Preoperative Patient Care A Outpatient Evaluation and Management 1 Provide patient care in complex sports medicine conditions with supervision 2 Perform examination of the central nervous system, eye, mouth, throat, skin, genitourinary (GU) system 3 Manage non-operative acute musculoskeletal injures (e.g., Grade 1 knee medial collateral ligament (MCL) tear, grade 1 ankle sprain) and overuse/chronic conditions in sports medicine (e.g., Achilles tendinopathy, stress fractures) 4 Interpret advanced imaging studies (e.g., pillar view of c-spine, magnetic resonance imaging [MRI]) B Advanced Evaluation and Management 1 Independently provide patient care in all aspects of sports medicine conditions 2 Manage all musculoskeletal aspects and acute sports medicine injuries 3 Refer medical sports medicine conditions to specialists (e.g., recurrent concussions, hyphema, cardiomegaly, eating disorders) appropriately 4 Correlate imaging studies with clinical findings C Preoperative H & P 1 Demonstrates basic skills for routine patient care 2 Performs regional physical examination of the musculoskeletal system history Age Gender HPI PMHx identify medical co-morbidities that might impact surgical treatment Social history physical exam ROM joint effusion joint tenderness complete neurovascular exam of extremity. 3 Provides patient care in routine sports medicine conditions without supervision 4 Orders appropriate radiographic image order triplanar standing radiographs of the knee review plain films for fractures, cartilage lesions, hindfoot and midfoot malalignment weightbearing radiographs AP of the foot and ankle lateral view of the foot 5 Perform operative consent describe complications of surgery including pain infection development of ossification at the anterior tibia with restriction of dorsiflexion damage to the deep peroneal nerve with subsequent hyposensitivity DVT arthrofibrosis Operative Techniques E Preoperative Plan 1 Determine pathology 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation standard arthroscopy pump 2 Room setup and Equipment standard OR table with leg holder 3 Patient Positioning supine leg holders G Ankle Distractor Placement 1 Check the instrumentation inspect all instruments confirm that all parts of the noninvasive external distractor are sterile on the operative field 2 Place the patient for placement of the ankle distractor place the patient on the operative table supine the foot should rest within 10 cm of the end of the bed place a bump under the hip to internally rotate the leg so that the toes are pointing straight up place a tourniquet on the calf below the level of the fibular head to prevent peroneal nerve impingement flex the hip 60 degrees place the posterior thigh on a well padded thigh holder secure with straps prep and drape the ankle with standard arthroscopic draping the distal portion of the arthroscopy drape is pulled off the end of the foot to allow distractor placement place the bed clamp as far distal on the bed as possible the external distractor strap is placed with the foam portions over the posterior inferior heel and on the dorsal foot after creating equal lengths on the medial and lateral sides of the foot pull the hook lop distally with manual distraction once this is connected use the threaded rod to provide further distraction to the ankle H Anterior Portal Placement 1 Prepare the ankle inject the ankle with 10 cc of sterile saline via the anteromedial ankle this allows identification of the correct orientation and location for the anteromedial arthroscopy portal 2 Make incision make a 5 mm longitudinal skin incision and spread the subcutaneous tissue down to and then through the capsule with a small hemostat A small gush of fluid will confirm the intra-articular location 3 Enter the joint use a blunt tip trocar with the arthroscopic cannula to enter the joint insert the arthroscope and start the water flow 4 Start the water pressure place the water pressure about 5 mmhg above the systolic pressure if possible but no higher than 120 mmhg this will help reduce the bleeding which often obscures the view unless there is severe arthrofibrotric tissue in the anterior ankle the anterolateral ankle should be easily visualized upon introducing the arthroscope 5 Make the anterolateral portal introduce the 18 gauge needle from the anterolateral portal location this serves 2 purposes allows for water flow through the needle which allows better visualization identifies the correct location of the portal incision in order to access the joint properly inspect the joint distraction allows for much greater joint inspection than otherwise possible make the anterolateral portal in the same fashion to the anteromedial portal I Anteromedial Inferior Portal Placement 1 Place the portal visualize the medial gutter with the arthroscope through the anteromedial portal 2 Place the 18 gauge needle introduce an 18 gauge needle into the inferior medial gutter which is usually 10 mm inferior to the normal anteromedial portal location once the needle is confirmed to be in the proper position a new portal is then made as described earlier this portal in combination with the conventional anteromedial portal can be used to first inspect and then debride the far anteromedial ankle joint and deltoid insertion J Posterior Coaxial Portal Placement 1 Make the skin incision with the arthroscope and inflow in the anterolateral portal make the posterolateral portal with a small vertical skin incision immediately posterior to the peroneal tendon sheath and 1.5 cm proximal to the tip of the fibula 2 Position the ankle hold the ankle in neutral dorsiflexion 3 Place the trocar insert the arthroscope sheath and blunt trocar anterior and slightly inferior on a plane parallel to the bimalleolar axis 4 Confirm placement confirm intracapsular placement by briefly inserting the arthroscope 5 Place switching rod insert a long switching rod through the cannula and direct it towards the medial malleolus use the rod to palpate the posterior colliculus and penetrate just anterior to the posterior tibial tendon 6 Place the posteromedial portal tent and incise the skin over the posteromedial ankle pass a second cannula over the switching stick into the posterior ankle recess 7 Maneuver the arthroscope 8 Place the sheath and blunt trocar appropiately insert the arthroscope sheat and blunt trocar anterior and slightly inferior on a plane parallel to the bimalleolar axis 9 Confirm placement confirm intracapsular placement by briefly inserting the arthroscope for synovectomies or posteromedial osteochondral lesions, place the arthroscope in the posterolateral cannula while the posteromedial cannula is used as the working portal K Anatomy Visualization 1 Visualize the ligaments 2 Test the lateral and medial ligament stability apply gentle varus, valgus and anterior pull stress evert and pronate the foot to test deltoid ligament stability check lateral instability check for talar tilting by supination stress of the foot L Wound Closure 1 Use 3-0 and 4-0 biosyn for closure 2 Apply steristrips 3 Cover with tegaderm and occlusive dressings Postoperative Patient Care O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds schedule follow up in 2 weeks outpatient physical therapy compression bandaging up to the thigh elevate the ankle perform immediate cryotherapy CPM POD 1 as tolerated for 6 to 8 hours a day for 4 to 6 weeks partial weightbearing of 15 kg allowed for the first 6 weeks 30 kg for the next 2 weeks R Complex Patient Care 1 Acts as a referral to manage complex conditions in sports medicine 2 Develops novel imaging techniques for sports medicine
A Outpatient Evaluation and Management 1 Provide patient care in complex sports medicine conditions with supervision 2 Perform examination of the central nervous system, eye, mouth, throat, skin, genitourinary (GU) system 3 Manage non-operative acute musculoskeletal injures (e.g., Grade 1 knee medial collateral ligament (MCL) tear, grade 1 ankle sprain) and overuse/chronic conditions in sports medicine (e.g., Achilles tendinopathy, stress fractures) 4 Interpret advanced imaging studies (e.g., pillar view of c-spine, magnetic resonance imaging [MRI]) B Advanced Evaluation and Management 1 Independently provide patient care in all aspects of sports medicine conditions 2 Manage all musculoskeletal aspects and acute sports medicine injuries 3 Refer medical sports medicine conditions to specialists (e.g., recurrent concussions, hyphema, cardiomegaly, eating disorders) appropriately 4 Correlate imaging studies with clinical findings C Preoperative H & P 1 Demonstrates basic skills for routine patient care 2 Performs regional physical examination of the musculoskeletal system history Age Gender HPI PMHx identify medical co-morbidities that might impact surgical treatment Social history physical exam ROM joint effusion joint tenderness complete neurovascular exam of extremity. 3 Provides patient care in routine sports medicine conditions without supervision 4 Orders appropriate radiographic image order triplanar standing radiographs of the knee review plain films for fractures, cartilage lesions, hindfoot and midfoot malalignment weightbearing radiographs AP of the foot and ankle lateral view of the foot 5 Perform operative consent describe complications of surgery including pain infection development of ossification at the anterior tibia with restriction of dorsiflexion damage to the deep peroneal nerve with subsequent hyposensitivity DVT arthrofibrosis
E Preoperative Plan 1 Determine pathology 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation standard arthroscopy pump 2 Room setup and Equipment standard OR table with leg holder 3 Patient Positioning supine leg holders G Ankle Distractor Placement 1 Check the instrumentation inspect all instruments confirm that all parts of the noninvasive external distractor are sterile on the operative field 2 Place the patient for placement of the ankle distractor place the patient on the operative table supine the foot should rest within 10 cm of the end of the bed place a bump under the hip to internally rotate the leg so that the toes are pointing straight up place a tourniquet on the calf below the level of the fibular head to prevent peroneal nerve impingement flex the hip 60 degrees place the posterior thigh on a well padded thigh holder secure with straps prep and drape the ankle with standard arthroscopic draping the distal portion of the arthroscopy drape is pulled off the end of the foot to allow distractor placement place the bed clamp as far distal on the bed as possible the external distractor strap is placed with the foam portions over the posterior inferior heel and on the dorsal foot after creating equal lengths on the medial and lateral sides of the foot pull the hook lop distally with manual distraction once this is connected use the threaded rod to provide further distraction to the ankle H Anterior Portal Placement 1 Prepare the ankle inject the ankle with 10 cc of sterile saline via the anteromedial ankle this allows identification of the correct orientation and location for the anteromedial arthroscopy portal 2 Make incision make a 5 mm longitudinal skin incision and spread the subcutaneous tissue down to and then through the capsule with a small hemostat A small gush of fluid will confirm the intra-articular location 3 Enter the joint use a blunt tip trocar with the arthroscopic cannula to enter the joint insert the arthroscope and start the water flow 4 Start the water pressure place the water pressure about 5 mmhg above the systolic pressure if possible but no higher than 120 mmhg this will help reduce the bleeding which often obscures the view unless there is severe arthrofibrotric tissue in the anterior ankle the anterolateral ankle should be easily visualized upon introducing the arthroscope 5 Make the anterolateral portal introduce the 18 gauge needle from the anterolateral portal location this serves 2 purposes allows for water flow through the needle which allows better visualization identifies the correct location of the portal incision in order to access the joint properly inspect the joint distraction allows for much greater joint inspection than otherwise possible make the anterolateral portal in the same fashion to the anteromedial portal I Anteromedial Inferior Portal Placement 1 Place the portal visualize the medial gutter with the arthroscope through the anteromedial portal 2 Place the 18 gauge needle introduce an 18 gauge needle into the inferior medial gutter which is usually 10 mm inferior to the normal anteromedial portal location once the needle is confirmed to be in the proper position a new portal is then made as described earlier this portal in combination with the conventional anteromedial portal can be used to first inspect and then debride the far anteromedial ankle joint and deltoid insertion J Posterior Coaxial Portal Placement 1 Make the skin incision with the arthroscope and inflow in the anterolateral portal make the posterolateral portal with a small vertical skin incision immediately posterior to the peroneal tendon sheath and 1.5 cm proximal to the tip of the fibula 2 Position the ankle hold the ankle in neutral dorsiflexion 3 Place the trocar insert the arthroscope sheath and blunt trocar anterior and slightly inferior on a plane parallel to the bimalleolar axis 4 Confirm placement confirm intracapsular placement by briefly inserting the arthroscope 5 Place switching rod insert a long switching rod through the cannula and direct it towards the medial malleolus use the rod to palpate the posterior colliculus and penetrate just anterior to the posterior tibial tendon 6 Place the posteromedial portal tent and incise the skin over the posteromedial ankle pass a second cannula over the switching stick into the posterior ankle recess 7 Maneuver the arthroscope 8 Place the sheath and blunt trocar appropiately insert the arthroscope sheat and blunt trocar anterior and slightly inferior on a plane parallel to the bimalleolar axis 9 Confirm placement confirm intracapsular placement by briefly inserting the arthroscope for synovectomies or posteromedial osteochondral lesions, place the arthroscope in the posterolateral cannula while the posteromedial cannula is used as the working portal K Anatomy Visualization 1 Visualize the ligaments 2 Test the lateral and medial ligament stability apply gentle varus, valgus and anterior pull stress evert and pronate the foot to test deltoid ligament stability check lateral instability check for talar tilting by supination stress of the foot L Wound Closure 1 Use 3-0 and 4-0 biosyn for closure 2 Apply steristrips 3 Cover with tegaderm and occlusive dressings
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds schedule follow up in 2 weeks outpatient physical therapy compression bandaging up to the thigh elevate the ankle perform immediate cryotherapy CPM POD 1 as tolerated for 6 to 8 hours a day for 4 to 6 weeks partial weightbearing of 15 kg allowed for the first 6 weeks 30 kg for the next 2 weeks R Complex Patient Care 1 Acts as a referral to manage complex conditions in sports medicine 2 Develops novel imaging techniques for sports medicine