The choice of anesthetic is made in conjunction with the surgeon, anesthesiologist, and the patient, taking medical co-morbidities, age, and prior history with anesthesia into consideration.
General anesthesia with concomitant IV sedation is most commonly performed. Preoperative femoral and/or sciatic nerve blocks are routinely performed as an adjuvant for postoperative pain relief. A Foley catheter may be placed intraoperatively to monitor fluid shifts during the procedure.

The patient is placed supine on the operating room table. The goal is to allow up to 80 to 90 degrees of static flexion of the knee to be maintained without manual assistance. To do so, a small bump is placed under the patients leg just distal to the greater trochanter with a lateral post placed at the same level. A sterile bump is wedged between the post and the thigh. To maintain flexion, the heel rests on a 4.5 kg sandbag that has been taped to the bed and prevents extension of the leg (Fig. 25.1). Due to the length of time these cases require, we do not use a tourniquet.

After properly positioning the patient on the operating table, a complete ligamentous exam, including anterior and posterior drawer tests, pivot shift, dial test, and posterior drawer with external rotation, is performed. These exam findings are corroborated with MRI findings to establish the proper surgical approach to address the anticipated pathologies.

Standard, osseous, knee anatomy including patella, Gerdy’s tubercle, the fibular head, and medial and lateral joint lines are marked. Special care is taken to palpate and identify the peroneal nerve as it courses around the fibular neck. The dorsalis pedal pulse is palpated and marked for continual monitoring. The standard anterolateral arthroscopic portal is placed just adjacent to the lateral border of the patella tendon, above the joint line. The anteromedial portal is established at the same level, approximately 1 cm medial to the patellar tendon. Additionally, a superolateral outflow portal is established in standard fashion, superior to the patella and posterior to the quadriceps muscle. The posteromedial portal is often required to address the tibial insertion of the PCL, and it is established intraoperatively using an inside-out technique with the aid of a 70-degree arthroscope.

The operative incisions vary according to the structures that require repair. Our standard ACL/PCL tibial tunnel is marked 3 cm longitudinally over the anteromedial proximal tibia, 2 cm distal to the joint line and 2 cm medial to the tibial tubercle. The incision for the PCL femoral tunnel is marked 2 cm medial to the medial articular surface of the trochlea in the subvastus interval. If the injury has an associated medial component, the incision for the tibial tunnels is extended proximally in curvilinear fashion to the medial epicondyle. The incision
for lateral and posterolateral injuries is made, with the knee in flexion, in curvilinear fashion and extends proximally from the lateral epicondyle distally to a location midway between Gerdy’s tubercle and the fibular head (see Fig. 25.1) The proximal portion of this incision parallels the plane between the biceps femoris tendon and the iliotibial band. The skin incisions are injected preoperatively with 0.25% Marcaine with epinephrine (1:100,000).

There are many options for graft selection in the knee injury involving multiple ligaments, most of which are surgeon dependent. The timing of surgery, extent of injury, experience of surgeon, and availability of allograft all factor into the selection process. The inherent advantages to autograft are offset in these complex cases by a choice of allograft, which will provide less donor-site morbidity and decreased operative time. For the ACL graft we currently prefer to use allograft bone-patellar tendon-bone graft. Soft-tissue allograft such as tibialis anterior is also a viable choice. For the PCL, we prefer to use Achilles tendon allograft because of its length, its girth, and the existence of the calcaneal bone plug for femoral fixation (Fig. 25.2). The lateral collateral ligament (LCL) is usually reconstructed with an Achilles tendon allograft with a 7- to 8-mm calcaneal bone plug, which will be fixed in a proximal fibular-bone tunnel at the native LCL insertion site. The posterolateral corner is usually reconstructed with either a tibialis anterior allograft or a semitendinosus autograft.

To minimize the chance of compartment syndrome, we use gravity inflow irrigation with a superolateral outflow portal rather than a pump. The arthroscopic technique should be abandoned in favor of an open approach should extravasation be noted or a compartment syndrome suspected. A 30-degree arthroscope is introduced through the anterolateral portal and a diagnostic arthroscopy is performed to assess the integrity of the cruciate ligaments, the menisci, and the articular cartilage. A 70-degree scope is now placed through the anterolateral portal to establish the posteromedial portal, which will be used as the working portal for the tibial insertion of the PCL. Extreme caution should be exercised in this area to avoid extension of the debridement beyond the capsule and thus causing injury to the neurovascular structures, which reside approximately 1.5 cm posterior to the tibial insertion of the PCL. The use of the 30- and 70-degree arthroscopes through both the anterolateral and the posteromedial portal will allow for excellent access, visualization, and triangulization of the tibial PCL insertion site. Our attention is now turned to the ACL. We attempt to preserve as much of the ACL footprint as possible for vascular and pro-prioceptive considerations.

Next, we evaluate for any concomitant meniscal or articular cartilage injuries. Peripheral tears will be repaired using our preferred inside-out method, leaving the sutures to be secured with the knee in 30 degrees of flexion after all other grafts have been passed and secured. Central and irreparable tears are debrided back to a stable rim at this time.