OT notes · Orthopaedics

Arthroscopic ACL reconstruction

Usual anaesthesia
Spinal or general, with or without adductor canal block
Position
Supine, knee able to flex to 90-120 degrees (lateral post or leg holder)
Setting
elective

Operative note template for arthroscopic single-bundle ACL reconstruction, with a filled example for a quadrupled hamstring autograft reconstruction under spinal anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • infection of the knee (septic arthritis)
  • deep vein thrombosis and pulmonary embolism
  • graft failure or re-tear
  • stiffness or loss of knee motion
  • anterior knee pain
  • numbness near the scar from saphenous nerve branch injury
  • meniscal repair or removal if a tear is found
  • arthritis of the knee in later years

Pre-operative details for this operation

  1. Side and diagnosisright / left; complete or partial ACL tear on MRI; associated meniscal, collateral or cartilage injury
  2. Date and mechanism of injurysport, twisting injury; time since injury
  3. Symptomsgiving way, locking, swelling
  4. Clinical tests in clinicLachman, anterior drawer, pivot shift; range of motion
  5. Graft plannedHamstring autograft (semitendinosus with or without gracilis)Bone-patellar tendon-bone autograftQuadriceps tendonAllograft
  6. Implants availablesuspensory femoral button (fixed or adjustable loop), interference screws in a range of sizes, post and washer as backup

Anaesthesia and position

  1. AnaesthesiaSpinalGeneralCombined spinal-epiduralany nerve block: adductor canal / femoral
  2. Examination under anaesthesiaLachman and pivot shift on both knees (normal side first)
  3. PositionSupine with lateral post and foot stopSupine in leg holder
  4. Tourniquetsite, pressure in mmHg, time inflated and deflated, total minutes
  5. Arthroscopy fluidnormal saline; gravity or pump; pressure
  6. C-armNot usedUsed (for what)

Operative findings

  1. ACLComplete tearPartial tearHealed to PCLEmpty notch
  2. PCLIntactTorn
  3. Medial meniscusintact / tear type, zone, length; what was done
  4. Lateral meniscusintact / tear type, zone, length; what was done
  5. Articular cartilagenormal / chondral lesion: site, size, grade
  6. Othersynovitis, loose bodies, notch shape

Procedure (steps)

  1. Graft harvestincision site and length; tendons harvested; stripper used; length and number of strands
  2. Graft preparationwhipstitch suture; pretensioned on board; final diameter in mm; length
  3. PortalsAnterolateralAnteromedialAccessory low anteromedial
  4. Diagnostic arthroscopyall compartments examined; findings above
  5. Meniscal or cartilage procedureNoneMeniscal repair (device, number of sutures)Partial meniscectomy (extent)Chondral debridement
  6. Notch preparationstump debrided, footprint marked; notchplasty yes / no
  7. Femoral tunnelAnteromedial portal techniqueTranstibialOutside-inknee flexion angle, diameter, depth, posterior wall kept
  8. Tibial tunnelguide angle, entry point, diameter, length
  9. Graft passagedirection; length of graft inside femoral tunnel (marked)
  10. Femoral fixationSuspensory buttonInterference screwCross pinloop length, button flipped and confirmed
  11. Tensioning and tibial fixationknee cycled; knee angle at fixation; screw type and size (diameter x length); backup fixation
  12. Final checkno impingement in full extension; graft taut on probing; Lachman and pivot shift after fixation

Closure, drains and dressing

  1. Harvest woundsubcutaneous and skin suture
  2. Portalssuture or adhesive strips
  3. DrainNoneIntra-articular suction drain
  4. Local infiltrationdrug, volume
  5. Dressing and bracecompression / cold sleeve; brace locked in extension or hinged
  6. Distal circulation and sensation at end

Specimens and implants

  1. Femoral implanttype, make, loop length or screw size, lot/batch; sticker pasted
  2. Tibial implanttype (metal / bioabsorbable / biocomposite screw, post), make, size, lot/batch; sticker pasted
  3. Meniscal repair devicesmake, number, lot/batch; sticker
  4. SpecimensNoneLoose body / meniscal tissue sent for HPE

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Distal circulation and sensationhourly for 4 hours, then 4-hourly
  2. Bracelocked in full extension; sleep in brace
  3. Weight bearingpartial with crutches, or as tolerated with brace locked in extension
  4. Exercises from day 1quadriceps sets, straight-leg raise, patellar mobilisation, full passive extension with pillow under heel
  5. Range of motion target0 to 90 degrees by 2 weeks
  6. Cold therapy and limb elevation
  7. Analgesiadrug, dose, frequency
  8. Thromboprophylaxisearly mobilisation; drug only if risk factors
  9. Watch for infectionfever, increasing pain or swelling, wound discharge: inform
  10. Stitch removal and physiotherapy follow-update

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. S.P., 24 years, footballer, twisting injury to the right knee 4 months ago, with episodes of giving way and an MRI showing a complete ACL tear.

Case details

Date: 18/06/2026. Elective. OT 5.

In OT 09:30. Spinal given 09:40. Tourniquet up 10:05. Tourniquet down 11:25. End 11:40.

Surgeon: Dr A. (consultant, Orthopaedics). Assistant: Dr B. (3rd-year resident), who harvested and prepared the graft. Consultant present throughout.

Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Diagnosis: complete tear of right ACL with instability. Lachman positive, pivot shift positive in clinic. MRI: complete ACL tear, menisci intact.

Plan: arthroscopic ACL reconstruction with quadrupled hamstring autograft.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from patient, father as witness. Includes possible meniscal repair or removal.

WHO checklist sign in and time out done. Right knee marked.

Inj cefazolin 2 g IV and inj ketorolac 30 mg IV at 09:55, before tourniquet inflation.

Anaesthesia and position

Spinal anaesthesia. Examination under anaesthesia: left knee normal; right knee Lachman grade 2 with soft end point, pivot shift positive.

Supine, lateral post at right thigh, foot stop to hold knee at 90 degrees. Tourniquet on upper right thigh.

Parts painted with povidone-iodine and draped. Limb exsanguinated with Esmarch bandage. Tourniquet inflated to 230 mmHg (systolic 130 + 100).

Normal saline irrigation by arthroscopy pump.

Findings

ACL completely torn from femoral attachment. PCL intact.

Medial and lateral menisci intact on probing.

Articular cartilage normal in all compartments. No loose body.

Procedure

4 cm oblique incision over pes anserinus. Semitendinosus and gracilis harvested with an open tendon stripper, detached distally. Graft lengths 26 cm and 24 cm.

Tendons doubled to four strands, ends whipstitched with No. 5 non-absorbable suture, pretensioned on graft board at 10 lb (4.5 kg). Final diameter 8 mm.

Anterolateral and anteromedial portals made. Diagnostic arthroscopy as above.

ACL stump and notch debrided with shaver, footprint outline kept. No notchplasty needed.

Femoral tunnel through accessory low anteromedial portal with knee flexed to 120 degrees: 8 mm, 30 mm deep, posterior wall about 2 mm kept. Lateral cortex drilled for button.

Tibial tunnel with guide at 55 degrees, starting about 1.5 cm medial to tibial tuberosity; guidewire exit at centre of tibial footprint checked arthroscopically. Reamed to 8 mm. Tunnel length 40 mm.

Graft marked 20 mm from the looped end and passed from tibia to femur. Button flipped on lateral femoral cortex and seated; mark seen at the tunnel aperture.

Knee cycled for about 3 minutes with tension held on the graft. No impingement in full extension.

Tibial fixation with knee in full extension using bioabsorbable interference screw 9 x 30 mm (1 mm larger than tunnel).

Graft taut on probing. Lachman negative and pivot shift negative after fixation.

Closure

Harvest wound: subcutaneous interrupted polyglactin 910 (Vicryl) 2-0, skin subcuticular poliglecaprone (Monocryl) 4-0. Portals closed with polyamide (Ethilon) 3-0.

No drain. Sterile dressing, cold sleeve and crepe bandage. Hinged brace locked in extension.

Tourniquet released at 11:25, total 80 minutes. Toes warm and pink, capillary refill normal at end.

Specimens and implants

Femoral: fixed-loop suspensory button, loop 20 mm, make ______, lot ______.

Tibial: bioabsorbable interference screw 9 x 30 mm, make ______, lot ______.

Both stickers pasted in the file and entered in the OT implant register. No specimen.

End of procedure

Estimated blood loss 100 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 78/min, BP 122/76 mmHg.

Post-op orders

Toe circulation and sensation hourly for 4 hours, then 4-hourly.

Brace locked in extension, including during sleep. Walking with crutches, partial weight bearing, from day 1.

Quadriceps sets, straight-leg raise and ankle pumps from today. Pillow under heel for full extension. Knee bending 0 to 90 degrees from day 1 with physiotherapist.

Cold sleeve and limb elevation.

Inj ketorolac 30 mg IV 8-hourly for 2 more doses (not more than 120 mg in 24 hours), if renal function normal.

Dressing check on day 2. Stitch removal in OPD on the date given in the discharge card.

Signature

Dr B., JR-3, Orthopaedics, for Dr A. Reg. no. ________. 18/06/2026, 12:00.

Must document for this operation

  • Examination under anaesthesia of both knees, and the same tests after fixation. It shows the instability that justified surgery and the stability achieved, which matters if the knee is unstable later.
  • Graft type, number of strands and final diameter. A revision surgeon plans the new graft and tunnels from this.
  • Tunnel diameters, lengths and technique for the femoral tunnel. The revision surgeon has to plan around the old tunnels.
  • Implant type, size, make and lot/batch number for each fixation device. Needed for traceability and recall, and the revision surgeon must know which screw or button to remove.
  • State of both menisci and cartilage, and what was done to them. A meniscal repair changes the rehabilitation plan, and cartilage damage explains later pain.
  • Tourniquet pressure and total time. Tourniquet use slows early quadriceps recovery, and audits often find the time missing.

Common mistakes in these notes

  • Writing 'ACL reconstruction done' with no graft diameter or tunnel sizes.
  • Not writing the implant sizes or pasting the stickers.
  • Writing 'menisci normal' without saying they were probed.
  • No record of tourniquet pressure or duration.
  • Leaving out the knee position at tibial fixation.
  • Brace and weight-bearing orders not written, so ward staff guess.

Indian practice and paperwork

  • NABH requires implant batch and serial numbers in the patient record, the master logbook and the discharge summary. Paste the button and screw stickers in all three. (NABH 5th ed., MOM.10(d))
  • An audit of orthopaedic operation notes in a Mumbai tertiary centre found tourniquet time recorded in only 41.8% of notes. (Tuteja S et al., Indian J Orthop 2022;56(12):2223-2227, PMID 36507202)
  • A two-cycle audit at a Lucknow institute raised documented op-note items from 35.8% to 90.2% after an RCS-based proforma, with the lowest baseline for surgical details, complications and post-op instructions. (Aslam MA et al., Cureus 2025;17(5):e84632, PMID 40546492)

Sources

  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 14, ACL reconstruction: anatomical single-bundle endoscopic reconstruction using BPTB graft; Technique 15, transepiphyseal ACL reconstruction using quadruple hamstring grafts (Phillips BB, Mihalko MJ), pp. 55-67.
  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2027, Ch 50, Knee injuries: ACL reconstruction with hamstrings (Technique 50.23), rehabilitation, complications, pp. 2085-2090.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Implantation of internal fixation devices: cefazolin; adult dose 2 g IV (3 g if 120 kg or more) within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Core Orthopaedic Procedures, Technique 14, printed p. 55: antibiotics before tourniquet inflation; tourniquet 100 mmHg above systolic pressure; more than 90 min of tourniquet time anticipated is a reason to do arthroscopy before inflation.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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