A tourniquet-less technique using saline epinephrine irrigation system in an arthroscopic ACL reconstruction in patient with history of popliteal artery ligation

INTRODUCTION: Pneumatic tourniquets use in surgery to create a bloodless surgical field. The majority of orthopaedic surgeon use a tourniquet inflated above systemic blood pressure during arthroscopic anterior cruciate ligament (ACL) reconstruction. A tourniquet use is not free of complications. The disadvantage of tourniquet application include an increased risk of vascular injuries. An arthroscopic ACL reconstruction in patient with history of popliteal artery ligation is challenging. The popliteal artery is the major contributor to the blood supply of the knee joint. This arthroscopic ACL reconstruction does not use tourniquets to preserve the collateral circulation that provides blood supply to the leg and prevent the vascular injuries in patient with history of popliteal artery ligation. PRESENTATION OF CASE: A-23-year-old female brought to the General Hospital with ACL rupture caused by car accident. The patient had a history of knee dislocation with an open wound and rupture of popliteal artery. The patient underwent open reduction surgery of her right knee joint by orthopaedic surgeon and popliteal artery repair by vascular surgeon. The reduction of the knee joint went good, but the popliteal artery repair was failed and the patient underwent popliteal artery ligation 1 week later. The patient received non-operative treatment for her ACL rupture. After 2 years, she did not get a good improvement to her knee and the patient still felt a giving way sensation and unstability of her knee. Then the patient transferred to the General Hospital for ACL reconstruction, but the surgery required a special consideration in the technique of ACL reconstruction because of the history of popliteal artery ligation. DISCUSSION: Positioning of the patient for ACL reconstruction The patient supine on an operating table. The leg to undergo surgery has no tourniquet placed because the patient had no popliteal artery and this operation needs to preserve and prevent the vascular ischemia of the collateral artery. Operating room set up with the patient prepped and draped for the diagnostic arthroscopy. It shows a normal cartilage, rupture of the ACL and PCL, rupture of body of the lateral meniscus in the white zone and rupture of body of the medial meniscus in the white zone. To make the bloodless arthroscopic field, cold saline and epinephrine pumped into the knee. Partial meniscectomy of the lateral and medial meniscus was performed. Single bundled ACL reconstruction was performed using hamstring autograft of the contralatelal site with the diameter was 8 mm and fixated by XO button and bioscrew (ConMed). After six months follow up, the patient did not feel giving way, catched, or locking. The patient had a good vascularity of the right lower extremity. There is improvement in Modified Cincinnati Rating System. The pre operative score was 49. The post operative score was 90. Tegner Lysholm Knee Scoring system before surgery was 35 and post operative score was 91. IKDC Scoring before surgery was 21,8 and the score had a good improvement. The IKDC Scoring after surgery was 73,6. CONCLUSION: ACL reconstruction in patient with popliteal artery ligation is challenging. A tourniquet-less technique using a cold saline and epinephrine solution can be successfully done for pressure controlled into the knee to preserve the collateral arteries flow to the distal limb while still permitting acceptable visual in operative field with good outcome after the surgery.