Book Review

Total Knee Replacement

Knee Pain and Disability

An Illustrated Guide to the Knee

Knee Ligaments: Clinical Examination

N Engl J Med 1993; 328:589-590February 25, 1993

Article

Total Knee Replacement
Edited by Richard S. Laskin. 268 pp., illustrated. New York, Springer-Verlag, 1991. $149. ISBN: 0-387-19644-7

Knee Pain and Disability
Third edition. By Rene Cailliet. 287 pp., illustrated. Philadelphia, F.A. Davis, 1992. $19.95. ISBN: 0-8036-1622-8

An Illustrated Guide to the Knee
By Alfred J. Tria, Jr., and Kenneth S. Klein. 168 pp., illustrated. New York, Churchill Livingstone, 1992. $59.95. ISBN: 0-443-08794-6

Knee Ligaments: Clinical Examination
By Guy Liorzou. 108 pp., illustrated. New York, Springer-Verlag, 1991. $89. ISBN: 0-387-53761-9

These four books have as their common subject the largest, most complex joint in the human body -- the knee. Beyond that, their focus and intended audiences are quite different.

The book edited by Laskin deals with a single operative procedure, total knee replacement. Laskin has assembled 23 contributors to discuss all aspects of knee-replacement surgery. The book contains four major sections and includes 228 figures and illustrations. The first section provides historical background, along with a review of our present understanding, of the biomechanics of the knee, materials, and future design considerations. This section also includes a discussion of the indications for and alternatives and contraindications to total knee replacement. It is not exhaustive, but it certainly gives the reader a fair understanding of the present state of knowledge.

The second section, written entirely by the editor himself, deals with the surgical technique for knee-replacement surgery. Its two parts deal with the soft-tissue techniques required for balancing and exposure and the bony resection necessary for total knee replacement. There are more than a few pearls to be gleaned here, not the least of which are the do's and don'ts listed in summary fashion at the end of the section.

The third section reports on the results obtained with common prosthetic designs. Each chapter also deals with specific techniques for using the individual prostheses, based on the author's extensive experience with each device. The final section focuses on problems related to total knee replacement, including bone loss and the rheumatoid knee. The two major reasons for failure remain tibial component loosening and extensor-mechanism problems. Little insight is provided into design modifications that help to resolve these continuing problems.

This book is one of the first to deal with all aspects of total-knee-replacement surgery. Its intended audience of total-joint surgeons and orthopedic residents will find it a useful reference against which present and future articles can be measured.

Cailliet's Knee Pain and Disability, by contrast, is intended for a wide audience of medical students and primary care physicians. This monograph, part of Cailliet's Pain Series, is in its third edition, which has increased by more than 100 pages over the second edition. The increased length is due primarily to the addition of detailed descriptions of the pathophysiology and pathomechanics of the knee.

The first two of the nine chapters deal with the structural and functional anatomy of the knee and are quite extensive. There follow chapters on traumatic lesions of the knee; patellofemoral pain and impairment, including a section on osteochondritis dissecans; arthritides and congenital and acquired deformities of the knee; and an extensive study of gait analysis. The strength of the book lies in its treatment of the pathophysiology of many disorders of the knee joint and, to some extent, its discussions of typical clinical histories and physical and laboratory findings. Its weakness lies in the discussions of treatment, particularly operative treatment. Most of this material has not changed since the second edition, which appeared in 1983. For instance, in the chapter on meniscal injuries, there is no discussion whatsoever of meniscus repair. Furthermore, Cailliet suggests that most total-knee-replacement devices are based on the Walldius design, which is no longer used. Finally, there is only limited discussion of the treatment of fractures about the knee with surgical techniques that are now considered standard for the majority of displaced fractures about the knee.

Cailliet's book is certainly not to be used by orthopedic surgeons or their residents, and its discussions of recommended treatment should be used cautiously by primary care physicians -- particularly with regard to traumatic lesions of the knee.

In contrast, Tria and Klein's Illustrated Guide to the Knee provides in much more concise and logical form the basic facts related to the knee and its many afflictions. As they state in the preface, their book is not meant to be a “tome” but an intentionally brief presentation of the facts. The many excellent illustrations, graphs, and tables present the information concisely, and the highlighted bibliographies at the end of each chapter provide a solid base of major books and articles dealing with the knee. The brevity of the text required the authors to steer clear of controversial issues and present “just the facts” as they saw them. This choice will undoubtedly stimulate some controversy. The 13 well-organized chapters, covering 161 very readable pages, make this book an ideal review for various examinations. Its extensive index, allowing easy access to information, and its suggested readings make it an ideal reference work as well. Medical students, orthopedic residents, and attending physicians will find An Illustrated Guide to the Knee a valuable addition to their libraries.

Finally, the monograph by Liorzou is a unique compilation of information on a very narrow subject, the examination of the knee ligaments. The author gained his information while on a self-directed “traveling fellowship” through Europe and North America, interviewing and keenly observing the “modern pioneers of clinical exploration of the knee.”

After a brief introductory chapter on terminology, Liorzou admonishes the reader to become a listener to the patient's story, rather than an interviewer. Through the use of quotations and delightful cartoons, he describes the many symptoms and mechanisms of injuries to the ligaments of the knee. The next section encourages the reader to become an observer of function, to see the actual disability experienced by the patient. In the final section, the author uses many photographs and illustrations, often showing the “godfathers” performing their own tests for specific instabilities of the ligaments. Many of the sophisticated, complementary, and often extensive technical tests available for the examination of the knee are briefly discussed, but the author encourages readers to sharpen their own clinical ability to listen, look, and examine.

This book is a necessity for all orthopedic surgeons and for anyone who deals with athletes or who is called on to examine injuries to the knee. It is articulate and precise, and the 341 illustrations provide many additional gems of information.

Donald B. Goodfellow, M.D.
Case Western Reserve University School of Medicine, Cleveland, OH 44106