DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Failed left anterior cruciate ligament reconstruction with persistent chronic lateral ligament laxity.
POSTOPERATIVE DIAGNOSIS:
Failed left anterior cruciate ligament reconstruction with persistent chronic lateral ligament laxity.
OPERATION PERFORMED:
Revision of left ACL reconstruction using patellar tendon autograft, removal of hardware and open lateral ligament reconstruction using anterior tibialis tendon allograft and Pegasus graft augmentation.
SURGEON: John Doe, MD
ANESTHESIA: General laryngeal.
TOURNIQUET TIME: 120 minutes.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF OPERATION: The patient was taken to the operating room. In the holding area, the patient’s left knee was scrubbed with Betadine. The patient was given 2 grams of Ancef IV piggyback and was then brought in to the operating room and placed in the supine position on the operating room table. General laryngeal anesthesia was administered by the anesthesia staff. The patient had examination of the knee under anesthesia and had a 2+ Lachman and 3+ pivot shift. The patient had no valgus laxity, but 3+ varus laxity. A tourniquet was placed high on the left thigh. An Esmarch tourniquet was used to exsanguinate the left lower extremity and the tourniquet was elevated to 300 mmHg. The left lower extremity was then placed in a leg holder and flexed to 90 degrees. The inferior pole of the patellar tendon joint lines was marked with a sterile marking pen.
The anterolateral port was made with a #11 blade and the arthroscope was carefully placed into the intercondylar notch of the suprapatellar pouch without difficulty and the knee was instilled with Ringer’s lactate solution. The suprapatellar pouch was inspected and noted to be free of loose bodies. The patella and femoral trochlea were then inspected and noted to be without gross degenerative changes. The medial compartment was entered. The patient had some fraying of the medial and lateral meniscus and subtotal medial and lateral meniscectomies were completed. The intercondylar notch was entered and the patient had a full-thickness failure of the ACL. This was debrided with a 5.5 resector shaver.
The arthroscope was removed at this point and a straight midline incision was made from the inferior pole of patella to the tibial tubercle. Sharp dissection was made down through the paratenon isolating the patellar tendon and using #10 graft at middle third of patellar tendon with a 2.5 cm block of bone from the patella and tibial tubercle were isolated. Using an oscillating saw, mallet and osteotome, the patellar tendon graft was removed without difficulty and passed to another sterile table and prepared for passing. The tibial guide was then placed through the anteromedial portal and Steinmann pin retrograde through the original incision.
At this point, we thought that the post of the tibial side would be in the way for our tunneled site, so using an extra small stab incision, that screw was removed without difficulty. Then, the tibial cut was made with a #11 reamer and the tibial plane was prepared with a rasp and shaver. The over-the-top guide was then placed through the tibial tunnel at approximately the 1 o’ clock position. A large Beath pin was exited anterior to the thigh. A #11 reamer of the Beath pin and the femoral tunnel was prepared with the rasp and shaver. The graft was pulled through retrograde pulling the Beath pin through the anterior thigh.
Then, with the knee in full flexion through an extra small stab incision through the fat pad, a guide pin was placed between the femoral bone block and the femoral tunnel. A 8 x 23 mm biodegradable screw was used to fix the femoral bone block to the femoral tunnel. The notch was very sclerotic with bone, possibly because of the two previous ACL reconstructions, and we thought for better fixation, we would use a metallic screw, so a 7 x 23 mm metallic screw was used adjacent to the biodegradable screw with excellent fixation of the graft. Then, with the knee at 30 degrees of flexion and slight external rotation and full tension on the graft and the posterior drawer, a 9 x 28 mm biodegradable screw was used to fix the tibial bone block to the tibial tunnel. Final arthroscopic visualization revealed excellent tension of the graft with no evidence of impingement and good tension. The arthroscope was then removed.
Our attention was drawn posterolaterally. A curvilinear incision was made posterolaterally from the Gerdy’s tubercle proximally approximately 8 to 10 cm. Sharp dissection was made down to the iliotibial band. Moderate medial and lateral skin flaps were made sharply. Then, the plane between the iliotibial band and the biceps femoris was isolated. We identified the peroneal nerve just posterior to the biceps femoris tendon and this was dissected out of the way to the fibular neck, and very carefully, a Penrose drain was placed around the peroneal nerve and it was reflected posteriorly out of the way. There essentially was no lateral collateral ligament remaining, so I thought that a posterolateral reconstruction with an anterior tibial tendon allograft would be used.
A guidepin was placed through the fibular head with complete visualization of the fibular head. From anterior to posterior, a 7 mm reamer was placed over the guidepin. The tunnel was rasped and the anterior tibial tendon allograft was then passed through this in a figure-of-eight and was passed underneath the iliotibial band. A 10 mm reamer was then used just at the lateral femoral epicondyle. The graft was placed into this 10 mm hole and a 9 x 28 mm Delta biodegradable screw was used to affix this. There was excellent fixation of the lateral ligament reconstruction. A Pegasus graft was then placed over this area and sutured in with a FiberWire for augmentation. This allowed for excellent position and excellent reconstruction of the lateral ligaments.
The wound was copiously irrigated with arthroscopic irrigation. An On-Q pain pump was placed into the suprapatellar pouch. All incisions were closed with the deep fascia closed with #1 Vicryl figure-of-eight suture, subcutaneous tissue with a 2-0 Vicryl undyed interrupted suture and the skin was closed with staples. Then, 30 mL of 0.5% Marcaine was injected around the incisions. Sterile dressings were applied. Compressive-type Ace bandage from toe to the groin was placed over a hot ice pad. Range of motion brace from 0 to 60 degrees was placed. Tourniquet was released. Tourniquet time was 120 minutes. The patient was then awakened and taken to the recovery room in stable condition.
