THE CRUCIAL PRINCIPLES IN CARE OF THE KNEE

THE CRUCIAL PRINCIPLES IN CARE OF THE KNEE Edited by John A. Feagin, Jr. (USMA ’55) and J. Richard Steadman 278 pp, $199.50 Philadelphia, PA, Lippincott Williams & Wilkins, 2008) ISBN-13: 978-0-7817-7250-1   A GENERATION AGO, JOHN A. FEAGIN JR WROTE A BOOK TITLED The Crucial Ligaments of the Knee. In that book, he promulgated the vital importance of the anterior cruciate ligament (ACL) to the stability and function of the knee. Many of his well-respected peers believed that high-level knee function was possible with an absent ACL, though that belief is now considered anathema. Feagin and his contemporaries used scientific principles to study the knee and ACL function and eventually proved that the ACL plays a vital role in knee kinematics and performance. At the same time, a half continent away, J. Richard Steadman became involved with the care of knee injuries in competitive alpine skiers. He also concluded that aggressive reconstruction of ACL ruptures gives skiers the best chance of returning to high-level competition and embarked on a mission to repair articular cartilage lesions using a process termed “microfracture.” Feagin and Steadman participated in the birth of the field of sports medicine, and their efforts helped shape it through its nascent stages. Thus, I was excited to learn that they had collaborated in a book detailing their experience. The Crucial Principles in Care of the Knee is the product of that collaboration. Although listed as editors, Feagin and Steadman author or coauthor the vast majority of the book, and it is fair to say that the contents directly reflect their knowledge and philosophy.   The first 5 chapters were written primarily by Feagin. They provide a thorough description of his philosophy regarding the treatment of the patient with knee injury. The list of 6 crucial principles found on page 8 and detailed in the following chapter provides a framework for the treatment of any patient with an injured knee. These principles are a product of decades of experience; principle 2, “A Treatment Program Aimed at Optimizing Return of Function Within Realistic Expectations,” is especially useful and should be internalized by all who treat patients with knee injuries. The case studies presented in chapter 3 effectively use the Socratic method in detailing the pathology and treatment of common knee injuries. Case study 3A concerns subluxation of the patella in the adolescent female athlete and presents a cogent discussion of the thought process guiding the treatment of this common injury. The highlight of the work is perhaps the “Classic Bibliography” (pp 44-50). The articles referenced describe the evolution of knowledge about knee injuries and detail the formation of the principles on which the science of sports medicine is based.   Nowhere is the role of collaboration in the establishment of a treatment algorithm more apparent than in chapter 9, simply titled “Microfracture.” In this chapter, the author logically and concisely presents the knowledge that he and his team of investigators have developed through their decades of work. The chapter begins with an outline of the basic science behind cartilage repair. It then flows to a clinical description of the problem, followed by a detailed description of the technique of microfracture. Last and most important, the clinical outcomes achieved by Steadman are presented. Readers will find the postoperative rehabilitation guideline detailed on pages 150 and 151 to be helpful in achieving the best outcomes possible from this surgery. Equally as important, the detail in which this postoperative rehabilitation is thought out and presented is emblematic of the level of compulsiveness Steadman and his team achieve in all aspects of the treatment of chondral lesions and is why their results are unrivaled.   The future of treatment of knee injuries is being determined by research currently in progress. The bulk of knowledge on the natural history of cartilage defects and their response to microfracture and other treatment modalities has and is being obtained through animal research. In chapter 16, McIlwraith and Rodkey describe the rich history of research using their horse model. They detail the classic experiments resulting in seminal publications in the field of cartilage repair. For example, they describe the classic report by Frisbie et al, in which they discovered the importance of eliminating the zone of calcified cartilage to the success of microfracture. This small nuance in surgical technique can determine the outcome of microfracture. Most importantly, the chapter concludes with descriptions of current experiments that will provide the basis of advances in future clinical procedures. Included in these descriptions are reports on ongoing research into gene therapy to augment cartilage repair. Articular cartilage repair is now considered the holy grail of orthopedic surgery, but thanks to decades of basic science and animal research, this vexing problem is close to a solution. I was intrigued by the potential possibilities that collaboration between Feagin and Steadman could produce. The product of their joint effort, The Crucial Principles in Care of the Knee, did not disappoint. It is a well-written, insightful description of the knowledge and philosophy of 2 talented clinicians who have dedicated their careers to the understanding and management of knee injuries. The book will be enjoyed by readers who consider themselves knee specialists and will serve as a reminder of the debt owed to these individuals and their peers for years of dedication and work spent on developing the principles and techniques on which orthopedic practice is based. Joseph A. Bosco, MD Department of Orthopedic Surgery New York University Langone Hospital for Joint Diseases New York, New York joseph.bosco@nyumc.org

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