Knee:

Arthroscopic portals and

findings
Dr Shirish Shrestha
Ortho resident
KISTMCTH
 • INDICATIONS
• PATIENT POSITIONS
• STANDARD PORTALS
CONTENT
• DIAGNOSTIC
ARTHOSCOPY
FINDINGS
 INDICATIONS
• Diagnostic arthroscopy: corroborate MRI
• Meniscus repair and resection.
• ACL and PCL reconstruction.
• Chondral defect repair.
• Removal of loose bodies.
• Synovial biopsy.
Position
Instruments required
• Marker pen and scale
• Blade
• Long straight artery forceps
• Trocar
• Scope
Markings
 Incisions

Vertic Hori
al zontal
 Portals
STANDARD PORTALS OPTIONAL PORTALS
• Anterolateral • Posterolateral,
• Proximal mid patellar medial and
• Anteromedial lateral
• Accessory far medial and lateral
• Posteromedial
portals
• Superolateral • Central trans patellar tendon portals
 Standard portal:
Anterolateral

• Lateral soft spot

• Location:
1 cm above the lateral
joint line
1 cm lateral to the margin
of the patellar tendon
• Most of the structures within the knee joint can
be seen.

• Structure cant seen

• Posterior cruciate ligament,
• Anterior portion of the lateral meniscus, and,
• The periphery of the posterior horn of the medial
meniscus in tight knee
 Standard portal: Anterolateral
universal portal
• Free from any hindrance by the contralateral leg
• the long axis of the lateral condyle is oriented along the sagittal plane,
• medial condyle is usually about 22° to the sagittal plane.
 Portal placement
• Near the joint line: The anterior horn
of the lateral meniscus.
• Superiorly: Between the femoral and
tibial condyles prevents viewing of
the posterior horns of the menisci and
other posterior structures.
• Inferiorly: Decrease view due to fat
pad.
 • 1 cm above the medial joint line,
Anteromedial • 1 cm inferior to the tip of the patella,
Portal
• 1 cm medial to the edge of the patellar
tendon
• Percutaneous spinal needle
• Visualized from the anterolateral portal.
• No. 11 blade
• Cutting edge pointed away from meniscus.
 Working horse portal.

Anteromedial
Insertion of a instruments.
Portal

Additional viewing of the

lateral compartment.
 Posteromedial
Portal
• Location:
1 cm above the
posteromedial joint line
1 cm posterior to the
posteromedial margin of
the femoral condyle.
• Triangular soft spot
 Guidelines
Draw
Knee flexion Make portal
landmark
close to 90 after
before the joint
degrees distension
is distended
 Uses
• Repair or removal of displaced
posterior horn meniscal tears
• Removal of posterior loose
bodies
• PCL reconstructions.
 Superolateral
• Just lateral to the
quadriceps tendon
• 2.5 cm superior to the
superolateral corner of
the patella
 Uses
• View the patellofemoral joint
• Excision of medial plicae
• Evaluation of patellar tracking, congruity, its lateral
overhang
• Viewed from extension into varying degrees of
 Posterolateral
• The landmark: point of
intersection between lines
• posterior margin of the femoral
shaft
• posterior aspect of the fibula
 • Knee flexed 90 degrees,
• Maximally distended knee
Criteria

• Lateral meniscus horn

repair
Uses • Total synovectomies
• Loose body removal
 Proximal
Midpatellar Medial
and Lateral Portals.
• Just off the medial and lateral edges of
the midpatella
• Broadest portion of the patella.

• View
• Anterior compartment structures
• Lateral meniscocapsular structures
• Popliteus tunnel
 Accessory Far
Medial and
Lateral Portals

• 2.5 cm medial or lateral

to the standard
anteromedial and
anterolateral portals.
• Insert spinal needle
under vision
• Above superior
surface of meniscus
 Central Transpatellar
Tendon (Gillquist)
Portal.
• 1 cm inferior to the lower pole of
the patella in the midline through
the patellar tendon.

• knee in 90 degrees of flexion

High Portal: Practical Philosophy for Positioning Portals in Knee Arthroscopy
Sung-Jae Kim, M.D., and Hyon-Jeong Kim, M.D

• Richard Bach, “The gull sees farthest who flies highest” .

• First, the location of portals should flexibly suit the surgeon’s

need rather than a fixed location.
• Second, the higher a portal position is in knee arthroscopy, the
wider view it generally provides inside the joint.
Diagnostic Arthroscopy
 Suprapatellar pouch and patellofemoral joint

Medial gutter

Medial compartment
Diagnostic Intercondylar notch
arthroscopy Posteromedial compartment

Lateral compartment

Lateral gutter and posterolateral compartment

 Suprapatellar
pouch
• Examine from superior to
medial and superior and lateral

• Synovium: adhesion, plica,

losse bodies
Patelo femoral
compartment
• Under surface of patella
• Trochlea
• Patellofemoral tracking
• Osteochondral defect
Lateral gutter
• Entry : knee in full extension
• Relax the soft tissue on lateral
aspect

• Structure seen
• Meniscosynovial capsular reflection
• Popliteal tendon
• Posterior limits of popliteal hiatus
• Posterior surface of lateral femoral condyle
Medial gutter
• Runs medial and distal to
patella
• Origin; medial wall of
suprapatellar pouch and
inserting fat pad.
• Occasionally cause
patellofemoral symptoms
 Meniscus
examination:
medial
• Anterior, middle,
posterior.
• Visually and by probing
• Wrinkle along the length
and peripheral
Both sides
Chondral defect and Bucket handle
tear
 Intercondylar notch
• Infrapatellar fat pad
• Ligamnetum mucosum
• Medial and lateral tibial spine.
• Attachment of both meniscus
• ACL ,PCL
• Meniscofemoral ligaments
• Intermensical ligament.
 ACL
• Knee flexed to 60 to 90 degree.
• Rotate lens until medial aspect of
lateral femoral condyle is visualized.

• 10 o clock on right
• 2 o clock on left
MENISCOFEMORAL LIGAMENT
• HUMPRY ANTERIOR
TO WIESBERG
• ORIGIN: Adjcent to
PCL
• INSERTION : posterior
horn of lateral meniscus
PCL
 LATERAL COMPARTMENT
• Figure of 4 with knee in
varus.
• Tibial attachment of PCL.
Lateral meniscus and popliteal tendon
 References
• Ward, B. D., & Lubowitz, J. H. (2013). Basic knee arthroscopy part 2:
surface anatomy and portal placement. Arthroscopy techniques.
https://doi.org/10.1016/j.eats.2013.07.013
.•Solomon, L., Warwick, D., Nayagam, S., & Apley, A. G.
(2010). Apley's system of orthopedics and fractures (10th ed.).
• Campbell's Operative Orthopedics'. 14th ed. Philadelphia, PA:
Mosby/Elsevier.
Thank you