Knee Deep

Going “Knee Deep”

The information provided below is intended as an educational resource intended for surgeons and trainees (medical students, postgraduate residents and fellows starting practice). The information included are my templates for patient expectations, handouts useful for counseling patients in the clinic, forms for completing letters and office paperwork, surgical operative note templates, and similar items. These are free to use for reference, but they should be edited as needed to suit your practice settings and should always be applied with clinical judgement to the treatment of individual patients. They are intended as guidelines and resources and do not constitute medical advice. Unintentional errors, intentional misuse, or unintentional misinterpretation or failure to update this information is the responsibility of the learner/user. Please reach out to me with specific questions.

I myself am always learning and am far from perfect. As seen above in the photograph taken 10 years into clinical practice, I am always seeking to learn and better understand my own techniques and principles. Any adopted modified or evolving techniques will be updated here occasionally, but should not be taken at face value as the exact technique which I am currently using or use in any particular case as I modify each note and resource to suit specific circumstances, the same as I would in clinical care. Please use your judgement but I hope the following information is helpful.

Visualizing Complex Multiligament Knee Reconstruction

Dr. Chip Routt once taught me that if you can draw it you can understand it and be a better surgeon. While my drawings are not up to the same level as Dr. Routt, I do like to sketch procedures for my patients, especially the more complex ones, like this example of a PCL primary repair with Arthrex FiberRings and repair tightrope, MCL reconstruction with Conmed Biobrace augmentation and an MPFL reconstruction. I generally like to repair more of these severe medial capsular injuries but this one presented closer to 3-4 weeks and we were not able to do as much with the native MCL and medial retinaculum as I would have liked. In severe injuries, particularly a femoral avulsion of the PCL, repair can be very gratifying, and if it fails can be converted to a reconstruction at a second stage. In most all multiligament cases, I stage the ACL reconstruction, do a planned lysis of adhesions and manipulation, reassess all meniscal and cartilage repairs, and check all the prior repairs or reconstructions. In some cases, the patient does not always need to return for that ACL reconstruction, but we talk about a second procedure at the 6 week postoperative visit. I have found that preparing patients for this earlier is helpful and less defeating than an ‘unplanned’ manipulation. The principle I like is: only one surgery that limits weight bearing and motion, and only limit it for 4 weeks. Certainly, no one has the perfect answer for these difficult cases, but I have found this approach to be utilitarian for many (but not all) situations.

Quiet Knee Protocol