- Discussion:
-
arthroscopy of the arthritic knee:
-
Arthroscopy following TKR:
-
chondral and osteochondral injuries of the knee
- meniscal
tears:
- prevalence of wrong pre-operative
diagnosis or additional pathology:
-
always consider an alternative diagnosis especially in younger patients (in
whom bone tumors
should
be considered);
- "
isolated medial
meniscal tear"
- actually occurs only 21% of time;
- additional dx in 23%;
- lateral meniscal tear 5% of time (referred pain)
- in 70% of
ACL
tears, there will be a meniscus tear;
-
Preparation and Anesthesia:
-
Portals:
-
anteroloateral portal
-
superomedial portal:
-
medial portals:
- superolateral portal:
- useful viewing
dynamics of patellofemoral articulation.
- portal located
just lateral to the quadriceps tendon about 2.5 cm superior to
the
superolateral corner of the patella;
- in addition to
the skin incision, the knife should nick the deep fascia to facilitate
portal
insertion;
- references:
- Posterior portals
for arthroscopic surgery of the knee.
Ogilvie-Harris DJ. et al Arthroscopy.
10(6):608-13, 1994 Dec.
-
Patellofemoral Joint:
- see:
chondromalacia and
osteochondral lesions);
- it is important to visualize the entire lateral and medial
patellar facets (including the odd facet at the medial
aspect of the medial
facet);
- normal patellar position in the extended knee is slightly lateral
to the lateral femoral condyle, patella moving
medially and distally w/
increasing flexion;
- increasing contact occurs
between lateral patellar facet & lateral femoral condyle;
- most often patella seats in
the center of trochlea at about 45 deg of flexion (and w/ suspected
patellar
subluxation, it is important to document
the amount of knee flexion that elicits patellar contact and
full patellar
seating);
- any plans for a
lateral retinacular release should be delayed until the arthroscopy is
completed, since bleeding
from this procedure will interfere with
visualization;
- Supra-patellar Pouch:
- most often affected by
inflammatory arthritis (w/ hypertrophic synovium);
-
medial
synovial plicae
- references:
- Arthroscopic visualization
of the patellofemoral joint.
U Lindberg et al. Orthop. Clin. North Am. Vol 17.
p 263-268. 1986.
- Medial
Compartment:
-
chondral injuries of the knee
- these lesions are identified by flexing the knee to 45 deg;
-
visualization of the
medial meniscus
- begin by flexing the knee and holding the tibia in external
rotation;
- while holding external rotation, apply valgus, and extend the leg to
between 10-30 deg;
- note that an ACL deficient will tend to pivot w/ valgus
stress, which brings the
tibia forward thus imparing visualization of the posterior compartment;
- solution is to firmly hold the tibia in external
rotation, which prevents the tibia from
subluxing forward;
- gently titrate flexion and extension to give the best
visualization of the posterior meniscal horn;
- in difficult cases, an assitant can ballott both the medial and
lateral menisci which can facilitate
visualization and menisectomy;
- if an assistant is not available a spinal needle can be
inserted into the posteror medial aspect of the
joint to hold the meniscus in a
anterior position;
- references:
- Arthoscopic visual field mapping at the periphery of the medial
meniscus: A comparison of different
portal approaches. Arthrosocpy. Vol 9.
1993. p 265-271.
- Evaluation of arthrography and arthroscopy for lesions of the
posteromedial corner of the knee.
Kimori et al. Am J Sports Med. Vol 17. 1989.
p 638-643.
- Intercondylar Notch:
-
ACL
-
PCL
- for optimal assessment of the intercondylar notch, the surgeon
should strive for the widest panoramic view
that is possible w/ the 30 deg
scope directed laterally;
- often the ligamentum mucosum
will have to be taken down inorder to improve visualization;
- if the fat pad appear to be
in the way, then try a quick "push - pull" with the arthroscope inorder to
pull
the fat pad backwards;
- if the fat pad continues to
obstruct visualization of the notch, it will need to be partially shaved away;
- extend the knee and begin shaving above the intercondylar notch, and then work
inferiorly;
- this method allows good visualization as the fat pad is being shaved;
- fat pad syndrome or Hoffa's
disease may be diagnosed arthroscopically when there is
hypertrophic
intercondylar / or infrapatellar synovitis extending to central to the inner rim of the anterior
horn of the meniscus;
- references:
- Hoffa's disease: arthroscopic resection of the infrapatellar fat pad. DJ
Ogilvie-Harris and J.
Giddens. Arthroscopy Vol 10. p 184-187. 1994.
-
Impingement of infrapatellar fat pad (Hoffa's disease): results of high-portal
arthroscopic resection.
- posteromedial drive thru:
- a required part of any knee
arthroscopy is the posteromedial drive thru;
- the scope is slid along the
lateral side of the medial femoral condyle (under the PCL) until it reaches
the
posterior compartment;
- in cases of large posterior
horn tears (or displaced bucket handle tears), the torn portion of the meniscus
may flip up into the posterior compartment;
- this portion of the meniscus will not been seen from the medial compartment;
- references:
- Arthroscopic examination of the posteromedial compartment of the knee joint.
J. Gillquist et al.
Int Orthop. Vol 3. p 13-18. 1979
- Lateral Compartment:
-
visualization of lateral compartment
-
lateral meniscus:
-
popliteus tendon:
- this tendon, arises from distal part of
lateral femoral condyle just anterior to origin of
the lateral collateral ligament;
- Complications of Arthroscopy:
-
infection:
- note that there are several different
methods of sterilizing arthroscopic instruments, and that some are better
than
others;
- references:
-
Septic arthritis following arthroscopic meniscus repair: a cluster of three
cases.
- Septic arthritis following arthroscopy: Clinical syndromes and analysis of
risk factors.
Armstrong RW, Bolding F, Joseph R: Arthroscopy 8:213-223, 1992
- vascular and nerve injury
- neural disruption /
neuropraxia - is
usually secondary to prolonged
tourniquet
times;
-
neurologic complications
- references:
-
Current Concepts Review. Neurological Complications Due to Arthroscopy.
-
Injury to infrapatellar branch of saphenous nerve in arthroscopic knee surgery.
- synovitis
- persistent drainage
- effusions are common;
- hemarthrosis
- iatrogenic fracture:
- references:
- Supracondylar
femoral fracture after anterior cruciate ligament reconstruction with
transfemoral fixation.
- Extra articular
arthroscopic release in post-traumatic stiff knees: a prospective study of
endoscopic quadriceps and patellar release.
- Serious
consequences of the wrong diagnosis of meniscal lesion in a case of stress
fracture of the
distal femur.
-
COMPLICATIONS OF KNEE SURGERY
- Complications in Arthroscopic Surgery Performed by Experienced Arthroscopists.
Arthoscopy 1988; 4: 215.
- Supracondylar femoral
fracture after arthroscopic reconstruction of the anterior cruciate ligament.
A
case report.
-
Knee surgery: complications, pitfalls, and salvage
-
deep venous
thrombosis
- in the report by Thomas
Wirth et al. inorder to evaluate the risk of VTE in knee arthroscopy patients
inorder to determine efficacy and safety of a
low-molecular weight heparin (LMWH) (reviparin sodium) in preventing VTE.
- there were 262 patients
undergoing elective knee arthroscopy prospectively randomized to receive
either
no treatment or reviparin once daily subcutaneously for 7 to 10 days.
- 239 patients were evaluable
(122 no treatment, 117 receiving LMWH). 6 DVT were detected - 5 in
control
group (5/117 - 4.1%) and only one in the active treatment group (1/116 - 0.85%).
- there was no major bleeding,
four patients with minor bleedings.
- 1 patient had a transitory
fall in platelet count below 100 giga-particles/L without any clinical symptoms.
- patients undergoing knee
arthroscopy have a moderate risk of VTE and effective prophylaxis can be
achieved with LMWH (reviparin).
- ref: Prevention of venous
thromboembolism after knee arthroscopy with low-molecular weight
heparin
(Reviparin). Results of a randomized controlled trial
Thomas Wirth, M.D. Arthroscopy April
2001 Volume 17 Number 4