Basic Knee Arthroscopy Part 2: Surface Anatomy

and Portal Placement

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 2), surface anatomy and the
anterolateral and anteromedial portals are reviewed. Accurate portal placement is critical to both diagnostic and operative
arthroscopy. Mastery of the surface anatomy allows accurate and reproducible portal placement.

K nee arthroscopy is the most commonly performed

orthopaedic procedure. Indications include diag-
nostic arthroscopy, meniscectomy, loose body removal,
Surgical Technique
This article will review the relevant surface anatomy
as well as placement of the anterolateral and ante-
chondroplasty, microfracture, irrigation and debride- romedial portals (Fig 1). Beginning arthroscopists will
ment, and ligament reconstruction. In this series of arti- find it beneficial to mark out the surface anatomy as
cles, we present a comprehensive review of the complete a reference for portal placement. The palpable borders
surgical technique for basic knee arthroscopy.1,2 of the patella, tibial tubercle, and patellar tendon, the
Knee surface anatomy and portal placement are medial and lateral tibial joint line, and the head of the
reviewed in this article and Video 1. Accurate portal fibula are marked on the skin. Typically, the lateral joint
placement is critical to both diagnostic and operative line is slightly more superior than the medial joint line.
arthroscopy. Mastery of the surface anatomy allows The marks will give a reference for placement of the
accurate and reproducible portal placement. Proper arthroscopic portals. The anterolateral and antero-
placement of the anterolateral portal just superior to medial portals can be vertical or horizontal. Horizontal
the lateral meniscus and just lateral to the patellar portals are more cosmetic, but if they are placed too
tendon allows optimal visualization of the compart- high or too low, they may be difficult to correct, so the
ments of the knee and proper access for the operative beginning arthroscopist may prefer a vertical portal.
instruments. Proper placement of the anteromedial The superomedial portal is an optional portal typically
portal just superior to the medial meniscus but inferior used for fluid outflow. The anterolateral portal is placed
enough for instruments to reach the posterior horn of 1 cm above the joint line and just next to the patellar
the meniscus is also critical. tendon in a palpable soft spot. The anteromedial portal
is placed 1 cm above the joint line and 1 cm medial to
the patellar tendon, also in a palpable soft spot. The
placement of the anteromedial portal can be confirmed
From the Taos Orthopaedic Institute, Taos, New Mexico, U.S.A. with a spinal needle using the arthroscope.
The authors report the following potential conflict of interest or source of After marking, the portals are typically injected with
funding: B.D.W. receives support from Arthrex Fellows Forum Travel and a local anesthetic. A No. 15 or 11 blade with the blade
Hotel; J.H.L. receives support from SNE, Arthrex, Ivivi, AANA, law firms not facing away from the patellar tendon is used to make
related to the orthopaedic industry (i.e., medical malpractice defense, ski
a 4- to 5-mm portal. The skin and the joint capsule are
industry defense), Breg, Donjoy, Smith & Nephew, MTF, DCI, patents pending
with Arthrex not related to manuscript, Taos Orthopaedic Institute, Taos incised, with care taken not to damage the ligaments or
Center for Sportsmedicine and Rehabilitation, and Taos MRI. cartilage and to stay above the meniscus. The arthros-
Received June 29, 2013; accepted July 25, 2013. copic cannula with a blunt obturator is then brought
Address correspondence to James H. Lubowitz, M.D., Taos Orthopaedic into the field and held with the index finger along the
Institute, 1219-A Gusdorf Rd, Taos, NM 87571, U.S.A. E-mail: jlubowitz@
cannula. The cannula is inserted into the anterolateral
kitcarson.net
Ó 2013 by the Arthroscopy Association of North America portal at an angle parallel to the tibial plateau and
2212-6287/13439/$36.00 directed between the condyles. The cannula is then
http://dx.doi.org/10.1016/j.eats.2013.07.013 pushed into the intercondylar notch. This motion is

Arthroscopy Techniques, Vol 2, No 4 (November), 2013: pp e501-e502 e501

e502 B. D. WARD AND J. H. LUBOWITZ

Fig 2. Arthroscopic view, left knee, of medial compartment

Fig 1. Surface anatomy markings for a left knee: (A) patella, taken from the anterolateral portal. A spinal needle is used to
(B) patellar tendon, (C) tibial tubercle, (D) anteromedial determine the placement of the anteromedial portal. The
portal, (E) anterolateral portal, (F) fibular head, and (G) needle should enter the knee just superior to the medial
superior medial portal (optional portal for fluid outflow). meniscus and inferior enough to reach the posterior horn of
the medial meniscus.
repeated a few times to ensure that the cannula moves
freely through the portal and fat pad. Then, the cannula point, a beginning arthroscopist and even some ad-
is pulled back just enough to be outside of the inter- vanced arthroscopists will put a cannula into the portal.
condylar notch, the knee is straightened into full A hemostat can also be used to spread the portal to make
extension, and the cannula is advanced under the the passage of instruments easier.
patella into the suprapatellar pouch. The obturator is
removed, and the arthroscopic camera is locked into the Discussion
cannula. The fluid flow is then started, and the Knee arthroscopy is a valuable diagnostic and thera-
arthroscopic procedure is begun. Basic diagnostic and peutic procedure for the treatment of various knee
operative arthroscopy will be discussed in the subse- disorders. Precise placement of the anterolateral and
quent articles. anteromedial portals allows for full access to the
The anteromedial portal is the main working or compartments of the knee. A key point to remember in
instrumentation portal. The placement of this portal is marking the surface anatomy is that the lateral tibial
critical for effectively reaching the various intra-articular plateau is usually slightly superior to the medial tibial
structures with the arthroscopic instruments. It is rec- plateau. Marking the surface anatomy will facilitate
ommended to create this portal under direct vision using accurate placement of the portals. The anterolateral
the arthroscope. A spinal needle is inserted into the portal should be placed just superior to the lateral
medial compartment through the previously marked meniscus and close to the patellar tendon. The ante-
portal. The needle is held toward the tip so as not to romedial portal is the main working portal and there-
over-penetrate and damage the cartilage. The needle is fore should be placed under direct visualization to
inserted just above the meniscus. Under direct vision, ensure that the instruments will be able to reach the
the needle is advanced to touch the posterior horn of the posterior meniscus and other structures.
medial meniscus (Fig 2). If the entry angle is too high or
too vertical, the femur will prevent access to the poste-
References
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