Case Study: Knee Arthroscopy: ACL Repair using Fiber Link
Internal Brace and Tight Rope with Distal Fixation using
SwiveLock and Chondroplasty in a 51 year-old female

In general, three transplant alternatives are available: a patellar tendon autograft, a hamstring autograft, and an allograft. In this case, surgeons anatomically narrow the space, drill across the two bones, and implant a hefty non-absorbable suture construct with metallic buttons at either end (the “tightrope”) to keep the bones together.

After repair, the internal brace functions as a secondary stabilizer, allowing for quicker rehabilitation and return to sports while resisting injury recurrence when possible.

A 51 year-old female patient visits the office with complaints of right shoulder and right knee pain for about months. She had pain and swelling in the left knee along with buckling and instability. Patient is allergic to penicillin and latex. MRI showed a tear of the proximal ACL.

Osseous structures: Alignment of the thoracic spine is anatomic. There are no compression deformities. The bone marrow signal is overall age-appropriate. Paraspinal soft tissues: The visualized paraspinal soft tissues are grossly unremarkable.

Intervertebral discs: A left paramedian disc herniations present at T6-T7 level impinging on exiting left C7 nerve roots, causing mild spinal canal stenosis. No spinal canal stenosis is present. The neural foramina are patented.

Spinal cord: No areas of focal signal abnormality are present in the thoracic spinal cord. The conus medullaris terminates at the T12 level and is within normal limits. The left paramedian disc herniation at T6-T7 level causes mild mass effect on the existing left C7 nerve roots.

The collateral ligaments has edema surrounding the medial collateral ligament compatible with a grade 1 partial tear. The lateral collateral ligament, biceps femoris tendon, iliotibial band, and popliteus tendon is intact. The cruciate ligaments is a full-thickness tear of anterior cruciate ligament proximally.

Posterior cruciate ligament is intact. The Menisci, the lateral and medial meniscus are intact. Cartilage, the chondral surfaces in the medial compartment and lateral compartment are intact also the anterior compartment is intact.

In bones, there is bone marrow edema in the posterior lateral tibial plateau compatible with micro trabecular fracture. Extensor Mechanism, there is a moderate to large knee joint effusion. No joint effusion and popliteal cyst are identified. The soft tissues are otherwise normal and the neurovascular structures demonstrate normal course.

It has an impression of complex tear of the anterior cruciate ligament proximally with associated likely trabecular fracture posterior lateral tibial plateau. Grade 1 partial tear in the medial collateral ligament. Moderate to large knee joint effusion.

We discussed treatment options and the patient opted for surgical management.

MRI-3T Thoracic Spine non-contrast

MRI-3T Thoracic Spine non-contrast

We discussed risks and benefits including infection, bleeding, injury to adjacent nerves and vessels, rehabilitation, knee stiffness, need for manipulation, failure and need for repeat surgery, possibility of doing a repair, which may fail and need for reconstruction, possibility of doing a reconstruction if the tear is not repairable, possibility of development of arthritis in future and need for total knee replacement among others.

We also discussed systemic complications including blood clots, cardiac, pulmonary, neurological complications including death. The patient understood and signed an informed consent.

The patient was taken to the operating room where she was placed on a well-padded operating table. General anesthesia was induced. IV clindamycin was given as a pre op antibiotic. Left lower extremity was prepped and draped aseptically in a usual fashion after application of high tourniquet.

The leg was held in a leg holder. Timeout was called. A tourniquet was applied and elevated at 325 mmHg. The 111 minutes of tourniquet time was used during the surgery.

Lateral entry portal was made and an arthroscope was entered. showed grade 2 to grade 3 patellar chondral lesions on the left facet. Examination of the medial tibiofemoral compartment showed intact medial meniscus and cartilage. The Medical entry portal was made using a spinal needle.

Probe was also used to examine the knee. Examination of the lateral tibiofemoral compartment showed intact meniscus and cartilage. Further examination of the intercondylar notch showed proximal tear of the ACL right from the bone.

There was minimal bone stump. Shaver was used to clear the fat pad of ACL from PCL as well as at its attachments.

The bone was debrided with a shaver. Decision was made to repair the ACL. Scope was entered into the patellofemoral joint where chondroplasty of the patella was performed using a shaver. Scope was brought back into the intercondylar notch. A Passport was inserted on the medial portal to allow access.

Scorpion was used to pass Fiberlink sutures x2, one each to the anteromedial and posterolateral bundle of ACL. The sutures were brought out through a secondary portal super medially. Now, the exit portal of the femoral condyle was marked and the canal was drilled using the ACL FlipCutter.

A 4-mm straight tip drill was tried to use through an accessory medial portal, but direction of the canal was too inferior. Finding an appropriate canal with the ACL Fiber Stick was passed the loop. Internal Brace Fiber Tape was loaded over a Tightrope RT.

One of the leading sutures was removed and one Fiber Link was passed through the hole and another Fiber Link was passed through the hole of the Tightrope.

These sutures were shuttled through the femoral tunnel and brought out. The button was brought out and flipped. Now, the passing suture from the Fiber Links were removed and ABS was tied while examining arthroscopically into the knee.

Once the Internal Brace was into the femoral tunnel, tibial tunnel was drilled using a tibial zig and Fiber Stick was again used to pass the loop. The distal end of the fiber Internal Brace was passed to the loop towards tibial tunnel. The Internal Brace was found to be in satisfactory position.

The distal tip of the tibial tunnel was tightened for SwiveLock #4.75 Arthrex. Now, the ABS was tightened proximally and tied over each other. The Fiber Links were also tightened and tied over each other.

Examination of the ACL with arthroscopy showed satisfactory direction to the bone. The Internal Brace was in satisfactory position. Final pictures were taken and saved.

The knee was copiously irrigated and drained. Closure was done using #2-0 Vicryl and #3-0 Nylon. 10 cc of Naropin was injected into the knee. Dressing was done using Xeroform, 4×4, ABD, Webril, Ace wrap. Knee immobilizer was applied in a -10-degree tension. The patient was extubated and moved to recovery in a stable condition.

The patient seen by the doctor or her one week post operative visit, no x-rays were needed. She denies fever, chills, and difficulty in pain are controlled. She stopped narcotics 2 days back.

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 went over the arthroscopic pictures and removed the stitches during visits.

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 this medication. The patient will be back in three weeks’ time to evaluate their progress.

After 4 weeks the patient visits the office for her post operative consultation, she denies fever, chills, the pain has been improving, though slow. She has been working with PT and making slow progress. We agreed to go with conservative management for now.

We discussed goals and the need for more rigorous involvement. She is motivated but has a low threshold for pain which has made rehab difficult. She is trying her best. We encouraged her and discussed home therapy also.

The patient went to the office for her 8 week post operative visit, no x-rays were needed, she denies all symptoms of fever, chills, the pain has been improving, though slow. She has been working with PT and making progress; however, she has difficulty lifting her leg up in the air.

We advised her to use an ice machine and CPM. With the continued follow up checkup the patient showed progress from time to time she visits the office. She gets well after the surgery and with the help of continued physical therapy.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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I had an extremely friendly and personalized medical consult with Dr Karkare. Dr Karkare was very knowledgeable and very professional. His communication skills was extremely good and explained my medical condition in very simple words. The office visit was very helpful in understanding my medical condition. Thank you Dr Karkare
Padmanabhan Nagaraj
20:49 25 Sep 23
Dr. Karlkare and his staff were excellent. Dr. Karkare explained everything clearly and took his time getting to know my Dad.
Anna Acker
22:46 07 Sep 23
Dr Vedant Vaksha had done emergency surgery in 2020 after a traumatic injury.His office at Complete Orthopedics handled the continued care thereafter.Dr V and his staff had been Professional and friendly throughout the process, taking the time to explain all the questions on how to proceed and what to expect.Whenever I needed to speak with Dr V or the office they were a phone call away, without waiting or calling several numbers like in so many other medical offices.The office was accommodating to scheduling to my needs at all times. Dr Vedant Vaksha earned the following5 out of 5 stars, highly recommended.
John Kuey
20:58 05 Sep 23
Dr. Vaksha helped me recover from an injury. I am very thankful that he took the time to explain the best treatment for my injury. Also thankful for the wonderful office staff!
Joseph Castelli
22:30 02 Aug 23
The office is wonderful!… Dr Paresh was very helpful and attentive and made my sister in laws recovery so much better.. Thank you for everything
Jazz Lorenzo
17:48 14 Jul 23
The ladies are very welcoming, the service is great, the doctor is very professional and caring and the building is super clean. I really like to come here, the atmosphere is very friendly... Come and you will love it too.
Joan Carasco
14:41 30 Jun 23
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
Dave
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
Eclectic54
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
Sam
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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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.