Anterior Cruciate Ligament Reconstruction Using a Mini-Arthrotomy Technique with Either an Ipsilateral or a Contralateral Autogenous Patellar Tendon Graft

Radiographs

Radiographs are obtained preoperatively to assist with surgery planning. Plain radiographs, including standing posteroanterior 45 degrees flexed weight bearing, lateral, and Merchant views are obtained. The radiographs allow us to measure the width of the intercondylar notch, length of the patellar tendon, tibial slope angle, and width of the patella, which is usually twice the width of the patellar tendon. These measurements are helpful for planning the angle and length of the femoral tunnel, and they aid in determining the amount of notchplasty that may be needed to accommodate for the width of the new ACL graft. A magnetic resonance imaging scan is not necessary for our preoperative evaluation but is reviewed if it has already been obtained elsewhere.

Rehabilitation

There is never a reason to do an isolated ACL reconstruction as an emergency surgery. Previous studies have shown that acute ACL reconstruction has a higher rate of postoperative arthrofibrosis than delayed ACL reconstruction when the patient has the opportunity to undergo rehabilitation to allow the knee to return to a quiescent state. All patients are evaluated by a physical therapist at the time of the initial evaluation. The physical therapist measures knee range of motion and strength before surgery and determines when the patient is ready to undergo surgery. The patient must have full knee range of motion equal to the contralateral normal knee, good leg control, and no knee swelling before he or she can undergo surgery. Furthermore, the patient must be mentally prepared for surgery. The surgery and rehabilitation program are fully explained to the patient and his or her caregiver, so that they fully understand what is expected of them after surgery. The surgery date is planned for a time when the patient has at least 1 week off school or work and when a family member or friend can be at home with him or her during the first week postoperatively.

Preparation

The patient lies supine on the operating table and is given a general endotracheal anesthesia. A knee evaluation for stability, range of motion, and effusion is performed after the patient is under anesthesia. The patient’s knees are positioned over the break in the table for flexion later. A tourniquet is applied to the thigh.

A 30-mg bolus of ketorolac is administered for preemptive pain management. Then 90 mg of ketorolac is mixed with 1000 mL of saline, and an intravenous drip is started to run at 40 m/hour until completion of the dose. Intravenous antibiotics are infused.

The knee is preinjected with 0.25% Marcaine (bupivacaine hydrochloride, Winthrop, New York) with epinephrine. The operative site is prepared with alcohol, and then the entire leg is painted with povidone-iodine (Cloraprep). An impervious stockinette is applied.

Arthroscopic Evaluation

An arthroscopy is performed to examine the knee joint for articular cartilage damage and meniscal tears. Meniscal tears are treated with repair, trephination, or removal, or are left in situ as appropriate. After the arthroscopy, the leg is redraped and Ioban (3M Healthcare, St. Paul, Minnesota) is placed on the knee over the openings cut in the stockinette. A bump is placed under the distal thigh to hold the leg in 25 degrees of flexion.

Exposure

The tourniquet is left inflated to 300 mmHg/psi (350 mmHg/psi for larger thighs). The Ioban drape is taken off the skin just over the site where the skin incision is to be made. A 6-cm incision is made down to the deep fascia along the medial side of the patellar tendon, starting 1 cm above the inferior pole of the patella and extending 4 cm distal to the joint line ( Fig. 83.1 ). The subcutaneous tissue is separated from the deep fascia medially, where the tibial tunnel is to be drilled 4 cm distal to the joint and 1 cm medial to the tibia tubercle. The subcutaneous tissue is separated from the deep fascia with Metzenbaum scissors and finger dissection approximately 1–2 cm medial to the patellar tendon.