Patient positioning, portal placement, and normal arthroscopic anatomy

OVERVIEW

Chapter synopsis

Prior to any arthroscopic procedure it is necessary to confirm the procedure with the patient and identify and mark the correct side. The chosen method of anesthesia depends on the length and type of procedure. There are a variety of available portals for knee arthroscopy, with most procedures utilizing an anterolateral viewing portal while working through the anteromedial portal. A systematic and efficient diagnostic arthroscopy should be done at the start of any knee procedure to evaluate all intra-articular structures for potential pathology. The authors’ preferred method for this is presented in the chapter. Additionally, while the postoperative course may differ based on procedure, weight-bearing status, pain control, and physical therapy protocols are vital to postoperative recovery.

Important points

Correct procedure and operative site must be discussed with the patient prior to surgery, with a marking placed over the operative location.
Surgeons must be familiar with the options for portal placement in knee arthroscopy.
A structured and efficient diagnostic arthroscopic exam should be conducted to start each procedure to thoroughly examine all intra-articular structures of the knee.

Clinical and surgical pearls:

Utilize the same method for portal placement and diagnostic arthroscopy for each procedure to ensure all intra-articular structures are examined for pathology.
Recognize that each procedure may require slight modifications to portal placement.
Multimodal pain control can be an effective option following knee arthroscopy to help decrease the utilization of postoperative narcotic medication.

Clinical and surgical pitfalls:

Improper portal placement may make visualization and access more difficult; ensure placement under direct visualization when possible.
Avoid unnecessary excessive fat pad debridement as this can lead to postoperative hemarthrosis or fibrosis.

Identification

Identification of the proper surgical site must be established prior to any procedure, before administration of anesthesia. In 1998, in response to growing concern over the number of wrong-sided surgeries, the American Academy of Orthopedic Surgeons started a “sign your site campaign” to encourage providers to initial the proper site prior to surgery. This should be done for all patients in the preoperative area prior to administration of pain medications or anesthesia. It is vital to confirm the patient’s name and birthday, as well as the planned procedure as written on the consent form. The current surgical site should be marked with the surgeon’s initials and confirmed by the patient. This should be done in an area that will remain visible after draping of the extremity. Finally, a timeout should be conducted both prior to induction of anesthesia and prior to incision to confirm the correct side and visibility of the marking on the surgical limb with the entire surgical team.

Anesthesia

Determination of type of anesthesia is multifactorial and should be discussed between the surgeon and anesthesiologist prior to entrance into the operating room. Options include local, regional, and general anesthesia, and selection should be based on the type and length of the procedure, patient preference, health of the patient, relevant medical history, and a discussion between medical providers.

Local anesthesia

Local anesthesia with or without intravenous sedation offers the benefit of requiring no airway manipulation during the procedure. Additional advantages include low cost, low morbidity, and potential for faster recovery and shorter hospital stay. The primary disadvantage is concern for pain and discomfort during instrumentation and manipulation of the leg. Positioning must allow for an alternative form of anesthesia should the need arise. An investigation on pain generation during awake knee arthroscopy under local anesthesia demonstrated that this can be a well-tolerated procedure, with slight increase in pain with the arthroscope in the suprapatellar pouch. Anesthetic may include both an intra articular injection as well as a skin injection surrounding portal sites utilizing lidocaine and bupivacaine for short- and long-term pain control. This type of anesthesia should be reserved for shorter procedures that will not require significant manipulation of the leg such as diagnostic arthroscopy, removal of loose bodies, synovial biopsy, and small partial meniscectomies.

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