Operative arthroscopy Partial lateral meniscectomyPartial synovectomy Anterior cruciate ligament reconstruction using tibialis anterior allograft.

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.

ANESTHESIA: Regional.

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.