular release

Transition 16–24 Matrix expansion Strength within 80–90% of contralateral extremity

Surgical treatment for cartilage lesions in PFJ is recommended when patient has persistent symptoms despite

when ACI was combined with unloading tibial tubercle osteotomy (AMZ), better results are found (85%) Clinically both microfracture and autologous chondrocyte implantation improve significantly over time after treatment. However, studies have demonstrated that quantitative assessment with T2-mapping in ACI is more

Satisfactory results are reported in the treatment of isolated cartilage lesions in the patella with ACI (65%); however,

**Author details**

**Important considerations**

conservative treatment

patellar inclination

lateral hiperpresion

Anell Olivos-Meza<sup>1</sup>

Rehabilitación, Mexico City, Mexico

, Antonio Madrazo-Ibarra<sup>1</sup>

2 Instituto Nacional de Rehabilitación, Mexico City, Mexico

\*Address all correspondence to: cibarra.corresponding@hotmail.com

1 Orthopedic Sports Medicine and Arthroscopy Service, Instituto Nacional de

and Clemente Ibarra Ponce de León<sup>2</sup>

Full weight bearing in patients with PFJ lesions

Arthroscopic ACI + MPFL reconstruction + lateral

Arthroscopic ACI + lateral retinacular release + Tibial

4 Weight bearing with toe or heel-touch for femoral condyle defects 8–12 Weight bearing for poorly contained lesions and

retinacular release

Tuberosity Osteotomy

patients with multiple lesions

\*


of osteochondral defects in the knee joint in young athletes. Arthroscopy. 2005;**21**(9): 10-10

**Section 2**

**Shoulder**


**Section 2**
