Hello,
could someone out there help me with this type of surgery, I am very confused. any opinion would be very much appreciated.
1 Right knee ACL reconstruction with Achilles tendon allograft.
2. Medial meniscus arthroscopic repair.
3. Lateral meniscus arthroscopic repair.
4. Chondroplasty, patella.
DESCRIPTION OF PROCEDURE: PT was identified in the preoperative area.
Identified the right knee as the operative site. This was initialed by
myself. He was then brought to the operating room, where he was placed
under general anesthetic. Examination under anesthesia of the right knee
revealed full range of motion from 2 to 3 degrees of hyperextension to 150
degrees of flexion. Grade 3B Lachman and grade 3B anterior drawer. Grade 2
pivot shift with near grade 3. Knee stable to varus and valgus stress at 0
and 30 degrees of flexion.
The leg was then placed into an OSI leg holder. The well leg and all bony
prominences were well-padded. The right lower extremity was then prepped
and draped in usual sterile fashion. He received a gram of cefazolin prior
to incision. A time-out procedure was performed, verifying correct patient,
operative site, as well as presence of necessary equipment. The procedure
was then initiated by injecting the right knee with a mixture of half-and-
half 0.25% Marcaine with epinephrine and 1% lidocaine plain. Standard
anteromedial and anterolateral portal sites were injected, as well as the
proposed location of anteromedial tibial skin incision. Portals were then
established with an 11 blade. Arthroscope was introduced through
anterolateral portal. Diagnostic arthroscopy was performed with the above-
mentioned findings. Chondroplasty of the patella was performed with use of
a 3.5-mm shaver to assure that no unstable flaps remained. Medial meniscus
repair was performed after preparation of the tear site with a ball-tip
meniscal rasp to create a healing surface. A USS Sports meniscal Polysorb
repair device was utilized. A single Polysorb repair staple was utilized
medially. On the lateral side again a ball-tip rasp was used to roughen up
the surfaces of the tear. Two USS Sports meniscal repair Polysorb devices
were
utilized for fixation on the lateral side. Menisci were probed after repair
and previous unstable tears were now stable.
Attention was then turned to the intercondylar notch. The OSI leg holder
was loosened. A 4.2-mm shaver was used to remove the remnant of the ACL,
which was minimal. The ACL footprint on the tibia at its insertion point
was débrided for identification and reference of the tibial tunnel
location. The 6-mm bur was then utilized to perform a notchplasty to assure
visualization of the over-the-top position and assure that the graft would
not impinge anteriorly. Over-the-top position was visualized and a curet
was utilized to mark a 10:30 position on the clock face anterior to the
over-the-top position for later reference when the knee was flexed. On the
back table, the assistant prepared an Achilles tendon allograft with a bone
plug measuring 10 mm in diameter and 25 mm in length. An Arthrex
RetroCutter was then utilized to retro-ream the tibial tunnel. A 10-mm
reamer was utilized. A guidewire was drilled and skin incision then made
and the tunnel reamed in reversed fashion. All debris was removed with the
shaver and a plug placed in the tibial tunnel hole. Attention was then
turned to femoral fixation. The knee was flexed by assistant up to 115
degrees. A 7-mm Arthrex over-the-top guide was placed in the over-the-top
position in the lateral aspect of the intercondylar notch utilizing the 10:
30 reference point. A guidewire was then drilled through the lateral
intercondylar notch at the 10:30 position. This was brought out the lateral
thigh through the skin. A 10-mm Arthrex Low-Profile femoral reamer was the
utilized to create a femoral tunnel of 10 mm in diameter and 25 mm in
length. Debris was removed with a shaver. A notcher was then utilized for
later interference screw fixation. A suture was then passed through the
guide pin and this was brought into the knee. The passing suture was then
retrieved through the tibial tunnel from the knee for graft passage.
Allograft was then brought to the field. Graft was then passed through the
tibial tunnel through the knee joint and into the femoral tunnel with the
bone plug seated in the femoral tunnel. This was verified on direct
visualization. The knee was then flexed to 115 degrees. A soft tissue
protector was placed over the soft tissue portion of the graft. A guidewire
for interference screw placement was then placed anterior-superior to the
cancellous surface of the bone plug. An 8-mm tap for interference screw was
then utilized and taken to a depth of 25 mm. Fixation was then performed
with an 8-mm x 23-mm BioComposite interference screw. Excellent purchase
was obtained. Femoral fixation was then visualized after the knee was
brought down to 90 degrees. Arthroscope was then removed from the knee
joint. The
graft was then cycled a dozen times to pretension it. Isometry was also
checked at that time and found to be excellent. Tibial fixation was then
accomplished with the knee in 30 degrees of flexion and a posterior drawer
applied by an assistant. Fixation was performed with an Arthrex
BioComposite 10-mm x 28-mm fully threaded screw. This was performed while
holding tension on the graft. Again excellent purchase was obtained. This
was visualized and palpated to assure that this was not proud and sunk into
the level of the anteromedial tibial cortex. The arthroscope was then
inserted back into the knee to assure that the screw did not protrude into
the joint, which it did not. Guidewire was then removed. Graft was probed
and found to have excellent tension. The knee was taken through a range of
motion to ensure that it did not impinge anteriorly, preventing knee
extension, which it did not. Final photographs were then taken. Arthroscope
was brought into the suprapatellar pouch. Excess debris and fluid was then
evacuated from the knee. Remainder of local anesthetic was then injected
through the arthroscopic sheath. Incisions and portals were then closed
with buried interrupted #3-0 Vicryl suture. This was performed with the
anteromedial tibial incision after the excess portion of graft was cut
flush with the tibial surface. Passing sutures were removed from the
lateral thigh. Incisions and portals were then covered with Steri-Strips.
Sterile dressings were then placed about the knee. This was followed by Ace
wrap and a hinged knee brace set from 0 to 90 degrees of flexion. He was
then awakened and brought to the recovery room in stable condition.
could someone out there help me with this type of surgery, I am very confused. any opinion would be very much appreciated.
1 Right knee ACL reconstruction with Achilles tendon allograft.
2. Medial meniscus arthroscopic repair.
3. Lateral meniscus arthroscopic repair.
4. Chondroplasty, patella.
DESCRIPTION OF PROCEDURE: PT was identified in the preoperative area.
Identified the right knee as the operative site. This was initialed by
myself. He was then brought to the operating room, where he was placed
under general anesthetic. Examination under anesthesia of the right knee
revealed full range of motion from 2 to 3 degrees of hyperextension to 150
degrees of flexion. Grade 3B Lachman and grade 3B anterior drawer. Grade 2
pivot shift with near grade 3. Knee stable to varus and valgus stress at 0
and 30 degrees of flexion.
The leg was then placed into an OSI leg holder. The well leg and all bony
prominences were well-padded. The right lower extremity was then prepped
and draped in usual sterile fashion. He received a gram of cefazolin prior
to incision. A time-out procedure was performed, verifying correct patient,
operative site, as well as presence of necessary equipment. The procedure
was then initiated by injecting the right knee with a mixture of half-and-
half 0.25% Marcaine with epinephrine and 1% lidocaine plain. Standard
anteromedial and anterolateral portal sites were injected, as well as the
proposed location of anteromedial tibial skin incision. Portals were then
established with an 11 blade. Arthroscope was introduced through
anterolateral portal. Diagnostic arthroscopy was performed with the above-
mentioned findings. Chondroplasty of the patella was performed with use of
a 3.5-mm shaver to assure that no unstable flaps remained. Medial meniscus
repair was performed after preparation of the tear site with a ball-tip
meniscal rasp to create a healing surface. A USS Sports meniscal Polysorb
repair device was utilized. A single Polysorb repair staple was utilized
medially. On the lateral side again a ball-tip rasp was used to roughen up
the surfaces of the tear. Two USS Sports meniscal repair Polysorb devices
were
utilized for fixation on the lateral side. Menisci were probed after repair
and previous unstable tears were now stable.
Attention was then turned to the intercondylar notch. The OSI leg holder
was loosened. A 4.2-mm shaver was used to remove the remnant of the ACL,
which was minimal. The ACL footprint on the tibia at its insertion point
was débrided for identification and reference of the tibial tunnel
location. The 6-mm bur was then utilized to perform a notchplasty to assure
visualization of the over-the-top position and assure that the graft would
not impinge anteriorly. Over-the-top position was visualized and a curet
was utilized to mark a 10:30 position on the clock face anterior to the
over-the-top position for later reference when the knee was flexed. On the
back table, the assistant prepared an Achilles tendon allograft with a bone
plug measuring 10 mm in diameter and 25 mm in length. An Arthrex
RetroCutter was then utilized to retro-ream the tibial tunnel. A 10-mm
reamer was utilized. A guidewire was drilled and skin incision then made
and the tunnel reamed in reversed fashion. All debris was removed with the
shaver and a plug placed in the tibial tunnel hole. Attention was then
turned to femoral fixation. The knee was flexed by assistant up to 115
degrees. A 7-mm Arthrex over-the-top guide was placed in the over-the-top
position in the lateral aspect of the intercondylar notch utilizing the 10:
30 reference point. A guidewire was then drilled through the lateral
intercondylar notch at the 10:30 position. This was brought out the lateral
thigh through the skin. A 10-mm Arthrex Low-Profile femoral reamer was the
utilized to create a femoral tunnel of 10 mm in diameter and 25 mm in
length. Debris was removed with a shaver. A notcher was then utilized for
later interference screw fixation. A suture was then passed through the
guide pin and this was brought into the knee. The passing suture was then
retrieved through the tibial tunnel from the knee for graft passage.
Allograft was then brought to the field. Graft was then passed through the
tibial tunnel through the knee joint and into the femoral tunnel with the
bone plug seated in the femoral tunnel. This was verified on direct
visualization. The knee was then flexed to 115 degrees. A soft tissue
protector was placed over the soft tissue portion of the graft. A guidewire
for interference screw placement was then placed anterior-superior to the
cancellous surface of the bone plug. An 8-mm tap for interference screw was
then utilized and taken to a depth of 25 mm. Fixation was then performed
with an 8-mm x 23-mm BioComposite interference screw. Excellent purchase
was obtained. Femoral fixation was then visualized after the knee was
brought down to 90 degrees. Arthroscope was then removed from the knee
joint. The
graft was then cycled a dozen times to pretension it. Isometry was also
checked at that time and found to be excellent. Tibial fixation was then
accomplished with the knee in 30 degrees of flexion and a posterior drawer
applied by an assistant. Fixation was performed with an Arthrex
BioComposite 10-mm x 28-mm fully threaded screw. This was performed while
holding tension on the graft. Again excellent purchase was obtained. This
was visualized and palpated to assure that this was not proud and sunk into
the level of the anteromedial tibial cortex. The arthroscope was then
inserted back into the knee to assure that the screw did not protrude into
the joint, which it did not. Guidewire was then removed. Graft was probed
and found to have excellent tension. The knee was taken through a range of
motion to ensure that it did not impinge anteriorly, preventing knee
extension, which it did not. Final photographs were then taken. Arthroscope
was brought into the suprapatellar pouch. Excess debris and fluid was then
evacuated from the knee. Remainder of local anesthetic was then injected
through the arthroscopic sheath. Incisions and portals were then closed
with buried interrupted #3-0 Vicryl suture. This was performed with the
anteromedial tibial incision after the excess portion of graft was cut
flush with the tibial surface. Passing sutures were removed from the
lateral thigh. Incisions and portals were then covered with Steri-Strips.
Sterile dressings were then placed about the knee. This was followed by Ace
wrap and a hinged knee brace set from 0 to 90 degrees of flexion. He was
then awakened and brought to the recovery room in stable condition.