The Value of Intercondylar Notch Visualization of the Posteromedial and Posterolateral Compartments During Knee Arthroscopy

Summary: The intercondylar notch views allow for visualization of the posteromedial and posterolateral compartments of the knee without the use of accessory portals. The purpose of this study was to prospectively evaluate whether these views are useful either diagnostically or therapeutically in the performance of knee arthroscopy. Two surgeons at one institution performed 150 consecutive knee arthroscopies. After arthroscopic examination of the knee using standard portals, a diagnosis and treatment decisions were made. Thereafter, visualization of the posteromedial and posterolateral compartments through the intercondylar notch was undertaken. Each view was performed initially with a 30° arthroscope and 3 questions were asked: (1) Did the view change the diagnosis or add additional information? (2) Did it change the surgical treatment? (3) Was it useful during performance of the procedure? The 70° arthroscope was then used and the same three questions were addressed. In 20.6% of the cases, the intercondylar notch views made a diagnostic and/or therapeutic difference, and the surgical procedure was changed in 11.3% based solely on this information. The views were 3 times as likely to make a difference in anterior cruciate ligament (ACL) reconstructions when compared with arthroscopy without ACL reconstruction (P < .01). The 70° arthroscope added nominal additional information. There were no significant complications. We advocate visualization of the posteromedial and posterolateral compartments through the intercondylar notch as a valuable part of routine knee arthroscopy.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 8 (November), 1999: pp 813–817     

The applications of arthroscopy on malleolus fractures

Historical perspective It was well known that in 1918 Takagi performed the first arthroscopic inspection of a cadaver's knee in Japan.~1 His interest in this area laid the foundation for arthroscopy and facilitated the development of arthroscope. In 1931, Burman reported an experimental study on the arthroscopic exploration of cadaveric joints, but he believed that the ankle joint was unsuitable for such techniques because it was too narrow to pass through the posterior puncture.~2 Unexpect…     

Double Posteromedial Portals for Posterior Ankle Arthroscopy in Supine Position

Both posterior and anterior arthroscopy of the ankle may be indicated in the same patient. With the patient supine, it is possible to reach most intraarticular structures of the ankle through the standard anterior portals, but difficult to examine the posterior compartments and to perform hindfoot endoscopy. In most patients following the anterior procedure the patient is positioned prone to operate on the posterior compartment. We describe a two-portal posteromedial hindfoot procedure that allows the surgeon to reach both the posterior joint space and the extraarticular compartment of the hindfoot with the scope and instruments, regardless of diagnosis, with the patient supine. After arthroscopy on the anterior portion of the foot using standard anterior portals, the two posteromedial portals allow endoscopic inspection and management of abnormalities in this region without repositioning the patient and without any remarkable local complication.     

Use of the 70° Arthroscope for Improved Visualization With Common Arthroscopic Procedures

The vast majority of common arthroscopic procedures are performed with a 30° arthroscope for visualization. Although the 70° arthroscope has been described for a myriad of applications, its utility has recently been forgotten. We have explored the use of the 70° arthroscope for a myriad of arthroscopic procedures and identified a number of circumstances in which it offers superior visualization to a 30° arthroscope. These procedures include arthroscopic shoulder stabilization, distal clavicle resection, acromioclavicular joint reconstruction, rotator cuff repair, elbow arthroscopy, anterior cruciate ligament reconstruction, posterior cruciate ligament reconstruction, arthroscopy of the posterior knee compartments, hip arthroscopy, and subdeltoid shoulder arthroscopy.     

Zone approach to knee arthroscopy

The zone approach to knee arthroscopy divides the knee into ten anatomic zones. This article presents the zone classifications and describes the combination of portals for the arthroscope, the probe, and the operating instruments. The particular leg position which is thought to allow the best visualization of each zone is also described. Alternate portals are necessary in certain situations, as in knees with tight ligamentous structures. This list of standard and alternate portals is not meant to be all-inclusive, but we do urge that all ten zones are examined during arthroscopy. The objectives of this article are to describe a method of arthroscopic examination that is both systematic and comprehensive, and to develop an arthroscopic nomenclature that allows easy localization and reporting of pathology in the knee joint.     

髋关节镜术的入路选择

目的探讨髋关节镜手术不同入路的可见视野和操作安全性.方法使用三点入路,2个入路分别位于大粗隆的外侧上方,1个入路位于前方.使用30/70镜头并更换镜头入路,记录关节镜下视野.通过18例髋关节镜检查和手术操作过程及并发症分析,评价不同髋关节镜入路的有效性和安全性.结果本研究显示,以30°/70°标准关节镜经髋关节前方及侧方入路,可确切观察到的髋关节结构包括髋臼上部的负重区,陷窝及圆韧带,上、前、外侧的髋臼盂唇;通过手术中台下外旋和内旋髋关节,可以观察到大部分股骨头关节面.本组未出现神经血管并发症.结论经由3个入路相配合交替使用镜头和手术器械,可以完成关节镜的系统检查与手术操作.该入路的操作具有安全、有效和可重复性.     

Dry Wrist Arthroscopy: Technique and Rationale

Wrist arthroscopy has been established as a useful, minimally invasive tool for diagnosing and treating many different wrist conditions. The standard portals are located on the dorsum of the hand and wrist and are named for their relation to the extensor compartments. They include the radiocarpal and midcarpal portals. The radiocarpal portals are 3-4, 4-5, 6R, 6U, and 1-2. The midcarpal portals are STT (scaphotrapeziotrapezoidal), MCR (midcarpal radial), and MCU (midcarpal ulnar). Traditionally, wrist arthroscopy is performed with constant inflow of saline solution for joint insufflation and visualization. Dry wrist arthroscopy (DWA) is a technique that allows for arthroscopic exploration and instrumentation without infusing any fluid into the joints. Some advantages of DWA include lack of fluid extravasation, less obstruction by floating synovial villi, decreased risk of compartment syndrome, and the ability to perform concomitant open procedures more easily than with a wet technique. Additionally, the risk of fluid displacing carefully laid bone graft is much less without constant flow. DWA can be used in the assessment and management of triangular fibrocartilage complex (TFCC) and scapholunate interosseous ligament tears and other ligamentous injuries. DWA can also be used in fracture fixation to assist with reduction and restoration of articular surfaces. Moreover, it is used in more chronic settings to diagnose scaphoid nonunions. DWA does have its disadvantages such as generation of heat through the use of burrs and shavers and clogging of these instruments during debridement of tissue. DWA is a technique that can be used to manage multiple orthopaedic conditions including soft-tissue and osseous injuries. With a minimal learning curve for surgeons who already perform wrist arthroscopy, DWA can be a useful addition to their practice.     

Arthroscopic "Cuff-Sparing" Percutaneous (CUSP) Technique for Posterior Instability Repair in the Beach-Chair Position

Arthroscopic posterior labral repair and capsular shift procedures are technically difficult in the beach-chair position as compared with the lateral decubitus position. Optimal visualization in the beach-chair position, and anchor placement in the posterior glenoid rim, necessitate various lateral trans-cuff portals, and these may result in damage to the rotator cuff tendons. The author has devised a new technique for posterior labral repair in the beach-chair position; the technique involves visualization of the posterior capsulolabral complex through a 70-degree arthroscope placed in the posterior axillary pouch portal, and labral repair is performed through percutaneous medial portals. The cuff-sparing and percutaneous (CUSP) nature of the technique utilizes safe anatomic zones for visualization and percutaneous repair of the entire posterior labrum, and lateral portals that may potentially damage the rotator cuff tendons are avoided. Technical variants of the procedure include: (1) a "CUSP shift" technique (combined labral repair and capsular shift); (2) a "CUSP-stitch" technique (isolated labral repair without a capsular shift); and (3) a "posterior labroplasty" technique for reconstruction of deficient posterior labral tissue. Technical tips to avoid neurological injury, and a detailed rehabilitation protocol are presented.     

Anterior portal selection for shoulder arthroscopy

A posterior portal site has become the accepted standard for introduction of the arthroscope for routine diagnostic procedures of the shoulder. Few published guidelines exist, however, on the optimum and safe positions of accessory portals for introduction of a probe or surgical instruments during shoulder arthroscopy. The relatively thick surrounding muscle layers and the close proximity of vital neurovascular structures would make guidelines for safer and more reproducible accessory portal selection helpful to minimize the risk of injury to these structures. The "intraarticular triangle" bounded by the humeral head, the glenoid rim, and the biceps tendon has been found to be an excellent intraarticular landmark for placement of an accessory anterior portal for shoulder arthroscopy. Anatomical dissections on 20 cadaver shoulders have confirmed that instruments passed through this location are at little risk to injure adjacent neurovascular structures about the shoulder. Clinical data in 30 shoulder arthroscopies performed utilizing this landmark for placement of an anterior portal have confirmed this position to be a safe and useful location for portal placement if proper precautions are followed.     

Arthroscopy of the subtalar joint: an experimental approach

Talocalcaneal articulations are relatively complex and functionally very important because they play a major role in the movements of inversion and eversion of the foot. Few reports on arthrography of the subtalar joints are available in the literature, and, similarly, little attention has been paid by arthroscopists to these joints. This preliminary study briefly defines the normal anatomy of the subtalar joints and describes a new technique of arthroscopic examination of the posterior subtalar joint. The distal lower extremities of six fresh cadavers were used in these experiments. All the subtalar joints were supple. A 2.7-mm arthroscope was used to carry out arthroscopic and anatomic examinations. A technique of examination with one anterior portal and one posterior portal is described in detail. When the anterior portal was used, the egress needle was placed posteriorly; when the posterior portal was used, the converse was true. By using the two portals, the following intraarticular structures could be visualized: a major part of the convex posterior calcaneal facet of the talus and the posterior talar facet of the calcaneus; the synovial lining laterally and posteriorly; the posterior aspect of the interosseous talocalcaneal ligament; and the posterior recess of the joint. The results of this experimental study indicate that arthroscopy of the posterior subtalar joint is technically feasible. Clinically, the possible indications for arthroscopy would include state of the articular cartilage in suspected cases of degenerative arthritis, rheumatoid arthritis, and infection; visualization of the joint after intraarticular fracture to evaluate chronic pain syndrome in the hindfoot; biopsy; management of sinus tarsi syndrome; loose body removal.     

The utility medial portal: a new arthroscopic approach to the knee

Placement of accurate arthroscopic portals is crucial in arthroscopic knee surgery. Unlike the inferolateral portal that is usually used initially in arthroscopic surgery, the utility medial portal allows excellent visualization of both the medial and lateral compartments as well as the patellofemoral articulation and suprapatellar pouch. Other diagnostic advantages include visualization of the anterior horn of the lateral meniscus, access into the posterior compartment of the knee, and visualization of the intercondylar notch. Surgically, this portal is invaluable in lateral meniscal procedures. Specifically, placement of the arthroscope in the utility medial portal allows access to the complete lateral meniscus, including the anterior and posterior horns, for both visualization and instrumentation. This portal is also outstanding for use in patellofemoral surgical procedures. This portal has been used with great success as a standard arthroscopic portal without difficulty, primarily in 550 arthroscopic procedures and secondarily in 240 procedures. This portal is recommended for examination of the knee in all cases except those in which there is a high suspicion of an isolated medial meniscus tear. Also, the portal may be used routinely for surgical visualization and instrumentation due to its flexibility.     

Posterior “back and forth” approach in arthroscopic surgery on the posterior knee compartments

We report the feasibility, indications, and usefulness of an arthroscopic approach to the posterior knee compartments. We developed an arthroscopic approach to the posterior knee compartment involving use of a posteromedial portal and a posterolateral portal opposite each other. Each posterior portal is used in alternation for the arthroscope and instruments. The posterior portals are established using an original “back and forth” technique. The feasibility of the technique was evaluated on a cadaver. It allowed us to define safety rules to protect the vessels and nerves that course through the popliteal fossa. The approach provided a broader field of view compared with classical techniques. After removal of the septum dividing the posterior compartment, the synovial fold enclosing the posterior cruciate ligament and lining the upper and posterior parts of the posterior capsule was readily accessed, suggesting that this approach may be particularly valuable for total synovectomy. This was confirmed in 6 patients with villonodular synovitis, in whom the new approach was used in combination with arthroscopic anterior synovectomy. This technique allows removal of parts of the synovium that are difficult to access through conventional arthroscopic approaches. For total synovectomy, it can be used as an alternative to open posterior synovectomy, in combination with arthroscopic anterior synovectomy.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: pp 321–325     

镜下“8”字法缝线固定后交叉韧带胫骨撕脱骨折

[目的]介绍关节镜下“4”字位三入路“8”字缝线固定治疗后交叉韧带(posterior cruciate ligament,PCL)胫骨止点撕脱骨折的手术技术与初步效果。[方法]2019年3月-2021年3月,采用“4”字位三入路“8”字法缝线固定PCL胫骨撕脱性骨折28例。常规建立前外、前内和后内3个人口。从前内侧人口将2根强生Orthocord缝线经PCL前侧绕过后,从后内侧入口将缝线拉出并打结,防止骨块松脱。然后,将缝线两端交叉后,分别导入两个骨道,由胫骨前拉出。再次将PCL胫骨隧道定位器钩端置于骨块上,用其将骨块向后推压,进行临时复位固定。调整固定缝线使其从骨块后上方跨过,对膝施加前抽屉应力,复位固定骨块,同时拉紧缝线两端,使缝线牢固嵌压固定骨折块,将缝线尾端在骨道外口固定到门形钉或Versalok上完成固定。[结果]28例患者均顺利完成手术,无血管、神经损伤等严重并发症。Lysholm评分由术前(33.14±9.60)分显著增加至末次随访时(84.07±5.43)分(P<0.05);IKDC评分由术前(32.39±84.79)分显著增加至末次随访时(84.79±4.42)分(P<0.05)。末次随访时,临床检查显示,28例患者均无膝关节松弛或不稳定,膝活动度与健侧对称。影像方面,28例骨折均达临床骨愈合,无骨折移位。[结论]本技术具有简便易行、固定牢靠的优点,临床疗效满意。     

Progress in ankle arthroscopy

Ankle arthroscopy is rapidly gaining in popularity as an important diagnostic and therapeutic procedure. Indications for this technique include pain, swelling, stiffness, instability, hemarthrosis, and locking of the ankle. The anteromedial, anterolateral, and posterolateral portals are most commonly used. The use of a short, 30 degrees oblique arthroscope, with an ankle holder and distractor, permits visualization of the entire joint. Operative treatment is facilitated by small joint shavers, burrs, knives, and baskets. Intraarticular problems such as chondromalacia, osteophytes, loose bodies, synovitis, osteoarthritis, fracture, and instability all can be addressed arthroscopically. Prior to this technique, the cause of chronic ankle pain was poorly understood. Now, lateral ankle impingement is a well-recognized entity that responds well to arthroscopic treatment. Ankle arthroscopy provides a safe, effective method of diagnosis and treatment with few complications. Further advances in equipment and technique should expand indications for this procedure.     

A New Noninvasive Controlled Intra-articular Ankle Distraction Technique on a Cadaver Model

Effective joint distraction is crucial in arthroscopic ankle surgery. We describe an effective and controlled intra-articular ankle distraction technique that we have studied by means of a fresh-frozen cadaver model. Using a kyphoplasty balloon, which is currently used in spine surgery, we tried to achieve a controlled distraction. After the fixation of the cadaver model, standard anteromedial and anterolateral portals were used for ankle arthroscopy. From the same portals, the kyphoplasty balloon was inserted and placed in an appropriate position intra-articularly. The necessary amount of distraction was achieved by inflating the kyphoplasty balloon with a pressure regulation pump. All anatomic sites of the ankle joint were easily visualized with the arthroscope during surgery by changing the pressure and the intra-articular position of the kyphoplasty balloon. Ankle distraction was clearly seen on the arthroscopic and image intensifier view. The kyphoplasty balloon is simple to place through the standard portals and the advantage is that it allows easy manipulation of the arthroscopic instruments from the same portal.     

Arthroscopy of the elbow joint: A cadaveric study of portal placement

Sixteen fresh cadaver elbows were examined by arthroscopy and dissection to evaluate the usefulness and the anatomic relationships of seven previously described portals for elbow arthroscopy. Most of the examined portals were found to be relatively close to neurovascular structures. The nerves that were found to be located closest to the portals were the posterior antebrachial cutaneous nerve at the direct lateral and antero-lateral portals, the radial nerve at the antero-lateral portal, and the medial antebrachial cutaneous nerve at the high and low antero-medial portals. The degree of flexion and fluid distension of the joint were found to influence the position of nerves and vessels in relation to the arthroscopy portals. At least three different portals were found to be required for thorough examination of the elbow joint. The combination of the low postero-lateral, the direct lateral, and the high antero-medial portals provided the largest visualized area.     

Therapeutic interest of wrist arthroscopy: about 1000 cases

Wrist arthroscopy is a relatively recent procedure because it was described in the 70's. During the first period of 80's it became an indisputable technique of diagnosis. Since the 90's many therapeutic procedure were described by several authors all over the world. This technique increase a lot the understanding of wrist pathologies and ameliorate significantly the results for patients. We report our experience about 1000 wrist arthroscopy between 1998 and 2005. The patients were always operated on outpatient basis under local regional anaesthesiology. The arm was laid on the table and the hand on in-line traction (5-7 kg). We used a 2.4 mm arthroscope, 30 degree angled. The both joints, radiocarpal and midcarpal, were systematically explored. The small portals were not closed. In our experience, only 42 arthroscopies (4%) were without surgical procedure. We separated the indications in 7 chapters: (1) arthoscopic assistance for fractures treatment (distal radius and scaphoid: 7%; (2) TFCC tears (17%); (3) treatment of intrinsic ligaments tears (scapholunate and lunotriquetral: 21%); (4) ectomy (radial styloidectomy, wafer, carpal boss 13%); (5) resection of wrist ganglia (21%); (6) partial prosthesis (2.5%); (7) others techniques (arthrolysis, synovectomy 14.5%).     

Diagnostic and operative arthroscopy of the ankle. An experimental approach

To determine safe and effective placements of the arthroscope, 14 freshly amputated ankle joint specimens were used for experimental diagnostic and operative procedures. Preoperatively, chondral and osteochondral lesions, articular defects, and loose bodies were created within the ankle joint. The following arthroscopic portals were investigated: anteromedial, anterocentral, anterolateral, posteromedial, and posterolateral. Overlapping of vision fields was noted with the three anterior portals. Optimum visualization of a lesion was obtained when the arthroscope was placed on the same side as the lesion. Lesions on the posterior aspect of the talar dome and within the posterior talar pouch required the posterior placement of the arthroscope for optimum visualization. The use of the anterocentral approach, with a 2.7-mm arthroscope yields good visualization of the anterior aspect of the joint, and very often, of the posterior compartment. Anatomic guidelines for the avoidance of neurovascular structures and the exact placement of the arthroscope in both anterior and posterior portals are presented and were specifically defined in two additional fresh ankle specimens.     

Ankle arthroscopy with patient in prone position

Anterior ankle arthroscopy is the most commonly performed foot and ankle arthroscopy. By means of the anterolateral and anteromedial portals, the anterior compartment of the ankle joint can be approached easily. Different posterior portals had been described to reach the posterior ankle compartment. With the patient in prone position and the combination of anterior and posterior portals, the medial and lateral gutters of the ankle joint can be reached together with the anterior and posterior compartment. This is useful for complete synovectomy of the ankle joint.     

Role of Arthroscopy in Various Ankle Disorders

IntroductionAnkle arthroscopy has come a long way since it was thought, it is not feasible because of tight joint and anatomical characteristics of ankle joint. The same anatomical features like capsular attachment and safe accessory portals are used to access the whole joint even with a rigid arthroscope. Ankle distraction method was routinely used to access the anterior ankle. However, nowadays, anterior arthroscopy is done in dorsiflexion as this increases the anterior ankle joint volume, and thereby easy access to various anatomical structures. On the other hand, intermittent traction is used to access the posterior ankle. Initially used as a diagnostic tool, ankle arthroscopy is now used extensively as a therapeutic and reconstruction tool. New evidence is published for all inside ligament reconstructions, effective management of impingement syndromes, and osteochondral lesions. The indications are being extended to fracture management and arthrodesis.MethodologyThis narrative review was performed following a literature search in the Pubmed database and Medline using the following keywords: ankle arthroscopy, portals, ankle OCD, functional outcome. Related articles were then reviewed.ConclusionComplications rate is reduced with a better understanding of the relative anatomy of surrounding neurovascular structures and tendons with regard to the position of ankle joint. This review on ankle arthroscopy focuses on anatomy, indications, and complications. Ankle arthroscopy is a safe and elegant tool as any other joint arthroscopy.