DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Anterior cruciate ligament deficient left knee, status post repair of posterolateral corner injury.
POSTOPERATIVE DIAGNOSIS: Anterior cruciate ligament deficient left knee, status post repair of posterolateral corner injury.
OPERATIONS PERFORMED:
1. Diagnostic arthroscopy of the left knee.
2. Anterior cruciate ligament reconstruction with tibialis anterior allograft.
3. EZLoc femoral fixation device and WasherLoc screw for the tibia.
SURGEON:
FIRST ASSISTANT: Jane Doe, PA-C
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF OPERATION: The patient was taken to the OR and general anesthesia was given by the anesthesiologist. The patient had already been given 1 gram of intravenous Ancef. The knee was examined under anesthesia and had full range of motion with positive Lachman, anterior drawer, and mild pivot shift. The patient had a 1+ varus laxity but no valgus laxity. A high thigh tourniquet cuff was placed. The entire left lower extremity was prepped with DuraPrep. The standard inferolateral and superomedial portals were made using prior incisions. Arthroscope was placed. Diagnostic arthroscopy of the knee was performed. A probe was placed in the inferomedial portal. The suprapatellar pouch and gutters showed no abnormalities. No loose bodies were identified. The patella and trochlear groove were without abnormality. The medial joint was pristine, without evidence of meniscal tear. The ACL had scarred down to the PCL. There was no evidence of attachment to the lateral wall. The lateral joint showed no abnormality.
At this point in time, the first assistant went to the back table to prepare the tibialis anterior allograft. I brought the table up and flexed the knee to 90 degrees. I brought in a large size shaver, debrided the stump of the remaining portion of the ACL. The PCL was intact. We then brought in the Howell tibial guide and put this at approximately 65 degrees to the joint surface, drilling a K-wire up into the tibia. A skin incision was made along the proximal anteromedial aspect of the tibia. The guidewire entered at the knee joint anterior to the PCL and just between the tibial spines. We had measured the tibialis anterior allograft and it fell into the 9 mm category. We therefore drilled a 9 mm tibial tunnel, debrided the margins of the above. I placed the impingement rod. There was no evidence of impingement with full knee extension. I removed a minimal portion of the medial wall of the lateral distal femur. A roof plasty was not required. I cleaned off the older top position.
We used the transtibial femoral guide, placed a guidewire through the tibia from distal lateral to proximal lateral through the lateral cortex, then obtained a 9 mm reamer and reamed our femoral tunnel at the 1:30 position up through the lateral cortex of the femur. We measured the length of the femoral tunnel and it measured 40 mm. We then obtained the EZLoc femoral fixation device and placed the tibialis anterior allograft. We then brought this through the tibial tunnel into the femoral tunnel, putting the pointed guide pin through the skin proximal and lateral. We pulled the EZLoc device through the femoral tunnel, bringing the reconstructed ACL graft into the femoral tunnel. The lever arm was lateral and came out through the tunnel into the soft tissue. I then removed the passing wire after cutting the suture and pulled on the suture proximal and then distal to deploy the lever arm. This caught on the lateral cortex of the femur, so I was unable to bring the EZLoc device or the reconstructed ACL back through the femoral tunnel. Prior to this, we had drilled the counter-bore for the WasherLoc device aiming towards the fibula. We obtained an extended spike WasherLoc and got this ready to fix the tibialis anterior allograft to the tibia.
I cycled the reconstructed ACL with 10 flexion/extension arcs. We put the knee into full extension, placed tension on the sutures holding the ACL graft, and then impacted the WasherLoc device pointing towards the fibula. I then drilled through the drill guide, measuring the depth of the tibial drill hole and it measured 58 mm. This was a very long tunnel for the tibia, therefore, I brought in the mini C-arm to confirm that this was not too long, but it did measure 58 mm, coming out just along the posterolateral cortex of the tibia. I obtained a 58 mm screw and we had excellent bite with the above, stabilizing the reconstructed anterior cruciate ligament using our tibialis anterior allograft. We put the arthroscope into the knee joint, confirming that the reconstructed ACL with the tibialis anterior allograft was in excellent position. There was no Lachman or pivot shift. We had excellent fixation both to the femoral site and the tibial site.
Therefore, I irrigated the knee joint copiously with irrigation solution. Multiple pictures were taken during the operative procedure. We cut off the long portion of the graft distal to the WasherLoc device. Multiple pictures were taken during the operative procedure. We irrigated the wounds copiously, as noted. The portals were closed with staples, and the subcutaneous for our tibial graft site was closed with 2-0 Vicryl followed by staples. The skin was cleansed, followed by a dry sterile dressing, followed by a knee brace in full extension. A femoral nerve block was performed by Anesthesia. Tourniquet was let down at 80 minutes. We had good capillary refill of all toes and normal dorsalis pedis and posterior tibial pulses. The patient was reversed from anesthesia and taken to the recovery room awake and in stable condition.
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