The procedure was performed under tourniquest control and antibiotic coverage. After the desired level of general anesthesia was obtained, the patient's left knee was prepped and draped in the usual sterile fashion. Examination under anesthesia did not show any pattern of instability in the lateral and medial collateral ligaments. There was gross instability of the knee in the anterior plane demonstrated by anterior drawer test, Lachman test, and a positive lateral pivot shift test.
At this point, the leg was elevated, exsanguinated, and the tourniquet was inflated to 350 mm Hg. The proximal soft tissue mass which the patient had complained of preoperatively on the proximal and medial aspect of the knee was approximately 3.5 inches to the patient's prior incision. This was measuring approximately 1.5 cm by 1 cm and was mobile in a subcutaneous area. It did not appear to be an intraarticular lesion. A skin incision was made in that area. Skin and subcutaneous tissue were retracted. The soft tissue mass was identified, and with a gentle dissection, was separated from the surrounding tissue, and was removed in one piece. This was sent for pathological examination. The subcutaneous tissue then was closed with a Vicryl suture, and the skin was closed with staples.
Once this was accomplished, the arthroscope was introduced into the joint. Inspection of the joint revealed some articular cartilage changes consistent with early degeneration in the trochlear area. There was a small medial osteophyte forming in the medial femoral condyle. No loose body was identified. As we entered the medial compartment, there was evidence of prior partial medial menisectomy. However, the articular cartilage of the femur was not showing any significant damage. A very early fibrillation on the tibia was noted.
The anterior cruciate ligament was almost completely disrupted, only about 10% of the fibers were present. There was regrowth of a very tight and stenotic notch. As we entered the lateral compartment, there was articular cartilage damage in the distal femur where there appeared to be a chondral fracture associated with possibly some chronic wear in the distal femur. At this point, the knee joint was irrigated, and a chondroplasty of the distal femur was carried out. A partial synovectmoy was performed in the joint.
Once this was accomplished, then a skin incision was made in the anterior aspect of the tibia, utilizing the patient's prior incision, extending distally about 1.5 cm. Skin and subcutaneous tissue were retracted. The end of the previously placed interferon screw was identified and that screw was removed. The soft tissue over that was closed with Vicryl suture.
The anterior cruciate ligament guidepin was assembled, and the anterior guidepin was introduced into the proximal tibia. This was over-drilled with a 10 mm cylinder solid drill. Excess tissue was removed both outside and inside the joint. This was followed by placment of a femoral aimer, and after a notchplasty was completed, a point was selected in the distal femur. The pin was introduced, and this pin was over-drilled by a 9 mm cannulated and calibrated reamer at the depth of 25 mm. All instrumentation then was removed.
The knee was copiously irrigated, and the graft which was prepared on a separate table by the first assistant was brought in to the main table, and was passed in a retrograde fashion into the joint. The proximal portion of the graft was press-fitted into the distal femur, and the knee was brought to full extension. Distal tensioning was applied. The distal portion was fixed to the tibia with 15 x 7 interferon screw. Approximatley 10 mm of the bone plug was protruding which was excised, and this left approximately 25 mm of bone in the proximal tibia. The area was copiously irrigated.
The knee joint was irrigated, and the stability of the knee was checked. Probing of the anterior cruciate ligament also indicated good tension in the intraarticular portion without any impingement. The subcutaneous tissue was then closed with Vicryl suture, skin with staples, and compression dressing was applied with a TED stocking and a Polar Care cryotherapy unit. The patient tolerated the procedure well and left the operating room in satisfactory and stable condition.