Hi, everybody. My name is Greg Ghandry. I'm from the University of Rochester and I will be going over diagnostic arthroscopy and basic portal placement. I don't have anything to disclose. One of the most key things about being able to do arthroscopy is actually getting the patient in the correct position to do the procedure. And there's multiple different ways of doing this, from just using a post on the side of the table to using a leg holder, for example, over here where it really envelops and encircles the leg. Typically, it's kind of dealer's choice and you figure out what works best for you. For most basic arthroscopy, I typically will use a post, but if I'm doing something that requires me getting significant varus or valgus on the knee to get into the back of the knee or posterior compartment, PCL, for example, I will use the more circumferential leg holder, leg protector. Portal placement is another thing that is somewhat controversial and is kind of dealer's choice. Most often, you'll see either a two portal or a three portal technique. The two portal technique has a working portal. The working portal is basically the portal that you have for your instrument that you are using and then a viewing portal, which is the portal for your arthroscope. And generally, the inflow or the outflow actually come off of the arthroscope itself. So that's why you only need the two portals. With the three portal technique, there's a separate inflow or outflow portal typically made superior medial or superior lateral. And I personally have done both and over time really transitioned to the two portal technique. The way that you make your portals can also be variable. So some people do horizontal portals, which are in Langer's lines. They're maybe a little bit more cosmetic and they allow you to extend the portal medial and lateral. Others are more comfortable making vertical portals, which allow you to extend superior and inferior. I would say that vertical portals definitely are the best rookie portals because if you're off in superior and inferior plane, you may have trouble either levering on the tibial plateau or levering on the femoral delt and be more difficult to get into the posterior knee if you're not in a superior and inferior position adequately. And so vertical portals are a little bit more forgiving. The key point here is really whatever technique you use and whatever type of portals you make, you really want to get them in the correct position because bad portals can really make a good arthroscopist look bad. And so if you feel like you're struggling because of portal placement, the other key thing here is portals aren't really big and people don't mind an extra scar, especially if it prevents you from nicking off a big chunk of their cartilage. So just go ahead and make a more appropriate position portal if you need to, as opposed to struggling with a bad portal. There's lots of different portals to choose from. This is just a depiction of several of the most common portals that are used for various different reasons. And so you can see most common, these superior medial and superior lateral portals are used for the inflow if you're using a three portal technique. And then obviously you've got your anterior lateral and anterior medial portals, which are the main workhorses for typical meniscus work. And then there's additional portals. Sometimes the central portal is used to get into the back of the knee. And some of these other portals can be used with ACL reconstruction, particularly if you're doing an intermedial drilling technique. So this is just a little video that'll show a kind of different methods of making sure you understand your landmarks. You can place these portals. The type of operation that you're doing may dictate some slight deviation in your portal placement. So for example, if you're doing an ACL reconstruction and you're going to be doing a lot of work in the notch, sometimes you make your portal a little closer to the patella tendon to facilitate that visualization. You can see, you know, what I did here was kind of this classic goalpost technique. So I find the most effective way at identifying your portal is just using your thumb and palpating the anatomy. And so you want to feel kind of that anterior lateral edge of the tibial plateau and put your thumb right on it. And then you kind of make your portal right above it. But sometimes in patients who are bigger or with difficult to palpate anatomy, you can use some of these other techniques. And so this is an example of the goalpost technique where you kind of palpated the edge of the patella tendon, or sorry, the patella itself, and then draw a line down from the edge of the patella, as well as a line right at the intermedial pole of the patella. And then where those two hashes cross kind of creates this goalpost. And you can actually see that that generally lines up. So this is just a quick example showing with the thumb on the tibial plateau, kind of making that portal there. And you can see that that really lines up with the goalpost technique. And you can see if I'm pushing on the patella tendon, you actually see the fluid actually pooch out and create almost like a little circle. And so another way to visualize whether you're in the right spot is whether your portal is kind of right in the middle of this out pooching of tissue that's called the bubble test. You can also needle localize. So feel free to take an 18 gauge needle and kind of stick it in there and make sure you're not hitting bone or hitting any resistance as you're going in to make sure you're in good position. The intermedial portal is generally created under direct visualization. So once you put in that interlateral visualization portal, you can kind of put in this intermedial portal using the spinal needle. And I actually insert the spinal needle all the way into the compartment to make sure that I can get that spinal needle to the posterior horn. If I can move my spinal needle there, then my instrument is going to be able to go there as well when I'm doing a partial meniscectomy or if I'm inserting a shaver in there as well. And so typically when you're putting sharp things into the knee, you want to make sure you're doing that under direct visualization. So I'm kind of looking at the capsule, watching myself actually cut a pretty robust hole in there so that I can get instruments easily in and out. What I see most often with residents is that they tend to be kind of pushed too close into the joint. And so they don't give themselves a wide field of view and then it makes it harder for them to triangulate. So kind of pull out so that you're almost out of the knee before you start trying to establish the portal. And then also think about where the medial compartment is by looking at the actual knee and looking at the anatomy when inserting the needle. So you don't really want to aim to the notch. If you aim to the notch, you usually end up over the top of your arthroscope and too far lateral, whereas you almost are putting the needle straight back into the knee as you're inserting it. When performing a diagnostic arthroscopy, the general gist of the procedure, again, key tips are give yourself as big a field of view as possible. Visualization is the key to good arthroscopy. And so make sure that you orient your light source to look where you want to go and then go there. Again, optimally position your arthroscope, especially when you're learning before moving your instruments. So make sure you have good visualization and then work on moving your hands and kind of develop your own standard order of the procedure. So this is the order of steps that I do when I'm doing a diagnostic arthroscopy. Certainly you can choose your own order, but sometimes it's nice to start off with a checklist. And so I've provided that here. So going into the super patellar pouch, generally you start with the knee in full extension. The objective on the light source, the little kind of hash mark is typically positioned at either nine o'clock or three o'clock, depending on whether it's a right or left knee. In the super patellar pouch, you're usually looking for loose bodies, inflamed synovium. You want to identify the portal plica. Sometimes things hide behind there, or if you have an inflow or outflow, sometimes you've sucked tissue into the portal plica and you're not getting good inflow because of that. And so you want to make sure that you're clear. You can look at your medial shelf plica, the undersurface of the quadriceps tendon. And like I mentioned, just make sure your outflow cannula is not clogged. The lateral gutter is one that often residents struggle with. So again, you want to look where you're going. So generally, you might start at three o'clock and then move the objective to six o'clock. And as you'll see here, as we're visualizing this, residents tend to stay too far in. If you back up, you'll see this synovial fold. Once you see that synovial fold, you can just kind of raise your hand and go right down into the popliteal hiatus. Often residents are kind of pushed in way too far and they just keep getting stuck and hung up on that synovial fold. So the key there is as you enter the top of that lateral gutter, kind of pull back till you see that fold, and then you can freely move up and down. And you'll look a lot more slick than just kind of getting stuck on the synovium. You can kind of milk the posterior joint. I always call the popliteal hiatus kind of the wastebasket of the knee. A lot of debris and stuff ends up over here. So after you've done a meniscectomy, you want to always check that lateral gutter in the popliteal faucet just to make sure that you don't have a bunch of debris or meniscal fragments that are still over there. On the medial gutter, typically you still have your knee extended. You want to evaluate your deep fibers, the AMCL and synovium here, and the capsular attachments to the medial meniscus. And then in the medial compartment, real key here is to make sure that your knee is flexed a little bit. So a lot of times residents put it right on top of their pelvic brim and that keeps the knee fully extended and really shrinks the space. So by flexing the knee 15 to 30 degrees and kind of having it on your upper hip and applying valgus, it'll actually expose more of that posterior compartment and make it easier for you to get instruments back into the posterior medial aspect of the knee. This just shows the probe kind of going in with appropriate visualization. Generally, I orient the arthroscope to the posterior horn of the meniscus. So in this case, it's at three o'clock. And then you want to make sure you're probing everything and specifically looking for flaps that kind of flip themselves under or behind the plateau. So this is a common one where I'll have residents go in, they'll trim out the meniscus, they'll stick a shaver in there, and they won't recognize this flap. They'll never peel it out. And so if that gets left in there, the patient still has symptoms because of that pressure of the meniscus fragment on the plateau. So you want to make sure you probe and identify those things fully. And then don't forget about the articular surfaces. So everybody focuses on the meniscus, but you also want to make sure that you flex and extend the knee to see the articular surfaces in each compartment fully. In the notch, you can allow the knee to flex down to 90 degrees. Generally, I still leave that scope oriented where it was originally at the posterior horn of the meniscus. This is where you see the ligamentum, which definitely gets in residents way. You can get hung up on it. So again, you want to kind of pull back. Generally, I recommend going over the top of the ligamentum instead of trying to drive through it and getting caught. And if it's really in your way, you can shave it out. And if you shave it out, you want to be at the very top where it comes right off of the articular surface. So, you're not really shaving the fat pad, you're detaching the ligamentum from the upper part of the notch. And when you do this, it'll just fall out of your way and kind of move to the anterior knee, which makes it a lot easier to see and probe the ACL and eliminates a lot of the bleeding that you get if you try to really just shave out the fat pad. And so when you're here, you want to probe the ACL and PCL and make sure that these structures are intact before moving on. And then the next step is to move into the lateral compartment. Generally, because I'm using a post, we put the position into the figure four position. You want to probe and kind of milk any debris. And again, my arthrostoc light position is not changed from where I was in the medial compartment. I did the medial compartment, the notch, and the posterior compartment all with the same position. I change it slightly as I go down to look at the anterior horn to make sure we get a good look. So there we get to five, six o'clock. And again, you might want to slightly flex or extend the knee to help you get over the tibial spine if it's blocking you with getting your probe into the compartment. And then lastly, we go up into the telephemeral compartment, generally start in flexion and then start to extend the knee as you drive your scope up the telephemeral groove to see the undersurface of the patella. So here you want to look and see how the patella is sitting within the notch, evaluate tracking, and then you want to make sure you look up and evaluate the medial and lateral patellar facets, which are areas that frequently get chondral pressure or cartilage loss or delaminations. The other thing that's really important, especially when you're here at a course like this and you have an opportunity to practice on a cadaver is to make sure that to complete a full systematic diagnostic arthroscopy, you want to get really good at all those steps that I just went over, but also take the time to make sure you understand and can easily get in and out of the posterior medial and posterior lateral compartments of the knee. If you're not good at doing this, if meniscal fragments go back there or loose bodies end up back there, you know, it can be a real mood breaker in the OR trying to get that stuff out. If you feel very comfortable going into those posterior medial and lateral compartments and inspecting in there, it just makes your job a lot easier. It's also very important, obviously, for doing PCL reconstruction if you're going to do an arthroscopic technique or for pigmented villanodular synovitis or other things where you need to shave the synovium in the back of the knee. So I find it easiest to kind of use the contralateral portal to get in there. I use the blunt trocar to kind of go in, so I position the arthroscope where I want it to be underneath the posterior medial aspect of the PCL, for example. And then I'll stick the trocar in and kind of gently maneuver the arthroscope into the back of the knee, and then I'll insert my camera lens again. Sometimes it's helpful to visualize back here with a 70-degree scope so that you can really see around all of the corners and the angles. This is just a very good illustration. You know, there's things you don't want to hit while you're putting in posterior portals. And so peroneal nerve is the big one when you're putting in a posterolateral portal. That kind of resides underneath the biceps femoris, so you want to make sure you really palpate that coming onto the fibular head and that you stay above that when making that portal. And similarly, on the medial side of the knee, you've got your saphenous nerve, which if you nick that, can cause some significant pain or neuroma. And then your saphenous vessels, which obviously can cause bleeding. So you want to feel your PES encerinus tendons and make sure that you're above that level when you're placing these portals. This is just a quick example of what a diagnostic arthroscopy of the posterior compartment looks like. So this knee is fully flexed, we're driving through the notch, kind of coming up here underneath the PCL femoral attachment, getting into the posterior compartment, and now kind of looking up and down. So this is the posterior aspect of the knee, the posterior femoral condyle, and now you're just using the objective on the lens to kind of look up and down to take advantage of that 30 degree angle on the scope to see everything, and then you can kind of do a little wiggling maneuver as you back up, and you'll see the posterior horn of the medial meniscus, and you see the posterior cruciate ligament here kind of coming down as we're backing up. So just a couple of tips and tricks before going to the lab. Portal position is the absolute foundation. You've got to have the portals to do a good arthroscopy. Visualization is the key. You can't see, you can't scope, and you want to understand how to optimize the limb position and the stress on your post. So having the knee, again, slightly flexed and good valgus stress for the medial compartment is really key to getting into that posterior horn, and then, you know, just taking a look at your knee and your instruments. So understanding the length of those instruments and kind of the trajectories into the back of the knee helps you understand how to triangulate. Generally for the lateral compartment, you're going to be applying various stress or using the figure of four position, and then typically to look posterior or lateral, you can consider switching out your scope and putting it in the medial portal. So, you know, don't always feel like you have to be hamstrung always using your lateral portal for visualization and your medial portal as your working portal. You can always switch it up if it gives you better angle at a meniscus or cartilage lesion. So practice that in the lab, moving around your portals and understanding what the anatomy looks like from different portals for visualization. Common rookie mistakes, you know, the biggest one I see is this. So, you know, when you're focused in really close on something, you have no idea what it is. So when a patient or a resident is in the notch, they tend to be jammed right up on the ACL and I have no idea what they're looking at. So I'll say get some perspective or telescope out. And so by moving back, you get that wider field of view, and then you can actually see, you know, what you're seeing. Work from known to unknown. So if you get yourself lost, figure out a home position in the knee that you can always find. Get your scope to the notch, and then get your instruments in and find your working instrument in the notch, and then kind of work yourself back over to the lateral portal in the figure of four position if you've lost yourself. Always go to that kind of home-based position, get yourself set, and then gradually work yourself over to the more difficult areas. Scope should be oriented to the floor and make sure you understand how to control the horizon by moving your hand. So, you know, it's not uncommon that residents sometimes will all of a sudden find themselves the scope is upside down, their brain is all scrambled, and they're not able to manipulate the instrument in their working portal anymore. It's often because that scope isn't in the right position relative to the horizon. And so think about it. If your brain's having a lot of trouble, make sure that you haven't, you know, lost your horizon. Also, take advantage of periscoping, using that 30-degree angle to get your best view. Move that light source and the objective so that you're sure that you're looking. I can't tell you how many times, you know, we're doing an ACL reconstruction and I see a resident has the light source angled so that they're looking at the front of the knee when really it should be 180 degrees from that so that they're optimally looking right at the ACL. And when you're first starting, try to keep your camera stable. It's hard to be bimanual at the beginning when you're just learning. So get your visualization, get your camera in a stable position, and then work your instrument into view and start doing your work. I would avoid trying to do both things at the same time. Over time, your hands will start to come together and they'll start working. And if you've had opportunity to work on the FAST workstation, remember, you know, all those pearls that we work on when we're doing the FAST training. So again, you know, the fundamentals of horizon control, deliberate linear motion tracking, telescoping in and out to get perspective, periscoping to understand and take advantage of that 30 degree angle. Cadaveric knees are a little bit different than regular human knees. And because we're going to be operating on cadavers in this course, you really want to make sure that you treat them well. So too much varicin valgus can break the femur. You know, you'll find that it's hard to visualize that medial compartment because these cadavers, the tissues are all contracted, and it's hard to get really good exposure, particularly to the posterior medial aspect of the medial meniscus. You know, for working with the cadavers, I'd kind of punt that area. Cutting the MCL ends up causing quite a bit of fluid outflow, and putting too much valgus ends up breaking your femur, and then you've kind of bagged your cadaver for the day. So if you're doing meniscus work, try to do and practice the work on the anterior horn or the lateral aspect of the body of the meniscus, or, you know, typically the lateral compartment is a lot easier to see. So even though most of the time in clinical pathology, it's in the medial meniscus, you may want to practice today using your lateral meniscus for doing the meniscal repairs and that sort of thing. And you also may want to consider doing your repair when you have good meniscus in there as opposed to doing a large meniscal resection and then not having anything to practice repair techniques later. If the femur breaks, there is ways to help, and so make sure you grab one of the OLC staff, and usually they'll insert a wooden dowel and secure it in a better way. Always ask for help with replamping if it becomes loose. I can't tell you how many times folks just keep tightening those clamps and then they end up fracturing the femur, and that's kind of a mood baker there. Also with these knees, they tend to fill with water over time. The patella and fat pad can really sag in and block visualization, and so sometimes just tying a heavy suture through the quadriceps tendon and then tying it to a clamp above can re-tension that extensor mechanism because, again, these are hemi-specimens, and so that quad isn't really anchored on anything and it just starts to weigh down with gravity. So pulling that back up to anchor it can really get that out of your view. And like I said, it's difficult to create a peripheral meniscus tear to repair, and so in many cases, I would just recommend don't make the tear. Just repair, use the devices, and put them in your normal meniscus to learn the techniques. Try to practice with multiple different devices so that you really understand how they all work and make lots of mistakes. The cadaver's not going to mind. This is your opportunity to learn from making mistakes. Don't try to be perfect. If you get into trouble, sometimes it's fun figuring out how to get out of trouble, and this is where you have time to do that. Make sure that you make your accessory posterior, medial, and lateral portals so that you can get into that posterior compartment of the knee. And there's multiple techniques that you can apply, as I mentioned in the previous lecture. So thank you very much. Hopefully, those fundamental skills will be something you remember and that will guide you going forward, and you have a great day in the lab.

diagnostic arthroscopy

portal placement

patient positioning

working portal

viewing portal

inflow or outflow portal