Download 10 - DrStorm

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 mmHg
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
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
1. Insert the blunt trocar through the
antero-lateral to
the patello
femoral
portal
to the patello
femoral
pouch. Attach 30° arthroscope and look
through suprapatellar pouch by rotating
the scope 180° back and forward and
scan the area.
Routine travel
1
3
8
2
9
10
7
5
6
4
2. Pull back gently scope overlooking
patellofemoral joint on the extended knee
from lateral and from medial side. If you
drain the joint you can examine the
patellofemoral joint stability better.
better..
3. Reopen water supply and return to
suprapatellar pouch. Follow capsular fold
medial through the medial gutter to
overlook the synovium and the medial
femoral condyle.
4. Note the anterior horn of the med
meniscus and apply a gentle valgus load
on the lower leg to open medial
compartment. Mark externally the spot for
the medial portal with finger on skin or
with a needle.
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
5
6
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
2
9
10
7
5
6
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
the scope 360°. Retract the scope while
overlooking the posterior cruciate and the
proximal part of the anterior cruciate.
Routine travel
1
3
8
2
9
10
7
5
6
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
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
3
2
6 5 4
Superior view of supra patellar pouch;
30° arthroscope
Patello femoral joint
Femoral condyle lateral
1
8
9
7
3
2
6 5 4
Femoral condyle lateral view; 30°
arthroscope
Patello femoral joint
Femoral trochlea
1
8
9
7
3
2
6 5 4
Femoral trochlea lateral view; 30°
arthroscope
Patello femoral joint
Patella
1
8
9
7
3
2
6 5 4
Femoral trochlea
Patello femoral joint proximal lateral
view; 30° arthroscope
Medial gutter
Patella
1
8
9
7
3
2
6 5 4
Medial view of medial gutter; 30°
arthroscope
Medial gutter
1
8
9
7
3
2
6 5 4
Medial distal view of medial gutter; 30°
arthroscope
Medial compartment
Knife in a-m portal
Tibial plateau
1
8
9
7
3
2
6 5 4
Distal view of medial meniscus anterior
horn, knife producing a-m portal; 30°
arthroscope
Medial compartment
Tibial plateau
1
8
9
7
3
2
6 5 4
Distal view of medial meniscus anterior
horn, probe through ant-med portal; 30°
arthroscope
Medial compartment
Tibial plateau
1
8
9
7
3
2
6 5 4
Antero medial view of medial meniscus
anterior horn underside, probe through
ant-med portal; 30° arthroscope
Medial compartment
Tibial plateau
1
8
9
7
3
2
6 5 4
Medial view of medial meniscus central
third; 30° arthroscope
Medial compartment
Medial femoral condyle
1
8
9
7
3
Tibial plateau
2
6 5 4
Medial view of medial meniscus central
third, probe through anteromedial portal;
30° arthroscope
Medial compartment
1
8
9
7
3
2
6 5 4
Tibial plateau
Posteromedial view of medial meniscus
posterior horn; 30° arthroscope
Medial compartment
Tibial plateau
1
8
9
7
3
2
6 5 4
Posteromedial view of medial meniscus
posterior horn, tested with a probe; 30°
arthroscope,
Medial compartment
1
8
9
7
3
2
6 5 4
Inferomedial view of anterior part of joint,
femoral condyles, trochlea and Hoffa’s
fat; 30° arthroscope
Intercondylar notch
1
8
9
7
3
2
6 5 4
Inferior view of distal tibial attachment of
anterior cruciate ligament, knee near
extension; 30° arthroscope
Intercondylar notch
1
8
9
7
3
2
6 5 4
Postero-central view of distal tibial
attachment of anterior cruciate ligament,
knee flexed 80°; 30° arthroscope
Intercondylar notch
1
8
9
7
3
2
6 5 4
Postero-central view of proximal femoral
attachment of anterior cruciate ligament;
30° arthroscope
Intercondylar notch
1
8
9
7
3
2
6 5 4
Postero-central view of posterior cruciate,
knee flexed 80°, PCL covered with
synovium; 30° arthroscope
Intercondylar notch
1
8
9
7
3
2
6 5 4
Postero-central view of posterior cruciate,
knee flexed 80°, PCL release from
synovium; 30° arthroscope
Lateral compartment
1
8
9
7
3
2
6 5 4
Anterior view of lateral meniscus anterior
horn; 30° arthroscope
Lateral compartment
1
8
9
7
3
2
6 5 4
Antero-lateral view of lateral meniscus;
30° arthroscope
Lateral compartment
1
8
9
7
3
2
6 5 4
Antero-lateral view of lateral femoral
condyle; 30° arthroscope
Lateral compartment
1
8
9
7
3
2
6 5 4
Postero-lateral view of posterior horn of
lateral meniscus and popliteus hole; 30°
arthroscope
Lateral gutter
Lateral gutter
1
8
9
7
3
2
6 5 4
Lateral view on lateral gutter; 30°
arthroscope
1
8
9
7
3
2
6 5 4
Lateral meniscus
Lateral gutter
Lateral view on lateral gutter; 30°
arthroscope
1
8
9
7
3
2
6 5 4
Lateral meniscus
Lateral gutter
Lateral view on lateral gutter; 30°
arthroscope
Posterior compartment
1
8
9
7
3
2
6 5 4
Medial view, scope along posterior cruciate
to posteromedial pouch; 30° arthroscope
Variation of normal
Medial view of the medial
plica; 30° arthroscope
1
8
9
7
3
2
6 5 4
Variation of normal
Posterolateral view of the
anterior plica, ligamentum
Mucosum; 30° arthroscope
1
8
9
7
3
2
6 5 4
Variation of normal
1
8
9
7
3
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 mmHg 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