Basic Knee Arthroscopy Part 3: Diagnostic Arthroscopy

Benjamin D. Ward, M.D., and James H. Lubowitz, M.D.

Abstract: Knee arthroscopy is an important diagnostic and therapeutic tool in the management of disorders of the knee.
In a series of 4 articles, the basics of knee arthroscopy are reviewed. In this article (part 3), step-by-step diagnostic
arthroscopy is reviewed. Diagnostic arthroscopy is a crucial skill for diagnosing intra-articular disorders of the knee
including meniscal, synovial, ligamentous, and articular cartilage pathology. Mastery of the basic diagnostic arthroscopy is
a critical tool for orthopaedic surgeons treating disorders of the knee.

K nee arthroscopy is the most commonly performed

orthopaedic procedure. Indications include diag-
nostic arthroscopy, meniscectomy, loose body removal,
arthroscope is placed into the suprapatellar pouch
through the anterolateral portal. The light cord is rotated
downward to look up at the patella, and then the light
chondroplasty, microfracture, irrigation and debride- cord is raised to look down at the trochlear groove to
ment, and ligament reconstruction. In this series of evaluate for cartilage injury (Fig 1). The arthroscope is
articles, we present a comprehensive review of the step- then moved medially into the medial gutter, and the
by-step surgical technique for basic knee arthroscopy.1,2 hand is raised to follow the floor down to the tibia,
Diagnostic arthroscopy involves visualization of all the checking for loose bodies. Next, the medial compartment
intra-articular structures of the knee. A standardized and is opened by straightening the knee and placing a valgus
step-by-step approach is presented in this article and force on the leg. The arthroscope is brought into the
Video 1. A complete diagnostic arthroscopy includes medial compartment. At this point, the anteromedial
visualization of the suprapatellar pouch, medial gutter, compartment is made, which will be covered in part 4 of
lateral gutter, medial compartment, lateral compart- this series. The medial meniscus is inspected and probed
ment, intercondylar notch, and posterior medial and for tears. The cartilage on the tibial plateau and the
posterior lateral compartments. Diagnostic arthroscopy is medial femoral condyle are evaluated (Fig 2). The knee
a crucial skill for diagnosing intra-articular disorders of flexion angle can be changed to inspect the entire
the knee including meniscal, synovial, ligamentous, and weight-bearing portion of the medial femoral condyle.
articular cartilage pathology. Mastery of basic diagnostic The knee is then bent to 90 , and the arthroscope is
arthroscopy is a critical tool for orthopaedic surgeons brought into the intercondylar notch to examine the
treating disorders of the knee.3 anterior cruciate ligament and posterior cruciate liga-
ment and to check for loose bodies (Fig 3). The ligaments
Surgical Technique can be probed to check for integrity. To enter the lateral
In this article basic diagnostic knee arthroscopy is compartment, a triangle between the lateral meniscus,
reviewed in a step-by-step manner (Table 1). The the lateral femur, and the anterior cruciate ligament is
From Taos Orthopaedic Institute, Taos, New Mexico, U.S.A.
identified. The light cord is turned to look laterally, and
The authors report the following potential conflict of interest or source of the arthroscope is advanced into the triangle. A varus
funding: B.D.W. receives support from Arthrex Fellows Forum Travel and force is applied to the knee either using the figure-of-4
Hotel; J.H.L. receives support from SNE, Arthrex, Ivivi, AANA, law firms not position or directly using the circumferential leg holder.
related to orthopaedic industry (i.e., medical malpractice defense, ski industry Care is taken to keep the arthroscope in the triangle as
defense), Breg, Donjoy, Smith & Nephew, MTF, DCI, Taos Orthopaedic
Institute, Taos Center for Sportsmedicine and Rehabilitation, and Taos MRI.
the leg is manipulated. The lateral meniscus and articular
Received June 29, 2013; accepted July 25, 2013. cartilage are examined similarly to the medially
Address correspondence to James H. Lubowitz, M.D., Taos Orthopaedic compartment (Fig 4). The popliteal hiatus and popliteal
Institute, 1219-A Gusdorf Rd, Taos, NM 87571, U.S.A. E-mail: jlubowitz@ tendon are also evaluated. Next, the arthroscope is
kitcarson.net brought directly into the lateral gutter to check for
Ó 2013 by the Arthroscopy Association of North America. Open access
under CC BY-NC-ND license.
loose bodies. In a tight knee it may be necessary to go
2212-6287/13440 back to the suprapatellar pouch to enter the lateral
http://dx.doi.org/10.1016/j.eats.2013.07.012 gutter.

Arthroscopy Techniques, Vol 2, No 4 (November), 2013: pp e503-e505 e503

e504 B. D. WARD AND J. H. LUBOWITZ

Table 1. Step-by-Step Guide to Diagnostic Knee Arthroscopy

Step Location Common Pathology
1 Suprapatellar Loose bodies
pouch Plica
Patellar and trochlear chondromalacia
2 Lateral gutter Loose bodies
Femoral osteophytes
3 Medial gutter Loose bodies
Femoral osteophytes
4 Medial Medial meniscus tears
compartment Femoral and tibial chondromalacia
5 Intercondylar Loose bodies
notch Anterior and posterior cruciate ligament tears
Trochlear chondromalacia
6 Lateral Lateral meniscus tears
compartment Femoral and tibial chondromalacia
7 Posterior medial Loose bodies
compartment Medial meniscus posterior root tears
8 Posterior lateral Loose bodies
compartment Lateral meniscus posterior root tears

Fig 2. Arthroscopic view of the medial compartment of

a right knee from the anterolateral portal. An arthroscopic
The techniques for addressing the 2 posterior probe rests on top of the medial meniscus. Assessment of the
compartments of the knee are more advanced but medial compartment is step 4 of diagnostic arthroscopy. The
necessary to learn to perform a complete arthroscopy. medial femoral condyle (A) and medial tibial plateau (C) are
The standard technique is to turn off the water, remove assessed for chondromalacia, and the medial meniscus (B) is
the camera from the cannula, and place the blunt obtu- assessed for tears.
rator. The cannula is inserted into the lateral portal across
from the medial femoral condyle. The surgeon places
the camera is reinserted. The camera can then be pulled
a finger along the axis of the cannula to prevent plunging.
back a few millimeters to visualize the posterior femur
The cannula is then brought into the notch while hugging
and posterior root of the medial meniscus and to check for
the medial femoral condyle. The cannula is raised to
loose bodies. Typically, posterior medial visualization
match the slope of the tibia and inserted posteriorly while
staying between the medial femur and the posterior
cruciate ligament. Once in the posterior compartment,

Fig 3. Arthroscopic view of the intercondylar notch of a left

knee viewed from the anterolateral portal. The anterior
Fig 1. Arthroscopic view of the suprapatellar pouch of a right cruciate ligament (A) and posterior cruciate ligament (B), as
knee from the anterolateral portal. This is the first step in a step- well as the ligamentum mucosum, are assessed as step 5 of
by-step approach to diagnostic arthroscopy. The patella (A) and step-by-step diagnostic arthroscopy. The anterior cruciate
the trochlear groove (B) can be assessed for chondromalacia. ligament should be assessed for attachment to the lateral wall.
 DIAGNOSTIC ARTHROSCOPY e505

have a faster recovery. The portals are closed with

simple sutures, often using No. 3-0 nylon. Often, the
knee is injected with a local anesthetic and then a sterile
compressive dressing is applied.

Discussion
Knee arthroscopy is a valuable diagnostic and thera-
peutic procedure for the treatment of various knee
disorders. A thorough, standardized, and systematic
approach is critical for diagnostic arthroscopy to ensure
that no pathology is missed. A complete diagnostic
arthroscopy includes visualization of the suprapatellar
pouch, medial gutter, lateral gutter, medial compart-
ment, lateral compartment, intercondylar notch, and
posterior medial and posterior lateral compartments.
Diagnostic arthroscopy is a crucial skill for diagnosing
intra-articular disorders of the knee including meniscal,
synovial, ligamentous, and articular cartilage pathology.
Fig 4. Arthroscopic view of the lateral compartment of a right Mastery of basic diagnostic arthroscopy is a critical tool
knee viewed from the anterolateral portal. Assessment of the for orthopaedic surgeons treating disorders of the knee.
lateral compartment is step 6 of diagnostic arthroscopy. The
lateral femoral condyle (A) and lateral tibial plateau (C) are References
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