1. Left knee arthroscopy with limited debridement of adhesions
and chondromalacia with arthrotomy and osteochondral
allograft using Cartiform grafts to medial femur, 28 mm
long, by 19 mm wide, fixed with 6 Arthrex bioabsorbable
fast track 2 mm suture anchors and sutures of bone and
fibrin glue.
2. Osteochondral allograft to medial patella using Cartiform
20 mm disc trimmed slightly, fixed with four Arthrex
bioabsorbable suture anchors and sutures around the
periphery with fibrin glue.
3. Biocartilage to chondral defect, femoral trochlea, mixed
with bone marrow aspiration from left iliac crest, left
knee.
4. Injection of bone marrow aspirate into left knee post
repair of chondral defects.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating
room and was given general anesthetic by Dr. Muthu. Preoperative
antibiotics were given. A left thigh tourniquet was placed, but
initially not inflated. Her left anterior iliac crest and her
left lower extremity were prepped and draped in a routine sterile
fashion.
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An operative time out was taken. The operative site was verified.
The knee was then flexed up without tourniquet and then
inferolateral incision was made. A superior medial outflow portal
was established and an inferomedial portal was established. The
suprapatellar pouch was cleaned. There were small chondral flakes
noted. There was chondromalacia under the patella. There was
chondromalacia in the trochlea. The chondromalacia in the patella
was mostly in the medial side. The lateral facet did not appear
to bad and actually appeared to be in good condition. The femoral
trochlea was mostly chondral, it was superiorly in the central
trochlea. It was estimated to be about 10 mm in width, about 15
mm in length. I then went down to the medial compartment. There
was some slight fraying in the anterior horn of the anterior
medial meniscus at the meniscal capsular junction, and I used the
shaver to smooth this. I then made an inferomedial portal and
inspected the medial meniscus. The meniscus, itself, was intact.
There were no signs of a residual tear whatsoever. As I probed
and inspected the articular cartilage, however, there was a large
area of grade 3 chondromalacia, nearly full-thickness
chondromalacia, in the weight-bearing portion of the femoral
condyle, which appeared quite severe and thinned. This was a
surprise, as I did not notice this much wear on the medial femur
on the x-rays. I felt that this probably should be resurfaced
with Cartiform graft, as well. I then used the probe with marks
to identify the length of the lesion. The lesion was about almost
30 mm in length and about almost 20 mm in width or 18-19 mm.
Since we had an oval graft, 28.5 x 19.0 mm, we felt this would
work for this area. I then inspected the intercondylar notch. The
anterior cruciate ligament and posterior collateral ligament
appeared to be intact. I brought the knee into figure-of-4
position.
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I brought the knee into figure-of-4 position and inspected the
lateral compartment. The lateral meniscus, femur, and tibia were
all in good condition. There were no tears noted.
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I then brought the knee into full extended position, checked the
trochlea again, and estimated this chondral defect to be about 10
x 15 mm in length, 10 mm in width. It was fairly soft centrally,
grade 3, with chondral flap. I then brought the knee into full
extended position and the chondromalacia in the patella was
present, mostly in the medial side. I placed a 70 degree
arthroscope through the superomedial portal and checked patellar
tracking. The patella did tilt slightly laterally, but this was
where the better cartilage was and I felt this would not be a bad
situation if there was a little bit more tension since I would be
doing a medial arthrotomy and I would be closing this slightly. I
then elected to perform the arthrotomy to do osteochondral
allograft to the medial femur and to the patella and do
biocartilage to the chondral defect in the trochlea.
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At this time, the arthroscopic instruments were removed.
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We then went to the iliac crest to prepare bone marrow aspirate.
I made a small stab incision over the iliac crest and used an
11-gauge Jamshidi needle, which had been flushed with heparin and
continued clotting. I then refilled 3 mL of ACT anticoagulant
with 230 mL syringes. I then used the Jamshidi needle and pocked
through the outer table of the crest of the iliac and in between
the tables to aspirate 30 mL of blood and bone marrow out of the
hip. After 30 mL were aspirated, I redirected the needle to a
different position and aspirated an additional 30 mL. This was
then spun in the centrifuge to obtain about 4 mL of platelet-rich
plasma, bone marrow concentrate.
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I placed a 4 x 4 over this.
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I then focused my attention back to the knee. I then
exsanguinated the leg with Esmarch the bandage and inflated the
tourniquet to 300 mmHg. I made a midline incision slightly medial
from just above the superior pole of the patella to just above
the tibial tubercle. The subcutaneous tissue was dissected
medially and slightly laterally. I performed a medial
parapatellar arthrotomy. I took care to not cut the meniscal rim
medially. I carefully teased up the fat pad off the proximal
tibial plateau to expose laterally and evert the patella to
inspect this. As I did so, I could see the lesion on the medial
patella. It involves almost the entire medial facet. I measured
this and it was about 18 mm in diameter. I then used a circle
template and cut with a 15-blade outline and with ring curettes
and straight curettes, removed all the cartilage and removed
calcified cartilage layer off the subchondral bone. I scraped
this and prepared it. The chondral defect in the trochlea was
then cut and I removed all the cartilage to the base of this.
This measured 11 mm by about 15 mm. I then hyperflexed the knee
up and used Z-retractors to retract the medial portion of the
knee and then exposed the chondral defect on the femur, which is
the largest. Again, this measured almost 30 mm in length and 20
mm in width. Fortunately, the Cartiform graft was 28 mm long and
20 mm wide, somewhat oval. I selected this and used this as a
template to remove as much of this area as possible to
incorporate this graft. On this graft, I elected to then drill
holes for anchors. I placed one at the superior apex and
anteriorly and posteriorly in a cruciform at approximately the
10:00 and 4:00 o’clock, and two in the 8:00 o’clock positions. I
drilled these with 2.0 mm bioabsorbable push lock anchors into
place loaded with 3-0 Vicryl guide sutures. I did this to the
patella, as well, placing four both medially and laterally,
superiorly and inferiorly. I then prepared the oval graft on the
medial femur as I made the template and trimmed this to fit. I
placed sutures through the top and bottom and the sides, and then
held in placed as I tied these and cut this. This was secured
anchored and then I placed additional fixation through the graft
and not through the articular cartilage with 3-0 Vicryl sutures.
This anatomically reduced this graft. This was rinsed with
antibiotic saline and then dried. I then used fibrin glue to glue
the edges around this and hold it for five minutes and then
brought it into full extension. I then focused my attention to
the patella. I placed a circular Cartiform graft with the bone
side down, cartilage side up, and sutured the path of sutures
through the mediolateral superior and inferior holes in the
Cartiform graft and then tied these down, anatomically holding
this. In addition, in the periphery, I placed additional suture
fixations at the corners diagonally, which gave very secure
fixation. I then used fibrin glue to glue the edges of this down,
as well. Finally, I used 1 mL of biocartilage granules and mixed
this with 0.8 mL of pure bone marrow aspirate, mixed it, and used
the slurry past to fill in the defect. I made this almost flush
with the articular cartilage surfaces and contoured the trochlear
groove appropriately. Once this was set, I used fibrin glue to
cover over this defect carefully. I left this for five minutes.
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It should be noted that at 90 minutes, I deflated the tourniquet,
which was during the Cartiform grafting of the patella. I
achieved hemostasis with Bovie electrocautery and then completed
the remainder of the procedure without tourniquet.
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Once all these were closed, I irrigated slightly. I placed 20 mL
of Exparel with 20 mL of 0.5% plain saline and 40 mL of 0.5%
plain Marcaine into the subcutaneous tissues and along the deep
periosteum, but out of the joint. I then closed the arthrotomy
with #2 MaxBraid inverted interrupted sutures and #1 Vicryl
interrupted sutures between these. I then irrigated and closed
the subcutaneous tissue with 2-0 Vicryl interrupted sutures. I
did place a 10 round Jackson-Pratt drain in the subcutaneous
tissue in the lateral gutter. It should be noted that I did do a
slight lateral retinacular lengthening by superficially cutting
through portion of the superficial lateral capsular structures
leaving this since there was a little tilt on the x-ray. The skin
was then closed with 3-0 V-Loc running intracuticular sutures and
the skin was glued shut with Dermabond and Prineo mesh. The knee
arthroscopy portals were infiltrated with the Exparel solution,
as well and closed with 3-0 nylon sutures. I did suture above and
below the drain with 3-0 nylon sutures and then Steri-Stripped
this down. The patient was kept in full extension and dressed
with Telfa, 4 x 4s, ABD pads, cast padding, and Ace wraps. It
should be noted that I put the platelet poor plasma into the
subcutaneous tissue and over the tissues for postoperative wound
healing properties. Blood loss was about 200 mL. The patient
tolerated the procedure well. The patient was then dressed with
cast padding, 6 inch Ace wrap, toe-to-thigh, and placed in a leg
immobilizer, locked in full extension. There were no other
complications. The postoperative plan of care will be
non-weight-bearing and locked in full extension for five days to
let the Cartiform cells adhere as well as the biocartilage to
adhere and then plan to start passive range of motion, 0-50, for
the first three weeks, followed by passive range of motion, 0-70,
for two weeks, followed by 0-90.
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