16 Knee Arthroscopy and Meniscectomy

10.1055/b-0040-174139

16 Knee Arthroscopy and Meniscectomy

John R. Tuttle

Summary

Knee arthroscopy and meniscectomy have evolved over the past several decades. As technology and techniques continue to be developed, there are a few basic principles that will remain cornerstones of the procedure. These principles are summarized here along with an example technique guide describing modern arthroscopic setup and execution.

16.1 Introduction

Knee arthroscopy was slowly developed throughout the early 20th century with early pioneers like Danish surgeon Severin Nordentoft, Japanese surgeon Kenji Takagi, and Swiss surgeon Eugen Bircher. These men paved the way for others like Masaki Watanabe, who performed the first arthroscopic partial meniscectomy in 1962 and Lanny Johnson, who developed the motorized suction shaver. These men, among others of their time, created a new era of surgical innovation in the 1970s and 80s. Today, whether it is 4K ultra HD cameras and displays, wireless image and video transmission, or the newest implant or arthroscopic instrument, technology continues to evolve. For this reason, knee arthroscopy has become one of the safest and most common procedures in the world today. ¹

16.2 Preop

Surgical table. Surgeon-specific flat table or adjustable foot to allow leg holder
Patient position. Supine with well leg flat on table or in well-padded stirrup leg holder. A tourniquet may be used or placed.
Leg positioners. Circumferential leg holder or side post are most common. The basic position with a side post is depicted in ▶Fig. 16.1.
Patient exam—preop. Note joint line tenderness, range of motion without mechanical blocks, McMurray, Apley, Thessaly tests. Under anesthesia: Test Lachman, pivot shift, varus and valgus stress at 0 and 30 degrees of flexion, for ligamentous laxity.

**Fig. 16.1** The operative knee is positioned with a side post just proximal to the lateral epicondyle. Optimal positioning of the post will allow for the knee to easily flex to 90 degrees, unobstructed access to the portal sites, and allow for the necessary leverage to distract the medial joint space. The operative foot and ankle are typically placed on the hip of the surgeon to allow for hands-free distraction of the medial joint space.

16.3 Portals

There are three standard knee arthroscopy portals: inferomedial, inferolateral, and superolateral. The superolateral portal is often not used. These portals are marked on a left knee in ▶Fig. 16.2. Note the patella (P), patellar tendon (PT), and tibial tubercle (TT) are used as landmarks.
The inferolateral portal is made lateral to the patella tendon and inferior to the distal pole of the patella. This is the most common viewing portal and made first to introduce the arthroscope.
The inferomedial portal is made medial to the patella tendon and inferior to the distal pole of the patella. This portal is often the “working” portal and made under direct visualization using a spinal needle for localization. This allows placement for optimum instrument angles to gain access to all aspects of the knee compartments.
The superolateral portal is placed 1–2 cm above the superior pole of the patella in line with the lateral sulcus of the patellofemoral joint. This portal is classically described for outflow but may also be used for instrument placement, especially if working on the patellofemoral articulation.

**Fig. 16.2** The basic structures of the anterior knee are marked and outlined as well as the standard arthroscopic portals. The anteromedial and anterolateral portals are made in line with the level of the joint and are marked here on either side of the patellar tendon. Their location along the horizontal axis will depend on surgeon’s preference as well as the necessary angles anticipated for the specific surgery. A superolateral portal site is pictured as well, which may be used as an injection site, a working portal in some cases, or an outflow portal. P, patella; PT, patellar tendon; TT, tibial tubercle.

The knee joint can be insufflated with normal saline prior to portal placement. The knee is injected with a 60 cc syringe and 18-gauge needle with an average of 120 cc’s typically from a superolateral position, similar to where the superolateral portal is placed. This allows patellofemoral joint distension and elevation of Hoffa’s fat pad. This may ease gaining access to the suprapatellar pouch upon introduction of the arthroscope.

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