mass31
Contributor
any help or insight coding this procedure please!!
PREOP DX:
1. RT knee anterior cruciate ligament avulsion fracture (femoral)
2. Medial retinaculum and medial patellofemoral ligament tears
3. Medial collateral ligament tear
4. Medial meniscocapsular ligament tear
5. Lateral meniscus tear
6. Lateral collateral ligament tear
7. Biceps femoris tendon tear
8. Proximal fibula fracture, displaced
9. Lateral tibial plateau fracture, non-displaced
10. Posterior aspect of comminuted displaced lateral femoral condyle fractures
POSTOP DX: SAME
PROCEDURES:
1. arthroscopic assisted ACL femoral avulsion fracture repair.
2. Arthroscopic partial lateral meniscectomy
3. Arthroscopic multiple loose body removal with osteochondral fracture fragments from posterior aspect of lateral femoral condyle fragments (at least 8 fragments, many of which were 12 to 15 mm in length)
4. Medial collateral ligament repair
5. Medial meniscus and meniscotibial ligament repair
6. Medial retinaculum/ medial patellofemoral ligament repair
7. Lateral collateral ligament repair
8. Biceps femoris tendon repair
9. Arthroscopic patellar chondroplasty
DESCRIPTION OF PROCEDURE: after adequate general anesthesia had been obtained, after receiving pre-op IV antibiotics he was placed in the routine supine position. A well-padded tourniquet was placed on the right upper thigh. A leg positioner was distal to this. Extremities were well padded. Venodyne boot was on the left leg. The right leg was prepped and draped in standard fashion. Limb was exsanguinated. Tourniquet was elevated. Anterolateral and anteromedial working portals were created. The medial portal had to be extended to allow passage of loose bodies. There was hemarthrosis that was evacuated from the knee. There are large clots that were removed from the knee. There were as mentioned above 8 significant loose bodies that were bony and articular cartilage. These were throughout the entire knee in the medial lateral gutters, suprapatellar pouch, anterior notch, and posterior compartment of the knee. These were all very carefully removed in case we could proceed with any type of fixation. These were all held in room temp. saline for the duration of the case. Underside of the patella had an unstable articular cartilage centrally. This area was debrided with motorized shaver, contoured with the arthrocare ablation tool. There was evidence of injury in the medial retinaculum with hemorrhage underlying soft tissues. This would later be repaired. Medial compartment had evidence of a tear in the periphery of the meniscus extending into the capsule. The meniscus however was essentially intact and articular cartilage medially was essentially intact. Laterllay there was a large radial tear of the mid-portion lateral meniscus. There is also complex tear of the posterior horn lateral meniscus. Meniscal tears were debrided back to stable peripheral rim. There was significant cartilage injury to the posterior tibial plateau with anterior-to-posterior line correcsponding with the fracture. There was scuffing of articular cartilage, femoral condyle, and tibial plateau. Unstable cartilage was debrided off the medial part of the lateral tibial plateau anteriorly coursing up towards the tibial spine. Popliteus tendon was inspected palpated with a probe and this was actually taut. The bone fragments were debrided around the tendon. The joint could be opened significantly medially and laterally. In the notch, there was some tearing of the anterior portion of the ACL; however, larger bone attachments to the femoral ACL. This was essentially in entire lateral wall coursing into more posterior fragment that was still attached to ACL. With a probe we could flip these fragments and actually have a decent appearance of a proposed repair of the anterior cruciate ligament tear. It was felt that repair of this ligament one it would hopefully allow the patient have avoidance of another ACL surgery and two will have his own tissue. As approximately 20% of the anterior portion was torn he would have 80% restoration of his ACL this was all healed well. We therefore proceeded with the 2 tunnel technique. As we were addressing the lateral pathology a standard hockey stick curvilinear incision was made laterally. IT band identified. This was split about midway using the approach for a 2 incision ACL. A rear-entry tip was utilized and the right hand retrograde reverse drill guide was utilized. Two Beath pins were passed into the femoral ACL footprint at the fracture site. Arthrex FiberStick suture was passed down one tunnel with two sets. These were then passed through the proximal most portion of the ACL in crisscross fashion and then back up through the second tunnel. We were able to tension and pull the ACL along with the bone nicely. After we did the lateral collateral ligament and biceps femoral portion of the case we then tied the corresponding tears over a polypropylene button laterally with the knee in about 20 degrees of flexion. Prior to tying the ACL over the button laterally we exposed the lateral side. Common peroneal nerve was identified crossing the fibular neck. This was protected and preserved throughout the case. A vertical anterior proximal fibular fracture was noted. A small hematoma was evacuated. The biceps femoris was identified and lateral collateral ligament was identified. A set of FiberTape was passed through lateral collateral ligament fibers and then separately through biceps femoral fibers. A SwiveLock 4.75 anchor was placed to the proximal fibula posterior the fracture line. An additional suture was passed from the internal through the tissues outside. We were able to tie the corresponding pairs affording repair of the bicep femoris and lateral collateral ligament with the knee in flexion and with a valgus stress. We then tied the ACL corresponding pairs and that portion of the case was concluded. The lateral IT band split incision was closed with interrupted figure-eight Vicryl sutures, subcutaneous tissues were closed with buried Vicryl. Skin was closed with staples.
All that was being closed the medial incision was made. We wanted to address medial retinaculum, medial patellofemoral ligament, and medial collateral ligament so we went proximal to the medial epicondyle and under the pes bursa region. Of note the patients leg was extremely large as he is about 300 LBS. this also tied into the posterior aspect of the lateral femoral condyle. We placed the knee in significant flexion and there was still articular cartilage contacting the tibial plateau. We did not proceed with attempted fixation of all the multiple comminuted fragments from the lateral femoral condyle posteriorly. The medial side soft tissues dissected down to the level of the fascia and pes tendons were identified. Proximal L-type incision was made to reflect these such that we could place our retractor. Medial collateral ligament deep fibers were identified. Tissue at the medial joint line was completely torn and flipped and reflected inferiorly and starting to scarring. This tissue mass was ?undone? and then all the meniscal tibial fragments, ligaments, and soft tissues were repaired after we placed the medial internal Arthrex FiberLoop Bridge with a SwiveLock just slightly proximal and posterior to the medial epicondyle and then we did flexion-extension to find the isometric point for the distal insertion of the internal fibertape bridge. This was then tightened holding the knee in slight varus stress at 20 degrees flexion. We incorporated with that suture the fibers of the medial collateral ligament. There was excellent stability to the knee with this. Lachman was also negative. The knee was placed in extension flushed off all small fragments with the arthroscope. Exparel had been infiltrated into the lateral soft tissues before closure and then medial tissues prior to closure of the pes reflected tissues, subcutaneous tissues, and skin with staples. Dry sterile dressing was applied. Knee brace was applied. Ice wrap has been applied. Knee brace is to be held in extension and locked. Of note during the case the tourniquet was up for just over 2 hours. We then released the tourniquet for 50 minutes. We then exsanguinated the limb again elevated the tourniquet as he had significant generalized oozing and bleeding making the visualization somewhat impaired.
PREOP DX:
1. RT knee anterior cruciate ligament avulsion fracture (femoral)
2. Medial retinaculum and medial patellofemoral ligament tears
3. Medial collateral ligament tear
4. Medial meniscocapsular ligament tear
5. Lateral meniscus tear
6. Lateral collateral ligament tear
7. Biceps femoris tendon tear
8. Proximal fibula fracture, displaced
9. Lateral tibial plateau fracture, non-displaced
10. Posterior aspect of comminuted displaced lateral femoral condyle fractures
POSTOP DX: SAME
PROCEDURES:
1. arthroscopic assisted ACL femoral avulsion fracture repair.
2. Arthroscopic partial lateral meniscectomy
3. Arthroscopic multiple loose body removal with osteochondral fracture fragments from posterior aspect of lateral femoral condyle fragments (at least 8 fragments, many of which were 12 to 15 mm in length)
4. Medial collateral ligament repair
5. Medial meniscus and meniscotibial ligament repair
6. Medial retinaculum/ medial patellofemoral ligament repair
7. Lateral collateral ligament repair
8. Biceps femoris tendon repair
9. Arthroscopic patellar chondroplasty
DESCRIPTION OF PROCEDURE: after adequate general anesthesia had been obtained, after receiving pre-op IV antibiotics he was placed in the routine supine position. A well-padded tourniquet was placed on the right upper thigh. A leg positioner was distal to this. Extremities were well padded. Venodyne boot was on the left leg. The right leg was prepped and draped in standard fashion. Limb was exsanguinated. Tourniquet was elevated. Anterolateral and anteromedial working portals were created. The medial portal had to be extended to allow passage of loose bodies. There was hemarthrosis that was evacuated from the knee. There are large clots that were removed from the knee. There were as mentioned above 8 significant loose bodies that were bony and articular cartilage. These were throughout the entire knee in the medial lateral gutters, suprapatellar pouch, anterior notch, and posterior compartment of the knee. These were all very carefully removed in case we could proceed with any type of fixation. These were all held in room temp. saline for the duration of the case. Underside of the patella had an unstable articular cartilage centrally. This area was debrided with motorized shaver, contoured with the arthrocare ablation tool. There was evidence of injury in the medial retinaculum with hemorrhage underlying soft tissues. This would later be repaired. Medial compartment had evidence of a tear in the periphery of the meniscus extending into the capsule. The meniscus however was essentially intact and articular cartilage medially was essentially intact. Laterllay there was a large radial tear of the mid-portion lateral meniscus. There is also complex tear of the posterior horn lateral meniscus. Meniscal tears were debrided back to stable peripheral rim. There was significant cartilage injury to the posterior tibial plateau with anterior-to-posterior line correcsponding with the fracture. There was scuffing of articular cartilage, femoral condyle, and tibial plateau. Unstable cartilage was debrided off the medial part of the lateral tibial plateau anteriorly coursing up towards the tibial spine. Popliteus tendon was inspected palpated with a probe and this was actually taut. The bone fragments were debrided around the tendon. The joint could be opened significantly medially and laterally. In the notch, there was some tearing of the anterior portion of the ACL; however, larger bone attachments to the femoral ACL. This was essentially in entire lateral wall coursing into more posterior fragment that was still attached to ACL. With a probe we could flip these fragments and actually have a decent appearance of a proposed repair of the anterior cruciate ligament tear. It was felt that repair of this ligament one it would hopefully allow the patient have avoidance of another ACL surgery and two will have his own tissue. As approximately 20% of the anterior portion was torn he would have 80% restoration of his ACL this was all healed well. We therefore proceeded with the 2 tunnel technique. As we were addressing the lateral pathology a standard hockey stick curvilinear incision was made laterally. IT band identified. This was split about midway using the approach for a 2 incision ACL. A rear-entry tip was utilized and the right hand retrograde reverse drill guide was utilized. Two Beath pins were passed into the femoral ACL footprint at the fracture site. Arthrex FiberStick suture was passed down one tunnel with two sets. These were then passed through the proximal most portion of the ACL in crisscross fashion and then back up through the second tunnel. We were able to tension and pull the ACL along with the bone nicely. After we did the lateral collateral ligament and biceps femoral portion of the case we then tied the corresponding tears over a polypropylene button laterally with the knee in about 20 degrees of flexion. Prior to tying the ACL over the button laterally we exposed the lateral side. Common peroneal nerve was identified crossing the fibular neck. This was protected and preserved throughout the case. A vertical anterior proximal fibular fracture was noted. A small hematoma was evacuated. The biceps femoris was identified and lateral collateral ligament was identified. A set of FiberTape was passed through lateral collateral ligament fibers and then separately through biceps femoral fibers. A SwiveLock 4.75 anchor was placed to the proximal fibula posterior the fracture line. An additional suture was passed from the internal through the tissues outside. We were able to tie the corresponding pairs affording repair of the bicep femoris and lateral collateral ligament with the knee in flexion and with a valgus stress. We then tied the ACL corresponding pairs and that portion of the case was concluded. The lateral IT band split incision was closed with interrupted figure-eight Vicryl sutures, subcutaneous tissues were closed with buried Vicryl. Skin was closed with staples.
All that was being closed the medial incision was made. We wanted to address medial retinaculum, medial patellofemoral ligament, and medial collateral ligament so we went proximal to the medial epicondyle and under the pes bursa region. Of note the patients leg was extremely large as he is about 300 LBS. this also tied into the posterior aspect of the lateral femoral condyle. We placed the knee in significant flexion and there was still articular cartilage contacting the tibial plateau. We did not proceed with attempted fixation of all the multiple comminuted fragments from the lateral femoral condyle posteriorly. The medial side soft tissues dissected down to the level of the fascia and pes tendons were identified. Proximal L-type incision was made to reflect these such that we could place our retractor. Medial collateral ligament deep fibers were identified. Tissue at the medial joint line was completely torn and flipped and reflected inferiorly and starting to scarring. This tissue mass was ?undone? and then all the meniscal tibial fragments, ligaments, and soft tissues were repaired after we placed the medial internal Arthrex FiberLoop Bridge with a SwiveLock just slightly proximal and posterior to the medial epicondyle and then we did flexion-extension to find the isometric point for the distal insertion of the internal fibertape bridge. This was then tightened holding the knee in slight varus stress at 20 degrees flexion. We incorporated with that suture the fibers of the medial collateral ligament. There was excellent stability to the knee with this. Lachman was also negative. The knee was placed in extension flushed off all small fragments with the arthroscope. Exparel had been infiltrated into the lateral soft tissues before closure and then medial tissues prior to closure of the pes reflected tissues, subcutaneous tissues, and skin with staples. Dry sterile dressing was applied. Knee brace was applied. Ice wrap has been applied. Knee brace is to be held in extension and locked. Of note during the case the tourniquet was up for just over 2 hours. We then released the tourniquet for 50 minutes. We then exsanguinated the limb again elevated the tourniquet as he had significant generalized oozing and bleeding making the visualization somewhat impaired.