Updated: 10/18/2016


Preoperative Patient Care


Outpatient Evaluation and Management


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


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.


Prescribes and manages non-operative treatment

  • Injects/aspirates knee
  • guides trial of medical managment
  • attempts trial of physical therapy
  • quad strength closed chain


Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention


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

Advanced Evaluation and Management


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


Provides complex nonoperative treatment

  • concomitant injuries
  • ligament
  • fractures


Modifies and adjusts post-operative treatment plan as needed

  • knee arthrofibrosis
  • continued pain

Preoperative H & P


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


Order basic imaging studies

  • order triplanar standing radiographs of the knee


Perform operative consent

  • describe complications of surgery including
  • pain
  • infection
  • neurovascular injury
  • loss of motion
  • degenerative joint disease [DJD])

Operative Techniques


Preoperative Plan


Determine pathology using MRI

  • radial
  • horizontal cleavage
  • displaced bucket handle
  • meniscal root
  • discoid meniscus


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

Room Preparation


Surgical instrumentation

  • standard arthroscopy tower
  • motorized meniscal shaver
  • varying arthroscopic baskets


Room setup and equipment

  • operative table, choice of using leg post, leg holder or neither.


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.

Scope Insertion


Mark out the anatomy of the knee

  • draw out the patella, patellar tendon, and joint line


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 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

Diagnostic Arthroscopy



  • 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

Meniscal Tear Evaluation and Preparation


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


Check location of tear if present

  • assess the zone of tear and decide if the tear is repairable

Meniscal debridement


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

Treats Intraoperative and Immediate Postoperative Complications


Treat intraoperative complications


Wound Closure


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


Apply sterile post-operative dressings

Postoperative Patient Care


Perioperative Inpatient Management


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

Complex Patient Care


Treat complex complications


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