After the desired level of general anesthesia was obtained, the patient's left knee was prepped and draped in the usual sterile fashion. Examination revealed full range of motion and no pattern of lateral or medial instability. There was no joint effusion and there was no significant patellofemoral crepitation. At this point the leg was elevated, exsanguinated and the tourniquet was inflated to 300 mmHg.
An arthroscope was introduced through the inferolateral portal, connected to the 3M pump system. Inspection of the suprapatellar pouch revealed reasonable alignment of the patellofemoral joint and very minimal chondromalacic changes on the patella. There was a small defect on the trochlea side which did not show subchondral exposure, no fissuring was noted and this was a focal small lesion in this area. As we entered the medial compartment and the medial compartment was exposed, there was evidence of the patient's prior menisectomy. There was a fairly large lesion on the medial femoral condyle with an overall central core measurement of approximately 25 mm x 22 m. There was some extension of this in the form of small and superificial fissures going in different directions. The intercondylar notch was inspected. The previously placed anterior cruciate ligament graft was intact, however, there was some increased laxity. The posterior cruciate ligament was intact. There was some marginal osteophyte in the rim of the intercondylar notch. Lateral compartment showed a larger lesion but not as deep as the medial side. The lateral meniscus was inspected. Again there was evidence of the patient's prior partial lateral menisectomy. The remainder of the meniscus at this point was intact. Once this inspection was completed there were fibrous adhesions in the joint, especially on the lateral side and suprapatellar pouch. These were very meticulously debrided. Once this was accomplished it was decided that this patient is a suitable candidate for autologous chondrocyte implantation due to the size and extent of the lesion and also considering the patient's age and activity. For this reason, utilizing the outer border of the lateral femoral condyle, strips of cartilage biopsy were obtained and these were placed in a container which will be transported to Genzyme facility in Boston. The cultivated cartilage will be cultured and grown for the purpose of tranplantation and resurfacing the joint at a later date. The knee was then copiously irrigated, all particles and the instrumentation were removed. The puncture incisions were closed with 0 nylon sutures.
Attention was then directed towards the proximal tibia. Again utilizing the patient's prior incision, the skin and subcutaneous tissue was exposed and retracted. The periosteum was exposed using a periosteum elevator. The end of the hardware was identified without any difficulty. Soft tissue surrounding this area was removed and the screw was removed. Once this was accomplished the area awas irrigated. A small piece of Gelfoam was applied and the soft tissue was closed with 2-0 Vicryl and the skin with staples. A compression dressing was applied with a TED stocking, ice packs and a knee immoblizer.
Overall, the three lesions measured approximately 25 mm x 22 mm on the medial femoral condyle, 35 mm x 25 mm on the lateral femoral condyle and there was a third lesion, a smaller one, 10 mm x 12 mm on the trochlea. Requests will be made for an adequate amount of cells and obviously we will proceed accordingly once the cells are available. The patient tolerated the procedure well and left the operating room in satisfactory and stable condition.