http://upload.orthobullets.com/topic/3031/images/portals.jpg
http://upload.orthobullets.com/topic/3031/images/pf joint.jpg
http://upload.orthobullets.com/topic/3031/images/popliteus insertion.jpg
http://upload.orthobullets.com/topic/3031/images/medial.jpg
http://upload.orthobullets.com/topic/3031/images/notch.jpg
http://upload.orthobullets.com/topic/3031/images/lateral.jpg
Indications
  • Arthroscopy is a surgical technique that can be applied to perform the following types of procedures:
    • Diagnostic surgery
    • Meniscal repair or resection 
    • Removal of loose bodies
    • ACL and PCL reconstruction
    • Synovial biopsy or synovectomy
    • Chondral defect repair, including microfracture
    • Osteochondritis dissecans treatment
    • Knee debridement for osteoarthritis
      • controversial whether or not it provides symptomatic relief
Positioning and Scope Insertion
  • Patient placed supine with ability to flex the knee
    • leg holder or post 
      • has benefit of allowing valgus stress
      • but makes figure-four position more difficult
  • Place tourniquet (important for safety, but often not inflated)
  • Make anterolateral incision over soft spot of knee
    • vertical incisions
      • have advantage of increased superior-inferior mobility of instruments
    • horizontal incisions
      • have advantage of increased medial-lateral mobility of instruments
  • Insert trochar into capsule
    • advance blade into capsule then follow with trochar.
    • do with knee flexed
  • Advance trochar into suprapatellar pouch
    • with knee straightened
Primary Portals 
  • Anterolateral 
    • function
      • standard portal 
      • used as the primary viewing portal
    • location & technique
      • make with knee in flexion, adjacent to patellar tendon over soft spot on joint line
  • Anteromedial
    • function
      • standard portal
      • used as the primary instrumentation portal
    • location & technique
      • make with knee in flexion, adjacent to patellar tendon over soft spot on joint line
  • Superomedial
    • function
      • accessory portal
      • most commonly used for water in/out flow
    • location & technique
      • make with knee in extension
  • Superolateral
    • function
      • accessory portal 
      • most commonly used for water in/out flow
    • location & technique
      • make with knee in extension
      • most common site for aspiration or injection 
Secondary Portals
  • Posteromedial portal 
    • function
      • helps visualize posterior horn and PCL
    • location & technique
      • 1 cm above joint line behind the MCL
  • Posterolateral portal
    • function
      • helps visualize posterior horn and PCL
    • location & technique
      • 1 cm above joint line between LCL and biceps tendon
  • Transpatellar portal
    • function
      • used for central viewing or grabbing
    • location & technique
      • 1 cm distal to patella and splits the patellar tendon
      • do not use if performing a bone-patella-bone graft harvest
  • Proximal superomedial portal
    • function
      • used for anterior compartment visualization
    • location & technique
      • 4 cm proximal to patella
  • Far medial and far lateral portals
    • function
      • used for accessory instrument placement
      • often helpful for loose body removal
    • location & technique
      • place where can be best utilized for need
Diagnostic Scope 
  • Should systematically check the following locations and structures 
    1. with knee fully extended start in suprapatellar pouch
      • loose bodies
    2. patellofemoral joint 
      • patellofemoral cartilage
      • patellofemoral tracking
    3. trochlear groove
    4. lateral gutter 
      • insertion of popliteus
    5. lateral compartment
      • anterior horn of lateral meniscus
    6. medial gutter
    7. with knee flexed to 90 move to medial compartment 
      • medial meniscus
      • medial femoral condyle cartilage
      • medial tibial plateau cartilage
    8. intercondylar notch 
      • ACL
      • PCL
      • posteromedial corner 
        • best seen with 70 degree scope placed through notch (Modified Gillquist view)
    9. with knee in figure-four position finish in lateral compartment 
      • lateral meniscus
      • popliteal hiatus
      • lateral femoral condyle cartilage
      • lateral tibial plateau cartilage
Complications
  • Iatrogenic articular cartilage damage
    • is most common complication
  • Hemarthrosis
  • Neurovascular injury
    • posteromedial portal
      • saphenous nerve
    • posterolateral portal
      • common peroneal nerve

 

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Questions (1)

(OBQ05.69) When performing an aspiration or intra-articular injection in the knee, the most accurate needle placement site is which of the following? Review Topic

QID:955
1

At the site of maximal tenderness

1%

(2/340)

2

Medial to patellar tendon with knee flexed

7%

(24/340)

3

Lateral to patellar tendon with knee flexed

13%

(43/340)

4

Medial to proximal patella with knee in extension

3%

(9/340)

5

Lateral to the patella with knee in extension

76%

(260/340)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Intra-articular administration of medications has been shown to be highest with the injection performed lateral to the middle to proximal patella with the knee in extension. Extension allows greater patellar mobility and increases the available space in the patellofemoral joint compared to flexion. A lateral starting point when injecting into the patellofemoral joint has less overlying soft tissue than medial, which makes it easier to palpate the bony landmarks and evert the patella.

Jackson et al. evaluated 240 consecutive injections in patients without clinical knee effusion placed anteromedial, anterolateral, or lateral midpatellar. Using fluoroscopy to confirm location, accuracy rates were highest for the midlateral portal (93%) compared to anteromedial (75%) or anterolateral (71%).


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