Anterior Dislocation
I was 20 when I suffered an anterior knee dislocation while playing flag football in college. I underwent three surgeries (1. Ligament repair 2. Nerve graft and tendon transfer 3. Knee reconstruction with alografts) over a 7 month period. It's been 4 years since my accident and I still have a great deal of pain, instability, and weakness. It's funny how something so silly as playing flag football can change your life in a major way. I almost lost my leg that night! However, I am also very thankful that I can walk normally today and still play golf (that's all anyone needs). Anyway, I wanted to share the notes from my first operation. I will share the notes from the second and third later:
PREOPERATIVE DIAGNOSIS:
Multiple tears of the ligaments of the right knee from anterior dislocation of the knee including ACL, PCL, lateral collateral ligament, biceps tendon, and posterolateral complex and posterior capsule, posteromedial complex and posteromedial capsule and posterior oblique ligaments, avulsion of the peroneal nerve.
POSTOPERATIVE DIAGNOSIS:
Same.
OPERATION PERFORMED:
Repair of above tendons and ligaments.
ANESTHESIA:
Epidural supplemented with general.
DESCRIPTION OF OPERATION:
Under adequate preop medication, the patient was brought to the Operating Room. The patient had an epidural anesthetic administered, and the right leg was prepped and draped in the usual fashion. Tourniquet was not used during the procedure. A standard anterior midline incision was made, starting about 4 inches above the superior patella and ending about 4 inches below the inferior patella. Incision was carried down through skin and subcutaneous tissues. Bleeders were clamped and Bovied as they were found. The quadriceps tendon was divided superiorly and carried medially in a medial capsular incision and carried down to the tibial tubercle. The patella was everted and the knee was flexed to 90 degrees in the leg holder. The patient’s knee was explored. The anterior cruciate ligament was torn within its mid substance with some portions reaching all the way to the tibia from the proximal attachment. The posterior cruciate was torn from its femoral attachment. The posterior cruciate was repaired first by drilling two drill holes in the proximal attachment to the femoral and medial femoral condyle and brought out through the medial aspect of the femoral condyle, about 1 cm apart, and through a suture passer, multiple, approximately 7-8 sutures of 0 Surgidek material placed through the posterior cruciate ligament at various stages according to the method of Marshall and brought out through these two holes. They were later sutured to themselves. In a similar manner, multiple sutures about six in the distal stump and seven in the proximal stump were placed through drill holes, about 1 cm apart in the tibia and the femur on the lateral side and later brought together and sutured. On both the posterior cruciate and the anterior cruciate, there was some synovium adjacent to this and this was tacked down with the sutures to the stumps, them being incorporated in the tear to help for vascularization. The medial and lateral meniscus were probed and visualized and found to be intact. With their substance, they were torn from their peripheral attachments, which were later repaired. The posterior and medial complex was approached first in interval between the __________ and medial collateral ligament was approached and at this area, ecchymosis was noted from the posterior medial femoral condyle and attachment of the posterior oblique ligament there was avulsed. In exploring the medial joint compartment, the medial capsule was also found to be avulsed from its attachment to the femur. This was repaired by bringing several horizontal mattress Surgidek sutures through the medial head of the gastroc at this area and then through the posterior capsule and then reattached. The posterior oblique ligament was brought up and attached to the soft tissues of the medial femoral condyle posteriorly and then the edges of it were repaired with the intact superficial medial collateral ligament. Next, attention was turned to the lateral compartment where after dissecting the soft tissues down, a large gap was noted in the posterolateral compartment which on further exploring this area without dissection, the patient was noted to have a complete avulsion of the peroneal nerve. The avulsion was approximately 8 cm proximal to the fibular head. The more proximal portion of it was tagged with 4-0 metal suture for later identification. The posterolateral complex was repaired by bringing the posterior capsular ligament together with drill holes going from anterolateral portion of the tibia to the posterior portion. There were three of them going across. There were two large 0 Surgidek sutures placed in horizontal mattress suture and tied anteriorly. Next, the lateral collateral ligament, which was torn within its midsubstance, was brought together by a Bunnell 0 Surgidek suture. The arcuate ligament which was avulsed from its femoral attachment was brought together and attached to soft tissues with 0 Surgidek suture and then using 0 Polysorb, the vertical portions of it were tacked together to the lateral collateral ligament and finally through a drill hole in the posterior portion of the fibula, the fibular _______ ligament was repaired with #1 Surgidek and another drill hole further on into the proximal fibula. The biceps tendon was reattached. The edges of these were all tied together with 0 Polysorb suture. Two Hemovacs were placed in the wound on the lateral aspect and the other in the knee joint, brought out through separate stab incisions. The quadriceps and patella tendons were brought together in the capsule with 0 figure-of-eight Surgidek suture. Subcutaneous tissue was approximated with 2-0 Polysorb and staples were used in the skin. The patient tolerated the procedure well.
ESTIMATED BLOOD LOSS:
200 cc.
A compression dressing was applied and a hinged lock brace at 40 degrees was applied to patient. The patient left the Operating Room in satisfactory condition.
From:
Josh Thompson - cutigers@sowega.net
