DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left knee anterior cruciate ligament tear.
POSTOPERATIVE DIAGNOSES:
1. Left knee anterior cruciate ligament tear.
2. Left knee medial meniscus tear, posterior third (white-white zone).
OPERATION PERFORMED:
1. Left knee arthroscopic anterior cruciate ligament reconstruction with hamstring autograft.
2. Left knee partial medial meniscectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia with regional femoral and sciatic nerve blocks.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who injured her left knee. Preoperative workup, both clinically and radiographically including the MRI, was consistent with a complete tear of the ACL and a possible tear of the posterior horn of the medial meniscus. Operative and nonoperative treatment options were discussed with the patient, and given the patient’s young age, risk of developing arthritis in an ACL-deficient knee, and her desire to continue with pivoting sports, the patient elected to proceed with surgical intervention.
DESCRIPTION OF OPERATION: After obtaining informed consent and correctly identifying the patient, the patient was brought to the operating room and placed on the operating table in the supine position. After adequate anesthesia was obtained and intravenous antibiotics were given, the left lower extremity was prepped and draped in the usual sterile fashion. A time-out was then taken to confirm the identity of the patient, consented procedure, and correct extremity. After this time-out, an exam under anesthesia confirmed 2+ anterior drawer and Lachman exam with a positive pivot shift test. Given these findings, the decision was made to proceed with the hamstring autograft harvest.
The skin overlying the pes anserine was incised with a 2.5 cm longitudinal incision. The subcutaneous tissue was dissected down exposing the underlying sartorius fascia. Meticulous hemostasis was obtained using Bovie cautery. The sartorius fascia was then incised to expose the underlying gracilis and semitendinosus tendon. The gracilis and semitendinosus tendons were then identified, divided, and tagged using a running locking Krackow stitch using #2 FiberWire suture.
Adhesions were then both bluntly and sharply dissected off of the tendon to allow for improved excursion of the tendon. The respective tendons were then harvested using a tendon stripper and passed off the back table sterilely. The hamstring tendons were then looped over a #5 Ethibond to create a quadruple loop hamstring autograft. The tendons were then prepared to pass through a 7 mm tunnel proximally and a 9 mm tunnel distally.
In the meantime, attention was focused to the arthroscopy. The skin, inferomedial and inferolateral patella, were injected with 0.5% bupivacaine. A small stab incision was then made inferolateral to the patella. An arthroscopic camera was introduced into the joint. The joint was then distended and diagnostic arthroscopy then ensued. The suprapatellar pouch was visualized. There was no evidence of synovial hypertrophy or loose bodies. The undersurface of the patella revealed no evidence of chondromalacia, and the patella appeared to track centrally within the trochlear groove.
The trochlear groove revealed minimal grade 1 change of chondromalacia. The medial and lateral gutters were then visualized. No evidence of synovial hypertrophy or loose bodies. The medial compartment was then entered, as the knee was held in the flexed position with the valgus stress. A spinal needle was then inserted inferomedially for patellar subluxation anteromedial portal. Once its position was confirmed, a small stab incision was made.
Arthroscopic probe was introduced. The articular cartilage of the medial femoral condyle and medial tibial plateau were, for the most part, pristine. The anterior middle third of the medial meniscus was also pristine. At the posterior third of the medial meniscus, there was noted to be a vertical tear in the white-white zone of the meniscus, which was unstable upon probing. Given that it was in the white-white zone, the decision was made to proceed with a meniscectomy. Using combination of arthroscopic biters and arthroscopic shavers, the meniscal tear was gently excised, taking great care in trying to preserve as much normal cartilage as possible.
A smooth transition zone was created between the area of normal meniscus and the area where the proximal meniscectomy was performed. Upon completion of the partial meniscectomy, the remaining meniscus was aggressively probed to ensure that a stable rim remained. The intercondylar notch was then visualized. The anterior cruciate ligament was noted to have completely avulsed off of the femoral origin and scarred down in a horizontal position. The tibial footprint of the ACL was noted for its location. The lateral compartment was then entered as the knee was held in the figure 4 position. The articular cartilage of the lateral femoral condyle and lateral tibial plateau were pristine. There was no evidence of lateral meniscus tear upon visualization and probing.
Attention was then focused to the intercondylar notch again. A limited notchplasty was created after the ACL stump was debrided and excised. Using combination of arthroscopic shavers and arthroscopic bur, the anterior aspect of the notch was heightened and widened to allow for improved visualization of the posterior aspect of the notch, as well as to ensure that no impingement on the graft would occur.
Then, the Arthrex tibial tunnel guide was inserted via the medial portal and set at the center of the noted tibial footprint. This corresponded with the posterior aspect of the anterior horn of the lateral meniscus and was approximately 7.5 mm anterior to the posterior cruciate ligament. A guidewire was then passed through the tibial tunnel, and over this guidewire, an 8 mm tunnel was then reamed in the tibia. Then, with a hand reamer, the distal-most aperture of the tibial tunnel was then hand reamed to 9 mm. Then, through the medial portal, a 6 mm femoral over-the-top guide was then hooked on to the posterior aspect of the intercondylar notch and set at approximately the 2 o’clock position.
A Beath pin was then passed through this over-the-top guide through the femur and out the anterolateral thigh. A looped #5 Ethibond was then passed through the Beath pin and out the anterolateral thigh. The looped end was then grasped through the tibial tunnel. The looped end of the Ethibond was then used as suture shuttle to pass the hamstring autograft and through the tibial tunnel intra-articularly to seat well in the femoral tunnel. A guidewire was then inserted into the femoral tunnel, and over this guidewire, an 8 mm tap was then used to create a pilot hole. Then, over this guidewire, an 8 x 23 mm Arthrex BioComposite screw was inserted into the femoral tunnel. Excellent bony purchase was noted with excellent tunnel fill. Strong downward longitudinal traction was applied on the ACL graft to confirm that the graft was well fixed in the femoral tunnel.
The knee was then put through full range of motion to ensure that no impingement on the graft would occur in full extension as well as no significant impingement on the PCL in flexion. The knee was then copiously irrigated and then drained after meticulous hemostasis was obtained. Then, the knee was put through multiple cycles of range of motion to eliminate any creep from the graft. Then, with the knee in near full extension, with a strong posterior drawer being applied, a guidewire was inserted into the tibial tunnel, and over this guidewire, an 11 x 35 mm Delta BioComposite Arthrex interference screw was inserted into the tibial tunnel. Again, excellent bony purchase was noted with excellent tunnel fill, and exam under anesthesia confirmed that there was no anterior drawer or Lachman, and pivot shift test was negative.
Meticulous hemostasis was again obtained using Bovie cautery. The tibial skin incision was then closed in layers with 0 Vicryl in the deep layer and 2-0 Vicryl in the superficial layer. The skin edges and portals were then closed using a running subcuticular stitch of 4-0 Monocryl. Steri-Strips were applied. Sterile dressings were applied. The patient tolerated the procedure well. There were no complications. All needle, sponge, and instrument counts were correct, and the patient was transported stable and extubated to the postanesthesia care unit.
