DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Chronic anterior cruciate ligament deficient left knee.
2. Possible chondromalacia, left knee.
POSTOPERATIVE DIAGNOSES:
1. Chronic anterior cruciate ligament deficient left knee.
2. Posterior horn medial meniscus tear, left knee.
3. Nondisplaced superior surface posterior horn lateral meniscus tear, left knee.
4. Grade 1 to 2 chondromalacia, medial patellar facet, left knee.
5. Fissuring, chondromalacia, lateral portion, medial femoral condyle, left knee.
OPERATION PERFORMED:
1. Anterior cruciate ligament reconstruction with central one-third patellar tendon autograft, left knee.
2. Repair of posterior horn medial meniscus tear with Polysorb meniscal staple, left knee.
SURGEON: John Doe, MD
ANESTHESIA: General LMA anesthesia.
TOURNIQUET TIME: 100 minutes.
DRAINS: One intra-articular Hemovac drain.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed on the operating room table in the supine position. After adequate general LMA anesthesia was obtained, the patient’s left knee was examined. She has 2 to 3+ Lachman and 1 to 2+ pivot shift. She did have a popping with McMurray testing. She had full range of motion of proximal left lower extremity. A well-padded tourniquet was placed at 275 mmHg. The left extremity was elevated and exsanguinated with an Esmarch. The tourniquet was then inflated, and the left lower extremity was placed in a well-padded arthroscopic leg holder. The right lower extremity was also well padded, bottom of the bed was dropped. The left lower extremity was sterilely prepped from toes to leg holder with DuraPrep solution x2 and sterilely draped in standard fashion with waterproof extremity drape and waterproof stockinette. A circumferential adhesive Ioban draped about the left knee.
At this time, attention was turned to the anterior aspect of the left knee, where an incision was made just slightly medial to the center of the patellar tendon, taken down through skin and subcutaneous tissue. The paratenon was split in line with the incision. The medial and lateral borders of the patellar tendon were identified and it measured 33 mm. An 11 mm DePuy graft knife was used to take the central third of the patellar tendon with associated tibial and patellar bone plugs. This was fashioned on the back table. It was fit through a 10 mm spacer and sutures were passed through the bone plugs to aid in passage of the graft.
Attention was then turned to the knee with the skin retracted. Then anteromedial and anterolateral portals were established. The arthroscope was introduced with blunt trocar in the suprapatellar pouch. The anterolateral portal and the knee was distended with lactated Ringer’s and copiously irrigated. The suprapatellar pouch was within normal limits. The undersurface of the patella did have chondromalacia in the medial patellar facet, that was probed and felt to stable, and it was grade 1 to 2.
The remainder of the patellar articular cartilage and the trochlear groove articular cartilage were within normal limits. The medial gutter was without plica synovitis and loose body. Medial compartment was entered. The probe was used through the anteromedial portal to probe the extent of the posterior horn medial meniscus tear measuring approximately 1 cm and superior surface of the posterior horn. A decision was made to repair. The tear was in the red zone. Decision was made to repair this tear. That was repaired with one Polysorb meniscal suture and it was felt to be stable.
The articular cartilage, medial tibial plateau, was within normal limits. The medial femoral condyle had fissuring, chondromalacia, lateral portion, which was stable. The intercondylar notch was entered. The ACL was lax. There did appear to be some fibers that had scarred down more medially. The lateral compartment and lateral meniscus were probed in its entirety and it was stable. There was a superior surface 5 mm tear of the posterior horn, which was stable. The articular cartilage, lateral femoral condyle, and lateral tibial plateau were within normal limits. The lateral gutter was without plica synovitis and loose body.
Attention was turned to the intercondylar notch where the remnant of previous anterior cruciate ligament was debrided using the 5.5 mm shaver in the oscillating fashion. A quarter-inch osteotome was used to enlarge the notch anteriorly and a 5 mm round bur was used to enter posteriorly to complete the notchplasty. At this time, the tibial guide was used to enter the medial portal placed to the center of the footprint on previous ACL and a guidewire was run from distal and proximal at that site and reamed with a 10 mm reamer. The intra-articular portions of the tunnel were rasped. All fluid was removed from the knee.
Attention was then turned to the lateral aspect of the left thigh where a 3 cm incision was made just proximal to lateral femoral condyle taking down through the skin and subcutaneous tissue. The iliotibial band was split in line with the incision. The vastus lateralis was elevated and held anteriorly with a Z-retractor. The knee was again distended with fluid with the scope through the anteromedial portal and femoral guide through the anterolateral portal was placed just over the top position at approximately 1 o’clock in a clock phase. The guidewire was running from proximal to distal without difficulty and reamed with a 10 mm reamer. The intra-articular portions of the tunnel were rasped. A 9.5 mm graft passer was passed from distal to proximal and the graft was passed from proximal and distal without difficulty. The bone plug was fixed in the femoral tunnel with a 8 x 20 mm Stryker screw with attention on the graft. The knee was taken through range of motion several times. There was no evidence of pistoning, it was examined arthroscopically, and there was no evidence of anterolateral impingement. At this time, tension on the graft and knee, approximately 10 to 15 degrees of flexion, mild posterior pressure on the tibia. The distal bone plug was fixed with 9 x 20 mm Stryker wedge screw.
The graft was again examined arthroscopically. It was probed and felt to be stable. The Lachman’s was felt to be obliterated. There was no evidence of anterolateral impingement. The knee was copiously irrigated. A drain was placed in the suprapatellar pouch exiting laterally through the anterolateral portal. The drain was injected with 30 mL of 0.5% Marcaine with epinephrine without preservative. The excess bone from the bone plugs was packed into the patellar defect. The patellar tendon was loosely approximated with two interrupted sutures of 0 Vicryl. The paratenon was loosely approximated with 2-0 Vicryl.
The subcutaneous tissue was irrigated and closed with interrupted sutures of 2-0 Vicryl and the skin was closed with running 4-0 subcuticular Vicryl. Benzoin and Steri-Strips were applied laterally. The wound was irrigated. The iliotibial band was closed with interrupted sutures of 1 Vicryl. The subcutaneous tissue was irrigated and closed with interrupted 2-0 Vicryl sutures. The skin was closed with a running 4-0 subcuticular Vicryl. Benzoin and Steri-Strips were applied. Sterile 4 x 4, ABD, Protouch, a cool temp pad, and Ace wrap dressing from the toes to the groin were applied. Tourniquet was released at the completion of dressing. Tourniquet time was 100 minutes. The patient tolerated the procedure well and was stable in the recovery room.
