Case Study: Knee Arthroscopic ACL with
Knee Arthroscopic Lateral Meniscus Repair
A 22 year-old female was seen in the office with right knee pain due to sports injury that happened while she was in Maryland (college). She was seen by an orthopedic surgeon who started PT. The knee pain and swelling have decreased but it still has instability.
MRIs were reviewed and discussed by the doctor; She has been doing physical therapy in the meantime. She came to my office in December and we discussed treatment options and offered for surgical management.
The patient was planned for surgery at the end of December but was COVID positive with minimal symptoms. The surgery was delayed due to those symptoms and was planned for surgery for today.
We discussed risks and benefits and complications including infections, bleeding, injury to various nerves and vessels, failure of surgery and need for repeat surgery, stiffness, need for rehabilitation, avoidance of contact sport for almost 9 months to a year, and need for therapy and home therapy.
We also discussed systemic complications including blood clot, cardiac or pulmonary complications among others. The patient consented and signed an informed consent.
The patient was taken to the operating room. Adductor canal block was given by the anesthesia team before the surgery. General anesthesia was induced. The examination of the knee and the anesthesia showed Lachman positive with no endpoint. Pivot shift was negative.
The right knee was prepped and draped aseptically in the usual fashion. All the bony landmarks were marked. Incisions were planned. A tourniquet was applied and elevated to 300 mmHg.
Incision was given along the midline between the tip of patella and to the tibial tubercle to take bone-tendon-bone graft. Paratenon was cut in the line of incision. The tendon was exposed. The tendon was about 28 mm wide. The middle 10 mm was marked to be excised.
At this time, the oscillating saw was found to have a breach of sterility and was sent for resterilization. Another saw handpiece was also not working at that time. A decision was made to wrap the knee in sterile draping and release the tourniquet.
The patient was also covered and all the instruments were covered. I scrubbed out for about half an hour during this period. The patient was stable during this period.
Once the oscillating saw was ready, we scrubbed back again and restarted surgery. Tourniquet was again elevated and started 15 minutes earlier. The blade was used to cut the 10 mm tendon. At this time, the drill was open but it was not working.
So, the decision was made to take the bone graft with the use of multiple drill holes and osteotomes. A 2.5 cm x 10 mm x 10 mm block on the tibial side was cut with the use of drill bit and osteotome.
The tendon was retroflected proximally and the patellar tendon was marked. At this time, the oscillating saw started working. So, it was used to cut a 20 mm x 10 mm x 10 mm block. There was no breach of the patellar articular cartilage.
The graft was prepared on the end table through a 25 mm x 10 mm on the femoral side and 2 holes were focused in the intercondylar notch where the ACL was ruptured. There was a thick ligamentum flavum which was excised. The rest of the remnant of the ACL was also excised. The PCL was exposed.
The medial wall of the lateral femoral condyle was exposed. Smith & Nephew radiofrequency wand was also used to debride the intercondylar notch. The anterior portal for the femoral and tibial side of the ACL was marked with the use of the radiofrequency wand.
Accessory portal was made through the tendon to look into the intercondylar notch. Anteromedial guide was used to place the femoral guidewire in an appropriate 10:30 position about 7 mm anterior to the posterior femoral condyle line margin.
Reaming was done over the sidewire to 30 mm and the canal was kept patent with the use of a FiberWire loop. Now, the tibial tunnel was planned and a 60-degree angle was used on the tibial ring. Guidewire was passed through the ring into the joint from a separate medial incision.
The tip of the guidewire was held with the hemostat and was done with the use of a 10.5 mm reamer. Once it was reamed, a shaver was introduced through the tibial tunnel to recess the posterior notch of the tunnel of the intra-articular portion.
Now, the loop part of the spiral loop was drawn into the tibial tunnel and graft was loaded with the femoral side up. The graft was then inserted through the tibial tunnel into the intra-articular portion of the knee into the femoral tunnel.
Once the graft was in, it was found to be in a satisfactory position on the femoral side. A notch on the superior part of the tunnel and a nitinol wire was inserted followed by insertion of 7 mm x 20 mm PEEK screw.
A good fixation was achieved. Now, the graft was found to be a little long, so twisting of the graft was done prior to insertion with A nitinol wire was again inserted posterior to the graft and on the tibial tunnel followed by tapping and insertion of 8 mm x 20 mm PEEK screw.
There was about 3 mm of bone protruding outside which was removed with a rongeur. Examination of the knee showed a stable knee with negative Lachman. Subtle notchplasty was done of the lateral femoral condyle. Final pictures were taken and saved. Knee was thoroughly irrigated and drained.
The wounds were closed in layers using 0 Vicryl for the patellar tendon, 2-0 Vicryl for the paratenon and subcu, and 4-0 Monocryl for the skin. Dermabond and Steri- Strips were applied. Dressing was done with the use of 4 x 8 ABD, Webril, Ace wrap.
Knee immobilizer was applied in a 10-degree extension and locked. A lock of beyond 90 degrees’ flexion was put on the knee immobilizer. The patient was extubated and moved to recovery in stable condition.
She is here for her post-operative consultation, no X-rays were needed. Pain is well controlled. She is in a knee immobilizer and using crutches. After discussing treatment options, we have decided to proceed with formal physical therapy as well as a home exercise program for rehabilitation of the knee.
We will continue with ice and elevation of the knee to decrease swelling and pain. We will continue to utilize early mobilization and mechanical prophylaxis to reduce the chances of a deep vein thrombosis. We will wean them off any narcotic medications and progress to anti-inflammatories and
Tylenol as long as there are no contraindications to these medications. We also discussed the risk and benefits and common side effects of taking these medications at today’s visit. I will see them back in three weeks’ time to evaluate their progress.
They will call us in the interim if they have any questions or concerns prior to their follow up visit. After the surgery, she continued taking physical therapy. With regular visits in the office, the patient did well and continued physical therapy for the knee.
Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
Please take a look at my profile page and don't hesitate to come in and talk.