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 2 Interprets basic imaging studies standing radiographs 30 degree flexion lateral AP weightbearing in extension 45 degree PA flexion weightbearing views 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 remove sutures diagnose and management of early complications continue touchdown weightbearing stationary biking without resistance and deep water exercises are started 1 to 2 weeks postoperatively postop: 4-6 week postoperative visit check range of motion after 8 weeks of touchdown weightbearing, touchdown weightbearing as tolerated low impact exercises is emphasized during weeks 9 to 16 diagnosis and management of late complications postop: 4 months year postoperative Visit no return to sports that involve pivoting, cutting and jumping until at least 4 to 9 months after treatment B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies MRI 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 gritty sensation of the joint loss of motion recurrent effusion 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 arthroscopy pump motorized meniscal shaver toothed grasper double loaded 2-0 or 0 nonabsorbable sutures with long flexible needles 2 Room setup and Equipment standard OR table with leg holder 3 Patient Positioning supine leg holders place leg holder 5 to 8 cm proximal to the superior pole of the patella to maximize control of the limb contralateral leg is placed in a well leg holder for the diagnostic portion of the procedure is placed at the foot of the bed for the remainder of the procedure, the foot of the bed is dropped 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 2 Place anterolateral portal use 22 gauge needle on syringe and bury the needle make wheal at skin and then 11 blade in same direction as the needle place scope in same direction as needle and blade hug the patellar tendon 3 Place anteromedial portal place knee in 30 degrees of flexion with valgus moment applied use a spinal needle to assess direction and appropriate superior/inferior direction. visualize with lateral portal H Diagnostic Arthroscopy 1 Visualize suprapatellar pouch patellofemoral joint (take picture) place bump under heel prn lateral gutter look for loose bodies and peripheral tears of LM get MFC in view bring knee into slight flexion and valgus as you go into medial compartment. foot goes on to opposite hip and use standee to stabilize your foot medial meniscus (take picture) drop leg to flexion (bump should be under knee) 2 Establish far anteromedial portal use 18-gauge needle to make sure that you clear the MFC and can get to the 2 o’clock (LEFT) or 10 o’clock (RIGHT) knee 3 Visualize medial compartment - probe medial meniscus, articular cartilage intercondylar notch – ACL/PCL (take picture) lateral compartment – probe lateral meniscus, articular cartilage (take picture) assess the full thickness articular lesion I Initial Preparation 1 Debride all unstable cartilage debride all of the exposed bone of all remaining unstable cartilage use a hand held curved curette and a full thickness radius resector to debride the cartilage it is critical to debride all loose or marginally attached tissue from the surrounding rim of the lesion 2 Remove the calcified cartilage layer remove the calcified cartilage layer that remains as a cap to many lesions this is preferabely done with a curette thorough and complete removal of the calcified cartilage layer is extremely important 3 Maintain the integrity of the subchondral plate do not debride to deeply the prepared lesion with a stable perpendicular edge of healthy well attached viable cartilage surrounding the defect provides a pool that helps hold the marrow clot (super clot) as it forms J Microfracture 1 Make multiple holes these are microfractures in the exposed subchondral bone plate use an awl with an angle that permits the tip to be perpendicular to the bone as it is advanced typically this is 30 or 45 degrees use a 90 degree awl on the patella or other soft bone this should only be advanced manually 2 Position the holes appropriately make the holes close together but not so close that one breaks into another IE breaking the subchondral plate between them this usually results in microfracture holes that are approximately 3 to 4 mm apart 3 Determine the appropriate depth of the holes when fat droplets can be seen coming from the marrow cavity, the appropriate depth of 2-4 mm has been reached 4 Drill holes in the appropriate order microfracture holes around the periphery of the defect should be made first these holes should be made immediately adjacent to the healthy stable cartilage rim complete the process by making the microfracture holes towards the center of the defect K Wound Closure 1 Use 3-0 and 4-0 biosyn for closure Apply steristrips 2 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 cold therapy for 1 to 7 days crutch assisted touch down weightbearing for 6 to 8 weeks passive range of motion starting postop day one begin therapy immediately after surgery with an emphasis on patellar mobility with instructions to perform medial to lateral and superior to inferior movement of the patella medial and lateral movement of the quadriceps and patellar tendons this is imperative to prevent patellar tendon adhesions ROM exercises without limitations are initiated during the day of surgery 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 2 Interprets basic imaging studies standing radiographs 30 degree flexion lateral AP weightbearing in extension 45 degree PA flexion weightbearing views 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 remove sutures diagnose and management of early complications continue touchdown weightbearing stationary biking without resistance and deep water exercises are started 1 to 2 weeks postoperatively postop: 4-6 week postoperative visit check range of motion after 8 weeks of touchdown weightbearing, touchdown weightbearing as tolerated low impact exercises is emphasized during weeks 9 to 16 diagnosis and management of late complications postop: 4 months year postoperative Visit no return to sports that involve pivoting, cutting and jumping until at least 4 to 9 months after treatment B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies MRI 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 gritty sensation of the joint loss of motion recurrent effusion
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 arthroscopy pump motorized meniscal shaver toothed grasper double loaded 2-0 or 0 nonabsorbable sutures with long flexible needles 2 Room setup and Equipment standard OR table with leg holder 3 Patient Positioning supine leg holders place leg holder 5 to 8 cm proximal to the superior pole of the patella to maximize control of the limb contralateral leg is placed in a well leg holder for the diagnostic portion of the procedure is placed at the foot of the bed for the remainder of the procedure, the foot of the bed is dropped 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 2 Place anterolateral portal use 22 gauge needle on syringe and bury the needle make wheal at skin and then 11 blade in same direction as the needle place scope in same direction as needle and blade hug the patellar tendon 3 Place anteromedial portal place knee in 30 degrees of flexion with valgus moment applied use a spinal needle to assess direction and appropriate superior/inferior direction. visualize with lateral portal H Diagnostic Arthroscopy 1 Visualize suprapatellar pouch patellofemoral joint (take picture) place bump under heel prn lateral gutter look for loose bodies and peripheral tears of LM get MFC in view bring knee into slight flexion and valgus as you go into medial compartment. foot goes on to opposite hip and use standee to stabilize your foot medial meniscus (take picture) drop leg to flexion (bump should be under knee) 2 Establish far anteromedial portal use 18-gauge needle to make sure that you clear the MFC and can get to the 2 o’clock (LEFT) or 10 o’clock (RIGHT) knee 3 Visualize medial compartment - probe medial meniscus, articular cartilage intercondylar notch – ACL/PCL (take picture) lateral compartment – probe lateral meniscus, articular cartilage (take picture) assess the full thickness articular lesion I Initial Preparation 1 Debride all unstable cartilage debride all of the exposed bone of all remaining unstable cartilage use a hand held curved curette and a full thickness radius resector to debride the cartilage it is critical to debride all loose or marginally attached tissue from the surrounding rim of the lesion 2 Remove the calcified cartilage layer remove the calcified cartilage layer that remains as a cap to many lesions this is preferabely done with a curette thorough and complete removal of the calcified cartilage layer is extremely important 3 Maintain the integrity of the subchondral plate do not debride to deeply the prepared lesion with a stable perpendicular edge of healthy well attached viable cartilage surrounding the defect provides a pool that helps hold the marrow clot (super clot) as it forms J Microfracture 1 Make multiple holes these are microfractures in the exposed subchondral bone plate use an awl with an angle that permits the tip to be perpendicular to the bone as it is advanced typically this is 30 or 45 degrees use a 90 degree awl on the patella or other soft bone this should only be advanced manually 2 Position the holes appropriately make the holes close together but not so close that one breaks into another IE breaking the subchondral plate between them this usually results in microfracture holes that are approximately 3 to 4 mm apart 3 Determine the appropriate depth of the holes when fat droplets can be seen coming from the marrow cavity, the appropriate depth of 2-4 mm has been reached 4 Drill holes in the appropriate order microfracture holes around the periphery of the defect should be made first these holes should be made immediately adjacent to the healthy stable cartilage rim complete the process by making the microfracture holes towards the center of the defect K Wound Closure 1 Use 3-0 and 4-0 biosyn for closure Apply steristrips 2 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 cold therapy for 1 to 7 days crutch assisted touch down weightbearing for 6 to 8 weeks passive range of motion starting postop day one begin therapy immediately after surgery with an emphasis on patellar mobility with instructions to perform medial to lateral and superior to inferior movement of the patella medial and lateral movement of the quadriceps and patellar tendons this is imperative to prevent patellar tendon adhesions ROM exercises without limitations are initiated during the day of surgery R Complex Patient Care 1 Treat complex complications