arthroscopy of the knee joint is a relatively common orthopedic procedure to treat a host of sports injuries and other knee diseases. Commonly a 4 mm size scope is used via two standard arthroscopy portals. Arthroscopic examination of the knee confirms MRI findings. Synovial fluid and biopsy can be taken to confirm diagnosis.

1. Basics of knee Arthroscopy
For the Beginners
Dr Bhaskar Borgohain
MBBS(AMC), MS Ortho (Delhi Univ), DNB Ortho, AO fellow (Germany),
Arthroplasty Fellow (Computer navigation)
Professor & HoD
Deptt. of Orthopaedics & Trauma
Chairman, Operation Theatres
Head ,Sports injury & Arthroscopy Clinic (SIAC)
NEIGRIHMS, Shillong
www.neigrihms.gov.in
26TH September 2018 at NEIGRIHMS , Shillong
Proceedings of Regional CME cum Workshop : NEROSA & Arthroscopy Society of North East (India)

2. First be good in clinical examination of the knee joint

3. Learn basic MRI skills of the knee: Sit with a radiologist friend

4. Its great idea to
Visit a football club or a sports training training facility to
understand sports injuries

6. Positioning
• Patient placed supine with ability to flex the
knee
– leg holder or post
• has benefit of allowing valgus stress
• but makes figure-four position more difficult
• Place tourniquet (important for safety, but
often not inflated)

7. INDICATIONS
• Diagnostic arthroscopy: corroborate MRI
• Removal of loose bodies
• Synovial biopsy or synovectomy
• Meniscal repair or resection
• ACL and PCL reconstruction
• Chondral defect repair, including microfracture
• Osteochondritis dissecans
• Knee debridement for osteoarthritis

8. Confirm things
• Persistent effusion not understood by clinical
evaluations, MRI and other tests
• Monoarticular
• Tuberculosis
• Gout
• PVNS
• Psoriatic

9. FIRST ENTRY OF SCOPE
• Advance trochar into suprapatellar pouch with
knee straightened
• Use a BLUNT TROCHER- Quads VMO Injury
• Straighten the knee fully or you scratch the PF
Joint cartilage

10. Placement of portals are critical steps

11. Portals
• Mark the portals with skin marker pen
• Viewing portal : Antero-lateral incision
• Identify the WINDOW: “Soft spot” of knee- ROM
– vertical incisions
• have advantage of increased superior-inferior mobility of
instruments
• May cut the meniscus- face blade upwards
– horizontal incisions
• have advantage of increased medial-lateral mobility of
instruments
• May injure veins to bleed- trans-illuminate to see veins

12. The Portals

13. Instrument portal
• Antero-medial portal is the main portal
• Counterpart of AL portal
• Open the track with a straight haemostate
• Use Blunt trocher- avoid injury to ACL- Cartilage
• Aim towards the Intercondylar notch
• Pass the Hook probe first
• “Triangulation” skill is needed – it has a
learning curve

14. Learning to triangulate
so that the tip of the introduced instrument appears before the
lighted area and in the video monitor for action
Walk along the scope by feeling down

15. Antero-medial portal: Functions
– A Routine & Standard portal
– Used as the primary instrumentation portal
• Location & technique
– Make it with knee in flexion,
– Adjacent to Patellar tendon
– Over the Soft spot on the Joint line

16. ACCESSORY PORTALS
• Superomedial
• most commonly used for water in/out flow
• make with knee in extension
• Superolateral
– most commonly used for water inflow/out flow
– make with knee in extension
– common site for aspiration or injection

17. others
• Posteromedial portal
– function
• helps visualize posterior horn and PCL
– location & technique
• 1 cm above joint line behind the MCL
• Posterolateral portal
– function
• helps visualize posterior horn and PCL
• 1 cm above joint line between LCL and biceps tendon
• Transpatellar portal
– function
• used for central viewing or grabbing
– location & technique
• 1 cm distal to patella and splits the patellar tendon
• do not use if performing a bone-patella-bone graft harvest

18. Serially examine one by one
• Should systematically check the following locations and structures
• with knee fully extended start in suprapatellar pouch
– loose bodies
• Patellofemoral joint
– patellofemoral cartilage
– patellofemoral tracking
• Trochlear groove
• Lateral gutter
– insertion of popliteus
• Lateral compartment
– anterior horn of lateral meniscus
• Medial gutter

19. Supra-patellar pouch
KNEE IN EXTENSION:
INSPECT THE

20. REMEMBER: KNEE POSITION WILL AFFECT THE SIZE AND SCOPABILITY
DONOT BREAK YOUR SCOPE !

21. INSPECT THE PATELLO-FEMORAL JOINT: PF Joint
UNDERSURFACE OF PATELLA
Femoral Groove
Do a patello-femoral tracking by gently flexing the knee to assess the PF joint

22. With knee at 90 degree flexion
• Now move to medial compartment to assess:
– Medial meniscus
– Medial femoral condyle cartilage
– Medial tibial plateau cartilage
• Intercondylar notch
– ACL
– PCL
– Posteromedial corner
• best seen with 70 degree scope placed through notch
(Modified Gillquist view)

23. Use of a tourniquet reduces bleeding and visibility is better

24. Put your monitor screen ergonomically

25. Arthroscopic View
Medial Compartment
Knee kept in 90 degree flexion

27. With knee in figure-four position
• Finish the tour in lateral compartment and evaluate the
– Lateral meniscus
– Popliteal hiatus- Popliteus tendon
– Lateral femoral condyle cartilage
– Lateral tibial plateau cartilage

28. Difficult part for the beginners
FIND THE POSTERIOR HORN OF LATERAL MENISCUS
Knee is in Figure of four position
May be able to see the popliteus tendon at the popliteal hiatus at the back of it

29. Triangulation technique:
A core competency needed for doing in Arthroscopy
Learn this psychomotor skills in simulator or cadavers if possible first

30. READ AND CLEAR YOUR GROSS & ARTHROCOPIC ANATOMY
MEDIAL FEMORAL
CONDYLE
KNEE IN 90 DEGREE FLEXION

31. ACL reconstruction
ACL PCL

32. Traingulation
• Psychomotor skills
• Visuo-spatial learning
• Skill lab- Arthroscopy Simulator
• Touch & Follow the scope distally
• Side to side- swiping- pistonning
• Rotation of camera
• 30-70 Degree- Variable

33. The HOOK PROBE
Remember:
The probe is extension of your finger!

34. Various common types of hook punches help to cut
tissues, take punch biopsies, meniscectomy etc

35. Arthroscopic Shaver: Use different types of tips for different needs

36. The hook probe
• Its the extension of
surgeon’s own finger
• Very handy and
important
• It “palpates to confirm
your “inspection”

37. Inflow irrigation fluid
• Normal Saline
• Ringer lactate
• Glycine solution- costlier
• Distension reduces bleeding
• Distraction of joint surfaces
• Bleeding control
• Gravity assisted technique and
• Arthro Pump also reduces bleed

38. Complications
• Iatrogenic articular cartilage damage
– is most common complication
– Over-diagnosis or Under-diagnosis
• Haemorthrosis
• Injury to meniscus in beginners
• Neurovascular injury
– Posteromedial portal
• Saphenous nerve
– Posterolateral portal
• Common peroneal nerve

39. Take membership of an arthroscopy society to learn more

40. Thank you