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Knee Arthroscopy with ACL Reconstruction and Arthroscopic Debridement of Medial Meniscus Tear

DESCRIPTION OF OPERATION: The patient was prepped and draped in the routine sterile manner. The patient was given 1 gram of Ancef prior to the start of the procedure. A graft was taken with a 4 cm incision overlying the insertion of the pes anserinus. The pes was dissected out and the insertion on the tibia was incised. The sartorius was reflected and the semitendinosus tendon and the gracilis tendons were identified and tagged with #2 FiberWire using the Krackow suture method. The fascial bands were dissected free of both, including the bands connecting to the gastroc. The close-ended harvesting device was then used to strip the muscles from the tendon. They were taken to the back table, cut to 19 mm and then the #2 FiberWire was whipped into both ends of the tendons. They were folded so we would have a quadruple graft and then placed on the tensioning board, placed under 15 pounds of tension. The graft was then baseball stitched to gather the tendons together. The tendons were marked at 25 mm at the folded ends to assure there would be good placement into the femur. At this point, diagnostic arthroscopy was started. The diagnostic arthroscopy showed no chondral lesions. The ACL was completely torn. The PCL was intact. The medial meniscus had a posterior horn medial meniscus tear that was complex type with a horizontal as well as a vertical zone. After debridement using a straight basket biter and a shaver, approximately 15-20% of the posterior horn was debrided leaving the majority of the meniscus. At this point, the lateral meniscus was evaluated and noted to have no tears. The ACL stump was debrided using shaver and cautery. A notchplasty was performed so the over-the-top position could be found. Once the over-the-top position was defined, a position approximately 5 to 6 mm from the over-the-top position was defined at a position of 10 o'clock. An awl was used to create a point spot there and the Beath pin was then placed at this position through the medial portal. The knee was hyperflexed and the pin was driven through the lateral cortex of the femur and then 8 mm reamer was used to ream a 30 mm tunnel. This was predetermined based on the graft thickness. Once this was drilled, a suture was passed through this tunnel. The tibial tunnel was then drilled using the Arthrex guide resting on the PCL and the pin was placed so it would be in the central portion of the ACL stump, slightly on the medial side. The reamer was then placed over this with a 9 mm reamer and this was reamed overlying. The shaver was then used to debride all of the bony elements within the joint. The suture was then passed through both tunnels. A notcher was then used to notch the tunnels to allow the BioScrews to be placed. The graft was passed. The knee was hyperflexed again and the femoral side was fixed using 8 x 23 mm BioScrew. The graft was cycled and noted to be isometric. The graft was then tensioned placing the knee to full extension and a guide pin was placed and a Delta BioScrew was then placed 9 x 35. This gave excellent fixation of the graft. The knee had full symmetric range of motion, had a negative Lachman and a negative pivot shift following fixation of the graft. The suture ends were then cut. The fascia was closed using 2-0 Vicryl, 3-0 Monocryl, and 4-0 Monocryl were used for the skin. The portals were closed using 4-0 Monocryl. Marcaine was infiltrated into the incisions and into the knee joint. A total of 25 mL was used. Sterile dressing was placed. The patient was taken to the recovery room in stable condition.

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