1. Mark Clathworthy, Patrick Djian, Bjorn Engstrom, Bent Wulff Jakobsen
The knee.
Mark Clathworthy, Patrick Djian, Bjorn Engstrom, Bent Wulff Jakobsen

2. Contents Position of the patient Standard portals anatomy
Additional portals
Routine travel through knee
Supra patellar pouch
Patello femoral joint
Medial gutter
Medial compartment
Intercondylar notch
Lateral compartment
Lateral gutter
Posterior cavity
Variation of normal
mediale plica
anterior plica
Take home message

3. Positioning of the patient
Supine
Lat support
Prepared
Draped

4. Tourniquet and irrigation
Pressure tourniquet mmHg
Irrigation options:
Arthroscopic pump
Gravity
Pressure saline bags

5. Standard portals Antero-lateral (1) Antero-medial (2)
the a-l portal is used as the standard viewing portal, through which you can access most of the joint
Antero-medial (2)
the a-m portal is used as the standard working portal through which you can probe the majority of the joint
Superior-lateral (3)
The s-l portal is used for optional outflow cannula and for probing the suprapatellar cavity
Posterior-medial (4)
The p-m portal is used accessing the posterior cavity
Antero-lateral (1)
the a-l portal is used as the standard viewing portal, through which you can access most of the joint
Antero-medial (2)
the a-m portal is used as the standard working portal through which you can probe the majority of the joint
Superior-lateral (3)
The s-l portal is used for optional outflow cannula and for probing the suprapatellar cavity
Posterior-medial (4)
The p-m portal is used accessing the posterior cavity
Antero-lateral (1)
the a-l portal is used as the standard viewing portal, through which you can access most of the joint
Antero-medial (2)
the a-m portal is used as the standard working portal through which you can probe the majority of the joint
Superior-lateral (3)
The s-l portal is used for optional outflow cannula and for probing the suprapatellar cavity
Posterior-medial (4)
The p-m portal is used accessing the posterior cavity
Antero-lateral (1)
the a-l portal is used as the standard viewing portal, through which you can access most of the joint
Antero-medial (2)
the a-m portal is used as the standard working portal through which you can probe the majority of the joint
Superior-lateral (3)
The s-l portal is used for optional outflow cannula and for probing the suprapatellar cavity
Posterior-medial (4)
The p-m portal is used accessing the posterior cavity 3 1 2 2 4
Courtesy to Pao Golano
Courtesy to Pao Golano

6. Anatomy
The subcutaneous nerve around the knee of importance related to the arthroscopic portals is the infrapatellar branch of the saphenus nerve.
The antero-medial portal is closely related to the branch.
The antero-lateral portal is only related to subcutaneous nerve branches in cases of abnormal anatomical arrangement.
The postero-medial portal is placed immediately proximal to the hamstring tendons thereby avoiding the nerve branch of the saphenus nerve and the vessels.
The subcutaneous nerve around the knee of importance related to the arthroscopic portals is the infrapatellar branch of the saphenus nerve.
The antero-medial portal is closely related to the branch.
The antero-lateral portal is only related to subcutaneous nerve branches in cases of abnormal anatomical arrangement.
The postero-medial portal is placed immediately proximal to the hamstring tendons thereby avoiding the nerve branch of the saphenus nerve and the vessels.
The subcutaneous nerve around the knee of importance related to the arthroscopic portals is the infrapatellar branch of the saphenus nerve.
The antero-medial portal is closely related to the branch.
The antero-lateral portal is only related to subcutaneous nerve branches in cases of abnormal anatomical arrangement.
The postero-medial portal is placed immediately proximal to the hamstring tendons thereby avoiding the nerve branch of the saphenus nerve and the vessels.
The subcutaneous nerve around the knee of importance related to the arthroscopic portals is the infrapatellar branch of the saphenus nerve.
The antero-medial portal is closely related to the branch.
The antero-lateral portal is only related to subcutaneous nerve branches in cases of abnormal anatomical arrangement.
The postero-medial portal is placed immediately proximal to the hamstring tendons thereby avoiding the nerve branch of the saphenus nerve and the vessels.

7. Additional portals Middle patella medial (5)
Additional portal convenient for viewing anterior of medial meniscus
Middle patella lateral (6)
Additional portal convenient for viewing anterior horn of lateral meniscus
Postero-lateral (7)
Additional portal convenient for viewing and exploring postero-lateral compartment
Middle patella medial (5)
Additional portal convenient for viewing anterior of medial meniscus
Middle patella lateral (6)
Additional portal convenient for viewing anterior horn of lateral meniscus
Postero-lateral (7)
Additional portal convenient for viewing and exploring postero-lateral compartment
Middle patella medial (5)
Additional portal convenient for viewing anterior of medial meniscus
Middle patella lateral (6)
Additional portal convenient for viewing anterior horn of lateral meniscus
Postero-lateral (7)
Additional portal convenient for viewing and exploring postero-lateral compartment 6 5 7
Courtesy to Pao Golano

8. Routine knee arthroscopy
Left knee

9. 1. Insert the blunt trocar through the antero-lateral portal to the patello femoral pouch. Attach 30° arthroscope and look through suprapatellar pouch by rotating the scope 180° back and forward and scan the area.
2. Pull back gently scope overlooking patellofemoral joint on the extended knee from lateral and from medial side. If you drain the joint you can examine the patellofemoral joint stability better.
3. Reopen water supply and return to suprapatellar pouch. Follow capsular fold medial through the medial gutter to overlook the synovium and the medial femoral condyle.
4. Note the anterior horn of the med meniscus and apply a gentle valgus load on the lower leg to open medial compartment. Mark externally the spot for the medial portal with finger on skin or with a needle.
1. Insert the blunt trocar through the antero-lateral to the patello femoral pouch. Attach 30° arthroscope and look through suprapatellar pouch by rotating the scope 180° back and forward and scan the area.
2. Pull back gently scope overlooking patellofemoral joint on the extended knee from lateral and from medial side. If you drain the joint you can examine the patellofemoral joint stability better.
3. Reopen water supply and return to suprapatellar pouch. Follow capsular fold medial through the medial gutter to overlook the synovium and the medial femoral condyle.
4. Note the anterior horn of the med meniscus and apply a gentle valgus load on the lower leg to open medial compartment. Mark externally the spot for the medial portal with finger on skin or with a needle.
1. Insert the blunt trocar through the antero-lateral portal to the patello femoral pouch. Attach 30° arthroscope and look through suprapatellar pouch by rotating the scope 180° back and forward and scan the area.
2. Pull back gently scope overlooking patellofemoral joint on the extended knee from lateral and from medial side. If you drain the joint you can examine the patellofemoral joint stability better.
3. Reopen water supply and return to suprapatellar pouch. Follow capsular fold medial through the medial gutter to overlook the synovium and the medial femoral condyle.
4. Note the anterior horn of the med meniscus and apply a gentle valgus load on the lower leg to open medial compartment. Mark externally the spot for the medial portal with finger on skin or with a needle.
1. Insert the blunt trocar through the antero-lateral portal to the patello femoral pouch. Attach 30° arthroscope and look through suprapatellar pouch by rotating the scope 180° back and forward and scan the area.
2. Pull back gently scope overlooking patellofemoral joint on the extended knee from lateral and from medial side. If you drain the joint you can examine the patellofemoral joint stability better..
3. Reopen water supply and return to suprapatellar pouch. Follow capsular fold medial through the medial gutter to overlook the synovium and the medial femoral condyle.
4. Note the anterior horn of the med meniscus and apply a gentle valgus load on the lower leg to open medial compartment. Mark externally the spot for the medial portal with finger on skin or with a needle.
1. Insert the blunt trocar through the antero-lateral portal to the patello femoral pouch. Attach 30° arthroscope and look through suprapatellar pouch by rotating the scope 180° back and forward and scan the area.
2. Pull back gently scope overlooking patellofemoral joint on the extended knee from lateral and from medial side. If you drain the joint you can examine the patellofemoral joint stability better.
3. Reopen water supply and return to suprapatellar pouch. Follow capsular fold medial through the medial gutter to overlook the synovium and the medial femoral condyle.
4. Note the anterior horn of the med meniscus and apply a gentle valgus load on the lower leg to open medial compartment. Mark externally the spot for the medial portal with finger on skin or with a needle.
Routine travel 1 3 8 2 9 10 5 4 7 6

10. Routine travel
5. Rotate the scope looking centrally while flexing the knee to 90° examining the anterior cruciate from distally to proximally carefully probing the femoral attachment site. Next rotate the scope more medial to check the posterior cruciate often covered with synovium.
6. Rotate the scope looking laterally while applying a light varus stress to the slightly flexed knee – thereby overlooking and probing anterior horn of the lateral meniscus. Go to the ”figure of 4” position while keeping the scope parallel to tibial surface overlooking the middle third and posterior horn of meniscus.
7. Extend the knee and go directly to the lateral gutter, flex the knee and examíne the popliteus tendon and hiatus.
5. Rotate the scope looking centrally while flexing the knee to 90° examining the anterior cruciate from distally to proximally carefully probing the femoral attachment site. Next rotate the scope more medial to check the posterior cruciate often covered with synovium.
6. Rotate the scope looking laterally while applying a light varus stress to the slightly flexed knee – thereby overlooking and probing anterior horn of the lateral meniscus. Go to the ”figure of 4” position while keeping the scope parallel to tibial surface overlooking the middle third and posterior horn of meniscus.
7. Extend the knee and go directly to the lateral gutter, flex the knee and examíne the popliteus tendon and hiatus.
5. Rotate the scope looking centrally while flexing the knee to 90° examining the anterior cruciate from distally to proximally carefully probing the femoral attachment site. Next rotate the scope more medial to check the posterior cruciate often covered with synovium.
6. Rotate the scope looking laterally while applying a light varus stress to the slightly flexed knee – thereby overlooking and probing anterior horn of the lateral meniscus. Go to the ”figure of 4” position while keeping the scope parallel to tibial surface overlooking the middle third and posterior horn of meniscus.
7. Extend the knee and go directly to the lateral gutter, flex the knee and examíne the popliteus tendon and hiatus. 1 3 8 2 9 10 5 4 7 6

11. Routine travel
8. Return to the ”figure of 4” position guiding the movement with the scope centrally in the notch looking laterally. Rotate the scope while probing the lateral meniscus. Note popliteus tendon above and below the meniscus runnning though the popliteus hole.
9. While in the ”figure of 4” position mark the triangular shape given from lateral femoral condyle, tibial plateau and anterior cruciate. Looking parallel to the tibial plateau pass gentle the scope through the triangle to the posterior cavity. Check posterior horn of lateral meniscus, posterior cavity by rotating the the scope 360°. Retract the scope while overlooking the posterior cruciate and the proximal part of the anterior cruciate.
8. Return to the ”figure of 4” position guiding the movement with the scope centrally in the notch looking laterally. Rotate the scope while probing the lateral meniscus. Note popliteus tendon above and below the meniscus runnning though the popliteus hole.
9. While in the ”figure of 4” position mark the triangular shape given from lateral femoral condyle, tibial plateau and anterior cruciate. Looking parallel to the tibial plateau pass gentle the scope through the triangle to the posterior cavity. Check posterior horn of lateral meniscus, posterior cavity by rotating the the scope 360°. Retract the scope while overlooking the posterior cruciate and the proximal part of the anterior cruciate. 1 3 8 2 9 10 5 4 7 6

12. 10. Put the knee 90 degrees of flexion
10. Put the knee 90 degrees of flexion. There will then be a triangle given from the medial femoral condyle, tibialplateau and the anterior cruciate ligament. Looking parallel to the tibial plateau pass gently the scope through the triangle to the posterior cavity. Sometimes you need to push the cruciate ligaments laterally and rotate the scope smoothly to pass this area. Check the posterior horn of the medial meniscus, posterior cavity by rotating the scope 360 degrees. Retract the scope while overlooking the posterior cruciate.
Routine travel 1 3 8 2 9 10 5 4 7 6

13. Supra patellar pouch 1 7 3 8 10 2 9 5 4 6
Superior view of supra patellar pouch; 30° arthroscope

14. Supra patellar pouch
Vastus lateralis of the quadriceps muscle 1 7 3 8 10 2 9 5 4 6
Superior view of supra patellar pouch; 30° arthroscope

15. Patello femoral joint Femoral condyle lateral view; 30° arthroscope2 4 6 8 7 9 1 5 10
Femoral condyle lateral view; 30° arthroscope

16. Patello femoral joint Patello femoral joint
Femoral trochlea 3 2 4 6 8 7 9 1 5 10
Femoral trochlea lateral view; 30° arthroscope

17. Patello femoral joint
Patella 3 2 4 6 8 7 9 1 5
Femoral trochlea 10
Patello femoral joint proximal lateral view; 30° arthroscope

18. Medial gutter Medial view of medial gutter; 30° arthroscope Patella2 4 6 8 7 9 1 5
Medial femoral condyle 10
Gutter
Medial view of medial gutter; 30° arthroscope

19. Medial gutter Medial distal view of medial gutter; 30° arthroscope
Medial femoral condyle 3 2 4 6 8 7 9 1 5
Gutter 10
Medial distal view of medial gutter; 30° arthroscope

20. Medial compartment
Medial femoral condyle
Medial meniscus
Knife in a-m portal
Tibial plateau 3 2 4 6 8 7 9 1 5 10
Distal view of medial meniscus anterior horn, knife producing a-m portal; 30° arthroscope

21. Medial compartment
Medial femoral condyle
Tibial plateau 3 2 4 6 8 7 9 1 5
Medial meniscus 10
Distal view of medial meniscus anterior horn, probe through ant-med portal; 30° arthroscope

22. Medial compartment
Medial femoral condyle
Medial meniscus, undersurface
Tibial plateau 3 2 4 6 8 7 9 1 5 10
Antero medial view of medial meniscus anterior horn underside, probe through ant-med portal; 30° arthroscope

23. Medial compartment
Medial femoral condyle
Medial meniscus
Tibial plateau 3 2 4 6 8 7 9 1 5 10
Medial view of medial meniscus central third; 30° arthroscope

24. Medial compartment
Medial femoral condyle
Medial meniscus 3 2 4 6 8 7 9 1 5
Tibial plateau 10
Medial view of medial meniscus central third, probe through anteromedial portal; 30° arthroscope

25. Medial compartment
Medial femoral condyle
Medial meniscus 3 2 4 6 8 7 9 1 5
Tibial plateau 10
Posteromedial view of medial meniscus posterior horn; 30° arthroscope

26. Medial compartment
Medial femoral condyle
Medial meniscus
Tibial plateau 3 2 4 6 8 7 9 1 5 10
Posteromedial view of medial meniscus posterior horn, tested with a probe; 30° arthroscope,

27. Medial compartment
Medial femoral condyle 3 2 4 6 8 7 9 1 5 10
Inferomedial view of anterior part of joint, femoral condyles, trochlea and Hoffa’s fat; 30° arthroscope

28. Intercondylar notch
Lateral femoral condyle
Anterior cruciate 3 2 4 6 8 7 9 1 5 10
Inferior view of distal tibial attachment of anterior cruciate ligament, knee near extension; 30° arthroscope

29. Intercondylar notch
Posterior cruciate
Lateral femoral condyle
Anterior cruciate 3 2 4 6 8 7 9 1 5 10
Postero-central view of distal tibial attachment of anterior cruciate ligament, knee flexed 80°; 30° arthroscope

30. Intercondylar notch
Lateral femoral condyle
Anterior cruciate 3 2 4 6 8 7 9 1 5 10
Postero-central view of proximal femoral attachment of anterior cruciate ligament; 30° arthroscope

31. Intercondylar notch
Posterior cruciate 3 2 4 6 8 7 9 1 5
Anterior cruciate 10
Postero-central view of posterior cruciate, knee flexed 80°, PCL covered with synovium; 30° arthroscope

32. Intercondylar notch
Posterior cruciate
Medial femoral condyle 3 2 4 6 8 7 9 1 5
Anterior cruciate 10
Postero-central view of posterior cruciate, knee flexed 80°, PCL release from synovium; 30° arthroscope

33. Lateral compartment
Lateral meniscus 3 2 4 6 8 7 9 1 5 10
Anterior view of lateral meniscus anterior horn; 30° arthroscope

34. Lateral compartment
Lateral femoral condyle
Popliteus
tendon
Lateral meniscus 3 2 4 6 8 7 9 1 5 10
Antero-lateral view of lateral meniscus; 30° arthroscope

35. Lateral compartment
Lateral femoral condyle 3 2 4 6 8 7 9 1 5 10
Lateral meniscus
Antero-lateral view of lateral femoral condyle; 30° arthroscope

36. Lateral compartment
Lateral femoral condyle
Popliteus tendon
Lateral meniscus 3 2 4 6 8 7 9 1 5 10
Postero-lateral view of posterior horn of lateral meniscus and popliteus hole; 30° arthroscope

37. Lateral gutter Lateral view on lateral gutter; 30° arthroscope2 4 6 8 7 9 1 5 10
Lateral view on lateral gutter; 30° arthroscope

38. Lateral gutter Lateral view on lateral gutter; 30° arthroscope
Popliteus tendon 3 2 4 6 8 7 9 1 5
Lateral femoral condyle
Lateral meniscus 10
Lateral view on lateral gutter; 30° arthroscope

39. Lateral gutter Lateral view on lateral gutter; 30° arthroscope
Popliteus tendon
Popliteus hole 3 2 4 6 8 7 9 1 5 10
Lateral meniscus
Lateral view on lateral gutter; 30° arthroscope

40. Posterior compartment
Medial femoral condyle 3 2 4 6 8 7 9 1 5
Posterior horn
Medial meniscus 10
Medial view, scope along posterior cruciate to posteromedial pouch; 30° arthroscope

41. Variation of normal Medial view of the medial plica; 30° arthroscope
Medial femoral condyle
Patella 3 2 4 6 8 7 9 1 5
Medial femoral
condyle 10
Plica

42. Variation of normal
Posterolateral view of the anterior plica, ligamentum Mucosum; 30° arthroscope
Medial femoral condyle
Plica
Anterior
cruciate 3 2 4 6 8 7 9 1 5 10

43. Variation of normal
Lateral femoral condyle 3 2 4 6 8 7 9 1 5
Discoid lateral meniscus 10
Postero lateral view of a discoid meniscus (this on 80% discoid); 30° arthroscope

44. Take home points
Always mark the involved side and relevant anatomical structures.
Never use sharp trocars, always bluntly instruments.
Prior to surgery pressure the tourniquet at 350 mmHg on the involved upper leg, use gravity, pressure saline bags or arthroscopic pumps for irrigation.
Always perform an examination of the knee including stability testing prior to arthroscopy.
Start the arthroscopy with applying the antero-lateral portal and insert the scope along the lateral edge of the patella with the knee in extension and while lifting the patella.
Apply the following portals guided by the arthroscopic view, using a needle if convenient.
Always perform the arthroscopic evaluation of all parts of the knee before performing any arthroscopic surgery.
Always use a probe to examine menisci, joint cartilage and ligements while overlooking the different structures.

45. Questionnaire What is the importance of the antero-lateral portal
Explain how to identify the antero-medial portal
Which subcutaneous nerve is at risk applying the antero-medial portal
Which anatomical structures are the landmarks when applying the postero-medial portal
What intraarticular structure should not be mistanken for the anterior cruciate ligament