Post on 14-Jan-2016
transcript
The knee.
Mark Clathworthy, Patrick Djian, Bjorn Engstrom, Bent Wulff Jakobsen
Contents
Position of the patientStandard portals
anatomy
Additional portalsRoutine travel through knee
Supra patellar pouchPatello femoral jointMedial gutterMedial compartmentIntercondylar notchLateral compartmentLateral gutterPosterior cavity
Variation of normalmediale plicaanterior plica
Take home message
Positioning of the patient
Supine
Draped
Lat support
Prepared
Tourniquet and irrigation
Pressure tourniquet 280-350 mmHg
Irrigation options:Arthroscopic pump
Gravity
Pressure saline bags
Standard portals
Courtesy to Pao Golano
Antero-lateral (1)the a-l portal is used as the standard viewing portal, through which you can access most of the joint
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
2
Antero-lateral (1)the a-l portal is used as the standard viewing portal, through which you can access most of the joint
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
3
Antero-lateral (1)the a-l portal is used as the standard viewing portal, through which you can access most of the joint
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
2
4
Antero-lateral (1)the a-l portal is used as the standard viewing portal, through which you can access most of the joint
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
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.
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.
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.
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
Courtesy to Pao Golano
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)Additional portal convenient for viewing and exploring postero-lateral compartment
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)Additional portal convenient for viewing and exploring postero-lateral compartment
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)Additional portal convenient for viewing and exploring postero-lateral compartment
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7
Left knee
Routine knee arthroscopy
1. Insert the blunt trocar through the antero-lateral 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.
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.
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.
Routine travel
1
3
2
46
8
7
95
1. Insert the blunt trocar through the antero-lateral 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.
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..
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.
1. Insert the blunt trocar through the antero-lateral 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.
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.
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.
1. Insert the blunt trocar through the antero-lateral 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.
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.
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.
10
1. Insert the blunt trocar through the antero-lateral 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.
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.
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.
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.
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.
Routine travel
1
3
2
46
8
7
95
10
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.
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.
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.
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.
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
2
46
8
95
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.
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.
7
10
Routine travel
1
3
2
46
8
95
7
10
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
Superior view of supra patellar pouch; 30° arthroscope
32
46
87
9
1
510
Supra patellar pouch
Superior view of supra patellar pouch; 30° arthroscope
32
46
87
9
1
5
Vastus lateralis of the quadriceps muscle
10
Patello femoral joint
Femoral condyle lateral
Femoral condyle lateral view; 30° arthroscope
32
46
87
9
1
510
Patello femoral joint
Femoral trochlea
Femoral trochlea lateral view; 30° arthroscope
Patello femoral joint
32
46
87
9
1
510
Patello femoral joint
Femoral trochlea
Patello femoral joint proximal lateral view; 30° arthroscope
Patella
32
46
87
9
1
510
Medial gutter
Medial view of medial gutter; 30° arthroscope
Medial femoral condyle
Gutter
Patella
32
46
87
9
1
510
Medial gutter
Medial distal view of medial gutter; 30° arthroscope
Medial fem
oral condyle
Gutter3
246
87
9
1
510
Medial compartment
Distal view of medial meniscus anterior horn, knife producing a-m portal; 30° arthroscope
Medial femora
l condyle
Tibial plateau
Medial meniscus
32
46
87
9
1
5
Knife in a-m portal
10
Medial compartment
Distal view of medial meniscus anterior horn, probe through ant-med portal; 30° arthroscope
Medial femoral condyle
Tibial plateauM
edial meniscus
32
46
87
9
1
510
Medial compartment
Antero medial view of medial meniscus anterior horn underside, probe through ant-med portal; 30° arthroscope
Medial femoral condyle
Tibial plateau
Medial meniscus,
undersurface
32
46
87
9
1
510
Medial compartment
Medial view of medial meniscus central third; 30° arthroscope
Medial femoral condyle
Tibial plateau
Medial meniscus
32
46
87
9
1
510
Medial compartment
Medial view of medial meniscus central third, probe through anteromedial portal; 30° arthroscope
Medial femoral condyle
Tibial plateau
Medial meniscus
32
46
87
9
1
510
Medial compartment
Posteromedial view of medial meniscus posterior horn; 30° arthroscope
Medial femoral condyle
Tibial plateau
Medial meniscus
32
46
87
9
1
510
Medial compartment
Posteromedial view of medial meniscus posterior horn, tested with a probe; 30° arthroscope,
Medial femoral condyle
Tibial plateau
Medial m
eniscus
32
46
87
9
1
510
Medial compartment
Inferomedial view of anterior part of joint, femoral condyles, trochlea and Hoffa’s fat; 30° arthroscope
Medial femoral condyle
32
46
87
9
1
510
Intercondylar notch
32
46
87
9
1
5
Lateral femoral c
ondyle
Anterior cruciate
Inferior view of distal tibial attachment of anterior cruciate ligament, knee near extension; 30° arthroscope
10
Intercondylar notch
32
46
87
9
1
5
Late
ral f
emor
al c
ondy
le
Anterior cruciate
Posterior cruciate
Postero-central view of distal tibial attachment of anterior cruciate ligament, knee flexed 80°; 30° arthroscope
10
Intercondylar notch
32
46
87
9
1
5
Late
ral f
emor
al c
ondy
le
Anterior cruciate
Postero-central view of proximal femoral attachment of anterior cruciate ligament; 30° arthroscope
10
Intercondylar notch
32
46
87
9
1
5
Postero-central view of posterior cruciate, knee flexed 80°, PCL covered with synovium; 30° arthroscope
Anterior cruciate
Posterior cruciate
10
Intercondylar notch
32
46
87
9
1
5
Postero-central view of posterior cruciate, knee flexed 80°, PCL release from synovium; 30° arthroscope
Anterior cruciate
Poste
rior c
rucia
te
Med
ial f
emor
al c
ondy
le
10
Lateral compartment
32
46
87
9
1
5
Lateral meniscus
Anterior view of lateral meniscus anterior horn; 30° arthroscope
10
Lateral compartment
32
46
87
9
1
5
Lateral femoral condyle
Popliteustendon
Lateral meniscus
Antero-lateral view of lateral meniscus; 30° arthroscope
10
Lateral compartment
32
46
87
9
1
5
Lateral femoral condyle
Lateral meniscus
Antero-lateral view of lateral femoral condyle; 30° arthroscope
10
Lateral compartment
32
46
87
9
1
5
Lateral femoral condyle
Popliteus tendon
Lateral m
eniscus
Postero-lateral view of posterior horn of lateral meniscus and popliteus hole; 30° arthroscope
10
Lateral gutter
32
46
87
9
1
5
Lateral view on lateral gutter; 30° arthroscope
Late
ral g
utte
r
10
Lateral gutter
32
46
87
9
1
5
Lateral view on lateral gutter; 30° arthroscope
Late
ral f
emor
al c
ondy
le
Poplite
us te
ndon
Late
ral m
enis
cus
10
Lateral gutter
32
46
87
9
1
5
Lateral view on lateral gutter; 30° arthroscope
Late
ral m
enis
cus
Pop
liteu
s te
ndon
Popliteus h
ole
10
Posterior compartment
32
46
87
9
1
5
Medial view, scope along posterior cruciate to posteromedial pouch; 30° arthroscope
Medial fem
oral condyle
Poste
rior h
orn
Med
ial m
enisc
us
10
Variation of normal
32
46
87
9
1
5
Medial fem
oral condyle
Medial femoral condyle
Plica
Plica
Patella
Medial view of the medial plica; 30° arthroscope
10
Variation of normal
32
46
87
9
1
5
Medial fem
oral condyle
Plica
Posterolateral view of the anterior plica, ligamentum Mucosum; 30° arthroscope
10
Anterior
cruciate
Variation of normal
32
46
87
9
1
5
Lateral femoral condyle
Discoid lateral meniscus
Postero lateral view of a discoid meniscus (this on 80% discoid); 30° arthroscope
10
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.
Take home points
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