Coded: 29889, 29881, 29877, 27405, 27429, and 27427
We began by establishing arthroscopic portals in the knee anteromedially and anterolaterally. Diagnostic arthroscopy ensued. The suprapatellar pouch, medial and lateral gutters were evacuated of hematoma. There was grade II chondromalacia over the lateral facet of the patella. The fibrillated articular cartilage was debrided back to a stable base. There was no evidence of full-thickness chondral loss. The trochlea demonstrated normal articular cartilage.
We entered the medial compartment. There was gross gapping of the medial collateral ligament without even valgus stress testing. The medial meniscus was inspected, noted to be intact, and showed no evidence of tear. The articular surface of the medial femoral condyle and tibial plateau were intact.
The intercondylar notch was inspected. The ACL was intact, but demonstrated pseudolaxity given the obvious tear of the posterior cruciate ligament.
We entered the lateral compartment. There was softening of the lateral femoral condyle and tibial plateau. There was tearing of the anterior horn, body, and posterior horn of the lateral meniscus involving the inner third. This was not felt amenable to repair. The tissue was rather macerated. We proceeded with partial meniscectomy. An arthroscopic biter and shaver was used to trim the inner third of the lateral meniscus back to healthy-appearing tissue. The remaining portion of the meniscus was probed and noted to be fully stable.
We proceeded to the PCL reconstruction. We used an arthroscopic shaver and ablator to remove remnants of the native posterior cruciate ligament with care to protect the anterior cruciate ligament. Once we dissected the PCL off the femoral attachment, we left small stump to be able to visualize its native insertion. We then were able to visualize the posterior aspect of the knee. We placed a spinal needle to create a posteromedial cannula. A cannula was placed and we used a combination of an arthroscopic shaver and ablator to debride soft tissue on the posterior aspect of the tibia down to the mammillary bodies. Once we were able to visualize that arthroscopically with the 70-degree arthroscope, we introduced the Arthrex PCL guide. Mini C-arm fluoroscopy confirmed appropriate position on the proximal tibia. We then advanced the guide pin to the posterior aspect of the knee from the anterior aspect. We placed a shaver to protect the neurovascular bundle and then used the Arthrex FlipCutter to place a 12 mm socket on the tibial side back to the cortex anteriorly. Tunnel edges were smoothed to avoid graft abrasion and we placed a passing stitch.
We then took the Arthrex FlipCutter guide for the PCL and placed it on the femoral attachment of the PCL. A longitudinal incision was made over the medial aspect of the knee. The guide was advanced to the cortex and we advanced the FlipCutter pin into the joint in appropriate position. We then created a 12 mm socket back to the medial cortex with confirmation that there was no violation of the articular surface. We had an appropriate 2 mm bridge of bone anteriorly. We were pleased with the tunnel position.
We placed a PassPort cannula in the anteromedial portal and retrieved our passing stitches.
We used an Achilles allograft for the PCL reconstruction. We measured the graft to be 90 mm in length and 12 mm in diameter. An Arthrex FiberTak TightRope was used for fixation on the femoral side with an internal brace. An attachable button TightRope was used for fixation on the tibial side.
We then brought the graft into the joint and fed it into the tibial tunnel. We over seated it in the tunnel and then were able to make the turn into the femoral socket quite nicely. We saw the TightRope button engage the cortex of the femur medially and then we tensioned the TightRope medially to bring 20 mm of graft into the femoral socket.
We then cycled the knee to remove crimp from the graft. We held the knee in 90 degrees of flexion with an anterior drawer applied, placed a 14 mm attachable button on the TightRope, and then tensioned the TightRope with the knee in 90 degrees of flexion. We then tensioned the internal brace, tied that over the button, and then re-tensioned the PCL graft and then tied that over the button as well.
Arthroscopic inspection demonstrated excellent position of the PCL and appropriate tensioning. We noted elimination of the pseudolaxity of the anterior cruciate ligament.
We extended the incision medially to perform the open medial reconstruction. We made a longitudinal incision down to the pes anserine fascia. Sharp dissection was carried down through the subcutaneous tissues. Care was taken to protect the saphenous neurovascular bundle. There was a complete and total medial-sided blowout of the MCL. It was avulsed proximally and retracted into the joint. We retrieved the native MCL fibers and placed a tag stitch for repair.
We then identified the adductor tubercle, which led us to the medial epicondyle. We identified our native insertion on the MCL just proximal and posterior to the medial epicondyle. This was confirmed with mini C-arm fluoroscopy. A guide pin was placed across the femur from medial to lateral aiming proximally and anteriorly to avoid intersection of the PCL tunnel. We then used an acorn reamer to create a 9 mm socket on the femoral side of about 40 mm in length.
We identified the semimembranosus attachment on the tibia. We marked just inferior to that and placed an Arthrex FiberTak suture that was double-loaded with SutureTape and needles into the native insertion of the posterior oblique ligament. Next, we identified the pes anserine tendons. We dissected deep to them to identify the native medial collateral ligament. We placed a passing stitch deep to the pes anserine tendons. We then measured 7 cm from our medial joint line and marked the posterior aspect of the tibia. This is where we created our tunnel for the superficial MCL on the tibial side. We placed the guide in that position, aimed anteriorly and distally to avoid intersection with the PCL tunnel, and we created a 7 mm tunnel on the tibial side in appropriate position.
Lastly, we placed another knotless FiberTak anchor about 1 cm distal to the joint line to reconstruct the deep medial collateral ligament.
We used a double-loaded FiberTak anchor just posterior to our femoral tunnel and placed the stitches in a locking whipstitch fashion through the native medial collateral ligament. Once we did that, we tensioned it to the anchor and this tensioned what was left of the medial collateral ligament structures and restored their appropriate tension with the knee held in 30 degrees of flexion.
We took a split Achilles allograft for reconstruction of the MCL and posterior oblique ligament. We placed an Arthrex FiberTak TightRope on the femoral side with an internal brace. The graft was 9 mm in diameter proximally. We made the graft on the MCL side 160 mm in length and on the posterior oblique ligament side 120 mm in length. Grafts were 7 mm at their tibial insertion in diameter.
We then passed the femoral portion of the Achilles graft into the femoral socket. The TightRope button engaged the lateral cortex of the femur and then we tensioned the TightRope to bring 20 mm of graft into the femoral socket.
We then passed the superficial MCL graft deep to the retinacular structures and then deep to the pes anserine tendons while placing him through the FiberTak knotless loops for later reconstruction.
We then brought the tibial end of the MCL graft into the tibial socket. We placed an 11 mm TightRope button on the TightRope and then tensioned the TightRope to bring 20 mm of graft into the tibial socket distally once it was passed deep to the pes anserine tendons.
We then re-tensioned the femoral side of the MCL in 30 degrees of flexion with a slight varus stress applied. This provided excellent tensioning of the MCL and had good stability at this point. We passed our internal brace stitches in a similar fashion to the superficial MCL graft and then placed an Arthrex 4.75 mm PEEK SwiveLock just distal to the tibial tunnel and then tensioned the internal brace in a similar fashion to the MCL.
We then tensioned the posterior oblique ligament with the knee out in terminal extension. We placed the SutureTape sutures in a locking whipstitch fashion through the posterior oblique ligament graft and then tensioned it and brought it into the anchor anatomically. We had excellent fixation without over-constraint of the knee in terminal extension.
Lastly, we tensioned the deep MCL fibers using the knotless FiberTak with the knee held in 30 degrees of flexion. We tensioned the loops and this brought excellent opposition of the MCL just about 1 cm from the joint line medially.
We began by establishing arthroscopic portals in the knee anteromedially and anterolaterally. Diagnostic arthroscopy ensued. The suprapatellar pouch, medial and lateral gutters were evacuated of hematoma. There was grade II chondromalacia over the lateral facet of the patella. The fibrillated articular cartilage was debrided back to a stable base. There was no evidence of full-thickness chondral loss. The trochlea demonstrated normal articular cartilage.
We entered the medial compartment. There was gross gapping of the medial collateral ligament without even valgus stress testing. The medial meniscus was inspected, noted to be intact, and showed no evidence of tear. The articular surface of the medial femoral condyle and tibial plateau were intact.
The intercondylar notch was inspected. The ACL was intact, but demonstrated pseudolaxity given the obvious tear of the posterior cruciate ligament.
We entered the lateral compartment. There was softening of the lateral femoral condyle and tibial plateau. There was tearing of the anterior horn, body, and posterior horn of the lateral meniscus involving the inner third. This was not felt amenable to repair. The tissue was rather macerated. We proceeded with partial meniscectomy. An arthroscopic biter and shaver was used to trim the inner third of the lateral meniscus back to healthy-appearing tissue. The remaining portion of the meniscus was probed and noted to be fully stable.
We proceeded to the PCL reconstruction. We used an arthroscopic shaver and ablator to remove remnants of the native posterior cruciate ligament with care to protect the anterior cruciate ligament. Once we dissected the PCL off the femoral attachment, we left small stump to be able to visualize its native insertion. We then were able to visualize the posterior aspect of the knee. We placed a spinal needle to create a posteromedial cannula. A cannula was placed and we used a combination of an arthroscopic shaver and ablator to debride soft tissue on the posterior aspect of the tibia down to the mammillary bodies. Once we were able to visualize that arthroscopically with the 70-degree arthroscope, we introduced the Arthrex PCL guide. Mini C-arm fluoroscopy confirmed appropriate position on the proximal tibia. We then advanced the guide pin to the posterior aspect of the knee from the anterior aspect. We placed a shaver to protect the neurovascular bundle and then used the Arthrex FlipCutter to place a 12 mm socket on the tibial side back to the cortex anteriorly. Tunnel edges were smoothed to avoid graft abrasion and we placed a passing stitch.
We then took the Arthrex FlipCutter guide for the PCL and placed it on the femoral attachment of the PCL. A longitudinal incision was made over the medial aspect of the knee. The guide was advanced to the cortex and we advanced the FlipCutter pin into the joint in appropriate position. We then created a 12 mm socket back to the medial cortex with confirmation that there was no violation of the articular surface. We had an appropriate 2 mm bridge of bone anteriorly. We were pleased with the tunnel position.
We placed a PassPort cannula in the anteromedial portal and retrieved our passing stitches.
We used an Achilles allograft for the PCL reconstruction. We measured the graft to be 90 mm in length and 12 mm in diameter. An Arthrex FiberTak TightRope was used for fixation on the femoral side with an internal brace. An attachable button TightRope was used for fixation on the tibial side.
We then brought the graft into the joint and fed it into the tibial tunnel. We over seated it in the tunnel and then were able to make the turn into the femoral socket quite nicely. We saw the TightRope button engage the cortex of the femur medially and then we tensioned the TightRope medially to bring 20 mm of graft into the femoral socket.
We then cycled the knee to remove crimp from the graft. We held the knee in 90 degrees of flexion with an anterior drawer applied, placed a 14 mm attachable button on the TightRope, and then tensioned the TightRope with the knee in 90 degrees of flexion. We then tensioned the internal brace, tied that over the button, and then re-tensioned the PCL graft and then tied that over the button as well.
Arthroscopic inspection demonstrated excellent position of the PCL and appropriate tensioning. We noted elimination of the pseudolaxity of the anterior cruciate ligament.
We extended the incision medially to perform the open medial reconstruction. We made a longitudinal incision down to the pes anserine fascia. Sharp dissection was carried down through the subcutaneous tissues. Care was taken to protect the saphenous neurovascular bundle. There was a complete and total medial-sided blowout of the MCL. It was avulsed proximally and retracted into the joint. We retrieved the native MCL fibers and placed a tag stitch for repair.
We then identified the adductor tubercle, which led us to the medial epicondyle. We identified our native insertion on the MCL just proximal and posterior to the medial epicondyle. This was confirmed with mini C-arm fluoroscopy. A guide pin was placed across the femur from medial to lateral aiming proximally and anteriorly to avoid intersection of the PCL tunnel. We then used an acorn reamer to create a 9 mm socket on the femoral side of about 40 mm in length.
We identified the semimembranosus attachment on the tibia. We marked just inferior to that and placed an Arthrex FiberTak suture that was double-loaded with SutureTape and needles into the native insertion of the posterior oblique ligament. Next, we identified the pes anserine tendons. We dissected deep to them to identify the native medial collateral ligament. We placed a passing stitch deep to the pes anserine tendons. We then measured 7 cm from our medial joint line and marked the posterior aspect of the tibia. This is where we created our tunnel for the superficial MCL on the tibial side. We placed the guide in that position, aimed anteriorly and distally to avoid intersection with the PCL tunnel, and we created a 7 mm tunnel on the tibial side in appropriate position.
Lastly, we placed another knotless FiberTak anchor about 1 cm distal to the joint line to reconstruct the deep medial collateral ligament.
We used a double-loaded FiberTak anchor just posterior to our femoral tunnel and placed the stitches in a locking whipstitch fashion through the native medial collateral ligament. Once we did that, we tensioned it to the anchor and this tensioned what was left of the medial collateral ligament structures and restored their appropriate tension with the knee held in 30 degrees of flexion.
We took a split Achilles allograft for reconstruction of the MCL and posterior oblique ligament. We placed an Arthrex FiberTak TightRope on the femoral side with an internal brace. The graft was 9 mm in diameter proximally. We made the graft on the MCL side 160 mm in length and on the posterior oblique ligament side 120 mm in length. Grafts were 7 mm at their tibial insertion in diameter.
We then passed the femoral portion of the Achilles graft into the femoral socket. The TightRope button engaged the lateral cortex of the femur and then we tensioned the TightRope to bring 20 mm of graft into the femoral socket.
We then passed the superficial MCL graft deep to the retinacular structures and then deep to the pes anserine tendons while placing him through the FiberTak knotless loops for later reconstruction.
We then brought the tibial end of the MCL graft into the tibial socket. We placed an 11 mm TightRope button on the TightRope and then tensioned the TightRope to bring 20 mm of graft into the tibial socket distally once it was passed deep to the pes anserine tendons.
We then re-tensioned the femoral side of the MCL in 30 degrees of flexion with a slight varus stress applied. This provided excellent tensioning of the MCL and had good stability at this point. We passed our internal brace stitches in a similar fashion to the superficial MCL graft and then placed an Arthrex 4.75 mm PEEK SwiveLock just distal to the tibial tunnel and then tensioned the internal brace in a similar fashion to the MCL.
We then tensioned the posterior oblique ligament with the knee out in terminal extension. We placed the SutureTape sutures in a locking whipstitch fashion through the posterior oblique ligament graft and then tensioned it and brought it into the anchor anatomically. We had excellent fixation without over-constraint of the knee in terminal extension.
Lastly, we tensioned the deep MCL fibers using the knotless FiberTak with the knee held in 30 degrees of flexion. We tensioned the loops and this brought excellent opposition of the MCL just about 1 cm from the joint line medially.