1600JohnF.KennedyBlvd. Ste1800 Philadelphia,PA19103-2899 NOYES’KNEEDISORDERS:SURGERY,REHABILITATION, ISBN:978-1-4160-5474-0 CLINICALOUTCOMES Copyright#2010bySaunders,animprintofElsevierInc. Allrightsreserved.Nopartofthispublicationmaybereproducedortransmittedinanyformorbyany means,electronicormechanical,includingphotocopying,recording,oranyinformationstorageand retrievalsystem,withoutpermissioninwritingfromthepublisher.Permissionsmaybesoughtdirectly fromElsevier’sRightsDepartment:phone:(þ1)2152393804(US)or(þ44)1865843830(UK); fax:(þ44)1865853333;e-mail:[email protected] on-lineviatheElsevierwebsiteathttp://www.elsevier.com/permissions. Notice Knowledgeandbestpracticeinthisfieldareconstantlychanging.Asnewresearchandexperience broadenourknowledge,changesinpractice,treatmentanddrugtherapymaybecomenecessaryor appropriate.Readersareadvisedtocheckthemostcurrentinformationprovided(i)onprocedures featuredor(ii)bythemanufacturerofeachproducttobeadministered,toverifytherecommended doseorformula,themethodanddurationofadministration,andcontraindications.Itisthe responsibilityofthepractitioner,relyingontheirownexperienceandknowledgeofthepatient,to makediagnoses,todeterminedosagesandthebesttreatmentforeachindividualpatient,andtotake allappropriatesafetyprecautions.Tothefullestextentofthelaw,neitherthePublishernortheEditors assumesanyliabilityforanyinjuryand/ordamagetopersonsorpropertyarisingoutoforrelatedto anyuseofthematerialcontainedinthisbook. ThePublisher LibraryofCongressCataloging-in-PublicationData Kneedisorders:surgery,rehabilitation,clinicaloutcomes/editor, FrankR.Noyes;associateeditor,SueD.Barber-Westin.--1sted. p.;cm. Includesbibliographicalreferences. ISBN978-1-4160-5474-0 1.Knee--Surgery.2.Knee--Surgery--Patients--Rehabliitation.I. Noyes,FrankR.II.Barber-Westin,SueD. [DNLM:1.KneeInjuries--surgery.2.JointDiseases--rehabilitation. 3.JointDiseases--surgery.4.KneeInjuries--rehabilitation.5.Knee Joint--surgery.WE870K67342009] RD561.K57452009 617.5’82059--dc22 2009007993 AcquisitionsEditor:KimberlyMurphy DevelopmentalEditor:AnneSnyder DesignDirection:StevenStave PrintedinChina Lastdigitistheprintnumber:9 8 7 6 5 4 3 2 1 DEDICATION To JoAnne, my loving and precious wife, and to all our families. Contributors Thomas P. Andriacchi,PhD and Treatment of Knee Arthrofibrosis; The Cincinnati Knee Professor, Stanford University, Stanford; Research Career Rating System; The International Knee Documentations Scientist, VA Palo Alto Research and Development, Bone Committee Rating System; Rating of Athletic and Daily and Joint Research Center, Palo Alto, California Functional Activities after Knee Injuries and Operative Human Movement and Anterior Cruciate Ligament Function: Procedures; Articular Cartilage Rating Systems Anterior Cruciate Ligament Deficiency and Gait Mechanics Asheesh Bedi,MD John Babb,MD Fellow, Shoulder Surgeryand SportsMedicine, Hospital for Staff Orthopedic Surgeon, Mid-America Orthopedics, Special Surgery, New York, New York Wichita, Kansas Biology of Anterior Cruciate Ligament Graft Healing Medial and Anterior Knee Anatomy Geoffrey A. Bernas,MD Sue D. Barber-Westin,BS Clinical Assistant Professor of Orthopaedic Surgery, Director, Clinical and Applied Research, Cincinnati Department of Orthopaedic Surgery, University at Buffalo, Sportsmedicine Research and Education Foundation, Buffalo; University Sports Medicine, Orchard Park, Cincinnati, Ohio New York AnteriorCruciateLigamentPrimaryandRevisionReconstruction: Management of Acute Knee Dislocation before Surgical Diagnosis,OperativeTechniques,andClinicalOutcomes;Scientific Intervention Basis of Rehabilitation after Anterior Cruciate Ligament Autogenous Reconstruction; Rehabilitation of Primary and RevisionAnteriorCruciateLigamentReconstructions;RiskFactors Lori Thein Brody,PT,PhD,SCS,ATC for Anterior Cruciate Ligament Injuries in the Female Athlete; Graduate Program Director, Orthopaedic and Sports LowerLimbNeuromuscularControlandStrengthinPrepubescent Physical Therapy, Rocky Mountain University of Health and Adolescent Male and Female Athletes; Decreasing the Risk of Professions, Provo, Utah; Senior Clinical Specialist, UW AnteriorCruciateLigamentInjuriesinFemaleAthletes;Function Health, Madison, Wisconsin of the Posterior Cruciate Ligament and Posterolateral Ligament Aquatic Therapy for the Arthritic Knee Structures; Posterior Cruciate Ligament: Diagnosis, Operative Techniques, and Clinical Outcomes; Posterolateral Ligament William D. Bugbee,MD Injuries:Diagnosis,OperativeTechniques,andClinicalOutcomes; Associate Professor, University of California, San Diego; Rehabilitation of Posterior Cruciate Ligament and Posterolateral Attending Orthopaedic Surgeon, and Director, Cartilage Reconstructive Procedures; Medial and Posteromedial Ligament Transplant Program, Scripps Clinic, La Jolla, California Injuries:Diagnosis,OperativeTechniques,andClinicalOutcomes; Valgus Malalignment: Diagnosis, Osteotomy Techniques, and Rehabilitation of Medial Ligament Injuries; Meniscus Tears: Clinical Outcomes; Osteochondral Grafts: Diagnosis, Operative Diagnosis, Repair Techniques, and Clinical Outcomes; Meniscus Techniques, and Clinical Outcomes Transplantation: Diagnosis, Operative Techniques, and Clinical Outcomes; Rehabilitation of Meniscus Repair and Transplantation Terese L. Chmielewski,PhD,PT,SCS Procedures; Primary, Double, and Triple Varus Knee Syndromes: Assistant Professor, Department of Physical Therapy, and Diagnosis, Osteotomy Techniques, and Clinical Outcomes; Affiliate Assistant Professor, Department of Orthopaedics Rehabilitation after Tibial and Femoral Osteotomy; Correction of and Rehabilitation, University of Florida, Gainesville, Hyperextension Gait Abnormalities: Preoperative and Florida Postoperative Techniques; Operative Options for Extensor Neuromuscular Retraining after Anterior Cruciate Ligament Mechanism Malalignment and Patellar Dislocation; Prevention Reconstruction vii viii Contributors A. Lee Dellon,MD,PhD Procedures; Rehabilitation after Tibial and Femoral Osteotomy; Professor of Plastic Surgery and Professor of Neurosurgery, Correction of Hyperextension Gait Abnormalities: Preoperative Johns Hopkins University; Director, The Dellon Institutes and Postoperative Techniques for Peripheral Nerve Surgery, Baltimore, Maryland Knee Pain of Neural Origin Susan Jordan,MD Assistant Professor of Orthopaedic Surgery, University of Alvin Detterline,MD Pittsburgh School of Medicine; University of Pittsburgh Orthopaedic Surgeon, Sports Medicine, Towson Medical Center, Pittsburgh, Pennsylvania Orthopaedic Associates, Baltimore, Maryland Scientific and Clinical Basis for Double-Bundle Anterior Cruciate Medial and Anterior Knee Anatomy Ligament Reconstruction in Primary and Revision Knees Eric W. Fester,MD Anastassios Karistinos,MD Assistant Professor of Surgery, Uniformed Services Assistant Professor, Baylor College of Medicine; Physician/ University of the Health Sciences, Bethesda, Maryland; Surgeon, Veterans Administration Hospital, and Ben Taub Clinical Assistant Professor of Orthopaedic Surgery, Wright General Hospital, Houston, Texas State University, Dayton, Ohio; Chief, Orthopaedic Sports Graft Options for Anterior Cruciate Ligament Revision Medicine, Wright-Patterson Medical Center, Wright- Reconstruction Patterson Air Force Base, Ohio Lateral, Posterior, and Cruciate Knee Anatomy Jennifer Kreinbrink,BS Research Technician Associate, Orthopaedic Surgery, Freddie Fu,MD University of Michigan Health System, Ann Arbor, ChairmanandDavidSilverProfessorofOrthopedicSurgery, Michigan University of Pittsburgh School of Medicine; Chief of Gender Differences in Muscular Protection of the Knee Orthopaedics, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Scott Lephart,PhD,ATC Pennsylvania Associate Professor, University of Pittsburgh; Director, Scientific and Clinical Basis for Double-Bundle Anterior Cruciate Neuromuscular Research Laboratory, Pittsburgh, Ligament Reconstruction in Primary and Revision Knees Pennsylvania Differences in Neuromuscular Characteristics between Male and Simon Go¨rtz,MD Female Athletes Research Fellow, Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, California Thomas Lindenfeld,MD Valgus Malalignment: Diagnosis, Osteotomy Techniques, and Adjunct Professor, Department of Biomedical Engineering, Clinical Outcomes; Osteochondral Grafts: Diagnosis, Operative and Volunteer Instructor Professor, Department of Techniques, and Clinical Outcomes Orthopaedics, University of Cincinnati; Associate Director, Cincinnati Sportsmedicine and Orthopaedic Center, and Edward S. Grood,PhD Cincinnati Sportsmedicine Research and Education Director,BiomechanicsResearch,CincinnatiSportsmedicine Foundation, Cincinnati, Ohio Research and Education Foundation; Professor Emeritus, Diagnosis and Treatment of Complex Regional Pain Syndrome Department of Biomedical Engineering, Colleges of Medicine and Engineering, University of Cincinnati, Frank R. Noyes,MD Cincinnati, Ohio Chairman and CEO, Cincinnati Sportsmedicine and The Scientific Basis for Examination and Classification of Knee Orthopaedic Center; President and Medical Director, Ligament Injuries; Knee Ligament Function and Failure Cincinnati Sportsmedicine Research and Education Foundation; Clinical Professor (Volunteer), Department of Timothy P. Heckmann,PT,ATC Orthopaedic Surgery, University of Cincinnati College of Co-Director of Rehabilitation, Cincinnati Sportsmedicine Medicine; Previous Adjunct Professor, Noyes Tissue and Orthopaedic Center; Rehabilitation Consultant, Engineering and Biomechanics Laboratory, Department of Cincinnati Sportsmedicine Research and Education BiomedicalEngineering,UniversityofCincinnatiCollegeof Foundation, Cincinnati, Ohio Engineering, Cincinnati, Ohio ScientificBasisofRehabilitationafterAnteriorCruciateLigament Medial and Anterior Knee Anatomy; Lateral, Posterior, and Autogenous Reconstruction; Rehabilitation of Primary and CruciateKneeAnatomy;TheScientificBasisforExaminationand Revision Anterior Cruciate Ligament Reconstructions; ClassificationofKneeLigamentInjuries;KneeLigamentFunction Rehabilitation of Posterior Cruciate Ligament and Posterolateral and Failure; Anterior Cruciate Ligament Primary and Revision Reconstructive Procedures; Rehabilitation of Medial Ligament Reconstruction: Diagnosis, Operative Techniques, and Clinical Injuries; Rehabilitation of Meniscus Repair and Transplantation Outcomes;ScientificBasisofRehabilitationafterAnteriorCruciate Contributors ix Ligament Autogenous Reconstruction; Rehabilitation of Primary Scott A. Rodeo,MD and RevisionAnteriorCruciateLigamentReconstructions;Risk Professor and Co-Chief, Shoulder and Sports Medicine FactorsforAnteriorCruciateLigamentInjuriesintheFemale Service, Hospital for Special Surgery; Professor, Weill Athlete;LowerLimbNeuromuscularControlandStrengthin Cornell Medical College, New York, New York PrepubescentandAdolescentMaleandFemaleAthletes;Decreasing Biology of Anterior Cruciate Ligament Graft Healing theRiskofAnteriorCruciateLigamentInjuriesinFemaleAthletes; FunctionofthePosteriorCruciateLigamentandPosterolateral David L. Saxton,MD LigamentStructures;PosteriorCruciateLigament:Diagnosis, Clinical Faculty, University of Oklahoma Health Sciences OperativeTechniques,andClinicalOutcomes;Posterolateral Center, Oklahoma City, Oklahoma LigamentInjuries:Diagnosis,OperativeTechniques,andClinical Diagnosis and Treatment of Complex Regional Pain Syndrome Outcomes;RehabilitationofPosteriorCruciateLigamentand PosterolateralReconstructiveProcedures;MedialandPosteromedial Sean F. Scanlan,MS LigamentInjuries:Diagnosis,OperativeTechniques,andClinical Stanford University, Stanford; Postdoctoral Fellow, VA Palo Outcomes;RehabilitationofMedialLigamentInjuries;Meniscus Alto Research and Development, Bone and Joint Research Tears:Diagnosis,RepairTechniques,andClinicalOutcomes; Center, Palo Alto, California MeniscusTransplantation:Diagnosis,OperativeTechniques,and Human Movement and Anterior Cruciate Ligament Function: ClinicalOutcomes;RehabilitationofMeniscusRepairand Anterior Cruciate Ligament Deficiency and Gait Mechanics TransplantationProcedures;Primary,Double,andTripleVarusKnee Syndromes:Diagnosis,OsteotomyTechniques,andClinicalOutcomes; RehabilitationafterTibialandFemoralOsteotomy;Correctionof Robert C. Schenck, Jr.,MD HyperextensionGaitAbnormalities:PreoperativeandPostoperative Professor and Chair, Department of Orthopaedic Surgery, Techniques;OperativeOptionsforExtensorMechanism University of New Mexico School of Medicine; Head Team MalalignmentandPatellarDislocation;PreventionandTreatmentof Physician, Department of Athletics, University of New KneeArthrofibrosis;DiagnosisandTreatmentofComplexRegional Mexico, Albuquerque, New Mexico PainSyndrome;TheCincinnatiKneeRatingSystem;The Classification of Knee Dislocations InternationalKneeDocumentationsCommitteeRatingSystem; RatingofAthleticandDailyFunctionalActivitiesafterKneeInjuries Timothy Sell,PhD,PT andOperativeProcedures;ArticularCartilageRatingSystems Assistant Professor, University of Pittsburgh; Associate Director, Neuromuscular Research Laboratory, Pittsburgh, Lonnie E. Paulos,MD Pennsylvania ResearchAssociate,DepartmentofHealth,Leisureand Differences in Neuromuscular Characteristics between Male and ExerciseScience,UniversityofWestFlorida;MedicalDirector, Female Athletes andPhysician/Surgeon,Andrews-PaulosResearchand EducationInstitute,GulfBreezeHospital,AndrewsInstitute Wei Shen,MD,PhD SurgicalCenter,PensacolaBeach,Florida Post-doctoral Associate, University of Pittsburgh, GraftOptionsforAnteriorCruciateLigamentRevisionReconstruction Pittsburgh, Pennsylvania Scientific and Clinical Basis for Double-Bundle Anterior Cruciate Lars Peterson,MD,PhD Ligament Reconstruction in Primary and Revision Knees Professor of Orthopaedics, University of Goteborg; Department of Orthopaedics, Sahlgrenska University Justin P. Strickland,MD Hospital, Gothenburg, Sweden Physician’s Clinic of Iowa, Cedar Rapids, Iowa Autologous Chondrocyte Implantation Lateral, Posterior, and Cruciate Knee Anatomy Michael M. Reinold,PT,DPT,ATC,CSCS Robert A. Teitge,MD Rehabilitation Coordinator and Assistant Athletic Trainer, Professor, Wayne State University, Detroit; Chief, BostonRedSox;CoordinatorofRehabilitationResearchand Orthopaedic Surgery, DMC Surgery Hospital, Madison Education, Division of Sports Medicine, Department of Heights, Michigan Orthopedic Surgery, Massachusetts General Hospital, Patellofemoral Disorders: Correction of Rotational Malalignment Boston, Massachusetts of the Lower Extremity Rehabilitation after Articular Cartilage Procedures Kelly L. Vander Have,MD Dustin L. Richter,BS Assistant Professor, University of Michigan, Ann Arbor, Medical Student, University of New Mexico School of Michigan Medicine, Albuquerque, New Mexico Anterior Cruciate Ligament Reconstruction in Skeletally Classification of Knee Dislocations Immature Patients x Contributors C. Thomas Vangsness, Jr.,MD Birmingham, Alabama; Rehabilitation Consultant, Tampa Professor, Keck School of Medicine, University of Southern Bay Rays, Tampa, Florida California, Los Angeles, California Neuromuscular Retraining after Anterior Cruciate Ligament Allografts: Graft Sterilization and Tissue Banking Safety Issues Reconstruction; Rehabilitation after Articular Cartilage Procedures Daniel C. Wascher,MD Professor, Department of Orthopaedics, University of New Edward M. Wojtys,MD Mexico, Albuquerque, New Mexico Professor, Department of Orthopaedic Surgery, Chief, Classification of Knee Dislocations Sports Medicine Service, and Medical Director, MedSport, University of Michigan, Ann Arbor, Michigan Kevin E. Wilk,DPT,PT Anterior Cruciate Ligament Reconstruction in Skeletally Adjunct Assistant Professor, Marquette University, Immature Patients; Gender Differences in Muscular Protection of Milwaukee, Wisconsin; Vice President, Education, and the Knee; Management of Acute Knee Dislocation before Surgical Associate Clinical Director, Physiotherapy Associates, Intervention Preface I am grateful to all of the contributors to this book on Knee statistics, and validated clinical outcome instruments always Disorders,whichisappropriatelysubtitled“Surgery,Rehabilita- remain as our light-posts for patient treatment decisions. For tion,ClinicalOutcomes.”Thechaptersreflect thewritingsand thisreason,thereisamplespacedevotedinchapterstothesesci- teachings of the scientific and clinical disciplines required for entificdisciplines.Equally,thedescriptionofsurgicaltechniques the modern treatment of clinical afflictions of the knee joint. is presented in a step-by-step approach, with precise details by Thegoalofthewritersofeachchapteristopresentrationalevi- experienced surgeons on the critical points for each surgical dence-based treatment programs based on published basic technique to achieve a successful patient outcome. It is hoped science and clinical outcomes to achieve the most optimal out- that surgeons in training will appreciate the necessity for the comes forourpatients. basic science and anatomic approach that, combinaed with sur- The “KEY” to understanding the different disorders of the gical and rehabilitation principles, is required to become a true kneejointencounteredinclinicalpracticetrulyrestsonamulti- “masterofkneesurgeryandrehabilitation”. pledisciplinarianapproachandincludesacomprehensiveunder- Thereisaspecialemphasisplacedineachofthemajorbook standing of knee anatomy, biomechanics, kinematics, and sections on rehabilitation principles and techniques including biologyofsofttissuehealing.Restorationofkneefunctionthen pre-operative assessment, postoperative protocols, and func- requiresaprecisediagnosisofthefunctionalabnormalityofthe tional progression programs to restore lower limb function. involvedkneestructures,asurgicaltechniquethatispreciseand We have published comprehensive rehabilitation protocols in successful,andarehabilitationprogramdirectedbyskilledpro- this book that have been used and continually modified over fessionals to restore function and avoid complications. Each many years which direct the postoperative treatment of our chapter follows a concise outline of indications, contraindica- patients. My co-author on these sections, Tim Heckmann, is a tions, physical examination and diagnosis, step-by-step open superb physical therapist. We have worked together treating and arthroscopic surgical procedures, clinical outcomes, and patients in a wonderful harmonious relationship for nearly analysis ofrelevantpublishedstudies. 30 years. In addition, there are special programs for the female The first two chapters comprise an anatomic description of athlete to reduce the risk of an ACL injury. Sportsmetrics, a the structures of the knee joint. The photographs and illustra- non-profit neuromuscular training and conditioning program tionsrepresenttheresultofmanycadavericdissectionstodocu- developedatourFoundation,isoneofthelargestwomen’sknee mentkneeanatomicstructures.Itwasapleasuretohavefourof injurypreventionprogramsintheUnitedStatesandhasbeenin our fellows (class of 2008-2009) involved in these dissections existence for over 15 years. A number of scientists, therapists, whichresultedintwosuperbinstructionalanatomicvideosthat athletic trainers, and physicians at our Foundation have been already have received awards and are included in the DVD. involvedintheresearcheffortsandpublicationsofthisprogram. Numerous anatomic textbooks and publications were consulted Allcenterstreatingkneeinjuriesinathletesareremindedofthe during the course of these dissections to provide to the best of importance of preventive neuromuscular and conditioning pro- ourabilityaccurateanatomicdescriptions,realizingthereisstill gramswhoseneedhasbeenwellestablishedbymanypublished ambiguityinthenomenclatureusedforcertainkneestructures. studies. SpecialthankstoJoeChovanwhoisawonderfulandhighlytal- TheentirestaffatCincinnatiSportsmedicineandOrthopae- ented professional medical illustrator. Joe attended anatomic dicCenterandtheFoundationfunctionsinateameffort,work- dissections and worked hand-in-hand with us to produce the ing together in various clinical, research, and rehabilitation finalanatomicillustrations.JoeandIheldweeklytobi-monthly programs. The concept of a team approach is given a lot of longworkingsessionsforovertwoyearsthatresultedintheana- attention; and those who have visited our Center have seen the tomic and medical illustrations throughout this book that are actual programs in place. This team effort is appreciated by all unique, highly detailed, and believed to be anatomically including patients, staff, surgeons, physical therapists, athletic accurate. trainers, administrative staff, and clinical research staff. Our All surgeons appreciate that surgical procedures come and administrative staff, directed by a superb clinical operations go, replaced by newer techniques that are more successful as manager Linda Raterman, manages five major MD-PT-ATC techniques are discarded that may have proven inadequate by orthopediccenters.AsthePresidentandCEO,Ihavebeenfreed long-termclinicaloutcomestudies.Iamremindedthatthebasic ofmanyoftheoperationaladministrative dutiesbecauseofthis knowledge of anatomy, biomechanics, kinematics, biology, excellent staff, allowing time required for clinical and research xi xii Preface responsibilities. I have been blessed to be associated with a MedicalResearchLaboratorieswiththeUnitedStatesAirForce highly dedicated group of orthopedic partners who, besides in Dayton, Ohio. The facilities and veterinary support for bio- providingexcellentpatientcareandlivelydiscussionsatouraca- mechanical knee studies were unheralded and it was here that demic meetings, have donated a definedincome“tithing” every some of the first high strain-rate experiments on mechanical year for funding research and clinical education programs at properties of knee ligaments were performed using the unique our Foundation. laboratory testing equipment available. I am indebted to Victor Nearly all of the patients treated at the Knee Institute are Frankel and Albert Burstein, the true fathers of biomechanics entered into prospective clinical studies by a dedicated clinical intheUnitedStates,astheyguidedmeintheseformativeyears researchgroupdirectedbySueBarber-WestinandCassieFleck- ofmycareer.Iwasparticularlyfortunatetohaveacloseassoci- enstein. The staff meticulously tracks patients over many years ation with Al Burstein who mentored me in the discipline of to obtain in published studies a 90 to 100% follow-up. I invite orthopedic biomechanics. This research effort also included you to read the forward of Sue Barber-Westin who has per- professorsandstudentsattheAirForceInstituteofTechnology. formed such an admirable and dedicated job in bringing our Iamgratefultoallofthemforinstructingmeintheearlyyears clinical outcome studies to publication. It is only through her ofmyresearchtraining.Asbiomechanicswasjustinitsinfancy, effortsthatwehavebeensuccessfulinlargeprospectiveclinical itwasobviousthatsubstantiveresearchwasonlypossiblewitha outcome studies. In each chapter, the results of these outcome combinedMD-PhDteamapproach. studies are rigorously compared with other authors’ publica- Oneofthemostfortunateblessingsinmyprofessionallifeis tions. Theresearch andeducationalstaffworkwithfellows and the relationship I have had with Edward S. Grood, Ph.D. I students from many different disciplines including physicians, establishedacloseworkingrelationshipwithEdndwecurrently therapists, trainers and biomedical students. There have been have the longest MD-PhD (or PhD-MD) team that I know of 125OrthopedicandSportsmedicineFellowswhohavereceived whichisstillactivetodayasweconductthenextroundofknee trainingatourCenter.Thescientificcontributionoffellowship ligament functionstudies usingsophisticated three-dimensional researchprojectsareacknowledgednumeroustimesinthechap- robotic methodologies. We worked together in establishing ters.Ourstaffenjoysthementoringprocessandfromapersonal one of the first Biomechanical and Bioengineering programs in note,thishasbeenoneof mygreatestprofessional joys. thecountryattheUniversityofCincinnatiCollegeofEngineer- Inregardtomentoring,onemightaskwherethespecialtyof ing,andIgreatlyappreciatedthatitwasnamedtheNoyesBio- orthopedics (or any medical specialty) would be today without mechanics and Tissue Engineering Laboratory. This initial the professional mentoring “system” that trains new surgeons effort expanded with leadership and dedicated faculty and andadvancesourspecialty,providingforacontinuumofpatient resulted in a separate Bioengineering Department within the treatmentapproachesandadvances.Theinformaldedicationof CollegeofEngineeringwithacompleteprogramforundergrad- theteachertothestudent,oftenprovidingwisdomandguidance uateandgraduatestudents.Dr.Groodpioneeredthiseffortwith overmanyyears,isactuallycontrarytocapitalisticprinciplesas other faculty and developed the educational curriculum for the the hours of dedication are rarely if ever compensated. It is the five-year undergraduate program. Many students of this pro- gift from one generation to another and I mention this specifi- gram have completed important research advances that are callyasIhopethatIhavebeenabletorepayinpartthementors referenced in this book. David Butler, Ph.D. joined this effort who provided this instruction and added time and interest for initsearlyyearsandcontributedimportantanduniqueresearch my career.Igraduated from the Universityof Utah witha phi- works that are also credited throughout the chapters. This col- losophydegreewhichprovidedanunderstandingofthewritings laborative effort of many scientists and physicians resulted in and wisdom of the great scientists and “thinkers” of our times, threeKappaDeltaawards,theOrthopedicResearchandEduca- taught by superb educators in premedical courses and philoso- tionClinicalResearchaward,AOSSMResearchAwards,andthe phy. I received an M.D. degree from George Washington supportofnumerousgrantsfromNIH,NSF,andotherorgani- University and am thankful to the dedicated teachers who laid zations. Thomas Andriacchi, Ph.D. collaborated on important asolidmedicalfoundationfortheirstudentsandtaughttheseri- clinicalstudiesthatprovidedanunderstandingofjointkinemat- ous dedication and obligation that physicians have in treating ics and gait abnormalities. It has been an honor to have Tom patients. I was fortunate to be accepted for internship and resi- associatedwithoureffortsthroughouttheyears. dencyattheUniversityofMichiganandremembertheopportu- My finest mentors were my parents, a dedicated and loving nity to be associated with truly outstanding clinicians and father,MarionB.Noyes, M.D.whowas a truerenaissance sur- surgeons. Under the mentorship of the chairman William S. geon entirely comfortable doing thoracic, general surgery, and Smith, M.D., I and my fellow residents knew one of the finest orthopedicsandwho,asChiefSurgeon,traineddecadesofsur- orthopedic surgeons and dedicated teachers one could be asso- gical residents. Early in my life, I read through classic Sobotta ciated with who was a truly humble man that inspired decades anatomic textbooks and orthopedic textbooks which remain in of orthopedic residents. Many graduates of this program have my library with his writings and notations along side. Later in continued as orthopedic educators and researchers, which is a mytraining,Iwasfortunatetoscrubwithhimonsurgicalcases. great tribute to Bill Smith and his mentorship. My fellow resi- My loving mother, a nurse by training, was truly God’s gift to dents remember one of his many favorite sayings provided to ourfamilyformanygenerationsassheprovidedunqualifiedlove remind residents of the need for humility. After a particularly andsageandexpertadvicetoourentirefamilywithknowledge, enthusiastic lecture or presentation by a prominent surgeon wisdom,andtheadmiration ofallofuslivingintohernineties. andglowingstatementsofadmiration,BillSmithwouldsaywith Sheexpectedexcellence,performance,andadherencetoarigor- a wink and smile, “He puts his pants on one leg at a time just ousvaluesystem.Thesearealsotheattributesofthemostwon- likeyoudo”. derfulgiftofall,theopportunitytogothroughlifewithaloving After orthopedic residency, I accepted a four-year combined and true soul mate, my wife JoAnne Noyes that I remain eter- clinical and research biomechanics position at the Aerospace nally grateful and devoted. Our family includes a fabulous Preface xiii daughter and son-in-law, two wonderful grandchildren, my In closing I wish to specially thank Kim Murphy, the Pub- devoted son who graduated in Physics and mentors me in lishing Director of Elsevier and their staff who are true profes- nuclear and atomic matters outside my reach, and a third won- sionals and were a joy to work with in completing this derful and dedicated son and daughter-in-law with three addi- textbook.Givenallthedecisionsthatmustbemadeinbringing tional grand-children. Together, with JoAnne and all our atextbooktopublication,attheendoftheprocesstheElsevier brothersandsisters,weenjoywonderfulfamilyeventstogether. team made everything work in a harmonious manner always As I look back on my career, it is the closeness of family and strivingforthehighestqualitypossible. friendsthathasprovided thegreatestenrichment. FRANKR.NOYES,MD