After a desired level of general anesthesia was obtained, the patient's left knee was prepped and draped in the usual sterile fashion. Examination under anesthesia showed full range of motion and no pattern of gross instability. The leg was elevated, exsanguinated and the trouniquest was inflated to 300 mmHg. Proximal tibial incision was made approximately 2-2½ in. length. The skin and subcutaneous tissue was retracted. Periosteum was exposed and a periosteal patch was obtained with width of approximately 35 mm and length of approximately 55 mm. The patch was placed on a separate sterile container. The periosteum was covered with a thin layer of epinephrine solution and then subcutaneous tissue was closed as well as the skin with staples.
Attention then was directed towards the knee joint. A midline incision was utilized. The skin and subcutaneous tissue was retracted and a median parapatellar incision was made with extension proximally and distally. The skin and subcutaneous tissue was retracted away in addition to the deeper incision and patellar was reflected laterally. Adequate exposure of the medial and lateral compartment was achieved. The lesions on the medial and lateral condyles were very clear and noted. The previously reconstructed anterior cruciate ligament appeared to be intact with good tension on its fibers. The lesions on the medial and then on the lateral femoral condyle were debrided and the depth of the lesion was preserved so that it would not have any bleeding. Once both lesions were completely debrided with vertical and smooth edges, the base was covered with a thin layer of epinephrine. Measurement then was performed with aluminum foil and exact diameter of the lesions was identified. The larger lesion on the lateral condyle measured 35 x 25 mm and the smaller lesion on the medial femoral condyle measured 25 x 22 mm.
At this point the periosteal patch was brought in, was divided in two segments and we started from the medial side the four-corner suture technique using 6-0 PDS suture. The periosteal patch was attached to the distal femur. This received approximately 24 separate sutures. The area between 11 o'clock and 1 o'clock position was left unsutured for the purpose of cartilage implantation. Attention then was directed towards the lateral lesion, and again, utilizing a four-corner technique, that area was sutured receiving 22 sutures. Again, the area between 11 o'clock and 1 o'clock was left for cartilage implantation. Once this was accomplished, then each lesion separately and independently was tested with 0.4 mL of saline. No seepage was encountered. The saline was withdrawn and the periphery of the lesion then was reinforced with biologic glue.
At this point the cells, which were mixed on a separate table, were brought to the main table, and two vials of cells were utilized for the medial lesion. Once the cartilage cells were implanted behind the periosteum patch, then additional suturing of the proximal area between 1 and 11 o'clock were carried out and the area was covered with biologic gule. Once this was sealed completely, the lateral lesion was addressed and again, two vials were utilized in that area and 11 to 1 o'clock suturings was completed and the area was covered with biologic glue.
Once this was accomplished, the knee was brought to extensions and suturing of the capsule was carried out with #1 PDS suture followed #2 Vicryl and the skin with staples. Compression dressing was applied with TED stocking polar care cryotherapy unit and knee mobilizer. The patient tolerated the procedure well and left the operating room in satisfactory and stable condition.