sinovels Chapter 1404 The Art of Surgery
Chapter 1404 The Art of Surgery
Chapter 1404 The Art of Surgery
The surgery was scheduled for the next morning, and the operating table was already prepared.
Gao Yuan stood to the patient's left, facing the right knee covered by a sterile drape. Purple markings marked the patella, tibial tuberosity, joint line, and entry point. He had drawn these marks by hand twenty minutes earlier, each stroke precise to the millimeter. As he drew the lines on the skin with the marker, several American experts in the observation room exchanged glances; they rarely saw anyone do such meticulous preoperative marking. Most people used templates or had resident physicians do it for them. Gao Yuan drew them himself, stroke by stroke.
Robert stood on the opposite side, his hands raised in front of his chest to maintain sterility. He was already dressed in his surgical gown and gloves, waiting for Gao Yuan to begin.
“Let’s begin!” Gao Yuan said.
He reached out, and the scrub nurse slapped the scalpel into his palm. He grasped the scalpel, gently twisted his wrist, and the tip poked into his skin, making a small incision—neither too deep nor too shallow, clean and precise, just enough to pierce through the skin, subcutaneous tissue, joint capsule, and the lining synovium.
With the arthroscopic approach established, Gao Yuan inserted a blunt puncture needle into the joint cavity, gently rotating his wrist to pass through the infrapatellar fat pad, around the femoral condyle, and precisely reach the intercondylar fossa. Throughout this process, he didn't look at the screen; he watched his own hand, feeling the sensation from the tip of the puncture needle.
He replaced the puncture cone with an arthroscope, turned on the light source, and the moment the screen lit up, the world inside the knee joint was revealed to everyone.
The observation room fell silent.
That's not a normal knee joint.
The synovial membrane was severely overgrown, resembling a patch of red seaweed floating in the joint cavity. The intercondylar fossa was filled with scar tissue, completely obscuring the normal anatomical structure. The remnant of the anterior cruciate ligament was almost invisible, leaving only a small bulge, like a tree stump uprooted. The posterior cruciate ligament was in even worse condition; the ruptured remnant was shrunken and stuck posteriorly, firmly enveloped by scar tissue. Several dark red areas were visible on the cartilage surfaces of the femoral condyles and tibial plateau—traces of cartilage damage, like the surface of an apple gnawed by insects.
The joint was badly damaged, and the usual approach would be staged surgery, but Gao Yuan and Robert chose to do it all in one go. Not because they liked taking risks, but because they had the skill. When you have sufficient skill, you don't need to split one surgery into two.
Gao Yuan switched to a probe, the "third hand" of an arthroscopic surgeon, and the most important sensory organ. It looks like just a thin metal rod with a slight bend at the tip, but in the hands of a skilled surgeon, it's a living tool. Gao Yuan's probe entered the joint cavity, gently parting the synovium. The movement was as light as brushing dust off rice paper with a brush; too much force would damage the tissue, too little would fail to part it. This level of pressure isn't learned, it's felt, the balance found through thousands of repetitive manipulations, refining the extremes of "force" and "gentleness."
Now, even with his eyes closed, Gao Yuan can use the probe in his hand to explore the entire joint cavity, and then use the tactile sensation of the probe to make accurate judgments about all the internal structures.
The probe continued to penetrate deeper, and Gao Yuan used its tip to slowly trace along the medial surface of the lateral femoral condyle, like reading Braille with his fingertips. He was searching for the original footprint of the anterior cruciate ligament, the original attachment point of that ligament before the injury. This was the most crucial step in the entire surgery.
The essence of any reconstructive surgery is simulation, simulating the function of the original structure. As for ligament reconstruction, its optimal start and end points should be the original positions, which was Yang Ping's theory. However, the original position is a fan-shaped surface, and the original ligament is a bundle. The start and end points of reconstruction are roughly circular. Although the reconstructed ligament is also a bundle, it is far from being able to simulate the original ligament. There is a contradiction here.
The later development of dual-bundle reconstruction was thought to improve the quality of the simulation, but it still did not achieve the expected results. Later, Yang Ping found the true biomechanical laws of ligaments, which finally achieved the expected results.
More than 70% of anterior cruciate ligament (ACL) reconstruction failures are due to incorrect femoral tunnel placement. If the tunnel is too anterior, the ligament will be too tight when extended; if it's too posterior, it will be too loose when flexed; if it's too high or low, it will cause impact and friction with the intercondylar fossa. The correct placement is that "original footprint," the optimal attachment point designed by the human body itself over millions of years of evolution.
Finding it means the surgery is half successful.
The probe, high and far, stopped. Its tip rested on a small indentation on the medial side of the lateral femoral condyle. The indentation was almost invisible, covered by scar tissue and a thin layer of fibrocartilage, but the probe could feel it. It wasn't visual, but tactile. The pressure feedback transmitted to the finger told him: this was it. The bone here was slightly harder, the surface slightly rougher, and the shape slightly more concave. All these "slightly" differences combined to form conclusive evidence.
“This is it!” Gao Yuan said.
The experts in the observation room stared at the screen, many unable to discern any difference between the point Gao Yuan was pointing to and its surroundings. The image on the screen was two-dimensional and planar, while the image in Gao Yuan's mind was three-dimensional and immersive. He not only saw the point, but also its position within the entire knee joint's trajectory, its spatial relationship with the tibial insertion, and the tension changes at 30, 60, and 90 degrees of knee flexion. He had simulated these scenarios countless times in his mind before the surgery; now, he was simply making a final confirmation in the real-world setting.
The sound of an electric drill rang out.
Gao Yuan picked up the guide and placed it against the medial wall of the lateral femoral condyle. The tip of the guide precisely embedded itself in the center of the original footprint, the depression he had found with a probe. He adjusted the angle twice: the first for initial positioning, and the second for fine-tuning. The adjustments were very small, perhaps only one or two degrees, but it was this difference of one or two degrees that determined whether the tunnel direction was parallel to the top wall of the intercondylar fossa or slightly deviated. Parallelism was best because the graft's course most closely resembled that of the original ligament, resulting in optimal biomechanics.
The drill started turning, and as Gao Yuan pulled the trigger, his left hand gripped the guide handle, while his right hand held the drill, forming a stable triangle. The moment the drill bit pierced the cortical bone, he felt an extremely subtle change in vibration, from the dull thud of drilling hard bone to the gentle vibration of drilling cancellous bone. He didn't stop, continuing to push. The drill bit moved through the cancellous bone like a needle piercing a sponge. Gao Yuan could judge the drill bit's position in the bone by the vibration frequency transmitted from the drill—too shallow, too deep, off-center, or straight. All this information was transmitted to his brain through his palms, his brain made a judgment within a fraction of a second, and then adjusted it through his fingers. The entire process required no visual confirmation, not even thought; it was an internalized, instinctive operation.
The moment the drill bit broke through the contralateral cortex, Gao Yuan's wrist sank slightly. He felt a sudden "dropping sensation" and immediately released the trigger, stopping the drill. He pulled out the drill bit and used a probe to insert into the tunnel, confirming its direction and depth. The tunnel's inner opening was in the center of the original footprint, and its outer opening was at the predetermined location on the lateral femoral cortex, with a total length of four centimeters, oriented parallel to the top wall of the intercondylar fossa, with an error of no more than one millimeter. Gao Yuan put down the drill and took a half-step back.
Someone whispered something in the observation room, but the sound was too soft for anyone to hear. However, everyone saw the location of the tunnel, perfectly positioned in the center of the original footprint, like a hole drilled using laser positioning. But Gao Yuan didn't use lasers, navigation, or any computer-aided equipment. He used only one hand, a probe, a guide, and a very ordinary electric drill.
The observing doctors sat up straight, realizing that today's surgery was indeed masterful, and the positioning method used was different from all the current mainstream methods.
Next, Gao Yuan needed to locate the tibial tunnel for the posterior cruciate ligament (PCL). This was the most technically challenging step in the entire surgery. The tibial insertion of the PCL is posterior to the tibial plateau, less than one centimeter from the popliteal artery. The popliteal artery is one of the most important major blood vessels in the lower limb; damage to it can have dire consequences, including massive bleeding, lower limb ischemia, and even amputation. Therefore, most surgeons using a special guide with protective devices, or X-ray fluoroscopy guidance, or even dividing the surgery into two parts—performing the PCL first and then the anterior PCL after healing—to minimize risks.
Similar to the anterior cruciate ligament tunneling method, the posterior cruciate ligament tunneling method is also an unprecedented new approach. The observing doctors were on high alert, their eyes glued to the screen.
“Okay!” Robert said.
The drill started up again, this time Gao Yuan drilled more slowly and carefully. The tibial tunnel is deeper than the femoral tunnel, requiring penetration through thicker bone, and its direction is obliquely forward and downward, forming a 45-degree angle with the tibial plateau. Gao Yuan stopped every centimeter he drilled in, using a probe to examine the tissue in front of the tunnel to confirm that he had not encountered any blood vessels.
The tunnel was completed, and Gao Yuan threaded a traction wire through it and pulled it out from the back, preparing for the introduction of the transplant.
Now, both tunnels are in place. The femoral tunnel for the anterior cruciate ligament and the tibial tunnel for the posterior cruciate ligament have both had their entrances, exits, angles, and depths confirmed to be correct.
Next came the preparation of the graft. Gao Yuan picked up the suture board and began weaving the graft. This was no simple operation; he had to suture the end of the tendon into a closed loop and place it onto the fixation device. The stitch spacing, the tension of the knots, the density of the weaving—every detail affected the final strength of the graft and the quality of healing. Gao Yuan sutured very quickly, but each stitch was precise. He used a new method that Yang Ping had taught him.
The experts in the observation room watched Gao Yuan's suturing quietly. What seemed like a simple operation was transformed into an art form by Gao Yuan, and the sutured graft looked like a fine work of art.
The grafts were ready. Gao Yuan inserted the two grafts into their respective tunnels and pulled them out from the other end using traction wires. The anteriorly crossed graft entered through the femoral tunnel and exited through the tibial tunnel; the posteriorly crossed graft entered through the tibial tunnel and was pulled out from the back. The two grafts crossed each other within the joint cavity, forming an "X" shape.
Gao Yuan and Robert simultaneously grasped the traction wire of the graft, which is the most crucial step in this surgery: tension adjustment.
Tension is the most difficult factor to control in ligament reconstruction. Textbooks provide a bunch of numbers, such as the initial tension in Newtons for the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL), but these numbers come from in vitro experiments and may not apply to living individuals. This is because everyone's joint morphology, ligament tension, and exercise needs are different. The ligament tension required by a professional athlete is different from that of an ordinary office worker. Professional athletes need higher tension to cope with high-intensity exercise loads, but too much tension can affect joint mobility, causing postoperative stiffness and pain. Where is this balance point? There is no formula that can tell you.
This is where the experience of medicine, especially surgery, comes into play. At this point, the most reliable thing is not data, but the surgeon's heart and hands.
Gao Yuan slowly applied tension to the traction wire, closing his eyes and feeling the resistance transmitted back from the graft. This resistance wasn't rigid; it was elastic, like stretching a rubber band—the tighter it was pulled, the more it tightened, but there was always a tendency to recoil. Gao Yuan was searching for that "critical point," the position where the graft was stretched just enough to avoid loosening but also before excessive tension began to build up. That critical point wasn't fixed; it varied with the knee's flexion and extension angles, with the tension of the posterior cruciate ligament, and with the patient's weight.
After a long pause, Gao Yuan said, "Fix it."
The fixation screws were screwed into the tunnel. The graft was securely locked in the bone tunnel. The two ligaments formed a perfect "X" at the center of the knee joint, like a miniature cable-stayed bridge, with each anchor point precisely in place and the tension of each "cable" just right.
Gao Yuan reinserted the arthroscope into the joint cavity for a final examination.
Starting from zero degrees, he slowly flexed the patient's knee joint to 30, 60, 90, and 120 degrees, observing the morphology and tension of the reconstructed ligaments at each angle. The anterior cruciate ligament (ACL) had the highest tension at 30 degrees of knee flexion and was relatively relaxed at 90 degrees; the posterior cruciate ligament (PCL) was the opposite, with the highest tension at 90 degrees. The tension changes of the two ligaments formed a complementary relationship, which is what Yang Ping called a "functional complex." When the knee joint flexes and extends, the two ligaments alternately bear the load, cooperating and restraining each other, like a pair of well-coordinated dancers.
Gao Yuan gently probed the anterior cruciate ligament with a probe. The ligament's tension was moderate, neither too loose nor too tight. He then probed the posterior cruciate ligament, which was equally perfect. He gently ran the tip of the probe along the ligament's course, checking for a smooth surface, any compression, and any risk of impingement with the intercondylar fossa. All examination results were negative.
He put down the probe and took a half step back.
The operation is over.
The doctors in the observation room unconsciously stood up, showing their respect for Director Gao's surgery. This was not a simple operation, but an art of surgery.