Chapter 2120: Chapter 1784: The Art of Surgery
The surgery was scheduled for the next morning, and the operating table was already prepared.
Gao Yuan stood on the patient’s left side, facing the right knee covered with a sterilized drape, marked with purple lines on the skin: the patella, tibial tuberosity, joint line, entry point. These marks were drawn by him twenty minutes ago, each stroke precise to the millimeter. As he drew lines on the skin with a marker, several experts from the United States exchanged glances in the observation room; they rarely saw anyone do preoperative markings with such precision. Most people use templates or let residents do it. Gao Yuan drew them himself, stroke by stroke.
Robert stood on the opposite side, hands raised to his chest, maintaining sterility. He had already donned his surgical gown and gloves, just waiting for Gao Yuan to begin.
"Let’s begin!" Gao Yuan said.
He reached out, and the instrumental nurse slapped the surgical knife into his palm. He grasped the knife, gently twisting his wrist, the tip of the knife puncturing the skin in a jab, completing the incision—not too deep nor too shallow, crisp and neat, just penetrating the skin, subcutaneous tissue, joint capsule, and the underlying synovial membrane.
The arthroscopy entry was established, and Gao Yuan inserted a blunt trocar into the joint cavity, gently twisting his wrist, passing through the infrapatellar fat pad and around the femoral condyle, accurately reaching the intercondylar notch. Throughout this process, he did not look at the screen; he watched his hand and felt the sensations transmitted from the trocar’s tip.
He switched the trocar for the arthroscope, connected the light source, and as the screen lit up, the inner world of the knee joint was displayed before everyone.
The observation room quieted down.
The knee joint was anything but normal.
The synovial proliferation was severe, resembling red aquatic plants drifting in the joint cavity. Scar tissue filled the intercondylar notch, distorting the normal anatomical structure. The remnants of the anterior cruciate ligament were nearly invisible, leaving only a small protrusion like a tree stump ripped from the roots. The posterior cruciate ligament’s situation was worse, with the torn ligament remnants shrinking into a mass, adhering to the back, tightly enveloped by scar tissue. There were several dark red areas on the cartilage surfaces of the femoral condyles and tibial plateau, indicative of cartilage damage, akin to the surface of an apple bitten by insects.
The joint was severely damaged; the conventional approach would be to stage the surgery, but Gao Yuan and Robert chose to complete it in one go. Not because they liked taking risks, but because they had the skill. When you have enough operational ability, you don’t need to split one surgery into two.
Gao Yuan replaced the probe; the probe is the "third hand" of arthroscopic surgeons and the most crucial sensory organ. It seems to be just a slender metal rod with a small curve at the tip, but in the hands of an excellent surgeon, it is a living tool. Gao Yuan’s probe reached into the joint cavity, gently brushing aside the synovium, as softly as if dusting off rice paper with a brush, a bit more force would damage the tissue, a bit less would fail to move it. This strength isn’t learned but felt, honed over thousands of operations, balancing the extremes of "forceful" and "gentle" to find that sweet spot in between.
Now, even with his eyes closed, Gao Yuan could traverse the entire joint cavity using the probe in his hand, then precisely assess all internal structures through the feel of the probe.
The probe continued deeper, and Gao Yuan used its tip to slowly glide along the medial surface of the femoral lateral condyle, like reading Braille with fingertips. He sought the original footprint of the anterior cruciate ligament, the primitive attachment point it had before injury. This is the most critical step in the entire surgery.
The essence of any reconstruction surgery is simulation—simulating the function of the original structure. For ligament reconstruction, the best starting and ending points should be original, which was Yang Ping’s theory back in the day, but the original location was a fan-shaped surface; the original ligament was a bundle, while the reconstruction’s starting and ending point is more circular, and although the reconstructed ligament is also a bundle, it falls short of simulating the original ligament, causing a conflict here.
The subsequent double-bundle reconstruction attempted to enhance simulation quality but failed to meet expectations. Later, Yang Ping discovered the ligament’s true biomechanical patterns, finally achieving the desired effect.
The failure of anterior cruciate ligament reconstruction is over seventy percent due to incorrect femoral tunnel positioning. If the tunnel is too anterior, the ligament will be too tight during extension; too posterior, it will be too loose in flexion; too high or too low, it will collide and rub against the intercondylar notch. The correct position is the "original footprint," designed by the body’s evolution over millions of years, the optimal attachment point.
Finding it means half the surgery is successful.
Gao Yuan’s probe halted. The tip pressed against a small indentation on the medial surface of the femoral lateral condyle. The indentation was almost invisible, covered by scar tissue, with a thin layer of fibrocartilage on top, but Gao Yuan’s probe felt it. It wasn’t vision but touch. The pressure feedback transmitted through the probe to his fingers told him: this is it. The bone here is slightly harder than elsewhere, the surface slightly rougher, the shape slightly indented. All these "slight" aspects combined constitute a solid piece of evidence.
"This is it!" Gao Yuan said.
The experts in the observation room stared at the screen; many couldn’t see the difference between the point Gao Yuan indicated and its surroundings. The screen’s imagery is two-dimensional, flat, while the image in Gao Yuan’s mind is three-dimensional, spatial. He not only saw the point but also its position in the trajectory of the entire knee joint movement, its spatial relationship with the tibial endpoint, and its tension changes at thirty, sixty, and ninety degrees of knee flexion. These were simulated countless times in his mind preoperatively, now just performing the final confirmation in the real setting.
