After desired level of general anesthesia was obtained, the patient was covered and administered an intravenous antibiotic. The left knee was prepared and draped in the usual sterile manner. Examination confirmend the presence of anterior cruciate ligament insufficiency, probably Grade III. There was palpation of osteophytes around the joint. After examination was completed, the leg was exsanguinated. The tourniquet was applied and was inflated to 350 mm of mercury.
Through the supramedial portal, irrigation solution and a drainage cannula were introduced; through the arthroscope from the inferolateral protal, the pump system was established. Patellofemoral joint showed osteophyte formation but no loose body, chronic synovial changes were present and chronic scar tissue also was present. These were not impinging at this time. As we entered the medial compartment, moderately severe degenerative changes with thinning of the articular cartilage and deformity of the medial compartment was noted in addition to the almost total absence of the medial meniscus.
The intercondylar notch showed no anterior cruciate ligament fibers which were functional. There was a portion of the old anterior cruciate ligament which had been granulated but was in a lax position. There was a large osteophyte formation and a very stenotic notch. Lateral compartment showed some degenerative changes in the lateral meniscus, no frank tear was identified and articular surface also showed some wear and tear, possibly Grade II to III. Again no loose body was identified.
At this point, debridement of the intercondylar notch was performed which was followed by a wide notchplasty and removing of all osteophytes. The graft had been taken prior to starting the arthroscopic procedure from the central third of the patellar tendon with a width of 12 mm with bone plugs of 25 mm on each side and had been passed along to the separate table for the assistant to prepare and size the graft. The central gap from the donor site had been closed. The anterior cruciate ligament guide was then assembled at the 55 degree angle. The knee was kept in 90 degree position and a point was selected an the center of the knee over the tibial spine. A 3/32 Steinmann pin was introduced here which came out in perfect position. This was then followed by overdrilling with the 10 mm drill and that was based on our measurement. This was drilled with a 10 mm drill and then the knee was kept in that position and Arthrex posterior femoral guide was introduced and a pin was introduced over that, about 2 mm from the posterior cortex. Based on our measurmeent, this was followed by drilling a 9 mm hole. The knee joint was then irrigated and after this irrigation, as well as completion of both femoral and tibial tunnels, a Beith pin was introduced from the tibia into the femur. The pin was passed through the femoral cortex and skin. The graft which was prepared on a separate table was tubed and measured then passed through the proximal tibial tunnel into the joint and it was press-fitted into the femur. Tensioning of the graft was performed distally; the knee was taken from 0 to 120 degrees of flexion and distal portion of the graft was fixed with a 20 mm x 7 interference screw. The remainder of the graft which was protruding from the tunnel was resected and this was approxiamtely 9 mm.
The area was covered with Gelfoam. Skin and subcutaneous tissue were closed. Puncture incisions were closed. Examination of the knee showed excellent stability and absence of the Lachman or anterior drawer test which was gently performed. The knee was placed in a compression dressing with the cryotherapy unit pad. A knee immobilizer was then applied. The patient tolerated the procedure well and left the operating room in satisfactory and stable condition.