The Knee : Form, Function, and Ligament Reconstruction

This new treatise is the most outstanding piece of work on the knee and its associated ligaments currently available. Never before have I seen such an extensive study of the biomechanics of the knee with such a comprehensive review of the literature. The first section of the book, which deals with the functional anatomy (structure and biomechanics), immediately alerts the reader to the necessity of understanding the natural develop­ ment and action of the related structures, clearly emphasizing that successful diagnosis and treatment cannot otherwise be expected; the many who want an easy standard approach to each classic problem may find this hard to accept. Study what Werner Muller has written and compare it with your own findings from repeated dissection of anatomical specimens. The author goes on to stress that to have a real grasp of reconstructive surgery of the ligaments, one must be properly acquainted with the pathology and the repair of acute lesions. In no other way can one learn to recognize chronic problems. Once this step has been mastered it can be seen that the reconstructive procedures that Muller advocates do, for the most part, follow the laws of Nature rather than create the kind of abnormalities which often disrupt natural anatomical func­ tion.

Anatomy.- Form, Function, and Synergisms.- Kinematics.- Kinematics of the Rolling-Gliding Principle.- Model of the Crossed Four-Bar Linkage.- Varying Ratio of Rolling to Gliding.- Kinematics and Anatomic Form of the Femoral Condyle.- Superposition of the Patellar Gliding Surface on the Femoral Condyle.- The Cruciate Ligaments as the Foundation of Knee Joint Kinematics.- Kinematics and Applied Physiology and Pathophysiology of the Ligaments.- Cruciate Ligaments.- Collateral Ligaments.- Medial Collateral Ligament.- Inevitable Placement of Some Ligament Fibers Outside the Theoretical Ideal Line.- The Ideal Lines of Ligament Insertion and the “Dynamization” of Articular Ligaments.- The Retinaculum and Pes Anserinus as “Dynamized Ligaments”.- The Medial Ligament System During Movement.- The Lateral Collateral Ligament.- The Lateral Ligament System During Movement.- The Iliotibial Tract as a Direct Femorotibial Collateral Ligament.- The Theoretical Interplay of the Cruciate and Collateral Ligaments.- Automatic Rotation, Terminal Rotation, Initial Rotation.- The Cruciate Ligaments and Movement of the Knee Joint in More Than One Plane.- The Three-Dimensional Four-Bar Linkage and the Central Pivot.- The Posteromedial Corner (Semimembranosus Corner).- Interaction of the Ligaments During Rotation.- The Posterolateral Corner (Popliteus Corner).- Active Stabilization Under Proprioceptive Control.- Rotation.- Physiology and Pathophysiology of Free and Active Rotation.- Active Rotation by the Extensors.- Active Rotation by the Flexors.- Varus-Flexion-IR and Valgus-Flexion-ER.- Injuries of the Active Rotational System.- Agonism and Antagonism Between Extensor-Flexors and Rotators.- Passive Rotatory Stabilization.- The Principle of the Triangular Structure in Passive Rotatory Stabilization.- The Role of the Fabella.- The Triangular Arrangement of the MCL and POL as an Aid to Passive Rotatory Stabilization.- Physiology and Pathophysiology of the Menisci During Rotation.- Examination of the Injured Knee Joint.- General Symptoms.- Testing the Stability of the Knee.- General Considerations and Methods.- Testing Lateral Stability.- Measurement of Instability.- Testing Anterior and Posterior Stability.- Roentgenographic Examination.- Testing Rotational Stability.- Pathophysiology of Rotatory Instabilities.- Cruciate Ligament Insufficiency and Lateral Subluxation Phenomena with the Corresponding Clinical Tests.- Classification of Instabilities.- Instabilities in One Plane or About One Axis.- Rotatory Instabilities.- Combined Instabilities.- Ligamentous Injuries and Instabilities.- Analysis of the Biomechanical Effects of Ligamentous Injuries on Stability in the Four Quadrants.- Instability ― Disability.- Injuries of the Ligaments and Capsule.- General.- The Layers of the Medial Capsuloligamentous System.- Medial Ligamentous Injuries with Disruptions of Bone and Ligament Continuity.- The Ligamentous Injury as a Function of the Force and Rate of Deformation.- The Three Degrees of Severity of Ligamentous Injuries.- General Operating Technique.- Suturing Technique for the Various Degrees of Ligamentous Injury.- The Fixation of Avulsed Ligaments with a Screw and Toothed Washer.- Surgical Approaches.- Vessels and Nerves.- Medial Incisions.- Lateral Incisions.- Lateral Long Parapatellar Incision.- Posterior Approach to the Knee Joint.- The Primary Repair of Special Injuries.- Injuries of the Medial Side and Their Repair.- General.- The Normal Medial Aspect.- Tears of the Deep Layer and the POL.- Proximal Avulsion of Both Medial Ligaments.- Principal Tears of the Classic Medial Collateral Ligament.- Temporary Internal Splinting.- Typical Lesions Accompanying Injuries of the Medial Side.- Special Injuries of the Semimembranosus Corner.- Concluding Remarks on Medial Injuries.- Injuries of the Lateral Side and Their Repair.- General.- The Major Passive and Active Stabilizing Structures of the Lateral Side.- Injuries of the Lateral Collateral Ligament (LCL).- Combined Injuries.- Injuries of the Cruciate Ligaments and Their Repair.- The Blood Supply of the Cruciate Ligaments.- The Normal Structure of the Cruciate Ligaments.- Tears of the Anterior Cruciate Ligament and Their Repair.- Recurrent Post-Traumatic Hemarthrosis.- Compensation Limit and Decompensation Threshold.- Compensatory Reserve.- Tears of the Posterior Cruciate Ligament.- Pure Ligamentous Ruptures.- Isolated Cruciate Ligament Tears.- Secondary Repair and Plastic Reconstruction of the Ligaments in Old Injuries.- General.- Cruciate Ligament Reconstruction and Repair of the Central Pivot.- Our Current Technique of Anterior Cruciate Ligament Reconstruction.- Posterior Cruciate Ligament Reconstruction.- Arthroscopy in the Planning of Cruciate Ligament Repairs.- Old Combined Ruptures of the Anterior and Posterior Cruciate Ligaments.- Secondary Repair of the Periphery and Reconstruction of the Five Main Ligaments and Capsule.- The Capsule.- The Semimembranosus Corner.- The Medial Collateral Ligament and Its Secondary Repair.- Repair of the Popliteus Corner.- Repair of the Lateral Collateral Ligament.- Repair of the Lateral Femorotibial Ligamentous Attachment.- Our Current Technique of Anterolateral Femorotibial Reconstruction (1979–1980).- Concomitant Traumatic Cartilage Damage and Its Treatment.- Fresh Concomitant Cartilage Damage.- Concomitant Cartilage Damage in Chronic Instability.- The Treatment of Concomitant Cartilage Damage.- The Effect of Cartilage Damage on Postoperative Care.- Complications.- General Guidelines for Operative Procedures.- Preparing for the Operation.- Instruments.- Suture Material.- Antibiotic Prophylaxis.- Postoperative Rehabilitation.- General.- Goals of Rehabilitation.- The Physiologic and Pathophysiologic Foundations of Postoperative Rehabilitation.- General and Patellar Cartilage Problems.- Muscular Atrophy.- Problems of the Suprapatellar Pouch.- General Pathophysiologic Considerations.- Tools of Rehabilitation.- Postoperative Positioning.- Postoperative Immobilization.- Recent Developments in Postoperative Mobilization.- Active Mobilization.- Weight-Bearing During Rehabilitation.- Physical Therapy.- Pharmacotherapy.- Local Anesthesia.- Examination and Mobilization Under General Anesthesia.- Psychological Guidance.- Clinical Material and Results.- General.- Operative vs. Non-Operative Treatment.- Indication for Operative or Non-Operative Treatment.- Our Results for the Period 1971 – 1977.- Clinical Material.- Results.- Assessment of Results.- List of Sources.- References.