The knee Mark Clathworthy Patrick Djian Bjorn Engstrom

The knee. Mark Clathworthy, Patrick Djian, Bjorn Engstrom, Bent Wulff Jakobsen

Contents Position of the patient Standard portals anatomy Additional portals Routine travel through knee Supra patellar pouch Patello femoral joint Medial gutter Medial compartment Intercondylar notch Lateral compartment Lateral gutter Posterior cavity Variation of normal mediale plica anterior plica Take home message

Positioning of the patient Supine Prepared Lat support Draped

Tourniquet and irrigation Pressure tourniquet 280 -350 mm. Hg Irrigation options: Arthroscopic pump Gravity Pressure saline bags

Standard portals Antero-lateral (1) the a-l portal is used as the standard viewing portal, through which you can access most of the joint 3 Antero-medial (2) the a-m portal is used as the standard working portal through which you can probe the majority of the joint Superior-lateral (3) The s-l portal is used for optional outflow cannula and for probing the suprapatellar cavity Posterior-medial (4) The p-m portal is used accessing the posterior cavity 1 2 2 4 Courtesy to Pao Golano

Anatomy The subcutaneous nerve around the knee of importance related to the arthroscopic portals is the infrapatellar branch of the saphenus nerve. The antero-medial portal is closely related to the branch. The antero-lateral portal is only related to subcutaneous nerve branches in cases of abnormal anatomical arrangement. The postero-medial portal is placed immediately proximal to the hamstring tendons thereby avoiding the nerve branch of the saphenus nerve and the vessels.

Additional portals Middle patella medial (5) Additional portal convenient for viewing anterior of medial meniscus Middle patella lateral (6) Additional portal convenient for viewing anterior horn of lateral meniscus Postero-lateral (7) 6 5 7 Additional portal convenient for viewing and exploring posterolateral compartment Courtesy to Pao Golano

Routine knee arthroscopy Left knee

Routine travel 1 3 8 9 2 10 7 6 5 4 1. Insert the blunt trocar through the antero-lateral to the patello femoral pouch. portal to the patello femoral Attach arthroscope and lookand through pouch. 30° Attach 30° arthroscope look suprapatellar pouch bypouch rotating scope through suprapatellar by the rotating 180° back 180° and forward and scan the scope back and forward andarea. scan the area. 2. Pull back gently scope overlooking patellofemoral jointscope on theoverlooking extended knee 2. Pull back gently from lateral andjoint from side. If you patellofemoral onmedial the extended knee drain the joint you canmedial examine the. If you from lateral and from side. patellofemoral jointcan stability better. drain the joint you examine the better. patellofemoral joint stability better. . 3. Reopen water supply and return to suprapatellar pouch. Follow 3. Reopen water supply and capsular return to fold medial through the medial to fold suprapatellar pouch. Followgutter capsular overlook the synovium andgutter the medial through the medial to femoral overlookcondyle. the synovium and the medial femoral condyle. 4. Note the anterior horn of the med meniscus applyhorn a gentle valgus 4. Note theand anterior of the med load on the lower to open medial meniscus andleg apply a gentle valgus load compartment. Mark externally on the lower leg to open medialthe spot for the medial portal with finger onthe skin or for compartment. Mark externally spot with a needle. the medial portal with finger on skin or with a needle.

5. Rotate the scope looking centrally while flexing the knee to 90° examining the anterior cruciate from distally to proximally carefully probing the femoral attachment site. Next rotate the scope more medial to check the posterior cruciate often covered with synovium. Routine travel 1 3 8 2 10 9 7 6 5 4 6. Rotate the scope looking laterally while applying a light varus stress to the slightly flexed knee – thereby overlooking and probing anterior horn of the lateral meniscus. Go to the ”figure of 4” position while keeping the scope parallel to tibial surface overlooking the middle third and posterior horn of meniscus. 7. Extend the knee and go directly to the lateral gutter, flex the knee and examíne the popliteus tendon and hiatus.

8. Return to the ”figure of 4” position guiding the movement with the scope centrally in the notch looking laterally. Rotate the scope while probing the lateral meniscus. Note popliteus tendon above and below the meniscus runnning though the popliteus hole. Routine travel 1 3 8 9 2 10 7 6 5 4 9. While in the ”figure of 4” position mark the triangular shape given from lateral femoral condyle, tibial plateau and anterior cruciate. Looking parallel to the tibial plateau pass gentle the scope through the triangle to the posterior cavity. Check posterior horn of lateral meniscus, posterior cavity by rotating the scope 360°. Retract the scope while overlooking the posterior cruciate and the proximal part of the anterior cruciate.

Routine travel 1 3 8 9 2 10 7 6 5 4 10. Put the knee 90 degrees of flexion. There will then be a triangle given from the medial femoral condyle, tibialplateau and the anterior cruciate ligament. Looking parallel to the tibial plateau pass gently the scope through the triangle to the posterior cavity. Sometimes you need to push the cruciate ligaments laterally and rotate the scope smoothly to pass this area. Check the posterior horn of the medial meniscus, posterior cavity by rotating the scope 360 degrees. Retract the scope while overlooking the posterior cruciate.

Supra patellar pouch 1 8 9 7 10 3 2 6 5 4 Superior view of supra patellar pouch; 30° arthroscope

Supra patellar pouch Vastus lateralis of the quadriceps muscle 1 8 9 7 10 3 2 6 5 4 Superior view of supra patellar pouch; 30° arthroscope

Patello femoral joint Femoral condyle lateral 1 8 9 7 10 3 2 6 5 4 Femoral condyle lateral view; 30° arthroscope

Patello femoral joint Femoral trochlea 1 8 9 7 10 3 2 6 5 4 Femoral trochlea lateral view; 30° arthroscope

Patello femoral joint Patella 1 8 9 7 10 3 2 6 5 4 Femoral trochlea Patello femoral joint proximal lateral view; 30° arthroscope

Medial gutter Patella Me dia l fe mo 1 9 10 3 dy le r 2 6 5 4 co n tte Gu 8 7 ral Medial view of medial gutter; 30° arthroscope

Medial gutter ial ed M yle d on c al or m fe 9 7 10 3 2 6 5 4 r 8 tte Gu 1 Medial distal view of medial gutter; 30° arthroscope

Medial compartment le y d on c al r o em f l ia d e M Medial meniscu s Knife in a-m portal Tibial plateau 1 8 9 7 10 3 2 6 5 4 Distal view of medial meniscus anterior horn, knife producing a-m portal; 30° arthroscope

Medial compartment le ndy o c l ora m e f l a Medi 8 9 7 10 3 2 6 5 4 eniscus 1 m Medial Tibial plateau Distal view of medial meniscus anterior horn, probe through ant-med portal; 30° arthroscope

Medial compartment a or m e f l a Medi yle d n o lc us c s i en m l dia urface e M ers und , Tibial plateau 1 8 9 7 10 3 2 6 5 4 Antero medial view of medial meniscus anterior horn underside, probe through antmed portal; 30° arthroscope

Medial compartment ndyle o c l a r o m Medial fe Med ial m enis cus Tibial plateau 1 8 9 7 10 3 2 6 5 4 Medial view of medial meniscus central third; 30° arthroscope

Medial compartment Medial femoral condyle Me dia lm eni scu s 1 8 9 7 10 3 Tibial plateau 2 6 5 4 Medial view of medial meniscus central third, probe through anteromedial portal; 30° arthroscope

Medial compartment e Medial femoral condyl Media l men iscus 1 8 9 7 10 3 2 6 5 4 Tibial plateau Posteromedial view of medial meniscus posterior horn; 30° arthroscope

Medial compartment oral m e f l ia d e M condyle Med cus enis ial m Tibial plateau 1 8 9 7 10 3 2 6 5 4 Posteromedial view of medial meniscus posterior horn, tested with a probe; 30° arthroscope,

Medial compartment e Medial femoral condyl 1 8 9 7 10 3 2 6 5 4 Inferomedial view of anterior part of joint, femoral condyles, trochlea and Hoffa’s fat; 30° arthroscope

Intercondylar notch le erio te ucia r cr al r te a L Ant al r o fem dy n co 1 8 9 7 10 3 2 6 5 4 Inferior view of distal tibial attachment of anterior cruciate ligament, knee near extension; 30° arthroscope

r c ior r ste o P te a i uc ior ter An te cia cru Lateral femoral condyl e Intercondylar notch 1 8 9 7 10 3 2 6 5 4 Postero-central view of distal tibial attachment of anterior cruciate ligament, knee flexed 80°; 30° arthroscope

ral f Late r cruci Anterio emo r al c ond y le Intercondylar notch 1 8 9 7 10 3 2 6 5 4 Postero-central view of proximal femoral attachment of anterior cruciate ligament; 30° arthroscope

Intercondylar notch Po 10 3 te cia 2 6 5 4 s cru 9 7 c ior 8 te ter An 1 or i r te ia ruc Postero-central view of posterior cruciate, knee flexed 80°, PCL covered with synovium; 30° arthroscope

Intercondylar notch cia te u r rc io r e t s o 9 7 10 3 2 6 5 4 te cia cru 8 Med ior ter An 1 ial f emo r al c ond yle P Postero-central view of posterior cruciate, knee flexed 80°, PCL release from synovium; 30° arthroscope

Lateral compartment us c s i n l me era t a L 1 8 9 7 10 3 2 6 5 4 Anterior view of lateral meniscus anterior horn; 30° arthroscope

le Lateral compartment ndy o c l o. Pra m e f l a op Later ten liteu s do n us c s i n l me era t a L 1 8 9 7 10 3 2 6 5 4 Antero-lateral view of lateral meniscus; 30° arthroscope

Lateral compartment le ndy o c l ora m e f l a Later 1 8 9 7 10 3 2 6 5 4 us c s i n l me era t a L Antero-lateral view of lateral femoral condyle; 30° arthroscope

Lateral compartment le em al f r e t a L Po plit ndy o c l a or s u c s i eu s te nd on l ra en m e t La 1 8 9 7 10 3 2 6 5 4 Postero-lateral view of posterior horn of lateral meniscus and popliteus hole; 30° arthroscope

Lateral gutter 1 8 9 7 10 3 2 6 5 4 Lateral view on lateral gutter; 30° arthroscope

9 10 3 2 6 5 4 on dy or al c em 7 er al f 8 La t 1 Lateral meniscus le Po pl ite us te nd o n Lateral gutter Lateral view on lateral gutter; 30° arthroscope

Popliteus tendon Lateral gutter s p 8 9 7 10 3 2 6 5 4 Lateral meniscus Po 1 u lite le o h Lateral view on lateral gutter; 30° arthroscope

ed M Posterior compartment ial fe on c al or m 8 9 7 10 3 2 6 5 4 Po M ste ed ri ia or l m ho en rn isc us le dy 1 Medial view, scope along posterior cruciate to posteromedial pouch; 30° arthroscope

Variation of normal M ia ca ed Pli Medial view of the medial plica; 30° arthroscope lf em or al co nd yl e Patella 1 9 10 3 2 6 5 4 Medial femor al condyle Plica 8 7

Variation of normal 9 7 10 3 2 6 5 4 yle 8 ond Plica rior Ante iate cruc 1 c ral mo l fe dia Me Posterolateral view of the anterior plica, ligamentum Mucosum; 30° arthroscope

Variation of normal c ral le o y nd o fem l ra e t a L Discoid l a 1 8 9 7 10 3 teral me niscus 2 6 5 4 Postero lateral view of a discoid meniscus (this on 80% discoid); 30° arthroscope

Take home points Always mark the involved side and relevant anatomical structures. Never use sharp trocars, always bluntly instruments. Prior to surgery pressure the tourniquet at 350 mm. Hg on the involved upper leg, use gravity, pressure saline bags or arthroscopic pumps for irrigation. Always perform an examination of the knee including stability testing prior to arthroscopy. Start the arthroscopy with applying the antero-lateral portal and insert the scope along the lateral edge of the patella with the knee in extension and while lifting the patella. Apply the following portals guided by the arthroscopic view, using a needle if convenient. Always perform the arthroscopic evaluation of all parts of the knee before performing any arthroscopic surgery. Always use a probe to examine menisci, joint cartilage and ligements while overlooking the different structures.

Questionnaire What is the importance of the antero-lateral portal Explain how to identify the antero-medial portal Which subcutaneous nerve is at risk applying the antero-medial portal Which anatomical structures are the landmarks when applying the postero-medial portal What intraarticular structure should not be mistanken for the anterior cruciate ligament