Key-Techniques-in-Orthopaedic-Surgery

felt to be appropriate for an attempt at meniscal
repair. Various methods can be employed. These
include placement of sutures using either inside-out
or outside-in techniques or placement of absorbable
intra-articular fixation devices (“arrows” or “tacks”).
Anterior cruciate ligament (ACL) tears
â For treatment of anterior cruciate ligament (ACL)
tears (Fig. 24–4D), see Chapters 25 and 26.
Loose body removal
â Loose bodies can be difficult to find in the knee.
Thus, when a loose body is found, it is appropriate
(and desirable) to immediately proceed with its
removal while it is easily visualized. Standard re-
moval techniques require triangulation with the
arthroscope and arthroscopic grabber and removal
of the loose body through the appropriate portal. If
necessary, make accessory portals to aid in loose
body removal.
Arthroscopic debridement
â If desired, loose and fibrillated articular cartilage
can be debrided arthroscopically. Use an arthro-
scopic shaver to debride the loose or fibrillated
articular cartilage.
â In general, attempt to limit the amount of debride-
ment performed to the amount necessary to remove
only the severely diseased articular cartilage. If pos-
sible, avoid debriding back to subchondral bone as
this can be counterproductive.
Closure
21. After the operative arthroscopy is completed, re-
evaluate the knee to ensure there is no further
pathology amenable to treatment.
22. Copiously irrigate the joint.
23. Inject bupivacaine (0.25%) into the joint to mini-
mize postoperative pain.
24. Close the portals per surgeon’s preference. The
author prefers a subcuticular suture and steristrips.
25. Dress the wound sterilely in the operating room.
Transfer the patient to the recovery room.
2 4 A RT H R O S C O P Y 1 6 5
Suggested Readings
Boland AL, Southerland SR. Meniscal tear and cyst:
arthroscopic menisectomy. In: Craig EV, ed. Clinical
Orthopaedics. Baltimore, MD: Lippincott Williams &
Wilkins, 1999, pp. 741–749.
Cannon WD Jr. Arthroscopic survey of the knee joint.
In: Scott WN, ed. The Knee. St. Louis, MO: Mosby-Year
Book, 1994, pp. 497–514.
1 6 6 K N E E A N D L E G
Indications
1. Active individual with an acute torn anterior cruci-
ate ligament (ACL)
2. Individual with recurrent instability who has failed
rehabilitation and bracing
3. A sedentary individual who displays instability
related to his or her anterior cruciate ligament—
deficient knee with daily activities
Contraindications
1. Active knee infection
2. Lack of neurovascular control
3. A sedentary individual without demonstrable 
instability
4. Older age (relative)
5. Pediatric patient with open growth plate
Preoperative Preparation
1. Knee radiographs: anteroposterior (AP), lateral, and
skyline
2. Magnetic resonance imaging (MRI): not a necessity,
but helps to assess other injuries.
3. Wait for knee swelling and active range of motion
to normalize prior to surgery (may necessitate pre-
operative physical therapy).
Special Instruments, Position, and
Anesthesia
1. Position the patient supine on the operating room
table.
2. The contralateral extremity should be padded to
avoid pressure on susceptible areas.
3. Leg holder or post
4. General, epidural, or spinal anesthetic
5. Routine arthroscopic setup and routine orthopaedic
surgical instruments
6. Tibial and femoral alignment guides for positioning
the tunnel guide pins
7. Interference screws for graft fixation; these can be
metal or bioabsorbable. A screw and washer may 
be used as a “post.” 
8. A tendon passer (either wire loop, Hewson tendon
passer)
Tips and Pearls
1. The anterior knee incision should extend from the
lower pole of the patella to a point slightly medial
to the tibial tubercle.
2. The lateral incision extends proximal from the lat-
eral epicondyle, approximately 2 to 3 cm.
3. Examine the knee under anesthesia. Assess the sta-
bility and document.
1 6 7
C H A P T E R 2 5
Anterior Cruciate Ligament Surgery
Two Incision
Gordon W. Nuber
 
4. Document all other intra-articular pathology. Con-
sider meniscal repair when appropriate to aid knee
stability.
5. The tibial hole should enter the joint at the posterior
insertion of the anterior cruciate ligament’s remnant.
This is just anterior to the posterior cruciate ligament.
6. The femoral guide pin enters the joint within 5 to 
6 mm of the intercondylar notch’s back wall. This
corresponds to an 11 o’clock position on a right
knee and a 1 o’clock position on a left knee.
7. Make an adequate notchplasty to optimize visuali-
zation of the drill holes.
8. Rasp the ends of the tunnels to avoid sharp edges.
9. Use a “carrot” to plug the tibial tunnel and avoid
fluid extravasation after the tunnel is created.
10. Use a rongeur to contour the end of the bone plug
into a bullet; the tip aids graft passage.
11. Minimize tourniquet use if possible.
12. In most cases, aim to harvest 25-mm-long bone
plugs from the patella and the tibia.
13. Insert the interference screw with the use of a 
guide pin.
14. If a meniscal repair is indicated, this should be per-
formed prior to the anterior cruciate ligament
reconstruction.
What To Avoid
1. Minimize the chance of patella fracture by avoiding
excessively long or deep bone cuts.
2. Lift the femoral guide’s handle to avoid breaking
out the back wall while creating the femoral tunnel.
3. Take care to minimize the chance of dropping the
graft on the floor.
Postoperative Care Issues
1. Consider placing a suction drain in the lateral
incision.
2. Place the leg in a compressive dressing with an elas-
tic wrap after surgery. Consider cryotherapy.
3. If a continuous passive motion (CPM) machine is
used, it can begin at 0 to 40 degrees on day 1 with
daily incremental increases of 5 to 10 degrees.
4. A hinged brace can be used when ambulating 
the first 4 weeks after surgery. Lock the brace in
extension for 2 weeks, then unlock and allow free
range of motion for 2 weeks. Alternatively, a knee
immobilizer can be used for the first few weeks after
surgery (commonly the first 2) and then discontin-
ued when the patient regains adequate quadriceps
control.
5. An accelerated rehabilitation protocol begins imme-
diately after surgery. Normally, active and active-
assisted flexion exercises and passive extension
exercises are instituted.
6. Patients commonly either go home the day of sur-
gery or spend one night in the hospital.
7. Protected weight bearing as tolerated with the
immobilizer or hinged-brace is allowed after surgery.
Most patients can wean themselves off crutches
during the first 2 weeks postsurgery.
Operative Technique
1. Position the patient supine on the operating room
table. Apply a thigh tourniquet as proximal as pos-
sible on leg. Place the opposite leg on a bolster to
flex the hip and avoid stretching the femoral nerve.
In addition, loosely tape the opposite leg to the
table (the leg of a large athlete may fall off a narrow
operating table).
2. Examine the knee and leg after adequate anesthesia
is obtained. This examination under anesthesia
(EUA) should assess medial, lateral, anterior, and
posterior knee stability prior to applying the leg
holder. Document the examination.
3. Prepare and drape the surgical leg in the hospital’s
routine manner. Exanguinate if inflating the tourni-
quet at this point. Alternatively, exsanguination
and tourniquet inflation can be done later in the
procedure at the time of graft harvesting. Try to
minimize tourniquet time, as increased tourniquet
use can increase postoperative leg atrophy. 
Arthroscopic evaluation and notchplasty
4. Make routine arthroscopic portals. The inflow por-
tal is made medial and superior to patella into the
suprapatellar pouch. The medial and lateral joint
line portals are made