Steven H. Stern

1. Symptomatic meniscal tear (medial or lateral)

2. Loose body

3. Osteochondritis dissecans

4. Septic knee

5. Evaluation of the articular cartilage and osteochondral structures of the knee

6. Arthritis (relative). Arthroscopy is an unpredictable procedure in treating mild to moderate arthritis or patellofemoral syndrome (“chondromalacia”). It is rarely beneficial in severe osteoarthritis unless there is a significant mechanical component causing the patient symptoms.

1. Unsatisfactory skin condition

2. History of knee reflex sympathetic dystrophy (relative)

1. Knee radiographs

2. Magnetic resonance imaging (MRI) depending on the patient’s symptoms and the specific surgical procedure planned

1. The patient is placed supine on the operating room table.

2. All pressure points should be padded.

3. The procedure can be done with general, spinal, or local anesthesia with sedation.

4. A leg holder or lateral support post can be used.

5. A pneumatic thigh tourniquet should be placed as proximal as possible on the thigh. However, most standard arthroscopic procedures can successfully be completed without tourniquet inflation.

6. Standard arthroscopic instruments are needed. These should include an arthroscopic “shaver.”

7. If a meniscal repair is contemplated, the instruments and implants for introduction of an absorbable fixation device should be available.

1. Arthroscopy is most reliable for symptomatic mechanical problems within the knee such as meniscal tears and loose bodies. The results achieved with articular cartilage debridement for patellofemoral syndrome (“chondromalacia”) or osteoarthritis or with menisectomy for asymptomatic or incidental meniscal tears are significantly less predictable. The best results occur when the patient’s preoperative symptoms and physical examination correlate with mechanical finding on a diagnostic study (i.e., MRI).

3. In general, all procedures should commence with a systematic diagnostic inspection of the entire joint performed in a standard manner prior to any operative surgery. However, if a loose body is found, it is appropriate (and desirable) to immediately proceed with its removal while it is easily visualized. The author’s preferred order for the systematic diagnostic inspection of the entire knee joint is: suprapatellar pouch, patellofemoral joint, lateral gutter, medial gutter, medial compartment, intercondylar notch, and lateral compartment.

4. Add epinephrine to the inflow bags to minimize bleeding.

1. Try to avoid multiple operations on the same knee for the same problem over a short time period.

2. Avoid violating the patella tendon with placement of the portals.

3. Attempt to minimize damage to the articular cartilage with the arthroscopic instruments and shavers.

4. Avoid leaving free meniscal debris floating within the joint after morselization of the meniscus.

1. Consider injecting a local anesthetic (i.e., 0.25% bupivacaine) into the knee at the end of the procedure to minimize postoperative pain.

2. A compressive dressing should be placed at the end of surgery and is normally removed approximately 48 hours after the procedure.

3. In most cases, patients can weight-bear as tolerated (WBAT) after surgery. Most patients are able to discontinue crutches in the first week after surgery.

4. Range-of-motion and strengthening exercises can be initiated immediately after the procedure. Routine formal physical therapy is not required for all patients. Most patients can successfully rehabilitate with a home exercise program.

Arthroscope insertion

1. Position the patient supine on the operating room table. Place a thigh tourniquet as proximal as possible on the thigh. While most cases can be performed without tourniquet inflation, the tourniquet can be inflated if bleeding impedes visualization.

2. Depending on surgeon preference, either a post or thigh holder can be used. Position the lateral post just distal to the thigh tourniquet. If a thigh holder is utilized, position it as proximal as possible.

3. Prepare and drape the limb in the hospital’s standard sterile fashion.