PREOPERATIVE DIAGNOSIS: Internal derangement of the right knee.
POSTOPERATIVE DIAGNOSES:
1. Complete anterior cruciate ligament tear,
right knee.
2. Hypertrophic synovitis.
3. Vertical tear lateral meniscus of the
right knee.
OPERATION PERFORMED:
1. Operative arthroscopy.
2. Partial lateral meniscectomy.
3. Partial synovectomy.
4. Anterior cruciate ligament reconstruction
using tibialis anterior allograft.
PROCEDURE IN DETAIL: After the smooth induction of anesthesia,
the patient was given intravenous Ancef in antibiotic prophylaxis. The right
lower extremity was prepped and draped in usual sterile manner. Arthroscope was
then inserted in the knee joint and taking the pump irrigation system through a
standard 3-portal approach. With the knee in valgus extension, the medial compartment
was examined and noted to be normal. After the synovium was cleared from the
intercondylar area, the ACL and PCL were visualized. The PCL was taut and
intact. The ACL was completely detached from its femoral origin. There was
evidence of hyperemia at the stump of the ACL. This was aggressively débrided.
The lateral aspect of the femoral condyle was also débrided. The over-the-top
position was identified. The knee was then placed in figure-four position,
lateral compartment was examined. There was a vertical tear at the midportion
of the lateral meniscus. It extended nearly to the periphery. It was trimmed
and contoured with basket full-radius resectors and shavers until smooth edges
were obtained. Electrocautery was used as well to smooth the tissue. There was
no significant chondromalacia. The knee was irrigated. The medial and lateral
gutters were cleared of synovium. Patellofemoral joint showed normal tracking
with no significant chondromalacia.
At this point, a notchplasty was performed
deepening and widening particularly the superior and lateral femoral condyle
portions of the notch. Smooth edges were obtained. In addition, the ACL
insertion was débrided down to the stump.
Meanwhile, the
tibialis anterior allograft was reconstituted. Double whipstitches were placed
with #2 Mersilene suture. The graft was then folded, and it measured
approximately 10 mm in diameter. It was then elected to do a 10 mm tunnel. The
graft was wrapped in a Kerlix soaked with saline. Using the Arthrex guide
system, the knee was extended and a guidewire was drilled through the medial
portion of the proximal tibia and into the previous ACL tibial spine stump.
After a 2 mm hole was made into the bone for subsequent fixation, a 10 mm
reamer was used to create the tibial tunnel. A 7 mm offset guide was now placed
in the over-the-top position with the knee flexed and another guidewire was
drilled through the lateral cortex of the femur. A 10 mm femoral tunnel was
then created. The depth of the tunnel measured 50 mm. The knee joint was
aggressively irrigated. At this point, the graft was passed through the _____
of the hook anchor and with the knee hyperflexed; the guidewire was passed
initially through the tibial tunnel, then the femoral tunnel, and out the
anterolateral cortex of the femur. The tunnel had measured 50 mm in depth. Once
the graft was determined to be positioned outside the lateral cortex of the
femur, the sutures were cut. The graft was retracted and the hook deployed into
the lateral cortex of the femur to act as a fixation device. This was confirmed
several times with the _____ maneuver. The knee was then flexed up to 30
degrees and a posterior traction was gently placed in the tibia. A
bioabsorbable washer was placed over the graft, and a bioabsorbable interference
screw was then secured into the washer locking the graft in place. This was
further augmented with a single Richards barbed staple. The remains of the
graft were transected. The knee was inspected in full extension and nearly 120
degrees of flexion obtained until the heel of the patient hit the Operating
Room table. The graft was probed and noted to be secure. Anterior drawer and
Lachman were noted to be zero. The wound was aggressively irrigated. All the
incisions were closed with nylon. The knee joint was injected with 20 mL of
Marcaine and 6 mg of Decadron. The wounds were washed and dried. A sterile
compression dressing applied followed by a knee immobilizer. Anesthesia was
reversed and the patient was brought to the recovery room, having tolerated the
procedure well without complications. Sponge count and needle counts correct.
Estimated blood loss was minimal. Tourniquet time was approximately 35 minutes.
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