Basic principle of Knee Joint arthroscopy and techniques for beginners. Basic Steps of Knee Joint Diagnostic arthroscopy and common complication following knee joint arthroscopy.

1. Principles of Knee arthroscopy
Presenter
Dr Kaushal Raj Kafle
Resident

2. History
• Early Endoscopic attempts on knee
1912 by Severin Nordentoft from Denmark
1919 by Kenji Takaji in Japan
• Eugene Bircher : Pioneer and parent of knee
arthroscopy(1920-30)
• Masaki Watanabe and Richard Connor: Parent
of interventional arthroscopy (1970-80)

3. Arthroscope
• an optical instrument.
• Three basic optical systems
– the classic thin lens system,
– the rod-lens system designed by Professor
Hopkins of Reading, England,
– graded index (GRIN) lens system.

4. Optical Characteristics
• Diameter
• Inclination
– Angle between the axis of arthoscope and perpendicular to
surface of lens
– 25o-30 o: Most common
– 70o-90o: Corners
• Field of Vision
– the viewing angle encompassed by the lens
– 1.9-mm : 65o
– 2.7-mm : 90o
– 4.0-mm : 115o

7. Television Camera
• Advantages
– More comfortable operating position for the surgeon,
– Avoidance of contamination of the operative field
– Involvement of the rest of the surgical team in the
procedure.
– can be connected directly to the arthroscope
• reductions in size
• better high-definition digital resolution.
• Cableless arthroscopic systems
– Miniature light source

8. Basic Instrument Kit
• Arthoscopes (30- and 70-degree)
• Probe
• Scissors
• Basket forceps
• grasping forceps
• arthroscopic knives
• motorized meniscus cutter and
shaver
• electrosurgical, laser, and
radiofrequency instruments
• Miscellaneous equipment
• Procedure Specific Instruments

9. Irrigation System
• Irrigation and Joint Distension
• Lactated Ringer solution
:physiological and minimal
synovial and articular surface
changes.
• Arthroscopic pumps
• Height 3 -4 feet : 66 -
88 mm Hg
• distention pressure
:approximately 30 mm Hg
below the systolic blood
pressure.

10. Tourniquet
• knee, ankle, elbow, and other distal joints
• C/I: thrombophlebitis and significant peripheral vascular
disease
• Advantage :
– increased visibility
– no significantly increased postoperative morbidity <90 to
120 minutes

11. • Disadvantage
– blanching of the synovium, differentiation and diagnosis
of various synovial disorders difficult,
– ischemic damage to muscle and nervous tissue with
prolonged tourniquet time
• addition of epinephrine (1 mg /liter of saline) significantly
increased visibility and reduced the need for tourniquet
inflation by 50%

12. Positioning
• Patient supine with ability to flex the knee
• Leg holder or post

13. Leg Holders
– knee is flexed 90
– medial fulcrum for both varus
and valgus stresses
– open the posteromedial
compartment for better viewing,
– manipulation of the meniscus,
– posterior horn meniscal surgery,
especially in tight knees
– Limited number of Positions

14. Lateral post
– lateral aspect of the distal thigh
can be levered against
– handwidth proximal to the base
of the patella
– opening of the posteromedial
compartment.
– unlimited number of positions,
including flexion and the figure-
four position,

15. Anesthesia
• General anesthesia and spinal anesthesia
• Local anaesthesia – may be added
• At portal sites
• Into the joint at the end of surgery

16. Common Therapeutic Indications
• Meniscectomies
• Meniscal suture
• ACL reconstructions,
• cartilage debridement
• less frequently
– PCL or multiligament reconstructions,
– patellar subluxations and cartilage repairs

17. Diagnostic Indication
• Historically Diagnostic Arthroscopy
• MRI : Routine non invasive diagnostic
modality

18. Contraindications
• Risk of Joint Sepsis from local skin condition
• Complete and partial Ankylosis
• Major collateral ligamentous and capsular
disruptions : excessive extravasation of fluids
into the soft tissues
• Minimally damaged joints responding to
conservative therapy

19. Advantages
• Reduced Post Operative Morbidity
• Smaller Incisions
• Less Intense Inflammatory Response
• Improved Visualization
• Absence of secondary effects
• Reduced Hospital Stay
• Reduced complication rates
• Improved follow up evaluation

20. Disadvantage
• Requires working through small portal and fragile
instruments
• Maneuvering through tight intraarticular spaces
may produce scuffing and scoring of the articular
surfaces,
• Extensive and Expensive Specialised equipment
• Proficiency in arthroscopic techniques requires a
great deal of patience and persistence.

21. Triangulation Technique
• use of one or more instruments that are
inserted through separate portals and brought
into the optical field of the arthroscope,
• the tips of the instrument and the arthroscope
forming the apex of a triangle.
• sufficient for handling the vast majority of
meniscal lesions suitable for arthroscopic
meniscal surgery.

22. Surface Anatomy

23. Portals
• Standard portals
Anterolateral 1 cm above joint line and 1 cm lateral to edge
of patellar tendon
Anteromedial 1cm above medial joint line and 1 cm medial to
edge of patellar tendon
Posteromedial Triangular soft spot between posteromedial
edge of femoral condyle and posteromedial
edge of tibia
Superolateral Lateral to quadriceps tendon and 2.5cm
superior to superolateral corner of patella

24. Portals
• Optional portals:
1. Posterolateral portal
2. Proximal midpatellar medial and lateral portals
3. Accessory far medial and lateral portals
4. Accessory Transpatellar tendon portal(Gillquist)

26. Scope insertion
• Make anterolateral incision over soft spot of knee
– vertical incisions
• have advantage of increased superior-inferior mobility of
instruments
– horizontal incisions
• have advantage of increased medial-lateral mobility of instruments
• Insert trochar into capsule
– advance blade into capsule then follow with trochar
– do with knee flexed
• Advance trochar into suprapatellar pouch
– with knee straightened

27. Diagnostic Arthroscopy
• Systematic and step wise Visualization of
1. Suprapatellar pouch and patellofemoral joint
2. Medial gutter
3. Medial compartment
4. Intercondylar notch
5. Posteromedial compartment
6. Lateral compartment
7. Lateral gutter and posterolateral compartment
• Diagnose intraarticular disorders meniscus,
synovium, ligament and articular cartilage

28. Steps
•Should systematically check the following locations and structures:
1.with knee fully extended start in suprapatellar pouch
•loose bodies
2.patellofemoral joint
•patellofemoral cartilage
•patellofemoral tracking
3.trochlear groove
4.lateral gutter
•insertion of popliteus
5.lateral compartment
•anterior horn of lateral meniscus

29. Steps
6. medial gutter
7. with knee flexed to 90 move to medial compartment
– medial meniscus
– medial femoral condyle cartilage
– medial tibial plateau cartilage
8. intercondylar notch
– ACL
– PCL
– posteromedial corner - best seen with 70 degree scope placed through
notch (Modified Gillquist view)
9. with knee in figure-four position finish in lateral compartment
– lateral meniscus
– popliteal hiatus
– lateral femoral condyle cartilage
– lateral tibial plateau cartilage

30. Location Common pathology
Supra patellar Pouch Loose bodies
Plica Patellar and trochlear chondromalacia
Lateral gutter Femoral osteophytes
Medial gutter Femoral o steophytes
Medial compartment Medial meniscus tears
Femoral and tibial chondromalacia
Intercondylar notch Loose bodies
Anterior and posterior cruciate ligament tears
Trochlear chondromalacia
Lateral compartment Lateral meniscus tears
Femoral and tibial chondromalacia
Posterior medial compartment Medial meniscus posterior root tears
Posterior lateral compartment Lateral meniscus posterior root tears

31. • Probing of the
medial meniscus
on it’s tibial and
femoral surfaces
• inspection of the
posterior horn and
insertion point of
the medial
meniscus
medial gutter seen
through the
anteromedial portal.
Arthroscopic views of
the patellofemoral
joint

32. intercondylar notch
viewed from the
anterolateral and medial
portals respectively,
normal ACL with the knee
close to extension and 90°
of flexion

33. Complications
• Damage to intraarticular structure
– Scuffing of intraarticular cartilage > Chondromalatic
changes and degenerative arthritis
• Damage to Menisci and Fat
• Damage to Cruciate ligament
• Damage to Ligaments and tendon
– MCL : accesory medial portal , excessive valgus stress
to open up medial compartment

34. • Damage to extra articular structures
–Blood vessels
• Popliteal artery : Menisectomy while cutting
intercondylar attachment
• Posteriorly placed sutures In meniscus repair
• Extensive articular synovectomy : Genicular
arteries

35. –Nerves
• Traction/Overdistraction
• Direct trauma
• Mechanical compression from extravasation
• Prolonged tourniquet use
• Inferior branches of saphenous nerve and
Sartorial branch of femoral nerve are
commonly injured

36. • Compartment Syndromes
– Lower pump pressure/gravity inflow with
adequate outflow
– Stopping inflow, Releasing torniquet, leveling limb
to heart, use of Esmarch wrap from distal to
proximal

37. • Hemoarthosis
– Most common post op complication
– Lateral retinacular release : superior lateral
geniculate vessel
– Lateral meniscetomy and Synovectomies : inferior
lateral geniculate vessel

38. • Thrombophebitis
– DVT
– Most dangerous post op complication
• 9.9% DVT and 2.1% proximal DVT after arthroscopy
• Pulmonary emboli <1 %
• With LMWH , DVT 1.8%
• age >70 years increases thromboembolic risk 10 times;
• BMI >29, smoking, and oral contraception increase the
risk three timesdiabetes and hypertension increase the
risk two times

39. • Infection
– <0.2% , very rare
– Limited incision, young Healthy patients, Short OT
time, irrigation and dilution effect
– Prophylactic Antibiotic : Controversial
– Beneficial for High risk patient: DM, immuno
compromsied and Skin disorder
– Post op use of steriod > Increased risk of infection
• early arthroscopic irrigation and debridement
and intravenous antibiotics

40. • Synovial Herniation and Fistula
– Larger ports
– Large cystic fluid filled herniation
– Fistula : Suture reaction, stitch abscess
• Instrument Breakage
– Stop outflow, keep joint distended, keep in visual field
– Gravitate to medial and lateral gutter, beneath
mensici, posterior or most dependent
– Radiographic location
– Suction, Magnet, grasping instrument
• Implant Complication
– Suture anchor, sutures and knots
– Chondral damage, synovitis, osteolysis, chondrolysis

41. References
• Campbells Textbook of Orthopedics
• Atlas of Knee Arthroscopy