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Knee Arthroscopy

Author: David Abbasi

Topic updated on 04/06/13 1:29pm

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 with knee fully extended start in suprapatellar pouch loose bodies patellofemoral joint patellofemoral cartilage patellofemoral tracking trochlear groove lateral gutter insertion of popliteus lateral compartment anterior horn of lateral meniscus medial gutter with knee flexed to 90 move to medial compartment medial meniscus medial femoral condyle cartilage medial tibial plateau cartilage intercondylar notch ACL PCL posteromedial corner best seen with 70 degree scope placed through notch (Modified Gillquist view) 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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Qbank (1 Questions)

TAG

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

Review Topic

1. At the site of maximal tenderness
2. Medial to patellar tendon with knee flexed
3. Lateral to patellar tendon with knee flexed
4. Medial to proximal patella with knee in extension
5. Lateral to the patella with knee in extension

PREFERRED RESPONSE ▶

DISCUSSION: 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%).

REFERENCES:

1. Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into the intra-articular space of the knee. J Bone Joint Surg Am 2002; 84: 1522-1527. PMID:12208907 (Link to Abstract)

2. Greene WB (ed): Essentials of Musculoskeletal Care, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp. 371-372.

Question Authors:

Patrick McCulloch MD, Derek Moore, Ben Taylor MD,

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Cases

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Groups

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Evidence & References Show References

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into the intra-articular space of the knee. J Bone Joint Surg Am 2002; 84: 1522-1527. PMID:12208907 (Link to Abstract)
Greene WB (ed): Essentials of Musculoskeletal Care, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp. 371-372.

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