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Multiple ligament reconstruction of the knee.

This case study explores the perioperative story of a 27-year-old man who came to Boulcott Hospital in Wellington to have his knee ligaments reconstructed. For the purposes of this article I will call him 'John'. John's injuries will be described and the journey through the operating theatre to reconstruct his knee detailed. The graft preparation carried out by specialist nurses at Boulcott will also be explained and how this has impacted on surgery times.

John suffered an injury to his knee playing rugby, rupturing what was probably his anterior cruciate ligament. Upon arrival at hospital he was diagnosed with patella dislocation and sent home. A few weeks later that he fell off a ladder at his home and did further damage to his knee, probably at that point rupturing his posterior cruciate ligament. It was a couple of months later before John was seen by the specialist surgeon to determine what damage had been done. Investigative imaging and physical examination determined that not only had John ruptured his anterior and posterior cruciate ligament, he had also damaged his medial and lateral collateral ligaments as well.

John had done major damage to his knee and it was important that it was repaired to restore the knee stability so he could carry on with his work and life without a brace. John has a young family and so needed to have that stability back so he could work and provide for his family.

Ligaments of the knee

Damage to the anterior cruciate ligament (ACL) is often associated with sports and high impact injuries and any activity that causes suddenly stopping or change of direction (AAOS, 2014). The ACL is needed in the knee to stop the tibia from moving forward from the femur and it provides a stable platform for rotation. The posterior cruciate ligament (PCL) is crucial for inhibiting the tibia from moving too far towards the back of the knee and is often injured with powerful trauma, such as a large man falling from height on to a bent knee (AAOS, 2009).

The medial collateral ligament (MCL) joins the tibia and femur together on the medial aspect of the knee and prevents the knee from moving to the side (Wilson, 2016). The lateral collateral ligament (LCL), sometimes known as the fibular collateral ligament, due to its attachment to the fibular, is an important ligament for resisting rotation of the tibia and stabilising the knee from lateral directed forces on the knee (Scheirs & Pot).

Pre-operative Planning

The surgery required detailed pre-operative planning. The team needed to borrow a 70 degree arthroscope, to use when reconstructing the PCL. Frozen allografts also needed to be ordered.

John required four ligaments reconstructed and was therefore unable to provide enough grafts from the hamstring or patella tendon without impacting on his other knee. Tendons from the operative knee could not be used as the hamstrings and quad muscles were all that was left holding his knee together. Intra-operative imaging for positioning the tunnel for the PCL graft was also required and needed to be booked. Four representatives from three different medical supply companies attended the surgery, along with a team of three nurses, an anaesthetist and anaesthetic technician and two surgeons.

The Surgery

John came into the theatre and was anaesthetised, given an adductor canal block and then positioned accordingly. Given the length of the surgery, great care was taken to protect pressure areas and calf pumps were used to prevent deep vein thrombosis (DVT). Surgery began with skin prep and draping and then I set up our camera and all the tools we would need for the case including the drill, shaver, coblation device and fluids for the arthroscopy.

An arthroscopy and inspection of the intercondylar notch and medial and lateral menisci was initially carried out. The surgeon debrided both menisci which were not in good shape, and we then prepared the intercondylar notch by removing the stumps of the ACL and PCL, with a combination of shaver and coblation.

Once preparation of the surfaces was finished, the starting tunnel for our PCL graft in the femur was carefully selected. Anatomical reconstruction of PCL is critical for its overall function in preserving knee stability (Nuelle & Stannard, 2015). It was therefore imperative that the position of the femoral tunnel was checked using intra-operative imaging. To get a full picture of the tunnel position, a port in the medial side of the knee was used to look into the posterior part of the knee to aid in positioning of the drill guide. This is where the 70-degree arthroscope was useful. Once that position was finalised, the tourniquet was let down and our graft preparation started.

For the graft preparation stage, an Achilles tendon graft was used for the PCL even though PCL is a much bigger and thicker ligament normally and a semi-tendinosus tendon was used for the ACL graft.

For the ACL graft, the graftlink[R] construct from Arthrex was used to create a strong graft. Because the graft was only 23cm long, it was folded twice to create a 70mm long graft which was 8mm thick. For PCL, a fibertag tape from Arthrex and several fibrewire sutures were used to create a thick graft construct.

The plan was for the PCL to be passed through the lateral arthroscopic portal towards the medial epicondyle of the femur and secured with a screw at one end and then passed through the tibia and secured with a PCL tightrope button at the tibial end. The rest of the 30cm long PCL graft was to be passed down the medial side of the knee to create a new MCL ligament. This would leave only LCL left to reconstruct with Swivelock[R] anchors on the lateral side. For LCL another semi-tendinosus graft with whip stitching at both ends of the tendon would be used.

The femoral tunnel for the PCL was prepared first. To do this an Arthrex Flipcutter[R] was used, enabling the surgeon to drill a hole and then flip the cutter on the other end to ream only as far as required. In this instance the whole femoral tunnel required reaming to allow the graft to be passed through and wrapped down the medial side. Once that was completed, the hole for the tibial end of PCL was positioned. Because of the multiple tunnels required for all of the grafts, the holes for the ACL need to be drilled before passing any grafts, due to the risk of damaging the grafts in situ.

Once all the tunnels had been drilled and all of the passing sutures had been threaded through, we then had the challenge of passing our grafts through without getting any tangling or crossover of the grafts. We realised some way into passing all of the sutures that it would be easier to remove the passing sutures for ACL as we were struggling arthroscopically to get everything in the right place for PCL.

Because PCL was such a large graft, it required the lateral arthroscopic portal to be widened and it posed great difficulty in getting the graft all the way through the tunnel. Once the graft was through we then had to pass the sutures from the tibial end through and seat the graft down into the tibial socket.

The ACL graft was next to be passed up through the medial tibial socket and through the femur on the lateral side, with a Tightrope[R] button on the femur and an ABS button[R] down onto the tibia. Once the team was happy with the position of the two cruciate ligaments, the repair of the lateral collateral ligament followed.

The lateral collateral ligament reconstruction involves identification of the common peroneal nerve and retracting it out of the way to avoid damage during surgery (Moatshe, Dean, Chahla, Cruz, & Laprade, 2016). Once the nerve was identified, the Arthrex collateral ligament set with its guides was used to drill the holes into the fibular head and the femur. The tunnel for the femoral attachment was drilled first and then secured to the graft with an interference screw. The graft was then passed under the iliotibial band and under the long head of biceps femoris. A tunnel was then made in the fibular head and the graft was passed and attached with a screw.

Once the lateral side was finished we then had to complete the medial side. This involved passing the rest of the PCL graft, currently hanging out of the medial femoral socket, down the medial side of the knee to be attached onto the tibia. In this instance the graft was not quite as long as required for anatomical reconstruction. This meant affixing the graft onto the tibia with a Richards staple, after a failed attempt with a Swivelock[R] anchor. Two Richards staples were required to complete the reconstruction.

Finally the wounds were closed, a bandage applied and a special range of motion brace fitted post-operatively to protect the knee. After ten hours of surgery the whole team was all pretty exhausted.

It is now about two months down the track and apart from some numbness on his foot in the initial post-operative phase, which resolved, John is recovering very well with a much more stable knee.

The graft preparation required for this surgery has traditionally been done by surgeons; however, in the last year and a half at Boulcott, some of the nurses have been trained to do the graft preparation for our ACL reconstructions.

The graft preparation involves cleaning the hamstring grafts, whip stitching and building the graft with the Arthrex tightrope anchors for passing through the knee. The nursing involvement has revolutionised ACL reconstruction procedures at Boulcott due to the time saved. Graft preparation typically takes between 20-30 minutes and so this is time the surgeon can use to prepare the tunnels or debride menisci, thereby saving 40-60 minutes of total time. This means less tourniquet time and less anaesthetic for the patient and the opportunity for nurses to improve their skill level doing the graft preparation

Conclusion

This was a very interesting case to work on and involved a large team comprised of three peri-operative nurses, two specialist surgeons, an anaesthetist and his anaesthetic technician and the medical supply representatives.

With complex cases of any kind in the perioperative environment, teamwork and good communication is essential and this was very evident throughout this case. The ability to work alongside other members of the healthcare team is a crucial skill for peri-operative nurses and is a part of what makes our profession so successful

By Tim Hall

About the author:

Tim Hill has worked at Boulcott Hospital in Lower Hutt for just over three years, starting as a new graduate nurse. He trained at Whitireia in Porirua and on completion of his degree, applied for a job at Boulcott Hospital in the operating theatre. Tim loves theatre nursing and has branched into anaesthetics and trained in recovery nursing as well, which gives him a wide variety of work. Tim comes from a family of four nurses with his father also working in theatre doing orthopaedics and his sister works in an orthopaedic ward in the UK, while his mother cares for a disabled man in his home. So it would seem nursing is in the blood.

References

AAOS. (2009). Posterior cruciate ligament injuries. Retrieved from http://www.cite.auckland.ac.nz/2_1_5.html

AAOS. (2014). Anterior cruciate ligament (ACL) injuries. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00549

Moatshe, G., Dean, C., Chahla, J., Cruz, R., & Laprade, R. (2016). Anatomic fibular collateral ligament reconstruction. Arthroscopic technology, 5(2), 309-314.

Nuelle, C., & Stannard, J. (2015). Combined PCL, posteromedial corner, and posterolateral corner reconstruction. In G. Fanelli (Ed.). Columbia, MO: Springer International Publishing.

Scheirs, D., & Pot, J. D. (n.d.). Lateral collateral ligament. Retrieved from http://www.physio-pedia.com/Lateral_Collateral_Ligament

Wilson, R. (2016). Medial collateral ligament of the knee. Retrieved from http://www.physio-pedia.com/Medial_Collateral_Ligament_of_the_Knee
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Title Annotation:case study
Author:Hall, Tim
Publication:The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation
Date:Jun 1, 2017
Words:2005
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