PORTALS IN ARTHROSCOPY

Dr.D.Raj kishorePG in Orthopaedics

Gandhi medical college

KNEE ARTHROSCOPY

oMeniscal repair or resection oDiagnostic surgeryoRemoval of loose bodiesoACL and PCL reconstructionoSynovial biopsy or synovectomyoChondral defect repair, including microfractureoOsteochondritis dissecans treatmentoKnee debridement for osteoarthritis

controversial whether or not it provides symptomatic relief

INDICATIONS

Patient placed supine with ability to flex the knee◦ leg holder or post 

has benefit of allowing valgus stress but makes figure-four position more difficult

Place tourniquet Make anterolateral incision over soft spot of knee

◦ vertical incisions have advantage of increased superior-inferior mobility of instruments

◦ horizontal incisions have advantage of increased medial-lateral mobility of instruments

Insert trochar into capsule◦ advance blade into capsule then follow with trochar.◦ do with knee flexed

Advance trochar into suprapatellar pouch◦ with knee straightened

POSITION & SCOPE INSERTION

Primary portals Anterolateral 

◦ function standard portal  used as the primary viewing portal

◦ location & technique make with knee in flexion, adjacent to

patellar tendon over soft spot on joint line

Anteromedial◦ function

standard portal used as the primary instrumentation

portal◦ location & technique

make with knee in flexion, adjacent to patellar tendon over soft spot on joint line

Superomedial

◦ function accessory portal most commonly used for water in/out flow

◦ location & technique make with knee in extension

Superolateral◦ function

accessory portal  most commonly used for water in/out flow

◦ location & technique make with knee in extension most common site for aspiration or injection 

Posteromedial portal 

◦ function helps visualize posterior horn and PCL

◦ location & technique 1 cm above joint line behind the MCL

Posterolateral portal

◦ function helps visualize posterior horn and PCL

◦ location & technique 1 cm above joint line between LCL and biceps tendon

Transpatellar portal

◦ function used for central viewing or grabbing

◦ location & technique 1 cm distal to patella and splits the patellar tendon do not use if performing a bone-patella-bone graft harvest

Secondary portals

Proximal superomedial portal

◦ function used for anterior compartment visualization

◦ location & technique 4 cm proximal to patella

Far medial and far lateral portalso function• used for accessory instrument placement• often helpful for loose body removal

o location & technique• place where can be best utilized for need

Iatrogenic articular cartilage damage◦ is most common complication

Hemarthrosis Neurovascular injury

◦ posteromedial portal saphenous nerve

◦ posterolateral portal common peroneal nerve

COMPLICATIONS

SHOULDER ARTHROSCOPY

Diagnostic surgery Loose body removal Rotator cuff repair or debridement Labral/SLAP and instability repair Subacromial decompression AC joint pathology Distal clavicle resection Release of suprascapular nerve entrapment Release of scar tissue/contractures Synovectomy Biceps tenotomy/tenodesis

INDICATIONS

POSITION Beach chair 

◦ advantage of ability to also do deltopectoral approach to shoulder

◦ reduces venous pressure and bleeding

Lateral decubitus ◦ advantage of joint

distraction can be associated with

neuropraxias from traction

General Needs: • Viewing portal/s • Working portal/s • Anchor placement/suture portals Isolate suture : to be tied or passed in

working portals

Anchor placement/Suture portals may not need a cannula

Posterior portal◦ function

primary viewing portal used for diagnostic arthroscopy◦ location and technique

located 2 cm inferior and 1 cm medial to posterolateral corner of acromion

portal may pass between infraspinatus (suprascapular nerve) and teres minor (axillary nerve) or pass through the substance of infraspinatus

this is usually the first portal placed direct anteriorly towards tip of coracoid

PRIMARY PORTALS(work horse portals)

Anterior portal◦ function

viewing and subacromial decompression

◦ location & technique lateral to coracoid process and anterior to AC joint portal passes between pectoralis major (medial and

lateral pectoral nerves) and deltoid (axillary nerve)◦ this portal is usually placed under direct

supervision from the posterior portal with aid of spinal needle

Lateral portal◦ function

subacromial decompression◦ location & technique

located 1-2 cm distal to lateral edge of acromium portal passes through deltoid (axillary nerve)

• midglenoid portal - Bankart repair • anteroinferior portal (5:00)- low anchor

placement • Neviaser portal - RTC repair • port of Wilmington – posterior SLAP • posteroinferior portal (7:00) - posterior

Bankart

Accessory Portals

Anteroinferior (5 o'clock) portal◦ function

placement of anchors in anterior labral repair

◦ location & technique located slightly inferior to coracoid this portal is usually placed under direct supervision from the posterior

portal with aid of spinal needle

Posteroinferior (7 o'clock) portal

◦ function placement of anchors for posterior labral repair

◦ location & technique this portal is usually placed under direct supervision from the posterior

portal with aid of spinal needle

Anterior Midglenoid Portal • made at the leading edge of the subscapularis • working portal for anchor placement

Neviaser (supraspinatus) portal

◦ function anterior glenoid visualization and RTC repair

◦ location & technique

located just medial to lateral acromion goes through supraspinatus muscle (suprascapular nerve) The modified Neviaser portal is located in the supraspinatus

fossa(passes thru trapezius from medial to lateral) slightly more medial to avoid injury to the suprascapular nerve and for easier passage of instruments through the rotator cuff from medial to lateral.

Port of Wilmington (anterolateral) portal

◦ function Used to evaluate/repair posterior SLAP and RTC lesions

◦ location & technique just anterior to posterolateral corner of acromion one cm lateral and one cm anterior to posterior lateral corner of acromion this portal is usually placed under direct supervision from the posterior portal

with aid of spinal needle

Posterior viewing portal (red) is first portal created, placed 2 cm inferior and 1 cm medial to posterolateral aspect of acromion.

Anterior working portal (yellow) is placed just lateral to coracoid process to allow insertion of cannula into rotator interval space. Used primarily for work in subacromial space

lateral portal (green) is placed 2 cm distal to lateral margin of acromion in line with posterior aspect of acromioclavicular joint.

Accessory portals that may be used depending on pathologic entity being treated include :

anteroinferior (5-o’clock) portal (orange),

posteroinferior (7-o’clock) portal (blue),

“Neviaser portal” (purple) “portal of Wilmington” (black).

Standard Posterior Portal • viewing portal Anterior Superior Portal Anterior Midglenoid Portal Port of Wilmington • posterior SLAP tear

Portals for SLAP Repair

Standard Posterior Portal • working portal Anterior Superior Portal • viewing portal Anterior Midglenoid Portal • working portal for anchor placement

Portals for Bankart Repair

Standard Posterior Portal Anterior Superior Portal • viewing portal • working portal

The arthroscopic cannula is inserted into the posterior portal, underneath the acromion. A switching stick is then placed through the cannula and out the anterior superior portal. A second cannula is then placed anteriorly and the assistant hold both cannulas end to end.

The arthroscope is then placed posteriorly and the

arthroscopic shaver is placed anteriorly, at the tip of the arthroscope. Careful debridement is then performed of the

bursa to create a “room with a view.”

Portals for the Subacromial Space

Standard Posterior Portal • viewing portal Anterior Superior Portal • working portal near the AC joint Lateral Portal • working portal and viewing portal • 50 yard line • acromioplasty and rotator cuff repair Accessory Portals for Rotator Cuff Repair 1] Postero-lateral Viewing Portal • especially useful to visualize anterior cuff tears 2] Portal of Wilmington 3] Naviaser portal

Portals for Rotator Cuff Repair

Posterior portal◦ axillary nerve 

leaves axilla through quadrangular space and winds around humerus on deep surface of the deltoid muscle and passes ~ 7 cm below tip of acromoium

at risk if the posterior portal is made too inferior◦ suprascapular nerve

runs through supraspinatus fossa and infraspinatus fossa before innervating both of these muscles.

at risk if the posterior portal is made too medial 

COMPLICATIONS

Anterior portal◦ cephalic vein

runs in deltopectoral groove & at risk if portal is too lateral

◦ musculocutaneous nerve enters muscles 2-8 cm distal to tip of coracoid at risk if anterior portal is made too inferior

Anesthesia◦ phrenic nerve

with intrascalence block (anesthesia) 

ANKLE ARTHROSCOPY

osteochondral lesions of the talus debridement of post-traumatic synovitis ATFL anterolateral impingement AITFL anterolateral impingement resection of anterior tibiotalar spurs

◦ such as anterior bony impingement os trigonum excision removal of loose bodies cartilage debridement in conjunction with

ankle fusions

INDICATIONS

Position◦ patient placed supine  ◦ leg over well padded bolster

Tourniquet◦ place tourniquet and exsanguinate limb

Joint distention◦ external traction device applied to distract tibiotalar

joint ◦ can load joint with saline to distend joint 

Scope insertion◦ nick and spread method commonly utilized to access

joint and minimize neurovascular injury

POSITION& SCOPE INSERTION

PORTALS Anteromedial 

◦ function primary viewing portal typically established first access to anteromedial joint

◦ location and technique medial to tibialis anterior

and lateral to medial malleolus

make portal between tibialis anterior and saphenous vein

Anterolateral◦ function

primary viewing portal access to anterolateral joint

◦ location and technique located just lateral to

peroneus tertius and superficial peroneal nerve and medial to lateral malleolus

can trace out superficial peroneal nerve prior to incision

Anterocentral◦ function

anterior viewing portal◦ location and technique

not commonly utilized due to danger to dorsal pedis artery

medial to extensor digitorum communis and lateral to EHL

Posterolateral◦ function

posterior viewing portal for access to os trigonum◦ location and technique

located 2cm proximal to tip of lateral malleolus medial to peroneal tendons and lateral to achilles

tendon Posteromedial

◦ function posterior viewing portal for access to os trigonum

◦ location and technique just medial to achilles tendon

Synovial cutaneous fistula◦ avoid by immobilization to allow portal skin healing and closure

Neurovascular injury from portal placement◦ Most common overall complication◦ Anterolateral portal

risks superficial peroneal nerve    most common neurovascular injury specifically, the dorsal intermediate cutaneous branch

◦ Anteromedial portal risks saphenous nerve and vein

◦ Anterocentral portal risks dorsalis pedis artery

◦ Posterolateral portal risks sural nerve and small saphenous vein

◦ Posteromedial portal risks posterior tibial artery

COMPLICATIONS

ELBOW ARTHROSCOPY

loose body removal  osteophyte debridement synovectomy capsular releases for stiffness osteochondritis dissecans of capitellum lateral epicondylitis

INDICATIONS

Patient position may be◦ supine  ◦ prone  ◦ lateral decubitus 

Anesthesia◦ general anesthesia (allows muscle relaxation and

placement of patient in prone or lateral decubitus position)

◦ regional anesthesia may be used but it does not allow for immediate evaluation of nerve function after surgery and patients may not tolerate uncomfortable position

POSITION

Portal placement technique◦ fully distend joint through lateral soft spot before

placing portals capsule distension moves NV structures away from the

joint when trocar is introduced◦ careful "nick and spread" technique using

hemostat ◦ posterior medial portal usually avoided due to

proximity to ulnar nerve   Elbow position

◦ establish anterior portals with elbow flexed 90deg◦ establish posterior portals in some extension

PORTAL & SCOPE INSERTION

PORTALS Proximal anterolateral• 2cm proximal, 1cm anterior

to lateral epicondyle• Nerve at risk :  Radial n.  Distal anterolateral• 1 cm anterior and 1-3cm

distal to lateral epicondyle• 1st portal for supine

position• See radial head, medial side

of elbow, coronoid, trochlea, brachialis insertion, coronoid fossa

• Nerve at risk: Radial and lateral antebrachial cutaneous

Direct lateral (or midlateral)• "soft spot" portal (in triangle formed by

olecranon, radial head, epicondyle)• Initial site for joint distension before scope

is inserted, viewing posterior compartment (capitellum, radial head, radioulnar articulation)

• relatively safe• Nerve at risk : lateral antebrachial

cutaneous nerve

 Anteromedial •  2 cm anterior and 2cm distal to medial

epicondyle.•  Place under direct visualization.• Nerve at risk :medial antebrachial

cutaneous and median

 Proximal medial (or superomedial)• 2cm proximal to medial epicondyle,

anterior to intermuscular septum• viewing entire anterior compartment,

radial head, capitellum, coronoid, trochlea• Nerve at risk : ulnar and median 

Straight posterior (transtriceps)• 3cm proximal to olecranon, triceps

midline (musculotend. junction)• Elbow partially extended, good for

removing impinging olecranon osteophytes and loose bodies from posteromedial compartment

• posterior antebrachial cutaneous , ulnar nerve

Posterolateral• 2-3 cm proximal to olecranon and just

lateral to triceps• center of anconeus triangle• Elbow 20-30deg flexion (to relax

triceps)• Best access to posterior

compartment, radiocapitellar joint (debridement of OCD capitellum), olecranon fossa and posterior structures

• posterior antebrachial cutaneous , medial brachial cutaneous, ulnar 

Nerve palsy (1-5%)◦ greatest risks for nerve palsy

underlying rheumatoid arthritis elbow contracture

◦ nerves transient ulnar nerve palsy (most common)   radial nerve palsy (second most common)

◦ mechanism direct injury

trocars and instrumentation failure to use blunt dissection (neuromas)

indirect injury compartment syndrome (aggressive distension, fluid extravasation) local anesthesia extravasation (transient)

COMPLICATIONS

Joint ankylosis/ heterotopic ossification◦ less than open surgery◦ minimize bleeding

Infection◦ sinus tract formation (posterolateral portal)

COMPLICATIONS(CONTD…)

HIP ARTHROSCOPY

Technically difficult because of deep location of hip joint Lower morbidity than open arthrotomy with easier post-

operative course Indications

◦ FAI◦ labral tears◦ AVN (diagnosis and staging)◦ loose bodies◦ synovial disease◦ chondral injuries◦ ligamentum teres injuries◦ snapping hip◦ mechanical symptoms◦ impinging osteophytes

INDICATIONS

Position ◦ may be done supine or in lateral decubitus position

Joint distension◦ can load joint with saline to distend joint

typically done under flouroscopic guidance◦ requires traction in line with the femoral neck

well padded perineal post ~50 pounds of traction

Scope insertion◦ anterolateral scope placed first

arthroscope insertion over guidewire◦ anterior portal placed second

then placed under fluoroscopic guidance with the hip flexed and in internal rotation

◦ posterior portal placed last

POSITIONING & SCOPE INSERTION

PORTALS Anterolateral portal 

◦ function primary viewing portal anterolateral hip joint access

◦ location and technique located 2 cm anterior and 2 cm

superior to anterosuperior border of greater trochanter

typically established first under fluoroscopic guidance

Posterolateral portal◦ function

posterior hip joint access◦ location and technique

located 2 cm posterior to the tip of the greater trochanter

Anterior portal◦ function

anterior hip joint access◦ location and technique

located at intersection between superior ridge of greater

trochanter & ASIS flexion and internal

rotation of hip loosens capsule and assists scope insertion

Distal anterolateral portal◦ function

provides access to the peripheral compartment in the region of the femoral neck

◦ location and technique used in conjunction with the anterolateral portal to visualize the

peripheral compartment traction is removed and the hip is placed in either neutral flexion and

extension or in 45 degrees of flexion to relax the anterior capsule fluoroscopy and direct arthroscopic visualization is used to guide

portal placement portal is established 3 to 5 cm distal to the anterolateral portal, just

anterior to the lateral aspect of the proximal femoral shaft and neck◦ structures visualized within the peripheral compartment

femoral head labrum zona orbicularis   

provides a landmark for the iliopsoas tendon  medial synovial fold femoral neck peripheral capsular attachments

Direct injuries◦ can occur from scope or cannula placement◦ most commonly reported complication

chondral injuries Neurovascular injury

◦ traction related pudendal nerve injury

most common neurovascular complication due to traction post in groin for traction neuropraxia or compression injury 

peroneal nerve injury traction neuropraxia

may prevent traction injuries with intermittent release of traction adequate anesthesia

COMPLICATIONS

anterolateral portal◦ risks superior gluteal nerve

posterolateral portal◦ risks sciatic nerve

increased risk with external rotation of hip  anterior portal

◦ risks lateral femoral cutaneous nerve injury ◦ risks femoral neurovascular bundle◦ risks ascending branch of lateral femoral

circumflex artery

COMPLICATIONS (CONTD..)

WRIST ARTHROSCOPY

TFCC injuries  interosseous ligament injuries anatomic reduction assistance (distal radius, scaphoid

fxs) ulnocarpal impaction debridement of chondral lesions removal of loose bodies synovectomy excision of dorsal wrist ganglia assistance in treatment of SNAC and or SLAC wrist septic wrist irrigation and debridement diagnosis in unexplained mechanical wrist pain

INDICATIONS

Patient Position◦ supine, elbow flexed to 90°◦ traction tower with 10lb traction to fingers

Landmarks◦ Lister's tubercle◦ Scaphoid, Lunate◦ DRUJ◦ ECU

Scope insertion◦ 2.7mm, 30° arthroscope is most common

POSITION & SCOPE INSERTION

Portals named for relation to extensor wrist compartments 

Created with sharp skin incision followed by hemostat dissection

PORTALS

RADIO-CARPAL PORTALS 3-4 Located just distal to Lister tubercle, between EPL

and EDC;  Established first, primary viewing portal At risk : EPL and EDC tendons 4-5 Located in line with ring finger metacarpal, between

EDC and EDM; Portal for instrumentation, visualization of TFCC At risk : EDC and EDM tendons 6R Located just radial to ECU tendon; Primary adjunct for visualization and

instrumentation, ulnar-sided TFCC repairs At risk : Dorsal sensory branch of ulnar nerve 6U Located just ulnar to ECU tendon; Primary adjuct for visualization and

instrumentation, ulnar-sided TFCC repairs At risk : Dorsal sensory branch of ulnar nerve 1-2  Located between APL and ECRB, along dorsal

aspect of snuffbox;  Not often utilized, provides access to radial styloid

and radial aspect of joint, sometimes used for inflow At risk : Superficial branch of radial nerve; Radial

artery

MID-CARPAL PORTALS MCR Located 1 cm distal to 3-4 portal along

axis of radial border of middle finger metacarpal, between ECRB and EDC.

Allows visualization of scapholunate, scaphocapitate, and scaphotrapezoid joints.

ECRB and EDC tendons MCU Located 1 cm distal to 4-5 portal along

axis of ring finger metacarpal, between EDC and EDM.

Allows visualization of lunocapitate, lunotriquetral, and triquetrohamate joints.

EDC and EDM tendons STT Located along axis of index finger

metacarpal just ulnar to EPL at level of STT joint.

Allows visualization of scaphotrapezial and scaphotrapezoid joints.

ECRB and ECRL tendons

1U Located on ulnar aspect of EPL at level of first CMC

joint (basal joint). Allows diagnosis of DJD of first CMC joint and

arthroscopic debridement. Superficial sensory branch of radial nerve 1R Located on radial aspect of EPL at level of thumb

CMC joint, just volar to APL tendon. Allows diagnosis of DJD of first CMC joint and

arthroscopic debridement. Superficial sensory branch of radial nerve

FIRST CMC PORTALS

Incidence◦ overall complication rate is 1-2%

Dorsal sensory branch of ulnar nerve◦ averages 8mm from 6R portal◦ at risk with establishment of 6U and 6R portals

to a lesser extent main ulnar nerve and artery also at risk◦ when performing a TFCC repair, small open incision is typically

made prior to knot tying to prevent injury to this nerve. Superficial sensory branch of radial nerve

◦ averages 16mm from 3-4 portal◦ at risk during arthroscopy of basal joint, as 1U and 1R portals

are on either side of the first branch of this nerve◦ at risk during placement of 1-2 portal 

COMPLICATIONS

Radial artery Injury◦ associated with establishment 1-2 portal, used for

arthroscopic radial styloidectomy. Extensor tendon injury

◦ most commonly EPL and EDM due to improper portal placement

Chondral injuries◦ iatrogenic from scope or instrument placement

Portal site infection Stiffness MCPJ pain

◦ typically caused by over-distraction

COMPLICATIONS(CONTD..)

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