Right knee arthroscopy with revision, ACL reconstruction complex

PREOPERATIVE DIAGNOSES:              Right knee ACL tear with medial meniscus tear with mild arthritis and retained hardware.

POSTOPERATIVE DIAGNOSES:           Right knee ACL tear with medial meniscus tear with mild arthritis and retained hardware.

OPERATIONS PERFORMED:

1.  Right knee arthroscopy with revision, ACL reconstruction complex.

2.  Partial medial meniscectomy.

3.  Microfracture with chondroplasty of the trochlear.

4.  Removal of deep hardware.

5.  Fluoroscopic guidance of procedure.

BLOOD LOSS:                                            Minimal.

FLUIDS:                                                        Crystalloid.

COMPLICATIONS:                                     None.

INDICATIONS:                                             The patient is a gentleman who has an ACL tear probably chronic after a reconstruction done elsewhere.  The risks, benefits and alternatives were discussed.  He notes of an MRI showing medial meniscal tear as well.  The risks, benefits, alternative treatments, allograft use etc., discussed preoperatively.  He wished to proceed.

PROCEDURE IN DETAIL:                        The patient was identified, brought to the operating room, and placed in a supine position.  After induction of general anesthetic, he received Ancef preoperatively.  Right lower extremity was prepped and draped in usual sterile fashion.  The knee was inflated with saline and portal sites were established.  The findings were as follows:  The patient noted to have a torn ACL.  There was no function to the ACL.  There was scars posteromedially and in the notch.  The patella actually looked to be in generally good shape considering, but the trochlear groove showed a grade III lesion.  The later compartment showed mild wear with an intact lateral meniscus.  At this point, we first performed partial medial meniscectomy using a full radius.  This was a non-repairable tear in the posterior horn.  It seemed that he may have had some meniscus removed previously.  At this time, we brought the fluoroscopy in sterilely.  We evaluated the knee.  We saw the two screws.  The tibial screw I felt could be bypassed, but the femoral screws needed to be removed in order to do an ACL reconstruction.  At this point, we performed a notch plasty.  We debrided back to the point where we could see the back wall.  We still did not see the screw.  We then used curette to finally see the screw and again using the fluoro, this was helpful to evaluate.  We then found the screw.  We carefully removed the surrounding bone.  This portion of procedure took about 45 minutes to carefully remove this tissue and then we were able to remove the screw.  The screw was then removed using a standard Arthrex screwdriver.  Next, the open top position was identified.  There were some osteophytes and we carefully had to debride this area to make sure that we have the over the top.

Next, we prepared a graft on the side table.  This was 95 mm graft.  Using the Biopunch technique and my assistant, Jessica Wheeler PA-C, prepared this with fiber wires to a 10/10 length approximately.  This was a good quality graft.  We then drilled the tibial tunnel from medial to lateral.  We tried to bypass the screw and we were able to do so using Arthrex guide set at 55.  We then overreamed with a 10-mm reamer.  We then went to the over the top 1 mm back wall and then reamed again to a depth of 40, we then placed our Transfix guide up and drilled across the knee with the wire over laterally and placed the wire down to the tibia.  We then placed the graft up, pulled it across through the knee and then fixed it with a 40-mm via Transfix, excellent fixation.  We _____ of the knee.  No notch impingement was noted.  We then fixated with a BioComposite screw, 11 x 35 delta with excellent fixation.  Once this was completed, we checked the knee once more.  The microfracture was then performed as follows:  The trochlear groove lesion was identified.  We gently debrided it using a curette and then we placed multiple punctate all of them to the lesion.  Once this was done, all instruments removed from the knee.  The knee was closed with simple nylon sutures with the portals, other surgicals with 2-0 Vicryl and subcuticular PDS.  The knee was injected with Marcaine for pain control and injected at all portal sites.  The anesthesia would then do a block following all procedure.  Sterile dressings applied for the knee.  The patient tolerated the procedure well.  My assistant was essential in this complicated case.