The Knee and the Cruciate Ligaments: Anatomy Biomechanics Clinical Aspects Reconstruction Complications Rehabilitation

633 Pages·1992·39.26 MB·English

by  H.-U. Stäubli

The Knee
and
the Cruciate Ligaments
Anatomy Biomechanics Clinical Aspects
Reconstruction Complications Rehabilitation
Edited by R.P.Jakob and H.-U.SHiubli
of the Orthopedic Study Group for the Knee
Translated by T. C. Telger
With 519 Figures in 1071 Separate Illustrations and 91 Tables
Springer-Verlag
Berlin Heidelberg New York London Paris
Tokyo Hong Kong Barcelona Budapest
Prof. Dr. RP.Jakob
Department for Orthopedic Surgery, University of Bern
Inselspital, 3010 Bern, Switzerland
PO Dr. H.-U.Staubli
Orthopedicsrrraumatology, Tiefenau Hospital of the City of Bern
Tiefenaustrasse 112, 3004 Bern, Switzerland
Title of the original German edition: Kniegelenk und Kreuzbander
© Springer-Verlag Berlin Heidelberg 1990
ISBN-13: 978-3-642-84465-2 e-ISBN-13: 978-3-642-84463-8
001: 10.1007/978-3-642-84463-8
Library of Congress Cataloging-in-Publication Data
Kniegelenk und Kreuzbander. English. The Knee and the cruciate ligaments: anatomy. biomechanics. clinical as
pects, reconstruction, complications, rehabilitation 1 edited by R.P.Jakob and H.-U. Staubli of the Orthopedic
Study Group for the Knee; translated by R. C. Telger. p. cm. Includes bibliographical references and index.
ISBN-I3:978-3-642-84465-2
1. Anterior cruciate ligament-Surgery. 2. Knee-Surgery. 3. Knee-Anatomy. I. Jakob, Roland. II. Staubli, H.-U.
III. Schweizerische Gesellschaft fur Orthopadie. Orthopedic Study Group for the Knee. IV. Title. [DNML:
1. Knee Injuries-therapy. 2. Knee Joint-anatomy & histology. 3. Ligaments-physiopathology. 4. Ligaments
Surgery. WE 870 K685j RD561.K5913 1992 617.5'82059-dc20 DNLM/DLC 92-49767
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© Springer-Verlag Berlin Heidelberg 1992
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24/3130-543210 - Printed on acid-free paper
To our families,
for their understanding, sacrifice,
and encouragement
"All in all you're just another brick in the wall."
Pink Floyd, The Wall
Foreword
This book summarizes the experience gained by the Orthopedic Study Group for
the Knee (OAK) of the Swiss Orthopedic Society in dealing with knee problems
relating to deficiencies of the cruciate ligaments. The editors, R.P. Jakob and
H.-U.Staubli, have collaborated with international authorities to produce this ex
cellent work dealing with a great many aspects of knee surgery and especially the
problems of the cruciate ligaments.
For clarity, the book begins with definitions and explanations of basic biomechan
ical terms. The chapters on Anatomy and Biomechanics present up-to-date scien
tific information based on anatomic and biomechanical principles as they are ap
plied in modern knee surgery.
The second part of the book focuses on the OAK-sanctioned approach to knee
documentation and evaluation, which is a valuable supplement to other knee
evaluation schemes. The European Society for Knee Surgery (ESKA) and the
American Orthopedic Society for Sports Medicine (AOSSM) are currently at
tempting to combine the advantages of the OAK system with an internationally
valid evaluation scheme to create a standard evaluation and documentation sys
tem that will be acceptable to all physicians.
Next, Noesberger, Jakob, Staubli and others take a comprehensive look at clinical
diagnosis, pathomechanics, and pathomorphology. Arthroscopic and radiologic
methods are described for documenting anterior subluxation of the tibia in pa
tients with anterior cruciate ligament insufficiency. The authors use various
methods to convey the techniques of knee stability testing in the position of near
extension to medical students and younger clinical colleagues. Werner MUller de
scribes in detail the various types of meniscus lesion that can develop in the ante
rior cruciate ligament-deficient knee. The natural history of untreated cruciate li
gament insufficiency is reviewed by the editors and by Jean Yves Dupont, who
gives us the perspective of the "French school." A long chapter is devoted to the
treatment of acute anterior cruciate ligament insufficiency and associated injuries
of the medial capsuloligamentous complex including meniscal tears. Various auto
logous, alloplastic, and synthetic ligament reconstructions are described in the
chapter on Chronic Anterior Cruciate Ligament Insufficiency, which reflects
state-of-the-art techniques practiced in Europe. Arthroscopically assisted tech
niques of cruciate ligament reconstruction - European modifications of American
techniques and original innovations - are described in detail. A separate chapter
is devoted to significant posterolateral injuries that can accompany lesions of the
anterior and posterior cruciate ligaments, and another to synthetic cruciate liga
ment substitutes and their problems. Additionally, there are several chapters on
late degenerative changes resulting from chronic cruciate ligament instability and
on the complications that can follow specific reconstructive procedures.
This book is comprehensive enough to meet the needs and interests of a very wide
readership. It is an excellent sourcebook on the status of reconstructive knee
surgery as it is successfully practiced in Europe today.
Stockholm, Summer, 1992 Ejnar Eriksson
Introduction
In 1981 the Orthopedic Study Group for the Knee (OAK) held its first advanced
training course on the anatomy and biomechanics of the knee. The course, in
which anatomic specimens were used to demonstrate ligament reconstruction
techniques, was quickly filled. It was repeated in 1982 and 1983, and in 1984 the
OAK was officially established as a professional working group of the Swiss Or
thopedic Society (SGO).
At the first congress of the European Society of Knee Surgery and Arthroscopy
(ESKA) in 1984, the preliminary course on anatomy and biomechanics was again
conducted chiefly by the OAK. This course, too, was highly successful.
More than 20 years ago, outstanding successes in the treatment of bone fractures
and degenerative joint disease prompted a number of foreign scientists to visit
Swiss orthopedic hospitals. While praising our methods of treating the spine, hip,
knee and foot, these visitors also pointed out that newer methods had been de
vised for managing the soft tissues about the knee.
This led me, in April of 1971, to join several hundred colleagues from France, Bel
gium, Spain, and Italy in a visit to the Journes de Chirurgie du Genou in Lyon. To
the credit of the great teacher Albert Trillat and his school, which is still active
today, this was the first time that I truly appreciated the importance of the essen
tial "third dimension" in knee surgery. Present-day exponents of the French
school such as Henri Dejour, Pierre Chambat, Bernhard Myoen, Jean-Luc Lerat,
and J ean-Yves Dupont, together with other OAK- affilitated European knee spe
cialists such as Carl J. Wirth and Michael Wagner, are among the key contributors
to this book.
Although the insights received at Lyon were important, the riddle of the knee was
far from solved. Too many therapeutic outcomes appeared to be random in na
ture. There had to be hidden principles at work. Why, for example, was a pivot
shift possible?
Biomechanics and kinematics, as elucidated by Alfred Menschik, provided the
key that guided us to the explanation while deepening our knowledge of soft
tissue biodynamics and biomechanical dynamics.
The definitive step from the "bone age" to the "soft-tissue age" has already been
taken in orthopedic surgery. One factor driving this development was sports
medicine, which already had a significant head start in the USA.
The four-bar linkage of Menschik and the Weber brothers led us through coup
ling curves and envelope curves to the concept of isometry as a new quality in
the healthy functioning of collagenous soft tissues like the ligaments. But isome
try is too narrow and rigid a concept. We must adopt a broader functional view
so that we can better grasp the new concepts of anatomometry and normo
metry.
W. Muller's book The Knee - Form, Function, and Ligament Reconstruction, pub
lished nearly a decade ago, offered the first comprehensive review of the problems
of anatomy and function as they were understood at that time. Further basic re
search has confirmed older hypotheses and added new knowledge. Isometry, yes,
but only in a limited sense and supported by tissue fibers that become tense when
X Introduction
the laws of biomechanics demand a greater fiber potential to supply the necessary
mechanical strength.
One lesson that can be drawn from these insights is that none of us can accomplish
much by ourselves, and that only through cooperation in groups and across na
tional boundaries can we achieve real progress in terms of improved patient care.
Implicit in this awareness is the need to develop a common language for the com
plex nomenclature of the phenomena, and also for the documentation and quali
tative evaluation of traumatic lesions and therapeutic outcomes.
In response to this need, the ESKA and the AOSSM (American Organization for
Surgery in Sports Medicine) have founded the IKDC (International Knee Do
cumentation Committee), in which 10 members each from the USA and Europe
focus their professional efforts on solving the problems that are so familiar to us
all.
Rik Huiskes from the team of Theo VanRens, the Cincinnati school of Frank
Noyes and Ed Grood, and Russel Warren and Peter Torzilli and their colleagues
at the Hospital for Special Surgery in New York have contributed much to the new
discoveries in soft-tissue biomechanics. This research has laid vital foundations for
the work of the IKDC. Fritz Hefti, Roland P. Jakob, Hans-Ulrich Staubli, and
Werner MUller of the OAK also have become members of the IKDC.
The knee continues to be of central importance in many respects:
- Anatomically, as the joint uniting the two longest lever arms of the musculo-
skeletal system, the femur and tibia
- In sports traumatology, as the most commonly injured critical joint
- In an actuarial sense, as an object of contention in disability judgments
- In the treatment of degenerative joint disorders (e. g., after meniscectomy),
ranking second only to the hip
- In individual cases where it is important to consider the possible effect of psy
chological factors on the knee joint and, conversely. the difficulty some patients
may have in coping with a chronically painful "problem knee"
For the future, much remains to be improved, and basic research needs to be fur
ther refined. The evolutionary path will probably take us past the ligaments and
menisci to the cartilage, to the functions of the synovial membrane including its
eutrophic function in maintaining articular homeostasis and the destructive cata
bolic effects that occur in synovitis (e.g., due to abrasion of artificial ligaments),
and finally to the still little-researched processes involved in proprioception.
With its comprehehsive. up-to-date summary of our knowledge of the knee and
cruciate ligaments, this book will be a valuable aid in furthering our under
standing and management of structures "about the knee."
Basel. Summer, 1992 Werner MUller
Preface
Members of the Orthopedic Research Group for the Knee (OAK) of the Swiss
Orthopedic Society and experienced European knee specialists have pooled their
authoritative knowledge to create The Knee and the Cruciate Ligaments, whose
major emphasis is on diagnostic and therapeutic problems. Though a compilation,
the work still manages to reflect the individual interpretive freedom of its con
tributors.
An introductory chapter on nomenclature is followed by numerous chapters,
grouped by common themes, dealing with anatomy and biomechanics, diagnosis,
pathomechanics, and pathomorphology of acute tears of the anterior cruciate liga
ment (ACL) and chronic knee instability.
Special attention has been given to the description of concomitant injuries of the
collateral ligaments and menisci and to the various techniques of open and arth
roscopically assisted ACL reconstruction. We have placed special emphasis on the
treatment of posterolateral and posterior knee instability. Problems relating to the
synthetic replacement of the ACL, chronic cruciate ligament insufficiency with
osteoarthritis, and intra- and postoperative complications of reconstructions and
their management are explored with the help of illustrative case materials. There
is also a chapter on rehabilitation and evaluation in which therapeutic results,
complications and their management are discussed on the basis of clinical
series.
The editors of this volume - members of the International Knee Documentation
Committee - have succeeded in incorporating the knowledge of that body into the
documentation and evaluation of knee instabilities.
Our main purpose, and that of the book as a whole, is to help young surgeons and
orthopedists to define indications while providing them with practical tools and
precise details on operative and instrumental techniques.
Acknowledgments
We are sincerely grateful to all those who have contributed to the creation of this
book: our secretaries Mrs. Charlotte Neuenschwander, Department of Ortho
pedic Surgery, Inselspital, and Mrs. Verena Oppliger, Orthopedics and Traumatol
ogy, Department of Surgery, Tiefenauspital, Bern; our illustrators Hans Holzherr,
Christian Langenegger, and Willi ,Hess, Department of Instructional Media
(AUM), University of Bern, Inselspital; and our photographers Mrs. Boa (Tie
fenauspital), Mrs. Steiner (Inselspital), Mrs. Widmer (Inselspital), Mr. Huber
(Inselspital), and Mr. Zimmermann (AUM).
Finally, we thank the staff at Springer-Verlag for their very high-quality produc
tion work.
Bern, Summer, 1992 R. P. Jakob H-U.Staubli
Table of Contents
Terms, Definitions, and Glossaries
H.-v. Stiiubli, R. P. Jakob ..... . 1
Historical and Current Perspectives in the Treatment
of Anterior Cruciate Ligament Insufficiency
R. P. Jakob,J. P. Warner ................ . 22
Anatomy and Biomechanics
Surgical Anatomy of the Knee Joint
E. B. Hunziker, H.-v. Stiiubli, R. P. Jakob 31
The Popliteus Muscle
C. Fabbriciani, M. Oransky 48
Structural Molecules in Articular Cartilage, Tendons and Ligaments
E. B. Hunziker ............................... 62
Functional Anatomy of the Cruciate Ligaments
N. F. Friederich, W.R. O'Brien .......... . 78
Anatomy and Biomechanics of the Anterior Cruciate Ligament:
A Three-Dimensional Problem
R. Huiskes, L. Blankevoort ..... ..... 92
Significance of Anatomy and Biomechanics
W. Hackenbruch .................................. 110
OAK Knee Documentation and Evaluation
OAK Knee Evaluation: A New Way to Assess Knee Ligament Injuries
We. Milller, R. Biedert, F. Hefti, R. P. Jakob, U. Munzinger, H.-v. Stiiubli ... 123
Evaluation of Knee Ligament Injuries: The OAK and IKDC Forms
F. Hefti, T. Drobny, W. Hackenbruch, W. C. Kipfer, P. Holzach, R. P. Jakob,
We. Muller, H.-v. Stiiubli ............................. 134
XIV Table of Contents
Diagnosis, Pathomechanics, and Pathomorphology
of Anterior Crnciate Ligament Insufficiency
Diagnosis of Acute Tears of the Anterior Cruciate Ligament,
and the Clinical Features of Chronic Anterior Instability
B. Noesberger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Pathomechanical and Clinical Concepts of the Pivot Shift Phenomenon
R. P. Jakob, H-U. StiiubU ........................... . 157
Anterior Subluxation in Knees with Chronic Anterior Cruciate Ligament
Insufficiency: A Comparison of Arthrometry and Stressradiography
H.-U.Stiiubli, R.P.Jakob, B.Noesberger ..................... 169
Our Current Technique of Stressradiography Near Extension
H-U.Stiiub/i,R.P.Jakob ................... . ....... 177
Anterior Subluxation in the Chronically Anterior Cruciate
Ligament-Deficient Knee: Comparison of Simultaneous Arthrometry
and Stressradiography Using the KT 1000
H-U.StiiubU, R.P.Jakob ............................. 184
The Various Faces of Anterior Cruciate Ligament Tears
During Arthroscopic Examination
A. Giichter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
New Imaging Techniques
A. Giichter . . . . . . . . . . ....... 193
The Drawer Simulator: A Practice-Oriented Training Device
for Anteroposterior Stability Testing in the Knee
M. H Oswald, S. Christen, R. P. Jakob ...................... 196
Morphology and Function of the Cruciate Ligaments
in a Computer Simulation Model
B. Schneider, P. Wirz, R. P. Jakob ......................... 201
Production of Mechanical Knee Models for Training
P. Wirz, B. Schneider, R. P. Jakob ........... . . . 215
Femoropatellar Problems Associated with Anterior Cruciate Ligament
Insufficiency
C. Gerber ...................................... 225
Classification of Meniscal Tears Associated with Lesions
of the Anterior Cruciate Ligament
We. Maller .......................... . . .. 230
Natural History of Untreated Tears of the Anterior Cruciate Ligament
H-U.Stiiubli, R.P.Jakob ............................. 237
Natural History of Associated Intraarticular Pathology
in the Chronic Anterior Cruciate Ligament-Deficient Knee
J. Y. Dupont, C. Scellier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246