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 postop: 4-6 week postoperative visit check range of motion return to sport when full range of motion is present, no effusion, and 80% of quad strength is back. usually at 4-6 weeks 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 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 Obtains history and performs basic physical exam history Age Gender HPI PMHx identify medical co-morbidities that might impact surgical treatment Social History physical exam complete neurovascular exam of extremity. ROM Joint tenderness Effusion NV status 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 horizontal cleavage displaced bucket handle meniscal root 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 arthroscopy tower motorized meniscal shaver varying arthroscopic baskets 2 Room setup and equipment operative table, choice of using leg post, leg holder or neither. 3 Patient positioning place patient supine on the table. thigh tourniquet may be placed but should not be needed. if using a leg post, position the patient’s heels at the edge of the bed and shift the patient closer to the side of the post. ensure that the post is in the proper location to produce a valgus stress. if using a leg holder, the end of the bed is often lowered allowing the operative leg to flex to 90 degrees free. the non-operative leg is either placed in a well leg holder or on padding. G Scope Insertion 1 Mark out the anatomy of the knee draw out the patella, patellar tendon, and joint line 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 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 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 J Meniscal debridement 1 Debride the meniscal tear radial tears trim to a stable peripheral rim horizontal tears resect the inferior leaf and trim the superior leaf discoid meniscus use basket forceps to begin the central resection make sure to leave at least 8 mm of meniscus around the periphery may require fixation of remaining segment use shaver to smooth down the meniscal rim K Treats Intraoperative and Immediate Postoperative Complications 1 Treat intraoperative complications L Wound Closure 1 Portal closure the skin can be closed with either external absorbable sutures using nylon or PDS in figure of eight or an inverted figure of eight the skin can also be closed with buried inverted absorbable sutures such as monocril 2 Apply sterile post-operative dressings Postoperative Patient Care O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds prescribe outpatient physical therapy assisted active and passive range of motion immediately postop straight leg exercise immediately schedule follow-up in 2 weeks 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 postop: 4-6 week postoperative visit check range of motion return to sport when full range of motion is present, no effusion, and 80% of quad strength is back. usually at 4-6 weeks 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 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 Obtains history and performs basic physical exam history Age Gender HPI PMHx identify medical co-morbidities that might impact surgical treatment Social History physical exam complete neurovascular exam of extremity. ROM Joint tenderness Effusion NV status 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 horizontal cleavage displaced bucket handle meniscal root 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 arthroscopy tower motorized meniscal shaver varying arthroscopic baskets 2 Room setup and equipment operative table, choice of using leg post, leg holder or neither. 3 Patient positioning place patient supine on the table. thigh tourniquet may be placed but should not be needed. if using a leg post, position the patient’s heels at the edge of the bed and shift the patient closer to the side of the post. ensure that the post is in the proper location to produce a valgus stress. if using a leg holder, the end of the bed is often lowered allowing the operative leg to flex to 90 degrees free. the non-operative leg is either placed in a well leg holder or on padding. G Scope Insertion 1 Mark out the anatomy of the knee draw out the patella, patellar tendon, and joint line 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 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 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 J Meniscal debridement 1 Debride the meniscal tear radial tears trim to a stable peripheral rim horizontal tears resect the inferior leaf and trim the superior leaf discoid meniscus use basket forceps to begin the central resection make sure to leave at least 8 mm of meniscus around the periphery may require fixation of remaining segment use shaver to smooth down the meniscal rim K Treats Intraoperative and Immediate Postoperative Complications 1 Treat intraoperative complications L Wound Closure 1 Portal closure the skin can be closed with either external absorbable sutures using nylon or PDS in figure of eight or an inverted figure of eight the skin can also be closed with buried inverted absorbable sutures such as monocril 2 Apply sterile post-operative dressings
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds prescribe outpatient physical therapy assisted active and passive range of motion immediately postop straight leg exercise immediately schedule follow-up in 2 weeks R Complex Patient Care 1 Treat complex complications