Help on knee arthroscopy - I am so confusing myself


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I am so confusing myself on this one and need some assistance....

1. Left knee patellar chondromalacia.
2. Left anterior cruciate ligament instability.
3. Status post left anterior cruciate ligament reconstruction in 9/2001.

1. Left knee medial femoral condyle, medial tibial plateau, and patellar grade II-III chondromalacia.
2. Partial left anterior cruciate ligament tear.
3. Pathologic medial plica.
4. Exuberant scar formation at anterior cruciate ligament base with cyclops lesion.

Left knee arthroscopy with:
1. Chondroplasties of medial and patellofemoral compartments.
2. Lysis of adhesions with removal of cyclops lesion and debridement/thermal shrinkage of partial anterior cruciate ligament tear.
3. Limited synovectomy with excision of medial pathologic plica.
Exam under anesthesia of the left knee joint reveals range of motion from 0-125 degrees. Retropatellar crepitation is present. Anterior drawer is 1+ with a questionable endpoint. Lachman's is trace to 1+. Pivot shift is negative. He has no instability with varus or valgus stress at 0 and 30 degrees.

Diagnostic arthroscopy of the left knee joint reveals patellar chondromalacia in the medial facet and median ridge region, grade II-III. The suprapatellar pouch has a thickened medial plica that extends down towards the medial gutter and anterior knee joint. No significant femoral trochlear chondromalacia. The medial compartment shows no meniscus tear. Grade II-III chondromalacia is noted at the most medial aspect of the tibial plateau. The femoral condyle has an approximately 5-7 mm area of a loose chondral flap, grade II in thickness and that was débrided. The intercondylar notch shows a highly frayed and partially torn ACL. Once this was cleaned up, I was able to further probe this. He does have some laxity per probing and this was touched up with the ArthroCare CoVac 50 wand. He had exuberant scar formation at the tibial footplate region and this was excised. After femoral shrinkage, debridement of the ACL and of the cyclops lesion. He had no impingement upon full extension and only minimal laxity per probing of the ACL. The lateral compartment shows mild fraying of the tibial plateau near the tibial eminence. No meniscal tears are noted.

The patient was given a general anesthetic. Exam under anesthesia was done with findings as above. A pneumatic tourniquet was placed about the left upper thigh and he was secured in the arthroscopic leg holder. The right lower extremity was placed well padded and well positioned in the well-leg holder. Sterile preparation of the left lower extremity was done with Betadine followed by draping in the usual sterile fashion. The limb was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg.

Stab incisions were made through his old arthroscopic portals and the arthroscopic equipment was applied. Diagnostic arthroscopy was undertaken with findings as above. Debridement of chondral surfaces was done with a 4.0 Aggressive plus shaver. The tibial footplate scar was débrided with the shaver and the ArthroCare wand. I carefully débrided the frayed ACL fibers with the shaver and then touched this up with the ArthroCare wand, so as to perform thermal shrinkage of the ligament itself. The patellar cartilage chondromalacia was shaved down, as was the pathologic medial plica. A look through the remainder of the joint was done. Any loose bodies or other pathology involved was taken care of with the shaver.

The scope was removed and excess fluid was compressed from the knee joint. The portal incisions were then closed with 4?0 nylon. These were infiltrated with 0.5% Marcaine with epinephrine as was the knee joint itself. Sterile dressings were applied and the tourniquet was deflated. He was awakened, extubated, and brought to recovery in good condition. No complications were noted.

This is a non-Medicare patient, commercial payer and I would appreciate any help anyone can give???