• Nonsterile tourniquet

• Thigh holder or lateral post (surgeon preference)

• 30- and 70-degree arthroscopes

• High-definition video camera

• Lactated Ringer solution or normal saline (3-L bags)

• Epinephrine (1 mg epinephrine/3-L bag [0.33 mg/L]) may improve hemostasis

• Arthroscopic pump

• Ideally, the arthroscopic pump has independent controls for both flow and pressure

• Arthroscopic pump tubing

• Arthroscopic cannulae

• Blunt arthroscopic trocar

• No. 11 scalpel

• 4-mm probe

• Arthroscopic basket punches (Fig. 34-1)

• Straight

• Up-biting

• Left-angled

• Right-angled

• Back-biting

• Tissue graspers

• Rotary shavers (toothed and nontoothed) (Fig. 34-2)

• Straight (4.0 mm, 5.0 mm)

• Curved

• Tapered

• The procedure can be done with the foot of the operating room (OR) table flexed downward 90 degrees or kept straight based on surgeon preference.

• If the foot of the OR table is flexed 90 degrees, the lower extremity can be flexed over the edge of the table with the thigh placed in a padded holder proximal to the table break and the tourniquet (if used) applied proximal to the thigh holder.

• If the lower extremity is kept in full extension, a nonsterile post should be placed lateral to the distal thigh.

• The contralateral lower extremity is flexed at the hip and supported by a padded well-leg holder, “butterfly” stirrup, and/or blanket(s) to relieve tension on the femoral nerve (Fig. 34-3).

• If the surgeon prefers the operative knee flexed to 90 degrees, the OR table can be placed in a Trendelenburg position to elevate the operative knee to the level of the surgeon’s waist to optimize arthroscopic manipulation.

• Basic portals (Fig. 34-4)

• Superomedial (SM): used for the outflow cannula

• Anterolateral (AL): used for initial arthroscope placement

• Anteromedial (AM): used for instrumentation (ie, shaver, basket punches)

• All portals are created with a no. 11 scalpel.

• The scalpel should be angled 45 degrees to the coronal plane for the AL and AM portals with the sharp edge upward to avoid inadvertent laceration of the anterior horn of the menisci.

• Some surgeons prefer to place the AM portal under direct arthroscopic visualization, whereas others prefer to create all three portals in a “blind” fashion.

• Accessory posterior portals occasionally are necessary to remove a displaced meniscal fragment or loose body in the posterior compartments (see below).

• Posteromedial (PM)

• Posterolateral (PL)

• The medial and lateral gutters are inspected to locate any displaced meniscal tissue (Fig. 34-5).

• Medial compartment

• The medial meniscus is viewed and sequentially probed starting at the posterior root and moving anteriorly along the superior and inferior surfaces to identify any displaced meniscal flap between the meniscal body and tibial plateau (Fig. 34-6).

• If a tear is identified, it is probed to assess its stability.

• If the medial meniscus can be pulled anteriorly past the “equator” of the medial femoral condyle, it is considered unstable and likely torn (Fig. 34-7).

• External pressure on the PM knee can help deliver the posterior horn into view.

• Lateral compartment

• The knee is placed in 20 degrees of flexion with internal rotation and a varus load applied.

• If the arthroscopy is performed with the lower extremity extended, placing the knee in the “figure-four” position can facilitate examination of the lateral compartment.

• Systematic evaluation begins at the posterior horn of the lateral meniscus, including the root insertion.

• The midbody of the lateral meniscus is evaluated around the popliteal hiatus by sweeping the arthroscope laterally and viewing inferiorly (Fig. 34-8).

• The anterior horn is evaluated by retracting the arthroscope and viewing inferiorly.

• Posteromedial compartment

• To view the PM compartment, the cannula, with blunt trocar, is introduced through the AL portal, directed posteriorly and inferiorly along the medial wall of the intercondylar notch under the posterior cruciate ligament.¹

• An accessory PM portal is created by trans-illuminating the skin over the PM corner of the knee. An 18-gauge spinal needle is inserted into the compartment 1 cm above the medial joint line, posterior to the medial femoral condyle. A longitudinal stab incision is made with a no. 11 scalpel, with care to avoid the saphenous nerve and vein, which can occasionally be seen by trans-illumination. A blunt trocar is then advanced through the incision, puncturing the capsule under direct vision (Fig. 34-9).

• Posterolateral compartment

• The PL compartment is examined by inserting the 70-degree arthroscope through the AM portal, over the anterior cruciate ligament (ACL), through the intercondylar notch, and past the lateral femoral condyle (Fig. 34-10).

• An accessory PL portal can be created 1 cm above the joint line just posterior to the lateral collateral ligament and anterior to the biceps tendon, avoiding the common peroneal nerve (Fig. 34-11).