Right knee arthroscopy and debridement of patellofemoral compartment and lateral release, painful right total knee replacement

PREOPERATIVE DIAGNOSES:  Patellofemoral pain post total knee replacement with positive patellofemoral tilt and mild subluxation.

POSTOPERATIVE DIAGNOSES:  Patellofemoral pain post total knee replacement with positive patellofemoral tilt and mild subluxation.

PROCEDURE:  Right knee arthroscopy and debridement of patellofemoral compartment and lateral release, painful right total knee replacement.

FINDINGS:  Positive impingement at the medial facet of the patella with scar tissue, positive tilt and tightness on the lateral retinaculum of the patella, otherwise normal components.

SPECIMENS REMOVED:  None.

COMPLICATIONS:  None.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Minimal.

PROCEDURE IN DETAIL:  A 22 mL of 0.5% Marcaine with epinephrine placed postprocedure.  No intraoperative complications noted.  The patient is a 55-year-old gentleman who had a right total knee replacement performed approximately a year and half ago with pain and soreness, difficulty with performing normal functional activities of daily living secondary to painful right total knee.  Upon evaluation, he was noted to have positive patellar subluxation with apparent tilt, painful patellofemoral articulation with also pain along the medial facet of the patella.  He was indicated for surgery after failure with conservative efforts.  Risks and benefits had been discussed prior to the procedure and all questions answered.

He was brought to the operating room, after adequate anesthesia maintained, IV antibiotic was given.  Tourniquet applied to the right upper thigh, placed into the arthroscopic legholder, prepped and draped in the usual sterile fashion.  At this point, I made standard infrapatellar lateral portal using stab wounds.  Spinal needle was used to obtain proper portal placement prior to the stab wound.  We then introduced the scope into the knee and distended the knee, made a second stab wound in the medial infrapatellar region.  At this point in time, we evaluated the patellofemoral articulation, which was noted to have a large amount of a scar and excessive hypertrophic tissue along the medial portion of the patella, which was impinging along the medial femoral condyle as we flexed and extended the knee.  The patella had some lateral tightness and some mild tilt.  There was no obvious dislocation present.  The remainder of the components were without evidence of abnormalities.  At this point in time, I placed the 4-0 full-radius shaver within the knee, debrided the large amount of scar tissue using both a 4-0 full-radius shaver as well as 4-0 full radius upbiting shaver to reduce the scar tissue along the medial facet and at this point, there was no further impingement noted.  We then reevaluated the patellofemoral articulation, which remained still tight laterally and at that point, performed a standard lateral release using the 90-degree ablator to perform an electrocautery of the lateral IT band and release of the lateral retinaculum.  Once established full lateral release, there was noted to be good overall excursion of the patella with good overall patellar tracking.  No excessive tightness.  There was no further impingement noted along the medial facet of the patella.  At this point, we copiously irrigated and removed all instruments and then closed the knee with a nylon, simple interrupted suture x2 followed by infiltration of the knee joint with 22 mL of 0.5% Marcaine with epinephrine and application of Adaptic sterile gauze dressing, ABD, Webril, ACE wrap over the cuff, and a knee immobilizer.  He tolerated the procedure well and was brought stable to postanesthetic period in good condition.  Prior to the procedure, we had exsanguinated the knee.  Tourniquet was up for a total of 39 minutes.  Again, there were no intraoperative complications noted.  He was brought stable to postanesthetic area in good condition.