PREOPERATIVE DIAGNOSIS: Torn right anterior cruciate ligament.
POSTOPERATIVE DIAGNOSIS: Torn right anterior cruciate ligament.
OPERATION PERFORMED: Right anterior cruciate ligament reconstruction using autograft bone-patellar tendon-bone.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIOLOGIST: Jean Doe, MD
INSTRUMENTS USED: Two Stryker interference screws, an 8 x 25 mm screw on the femoral side and a 8 x 20 mm screw on the tibial side.
TOURNIQUET TIME: 67 minutes.
DRAINS: One Hemovac drain.
DESCRIPTION OF OPERATION: The patient was given 2 grams of IV Ancef, IV piggyback, prior to going back to the operating room. Once he was back, he was transferred from the OR stretcher onto the operating room table without complications. After induction of general anesthesia, laryngeal mask airway was placed by the anesthesia department, a well-padded tourniquet was placed on the proximal aspect of the right thigh, and exam of the right knee showed a 3+ anterior drawer, Lachman positive, and pivot shift. A double DuraPrep scrub was performed on the right lower extremity. The right leg was placed in the leg holder and exsanguinated in the routine fashion prior to inflation of tourniquet to 300 mm of pressure.
An anteromedial longitudinal incision was made over the right knee measuring about 5-6 cm. Dissection was continued down to the patellar tendon that was identified. A 10 mm graft knife was used to harvest the central third of the patellar tendon with bone blocks in the inferior patella and superior tibial tubercle. The graft was harvested and taken onto the back table. Each of the bone blocks measured 25 mm. They were fitted through 10 mm spacers.
A routine arthroscopy was then performed to the right knee via anteromedial-anterolateral portals. The arthroscope was introduced in the knee via the anterolateral portal. In the suprapatellar pouch, there was no evidence of loose bodies or abnormalities. The mediolateral gutters were normal. The patellofemoral articulation was normal. The medial compartment was entered. The medial meniscus was probed; it was normal. The lateral compartment was entered. Lateral meniscus was probed; it was normal. There was no evidence of chondral defects.
The ACL was completely torn. The remnant was debrided with a 5.5 shaver, and notchplasty was performed in the medial aspect of the lateral femoral condyle with a 5.5 bur until there was appropriate visualization of the over-the-top position at 10:30 to 11 o'clock. Once this was completed, the tibial tunnel guide was placed through the anteromedial portal. The guidewire was reamed through the anteromedial tibia. A 10 mm reamer was used to ream the tibial tunnel in a cannulated fashion. The opening site was at the tibial spine at the level of the anterior horn of the lateral meniscus.
Once this was smoothed off and all excess bony shavings were removed, a 6 mm over-the-top guide was placed through the tibial tunnel into the over-the-top position while holding the knee at 90 degrees of flexion and a long-threaded Beath pin was placed at the distal femur exiting the anterolateral thigh. A 10 mm reamer was used to ream the femoral tunnel to a depth of about 35 mm. All excess bony shavings were removed with a 5.5 shaver. The graft was then passed through the tibial tunnel, past the posterior cruciate ligament into the femoral tunnel until it was fully seated.
The knee was hyperflexed. A guidewire was placed through the anteromedial fat pad in the bone-bone interface, and an 8 x 25 mm interference screw was used to stabilize the femoral bone block. Excellent purchase was achieved. The guidewire was removed. The knee was placed under tension. The graft was placed under tension. Full range of motion of the knee was checked, and there was no evidence of lateral wall or roof impingement. Tensioning of the graft was performed at 30 degrees of flexion, and an 8 x 20 mm screw was used to stabilize the tibial bone block. There was excellent stability of the graft with full range of motion of the knee.
The arthroscope was removed from the knee. Copious amount of normal saline was used to irrigate out the knee joint. Excess bone graft was impacted in the patella and tibial defects. The patellar tendon was closed with interrupted #0 Vicryl figure-of-eight sutures. Paratenon was closed with interrupted inverted #2-0 Vicryl sutures. A medium Hemovac drain was placed exiting superolaterally. The subcutaneous tissue was closed with interrupted inverted #2-0 Vicryl sutures, and the skin was reapproximated with staples. The knee was injected with 30 mL of 0.5% Marcaine with epinephrine. Dressings were placed with Xeroform, 4x4, ABD, soft bulky dressing, a double 6-inch Ace bandage and a cold pack. After reversal of general anesthesia, the patient was extubated in the operating room and transferred to the recovery room in stable condition.