Case Study: ACL Reconstruction using Quad Tendon

Autograft andMeniscus Repair in a 25-year-old Female

A 25-year-old female injured her left knee during a soccer game a month ago. She felt a snapping sensation in her left knee while playing soccer. The injury was followed by knee pain and swelling. The swelling subsided over the last month but the patient reports a sensation of her knee giving away during her day-to-day activities.

The patient works as an UPS driver but is currently not working secondary to the knee injury. The patient reports pain and a feeling of her knee giving away while walking, climbing stairs, and turning. The patient’s medical history is significant for polycystic ovarian syndrome and is currently on oral contraceptive medications. She is a current smoker and denies any illicit drug use.

On physical examination of the left knee, the effusion has significantly subsided compared to her visit at the time of the injury. Anterior drawer test and Lachman test are positive (2+). Mcmurray’s test for medial and lateral meniscus is positive. The range of motion of the left knee is limited secondary to pain (flexion 80 degrees and extension 15 degrees).

MRI of the left knee showing complete tear of the ACL.

MRI of the left knee showing complete tear of the ACL.

Radiological study in the form of an MRI suggested a complete tear of the ACL along with complex tears of both the medial and the lateral meniscus. The patient desired to be athletically active and to continue her job without any episodes of instability.

Various treatment options were discussed for the patient’s diagnosis, which included: living with the extremity as it is, organized exercises, medicines, injections, and surgical options. The patient has expressed a desire to proceed with surgery. The risks, benefits, and potential complications were all discussed with the patient at length.

The patient also quit smoking before the surgery with a plan not to start it after the surgery, considering our discussion with regards to detrimental effects of smoking on healing and high risk of failure..

PREOPERATIVE DIAGNOSES:

  1. ACL tear of the left knee.
  2. Medial meniscus tear of the left knee.
  3. Lateral meniscus tear of the left knee.

POSTOPERATIVE DIAGNOSES:

  1. ACL tear of the left knee.
  2. Medial meniscus tear of the left knee.
  3. Lateral meniscus tear of the left knee.

OPERATION:

  1.  Left knee arthroscopic medial meniscus repair.
  2. Left knee arthroscopic lateral meniscus repair.
  3. Left knee arthroscopic ACL reconstruction using quad tendon autograft.

PROCEDURE: The patient was taken to the operating room where he was placed on a well-padded operating table. General anesthesia was induced. Adductor canal block was given. A mid-thigh tourniquet was applied. Left lower extremity was prepped and draped in the usual fashion.

A timeout was called. The preop antibiotic was given. Esmarch was used to exsanguinate the limb and the tourniquet was elevated to 300 mmHg. The timeout was called.

Intraoperative arthroscopic image of the left knee.

Intraoperative arthroscopic image of the left knee.

A lateral entry portal was made and an arthroscope was introduced into the knee joint. There was no osteochondral lesion of the patellofemoral joint, medial condyle, lateral condyle. Examination of the medial meniscus showed a mid body oblique vertical tear of the medial meniscus along with a tear of the posterior horn of the medial meniscus.

There was an ACL tear, which was not repairable due to it being midsubstance. There was a lateral meniscus tear along with the mid substance and anterior body of the lateral meniscus, which was flipped inside.

A Medial entry portal was made. The probe was introduced and the lateral meniscus tear was reduced with difficulty. The lateral meniscus tear was held in place using a spinal needle, through which a FiberWire was passed. The FiberWire was used as a holding suture. Meniscal stitcher from Arthrex were used x 2 to repair the lateral meniscus. Similarly, the medial meniscus was also reduced and sutured using two meniscal stitches from Arthrex. The repairs were satisfactory. Pictures were taken and saved..

Intraoperative picture showing knee arthroscopic surgery.

Intraoperative picture showing knee arthroscopic surgery.

Now, the quadriceps tendon graft was harvested through a 3-cm anterior midline prepatellar incision. The fascia was cut in the line of the incision. The quadriceps tendon was identified. A 10 mm double blade with 10 mm depth was used to cut the tendon in between vastus medialis and vastus lateralis to a depth of 80 mm.

The undersurface of the tendon was freed by sharp dissection. Closed quadriceps tendon cutter was used to harvest the tendon. The tendon was prepped on the back table and FiberWire with the FiberTag was used to prep each end.

The length of the graft was 80 mm. The graft was marked at 35 mm on the femoral side. The intercondylar notch was prepped for ACL insertion with the use of shaver. The entry portal was made using the ACL guide.

The lateral exit point was marked through the guide and incision given. The ACL femoral guide was inserted and a FlipCutter was inserted from the lateral condyle towards the femur inside a drill sleeve. When it came into the medial end of lateral condyle and seen arthroscopically, the cutter was flipped.

About 30 mm tunnel was made on the femoral side with the FlipCutter. Similarly, the tibial footprint was cleaned and a tibial tunnel was made with an ACL tibial guide using the flip cutter.

A passport cannula was inserted on the medial portal for easy suture management and passage of the graft. Once the tunnels were done, FiberLoop was passed on either side. The femoral side was brought out of the passport with TightRope was passed and passed through the femoral tunnel under arthroscopic visualization.

Once 25 mm was crossed, the tibial loop was extracted and the tibial TightRope was passed. Once the tibial TightRope was out of the bone, the button was flipped and tightened. Similarly, the button was flipped on the femoral side and tightened. The sequential tightening was done on the tibial and femoral sites for the TightRope.

The knee was cycled 30 times into flexion and extension. The final tightening was again performed in extension on the femoral and tibial side and the TightRopes were tied over each other.

The wounds were thoroughly washed and irrigated, all the debris was removed with the shaver. After proper irrigation, the knee was irrigated and closed using #3-0 nylon. The quadriceps tendon incision was irrigated and closed in layers using #2-0 Vicryl and #3-0 Monocryl.

The wounds were dressed using 4 x 8s, ABDs, Webril, and Ace wrap. The Bledsoe knee immobilizer was advised. The patient was extubated and moved to recovery in stable condition. The patient’s neurological status was intact after the surgery.

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

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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 .
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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.
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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.
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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.
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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
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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.
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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
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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.
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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❤️🙏🏼
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The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
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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
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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!
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02:49 24 Mar 22
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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 Brigandi
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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My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.