PREOPERATIVE DIAGNOSIS: Left knee anterior cruciate ligament re-tear, status post hamstring reconstruction, medial and lateral

meniscus tear and medial compartment chondrosis. PROCEDURE PERFORMED: Left knee arthroscopy. 1. Anterior cruciate ligament revision reconstruction with patellar tendon autograft (29888 82). 2. Partial medial and lateral meniscectomy (29880). 3. Patellar bone grafting autograft (20900). ANESTHESIA: General. COMPLICATIONS: None. TOURNIQUET TIME: 40 minutes. BLOOD LOSS: Minimal. INDICATIONS: A 39-year-old with a history of left knee anterior cruciate ligament tear with significant medial meniscal injury. She has had a re-tear related to roller skating. Given the desired level of activity, risks of further meniscal and chondral injury and recurring instability, plan was made for revision reconstruction. Risks, benefits and alternative options were reviewed. An appropriate consent was obtained. DETAILS OF PROCEDURE: Patient was brought to the operative room where a successful anesthetic was administered. Prophylactic Kefzol was given. A contralateral Plexipulse boot was placed prior to induction. The left knee was examined under anesthesia. Patient had full range of motion with a clearly positive Lachman with no end point. She was otherwise stable. The left knee was confirmed. It was formally prepped and draped. The limb was elevated and exsanguinated with an Esmarch tourniquet which was raised to 300 mmHg. A longitudinal incision was made incorporating prior incision. The patellar tendon was identified and the paratenon was incised in the midline. The central one-third of the patellar tendon was then incised removing 10 mm with a 10 mm x 15 mm tibial plug and a 10 mm x 15 mm patellar plug. The patellar tendon was then repaired with the knee in 90 degrees of flexion side-to-side. The paratenon was oversewn and the patellar defect was left open for later bone grafting from local harvest The graft was then brought to the back table by an assistant who facilitated and expedited the case by preparing it to fit through 10 mm bony tunnels on both the femoral and tibial side. Three drill holes were placed in each bony plug through which #3 ORTHOBRAID was placed. The overall graft length was 85 mm. A diagnostic arthroscopy was performed. Arthroscopic findings showed intact chondral surface of the patellofemoral joint with only mild superficial chondrosis.

The lateral compartment showed some mild superficial chondrosis, more so of the tibial plateau. None of it was unstable. There is a small tear on the inner periphery of the posterior middle horn which was simply dbrided with a full radius resector back to a smooth and stable margin. The majority of the meniscus was stable and functional. Cruciate complex showed an obvious deficient ACL with a complete tear. The PCL was otherwise intact. The medial compartment showed a bit more advanced chondrosis diffusely grade 2 and focal areas grade 3, particularly the posterior tibial plateau. There was some focal tear of the middle horn and anterior horn medial meniscus. This was amenable to full radius resector shaving and contouring back to a smooth and stable margin. The majority of the posterior horn had been resected from prior injury and showed no significant pathology at this point. No formal chondroplasty was necessary. The notch was then addressed. The residual ACL was dbrided. A mild notchplasty was performed to facilitate visualization of _____ impingement. examined. He had an obvious tear which was a delamination type of the anterior cruciate ligament. The PCL was intact and stable. The trajectory of the graft appeared appropriate and satisfactory as did bony tunnels based on preoperative evaluation as well. The ACL was debrided using a meniscal punch and shaver. The tibial footprint was exposed as was the over-the-top position. At this point, the ACL guide was introduced at 58 degrees. A guidepin was then placed into the anatomic footprint. This appeared reasonably well centered within the prior tunnel. He had a retained staple for fixation. This was not seen with our dissection and was not in the way so it was left as is. Once the guidepin was placed into the anatomic tibial footprint, an 8 mm reamer was used initially to ensure that we were satisfactorily centered within the hole. Some residual hamstring graft was removed. This was then over drilled with a 10 mm reamer. The tunnel position was excellent. The arthroscope was then placed within the tunnel which showed excellent bony structure circumferentially for satisfactory healing. At this point, the over-the-top position was identified and a 5 mm guide was placed at the 2:30 position. This appeared a bit lower and more posterior than the prior tunnel position although the other tunnel appeared in the satisfactory place. The guidepin was then placed and exited the anterior lateral thigh. The EndoButton drill bit was then engaged and drilled to a depth of 60 mm. The bone was notably sclerotic. The 10 mm Mushroom reamer was then placed and drilled to a depth of 45 mm. The measuring guide was then inserted after removal of all residual debris and tissue. The guidepin had to be replaced and drilled with the EndoButton drill bit since the cortex was not satisfactorily perforated. This appeared to be related to the sclerotic bone related to prior fixation in this region. The arthroscope was then introduced up to femoral tunnel. It was debrided of any residual tissue and debris using a pulse lavage-type maneuver. All excess debris was then removed with a shaver. A passing stitch was placed and the overall femoral tunnel length was again confirmed at 60 mm. The graft was then prepared on the back table with a standard Smith & Nephew EndoButton with a loop secured at 25 mm. This would recess 35 mm of tissue and bone of the femoral tunnel. The graft was then placed. The graft passed nicely. The EndoButton clearly slipped with excellent position and trajectory. It appeared there was no evidence of roof or lateral wall impingement. A small notchplasty was warranted and was done using an osteotome and shaver prior to graft placement. The knee was brought through range of motion and overall position was excellent without impingement. The graft was then secured with a 19 mm Poly button on the tibial side. The graft was then reinspected with satisfactory tension and the Lachman was negative.

At this point, additional bone had to be harvested from the tibial plug site for added bone graft material beyond that obtained from the bony plugs and the patella was then meticulously bone grafted and then the overlying paratenon repaired with a 0-Vicryl. The tourniquet was released at 68 minutes. Hemostasis was satisfactory. The deep soft tissue was repaired with interrupted 0Vicryl. A 2-0 Vicryl was used subcutaneously and 3-0 Prolene on the skin followed by SteriStrips. A second dose of prophylactic Kefzol was given. A sterile dressing was applied. Patient was extubated without difficulty and brought to the recovery room in a satisfactory condition. I see no complications. All counts were correct at the end of the case. Postoperative plan will be early mobilization, pain control. Follow up in 1 week. Given the added complexity, additional reaming steps and preoperative planning necessary for the revision ACL a modifier 22 was used with code 29888 with an added 15% complexity to the procedure and evaluation.