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Preoperative Patient Care
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
 

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