Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam concomitant and associated orthopaedic injuries evaluate for knee pain mechanical symptoms pain or swelling with ADLs and sports joint line tenderness knee effusion associated with decreased quadriceps strength positive McMurrays, Apley grind and Thesaly tests 2 Interprets basic imaging studies standing radiographs 30 degree flexion lateral AP weightbearing in extension 45 degree PA flexion weightbearing views identify fairbanks changes discoid meniscus on radiograph tibial spine hypoplasia, widening of the lateral joint line or flattening of the lateral femoral condyle on AP view. 3 Prescribes and manages non-operative treatment Injects/aspirates knee guides trial of medical managment NSAIDS attempts trial of physical therapy quad strength closed chain 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check prescribe Nsaids remove sutures diagnose and management of early complications limit range of motion to 90° for the first three weeks for nondisplaced meniscus tears and six weeks for displaced bucket handle tears postop: 4-6 week postoperative visit discontinue crutches return to pivoting sports when full range of motion is present, no effusion, and can show full extension and painless terminal flexion usually at 4-6 months diagnosis and management of late complications postop: 1 year Postoperative Visit B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies MRI 3-T gives excellent visualization on pathology. useful in distinguishing tear, location and morphology MRI abnormality of thickened "bow tie" on coronal view on greater than 3 cuts with continuity of the anterior horn and posterior horn on 5 mm thick saggital view cut is diagnostic for discoid meniscus MRI classification of tears grade one small: focal area of increased signal not extending to the joint surface grade two: linear area of increased signal not extending to the joint surface grade three: linear area of increased signal extending to the joint surface 2 Provides complex nonoperative treatment concomitant injuries ligament fractures 3 Modifies and adjusts post-operative treatment plan as needed knee arthrofibrosis continued pain C Preoperative H & P 1 Obtain history and perform basic physical exam 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. 2 Order basic imaging studies order triplanar standing radiographs of the knee 3 Perform operative consent describe complications of surgery including pain infection neurovascular injury loss of motion degenerative joint disease [DJD]) Operative Techniques E Preoperative Plan 1 Determine pathology using MRI radial tear horizontal cleavage tear displaced bucket handle tear meniscal root tear discoid meniscus 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 knee arthroscopy setup double loaded 2-0 or 0 nonabsorbable sutures with long flexible needles 2 Room setup and Equipment standard OR table with choice of leg holder or post patient is supine on bed tourniquet may be used G Scope Insertion 1 Mark out the anatomy of the knee draw out the patella, patellar tendon, medial and lateral joint lines and the posterior contours of the medial and lateral femoral condyles mark future portals as well as the incision for the medial / lateral meniscus repair 2 Place anterolateral portal an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella insert the blunt trocar at the same angle as incision place scope in the trocar after removing the inner cannula 3 Place anteromedial portal created under direct visualization once the medial compartment is entered use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal the medial portal should be located just superior to the medial meniscus and able to provide access to the medial meniscal root if needed H Diagnostic Arthroscopy 1 Visualize suprapatellar pouch undersurface of the patella and trochlear groove lateral and medial gutters medial compartment visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment the foot will be positioned on your opposite hip for control medial meniscus, medial femoral condyle, and medial tibial plateau once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage intercondylar notch – ACL/PCL use the probe to assess the ACL and PCL Lateral compartment the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment lateral meniscus, lateral femoral condyle, and lateral tibial plateau a probe is used to assess the lateral meniscus and cartilage I Meniscal Tear Evaluation and Preparation 1 Diagnose tear and determine configuration if present investigate superior and inferior portion of the meniscus with the probe check the capsule attachment of the meniscus by pulling the meniscus from the posterior capsule gently assess the meniscal root 2 Check location of tear if present assess the zone of tear and decide if the tear is repairable 3 Check stability, size and extent of tear extent partial or complete J Exposure 1 Make incision posteriomedially or posterolaterally for needle capture posteromedial incision place the knee in 20 to 30 degrees of flexion make a 4 to 6 cm incision just posterior to the medial collateral ligament the incision should be one third above and two thirds below the joint incise longitudinally through the sartorial fascia and continue the dissection anterior to the semimembranosus deep to the head of the gastrocnemius without violating the capsule. posterolateral incision place knee in 90° of flexion this allows the peroneal nerve, popliteus and lateral inferior geniculate artery to fall posteriorly make a 4 to 6 cm incision just posterior to the lateral collateral ligament anterior to the biceps femoris tendon the incision should be one third above and two thirds below the joint incise longitudinally through the iliotibial band and continue the dissection staying superior and anterior to the biceps tendon to protect the peroneal nerve. proceed deep and anterior to the lateral head of the gastroc without violating the capsule. K Inside-Out Repair 1 Place a popliteal retractor "Henning retractor" against the capsule a needle driver can be clamped to the retractor and held secure to the leg with a sterile coban to help hold the retractor in place 2 Place a single or double lumen cannula through the arthroscopic portals the long flexible needles can be passed through the cannula by an assistant and slowly progressed at 1 cm increments until visualized at the medial or lateral incision through the retractor 3 Capture the needles one at a time as they pass through the capsule and cut the suture free from the needles. be sure not to pull either suture all the way through until both needles are passed keep each pair of sutures together for later repair with the knee in full extension. 4 Tension then tie the sutures over the capsule the sutures are tensioned to simulate the tying. the knee is then brought into extension during the suture tying so that the capsule is not tightened. ensure that the sutures are directly on the capsule prior to suture tying. L Treats Intraoperative and Immediate Postoperative Complications 1 Treat any intraoperative complications 2 Treat any immediate postoperative complications N 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 place in a knee immobilizer or hinged brace locked in extension partially weight-bearing with crutches for one month passive range of motion starting postop day one limit range of motion to 90° R Complex Patient Care 1 Treat complex complications
A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam concomitant and associated orthopaedic injuries evaluate for knee pain mechanical symptoms pain or swelling with ADLs and sports joint line tenderness knee effusion associated with decreased quadriceps strength positive McMurrays, Apley grind and Thesaly tests 2 Interprets basic imaging studies standing radiographs 30 degree flexion lateral AP weightbearing in extension 45 degree PA flexion weightbearing views identify fairbanks changes discoid meniscus on radiograph tibial spine hypoplasia, widening of the lateral joint line or flattening of the lateral femoral condyle on AP view. 3 Prescribes and manages non-operative treatment Injects/aspirates knee guides trial of medical managment NSAIDS attempts trial of physical therapy quad strength closed chain 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check prescribe Nsaids remove sutures diagnose and management of early complications limit range of motion to 90° for the first three weeks for nondisplaced meniscus tears and six weeks for displaced bucket handle tears postop: 4-6 week postoperative visit discontinue crutches return to pivoting sports when full range of motion is present, no effusion, and can show full extension and painless terminal flexion usually at 4-6 months diagnosis and management of late complications postop: 1 year Postoperative Visit B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies MRI 3-T gives excellent visualization on pathology. useful in distinguishing tear, location and morphology MRI abnormality of thickened "bow tie" on coronal view on greater than 3 cuts with continuity of the anterior horn and posterior horn on 5 mm thick saggital view cut is diagnostic for discoid meniscus MRI classification of tears grade one small: focal area of increased signal not extending to the joint surface grade two: linear area of increased signal not extending to the joint surface grade three: linear area of increased signal extending to the joint surface 2 Provides complex nonoperative treatment concomitant injuries ligament fractures 3 Modifies and adjusts post-operative treatment plan as needed knee arthrofibrosis continued pain C Preoperative H & P 1 Obtain history and perform basic physical exam 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. 2 Order basic imaging studies order triplanar standing radiographs of the knee 3 Perform operative consent describe complications of surgery including pain infection neurovascular injury loss of motion degenerative joint disease [DJD])
E Preoperative Plan 1 Determine pathology using MRI radial tear horizontal cleavage tear displaced bucket handle tear meniscal root tear discoid meniscus 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 knee arthroscopy setup double loaded 2-0 or 0 nonabsorbable sutures with long flexible needles 2 Room setup and Equipment standard OR table with choice of leg holder or post patient is supine on bed tourniquet may be used G Scope Insertion 1 Mark out the anatomy of the knee draw out the patella, patellar tendon, medial and lateral joint lines and the posterior contours of the medial and lateral femoral condyles mark future portals as well as the incision for the medial / lateral meniscus repair 2 Place anterolateral portal an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella insert the blunt trocar at the same angle as incision place scope in the trocar after removing the inner cannula 3 Place anteromedial portal created under direct visualization once the medial compartment is entered use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal the medial portal should be located just superior to the medial meniscus and able to provide access to the medial meniscal root if needed H Diagnostic Arthroscopy 1 Visualize suprapatellar pouch undersurface of the patella and trochlear groove lateral and medial gutters medial compartment visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment the foot will be positioned on your opposite hip for control medial meniscus, medial femoral condyle, and medial tibial plateau once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage intercondylar notch – ACL/PCL use the probe to assess the ACL and PCL Lateral compartment the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment lateral meniscus, lateral femoral condyle, and lateral tibial plateau a probe is used to assess the lateral meniscus and cartilage I Meniscal Tear Evaluation and Preparation 1 Diagnose tear and determine configuration if present investigate superior and inferior portion of the meniscus with the probe check the capsule attachment of the meniscus by pulling the meniscus from the posterior capsule gently assess the meniscal root 2 Check location of tear if present assess the zone of tear and decide if the tear is repairable 3 Check stability, size and extent of tear extent partial or complete J Exposure 1 Make incision posteriomedially or posterolaterally for needle capture posteromedial incision place the knee in 20 to 30 degrees of flexion make a 4 to 6 cm incision just posterior to the medial collateral ligament the incision should be one third above and two thirds below the joint incise longitudinally through the sartorial fascia and continue the dissection anterior to the semimembranosus deep to the head of the gastrocnemius without violating the capsule. posterolateral incision place knee in 90° of flexion this allows the peroneal nerve, popliteus and lateral inferior geniculate artery to fall posteriorly make a 4 to 6 cm incision just posterior to the lateral collateral ligament anterior to the biceps femoris tendon the incision should be one third above and two thirds below the joint incise longitudinally through the iliotibial band and continue the dissection staying superior and anterior to the biceps tendon to protect the peroneal nerve. proceed deep and anterior to the lateral head of the gastroc without violating the capsule. K Inside-Out Repair 1 Place a popliteal retractor "Henning retractor" against the capsule a needle driver can be clamped to the retractor and held secure to the leg with a sterile coban to help hold the retractor in place 2 Place a single or double lumen cannula through the arthroscopic portals the long flexible needles can be passed through the cannula by an assistant and slowly progressed at 1 cm increments until visualized at the medial or lateral incision through the retractor 3 Capture the needles one at a time as they pass through the capsule and cut the suture free from the needles. be sure not to pull either suture all the way through until both needles are passed keep each pair of sutures together for later repair with the knee in full extension. 4 Tension then tie the sutures over the capsule the sutures are tensioned to simulate the tying. the knee is then brought into extension during the suture tying so that the capsule is not tightened. ensure that the sutures are directly on the capsule prior to suture tying. L Treats Intraoperative and Immediate Postoperative Complications 1 Treat any intraoperative complications 2 Treat any immediate postoperative complications N 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 place in a knee immobilizer or hinged brace locked in extension partially weight-bearing with crutches for one month passive range of motion starting postop day one limit range of motion to 90° R Complex Patient Care 1 Treat complex complications