A Colour Atlas of Traditional Meniscectomy [Reprint 2021 ed.] 9783112419946, 9783112419939

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Traditional Meniscectomy

Single Surgical Procedures A Colour Atlas of

Traditional Meniscectomy I.S.Smillie

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lñldlter de Gruyter • Berlin - New York 1984

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Ian S. Sraillie OBE, Ch. M, FRCS (Ed.), FRCS (Glas.); Sometime Professor of Orthopaedic Surgery, University of St. Andrews; Emeritus Professor of Orthopaedic Surgery, University of Dundee; President of the International Society of the Knee Copyright © Ian S. Smillie 1983 Original Publishers: Wolfe Medical Publications Ltd., • London Exclusive co-publishers for the Federal Republic of Germany and Austria: Walter de Gruyter & Co., Genthiner Strasse 13, D-1000 Berlin 30.1984. Printed by Royal Smeets Offset b.v., Weert, Netherlands Cover design: Rudolf Hiibler General Editor, Wolfe Surgical Atlases: William F. Walker, DSc, ChM, FRCS (Eng.), FRCS (Edin.), FRS (Edin.) CIP-Kurztitelaufnahme

derDeutschen

Bibliothek

Smillie, Ian S.: A colour atlas of traditional meniscectomy /1. S. Smillie. Berlin; New York: de Gruyter, 1984. (Single surgical procedures; 2) ISBN 3-11-010009-6 ISBN 3-11-010008-8 (Subskr.-Pr.) NE: G T

All r i g h t s r e s e r v e d . T h e c o n t e n t s o f t h i s b o o k , b o t h p h o t o g r a p h i c a n d t e x t u a l , m a y n o t b e r e p r o d u c e d in a n y f o r m by p r i n t , p h o t o p r i n t , p h o t o t r a n s p a r e n c y , m i c r o f i l m , m i c r o f i c h e o r a n y o t h e r m e a n s , n o r m a y it b e i n c l u d e d in a n y c o m p u t e r r e t r i e v a l s y s t e m , w i t h o u t w r i t t e n p e r m i s s i o n of the p u b l i s h e r D i e W i e d e r g a b e v o n G e b r a u c h s n a m e n , W a r e n b e z e i c h n u n g e n u n d d e r g l e i c h e n in d i e s e m Buch berechtigt nicht zu der A n n a h m e , d a ß solche N a m e n o h n e weiteres von j e d e r m a n n b e n u t z t w e r d e n d ü r f e n . V i e l m e h r h a n d e l t es s i c h h ä u f i g u m g e s e t z l i c h g e s c h ü t z t e , e i n g e t r a g e n e W a r e n z e i c h e n , a u c h w e n n sie nicht eigens als s o l c h e g e k e n n z e i c h n e t sind.

Contents Introduction Meniscotomes Draining the limb Position of surgeon Incision site Capsule division Defining meniscus Dealing with effusion Effect of tibial rotation Excising torn meniscus Cystic degeneration Rupture of lateral meniscus Termination of operation Exercise therapy Haemarthrosis Patellar plexus injury References Index

Page 7 9 13 16 18 21 24 27 30 33 40 41 44 47 51 56 59 61

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Introduction The operation of meniscectomy, the commonest performed in orthopaedic surgery, is one of simplicity or, alternatively, fraught with technical difficulties even in the most expert hands. All in all it appears to pose problems for the average surgeon. It is the operation I am asked to perform for visitors. It is the only operation I am asked to demonstrate overseas. It is an operation which depends for success on 'know-how' at every step. It is the object of this monograph to describe the 'knowhow'. The operation to be described depends on the use of knives (meniscotomes) to my design to achieve total meniscectomy through a limited exposure. The design was finalised in 1939 and has not been modified in any respect since then. I am frequently asked what prompted my interest in the knee joint, in the pathology of the menisci, and meniscectomy in particular. When the Orthopaedic Department of the Royal Infirmary of Edinburgh was inaugurated in 1936 and I became Clinical Assistant to Mr Walter Mercer, later Professor Sir Walter, I noted a certain reluctance on the part of patients to accept surgery as a solution to problems of internal derangement relative to a meniscus. All had friends or relatives subjected to operations whose knees no longer locked but who were not cured in so far as the joint remained unstable. They were not impressed by the results of surgery as then performed. The reason soon became clear: none of the surgeons for whom I worked could perform a total meniscectomy. Failure to remove the posterior segment was the reason for the dissatisfaction. Here was a challenge: design instruments for total excision. I found at an early stage of development that you could not push a knife into a joint in one direction and expect it to cut in another. All the modifications of 'Smillie's knives', of which three are illustrated, attempt to do just that. The curves of the knives cannot be increased without revealing total ignorance of their mode of use. There are three knives. The one in the centre (see 1) is no more

than a miniature chisel. It is intended to be passed, blade vertical, between the periphery of the meniscus about its mid point and the long fibres of the medial ligament. It is the least important of the three in that a scalpel can perform the same function. The other two, right and left, consist of a curved cutting edge between blunt points of different length, the longer of which lies on the tibial table. The terminal three centimetres or so is gently curved. The knives are used at an angle of 45 degrees to the vertical; and this is the reason why the curve cannot be increased. Finally, after the meniscus is dislocated into the intercondylar notch, is shown the semi-diagrammatic method of division of the postero-central attachment whereby the longer beak of one of the curved knives is placed underneath the meniscus and division effected by backward pressure. The exact dimensions of the knives are of importance. So many distortions, but particularly enlargements, of the instruments are on sale in world markets, and presented to me to use as my own abroad, that in my defence, and in the hope of better things, engineers' drawings were published (Smillie, 1978). Alas, without any noticeable improvement. Instrument manufacturers do not consult surgical monographs. The importance of these meniscotomes and their mode of use has determined that pride of place should be given to them in the detailed description of the steps of meniscectomy. I have no vested interest in these knives other than the wish to instruct in their exact mode of use in the manner intended. It is suggested therefore that several sets of the curved models be available when a meniscectomy is performed. If the surgeon is given a blunt knife others, hopefully sharp, are available. It is well known that instruments designed for one purpose are found to be equally useful for another. It is relevant to interpose at this point, that in the anterior compartment syndrome the deep fascia can be split with a curved knife through an incision little bigger than a stab wound. In a similar fashion the lateral capsular expansion at the knee can be divided in the so-called 'lateral release' operation. In the carpal tunnel syndrome the transverse carpal ligament can be divided with a curved knife. 7

Meniscotomes 1 The knives (meniscotomes). The operation to be described depends on the use of special meniscus knives. In the centre is the chisel knife intended to be passed, the blade vertical, between the centre of the periphery and the collateral ligament. The two curved knives, right and left, consist of a blade enclosed between blunt beaks. In use the long beak lies on the tibial head. The gentle curve involves the terminal 2.5 to 3 cm and enables them to be used at 45 degrees to the vertical (see 2 and 3) where they take up the minimal space within the joint.

2 The knives: mode of use (semi-diagrammatic). Right lateral meniscus is mobilised by division of the peripheral synovial attachments with the knife rotated 45 degrees towards the centre of the joint. The attachments are divided under tension by traction exerted by the Martin's forceps (not shown).

3 The knives: modes of use (semi-diagrammatic). Left lateral meniscus mobilised by division of the synovial attachments with the knife rotated 45 degrees towards the periphery. The attachments are divided under tension by traction exerted by the Martin's forceps 22 (not shown).

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5 The knives: maintenance. It is essential that the cutting edges be kept sharp; and a special hone is available to this end. It is dangerous to be required to use force with a blunt knife. The flat side of the hone is used on the chisel knife. The rounded margin on the curved knives.

4 The knives: mode of use (semi-diagrammatic). The final action in meniscectomy is division of the postero-central attachment after the meniscus has been dislocated into the centre of the joint. This is accomplished, using the appropriate curved knife, by placing the long beak beneath the postero-central attachment and with the meniscus under tension, pushing the knife directly backwards.

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9 mm

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6, 7 and 8 Meniscotomes. Numerous meniscotomes are available on the market, based on my design, of which three are illustrated here. They seek by greatly increasing the curve of the blade, to improve on the originals. The Introduction states that it was discovered at an early stage of development that you cannot push a knife into a joint in one direction and expect it to cut in another. To increase the curve of the knives is to fail to understand their mode of action.

Draining the limb 9 Meniscectomy step by step. The limb is drained with an elastic (Esmarch) bandage and the pneumatic tourniquet inflated. Note sandbag beneath thigh. Note also that the end of the operating table has been removed.

10 Position on table. The sandbag beneath the thigh can with advantage be triangular in section. The knee is prepared and the antiseptic of choice applied in extension.

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11 Re-apply antiseptic in flexion. When the joint is flexed the white creases indicate that the antiseptic has not penetrated and should be reapplied.

Position of surgeon 12 Position of surgeon. T h e height of the operating table is adjusted so that the surgeon's knees grip the patient's foot to p r o d u c e lateral rotation of the tibia at the critical phase of the o p e r a t i o n . T o this end the surgeon's gown should be long so that in the action no lapse of aseptic technique can occur.

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13 Popliteal structures to be mobile. The knee must hang clear of the table and the sandbag beneath the thigh so located that the popliteal structures are not fixed. If they are free, even if a meniscus knife slipped at a critical stage of the operation, they would probably escape injury. In no circumstances should the operation be performed with the knee flexed over a large wedgeshaped cushion.

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Incision site 14 Site of incision. T h e incision on the medial side should not extend m o r e than a finger's breadth below the joint line, lest the infrapatellar branch of the s a p h e n o u s nerve be e n d a n g e r e d .

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15 Site of incision. T h e location of the incision is important if the m a x i m u m access is to be o b t a i n e d through a limited exposure. It is m a d e through alcohol-soaked muslin, stockinette or other cloth material and begins at or about the junction of the broad upper-third of the patella with the inferior two-thirds.

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16 Site of incision. It extends d o w n w a r d s and slightly backwards to terminate not m o r e than a finger's b r e a d t h below the joint line lest, as has been indicated, the infrapatellar branch of the s a p h e n o u s nerve be e n d a n g e r e d . O n the lateral side the inferior limit of the skin incision is not critical. Transverse incisions should be avoided because they prejudice healing of any f u t u r e vertical incision. Vertical incisions which slope forwards rather than backwards provide less c o m f o r t a b l e access to the posterior third of the meniscus at the most difficult part of the operation. T h e divided cloth material is turned over and clipped to the margins of the w o u n d with light-weight Allis tissue forceps or Michel clips in such a m a n n e r that the edges are completely covered. Adhesive skin covering is not recomm e n d e d in such a short incision in that the potentially dangerous skin edges, over which instruments will be passed, are not covered. The scalpel used to m a k e the skin incision is discarded.

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Capsule division 17 Division of capsule. The capsule is divided in the line of the skin incision using a fresh scalpel and exposing the extra synovial fat. The extra synovial fat and synovial membrane are divided vertically down to but not damaging the superior surface of the periphery of the meniscus. Retractors (24) are inserted to permit inspection of the interior of the joint. If it is a displaced bucket-handle tear the central portion will be immediately evident. If it is the more common horizontal cleavage lesion, nothing will be seen unless a flap from the undersurface of the posterior half has been displaced centrally. If it is a bucket-handle tear, decide before proceeding further whether the displaced portion only is to be removed or the entire meniscus excised. If the former action is selected the anterior horn must not be mobilised but the displaced portion divided at the limits of the tear anteriorly and posteriorly with one of the curved knives (2 and 3).

m1 Mm

mm

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18 Avoiding postoperative haematoma. Subcapsular veins as large as these require ligation or coagulation.

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19 Avoiding postoperative haematoma. In the bloodless field provided by the tourniquet arteries in the extra synovial f a t , the lumen of which can be seen, require ligation or coagulation.

20 Dividing antero-central attachment. If it is decided to excise the entire meniscus, the anterior horn is lifted off the tibial head with t o o t h e d dissecting forceps and a horizontal incision m a d e between the u n d e r s u r f a c e of meniscus and tibial head. It is now possible to locate the antero-central a t t a c h m e n t which is divided close to the midline.

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Defining meniscus 22

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21 Defining the periphery of meniscus. The next move is to define the periphery of the meniscus. It is in doing so that the first serious error can occur in the uninitiated: with a retractor (24) exerting traction on the capsule it is very easy to cut into the periphery of the meniscus. Both retractors are therefore removed thus relaxing the capsule completely. With the anterior horn of the meniscus held with toothed dissecting forceps, the blade of the lightly held scalpel picks up the soft line of cleavage between periphery of meniscus and capsule. 24

22 Meniscus clamp. Excision of the meniscus demands, from the nature of the tissue involved, a special clamp to ensure the grip is maintained when traction is exerted. 'Martin's meniscus forceps' has square-cut teeth which grip the fibrocartilage firmly. The total length should be limited to say 15cm, so that the hand so accommodated does not obscure the vision of the surgeon.

Use of retractors 23 Meniscus clamp: mode of use. It is at this stage, and not b e f o r e , that the meniscus clamp is applied. It is attached to the convex margin, not to the concave side w h e r e traction is apt to p r o d u c e a transverse r u p t u r e . T h e forceps is gripped in the m a n n e r indicated so that the hand does not obscure the view. T h e h a n d of course is d r o p p e d below the level of the tibial h e a d . A certain a m o u n t of traction is necessary to k e e p the peripheral synovial attachment under tension as the blade of the curved knife is applied. This traction should be applied in the direction towards the midline of the joint r a t h e r than directly towards the o p e r a t o r . This ensures that the concave margin is not u n d e r tension with danger of rupture.

24 Retractors. T h e r e is no exact point at which a description of the retractors should be interposed: they are used as soon as the skin incision is c o m p l e t e d . On the other h a n d they only become essential when the joint cavity is e n t e r e d . T h e y are of sufficient importance to be illustrated and described individually r a t h e r than en masse. A l t h o u g h few in n u m b e r they cover most circumstances likely to be e n c o u n t e r e d in the surgery of the menisci. First are simple conventional models of which two are required. T h e hand-hold is transverse in all of t h e m thus eliminating the necessity to grip. 25

25 Retractors. T h e next three are wide-bladed ( 1 9 m m ) used in three lengths (32, 41 and 5 7 m m ) and used to retract the fat pad centrally in the variety of circumstances e n c o u n t e r e d . T h e angle in the shaft is 160 degrees and between shaft and blade 60 degrees.

26 Retractor. This instrument with a curved blade 10mm wide, is inserted between femoral condyle and collateral ligament when it is desirable to gain access to the periphery of the joint.

Dealing with effusion 27 Dealing with effusion. W h e n an effusion is present it is helpful if it is eliminated in its entirety at the c o m m e n c e m e n t of the operation. This avoids passing dry swabs in and out of the joint t h r o u g h o u t the p r o c e d u r e with consequent irritation of the synovial m e m b r a n e and risk of postoperative effusion. With the joint in rightangled flexion the fluid will be lodged in the posterior c o m p a r t m e n t . With a small towel covering the gloved hand the fist is placed in the popliteal space, the fluid is pushed forward where it is removed by saline-moistened swabs or sucker.

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28 Use of curved knives in mobilising posterior half. M o d e of use of curved knife in dividing the peripheral synovial a t t a c h m e n t s kept under tension by traction on the clamp. N o t e knife rotated 45 degrees towards centre of joint. (See 2.)

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29 Use of curved knives in mobilising posterior half. Alternatively the knife may be rotated 45 degrees towards the periphery. T h e y are not held vertically and driven directly backwards into the joint.

30 Loss of orientation. If at any time, but particularly after the anterior half has been mobilised, there is a loss of orientation look under rather than on top of the meniscus to find your way.

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Effect of tibial rotation 32

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31 Effect of ability to rotate tibia. It is at this point of difficulty that the surgeon's knees, gripping the patient's foot, rotate the tibia laterally. This action, plus increasing the flexion of the knee, is quite r e m a r k a b l e in bringing the posterior synovial a t t a c h m e n t within the compass of the curved knife.

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32 Effect of ability to rotate tibia. N o t e area of medial tibial head brought into view by lateral rotation of tibia.

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33 Effect of ability to rotate tibia. The posterior peripheral a t t a c h m e n t is brought within the compass of the curved knife.

34 Effect of ability to rotate tibia. The curved knife, rotated 45 degrees towards the centre of the joint, follows the periphery of the meniscus towards the postero-central a t t a c h m e n t .

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35 The final move. T h e meniscus is displaced into the centre of the joint ready for division of the postero-central attachment in the m a n n e r indicated in (4). Note retractor (24) at periphery. R e t r a c t o r (25) at fat pad and giving wide view of interior of joint. Note meniscus clamp (22) attached to periphery of anterior extremity and d r o p p e d below level of tibial table where it d o e s not obstruct vision.

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Excising torn meniscus 36 Excising torn meniscus from worn joint. It will be recognised that the knee does not wear evenly throughout the entire range of flexion but in the weight-bearing arc.

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38 Excising torn meniscus from worn joint. In the difficult circumstances of removing a meniscus with a horizontal cleavage lesion f r o m a worn joint, the posterior unworn part of the femoral condyle can be used in increasing the space available by hyperflexion of the knees. This is the reason for the necessity to have an operating table which will permit hyperflexion.

39 Situations demanding additional posterior incision. A second incision, of the size and site indicated, is required if accidental rupture of the meniscus takes place during the operation leaving a mobile posterior segment within the weightbearing arc, and in failure to mobilise the posterior half through the anterior incision.

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Posterior incision site 40 Site of posterior incision. T o locate t h e site of t h e posterior incision curved mosquito forceps is e n t e r e d along the joint line, w h e r e b y the point indicates the centre of t h e incision.

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41 Site of posterior incision. The saphenous vein should be avoided. It will, of course, be empty under the control of the tourniquet. The capsule is divided in the line of the skin incision, the periphery of the meniscus located and separated from the capsule with one of the curved knives. The postero-central attachment is divided through the anterior incision again using one of the curved knives.

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¡IP

Hi

Second incision site 42 Situations demanding second incision: retained posterior segment. If, in circumstances of i n a d e q u a t e surgery, open or arthroscopic, the posterior half of the meniscus has been retained and is causing s y m p t o m s it must be r e m o v e d . O p e r a t i o n cannot be p e r f o r m e d through a single anterior incision: the junction between the regenerated anterior segment and the retained posterior segment is weak and will not permit traction to be exerted. In such circumstances the regenerated portion is mobilised through the anterior incision and the retained posterior segment mobilised through the posterior incision as described. T h e o p e r a t o r then returns to the anterior incision for division of the postero-central attachment.

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43 Other situations demanding second incision. The circumstances of cystic degeneration of the posterior segment of the medial meniscus with symptoms suggesting that the meniscus is torn demand that the posterior incision, to mobilise and identify the cyst, is made initially. The anterior incision is added to mobilise the anterior two-thirds of the meniscus.

44 Other situations demanding second incision. In cystic degeneration of the posterior segment of the medial meniscus the cyst together with attached meniscus is eventually presented through the posterior incision before the central fixation is divided.

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Cystic degeneration

45 Cystic degeneration posterior segment medial meniscus. But the cyst must be positively identified as arising in the meniscus lest a normal meniscus be excised in error.

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46 Cystic degeneration diagnosis. A popliteal sometimes presents on swelling similar to cystic

posterior segment medial meniscus: differential cyst (gastrocnemio-semimembranosus bursa) the medial joint line posteriorly producing a degeneration.

Rupture of lateral meniscus 48

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48 Access to lateral compartment. If the hip is flexed and rotated laterally so that the lateral aspect of the ankle rests on the suprapatellar region of the other knee the joint is in maximum varus angulation in maximum lateral rotation. In this position a wide gap exists between femur and tibia. 47 No additional incision is necessary on lateral side. On the lateral side rupture of a meniscus, the site of a parrot-beak tear, is common leaving the posterior two-thirds of the meniscus requiring to be removed. In contrast to the medial side a second incision is never necessary.

50 Access to lateral compartment. T o reach the postero-lateral aspect of the joint the retractors in the limited vertical incision remain in position held by an assistant. T h e k n e e is flexed to a right angle and r o t a t e d into the position shown in (48) and (49). T h e incision is now horizontal in the eyes of the surgeon.

49 Access to lateral compartment: the position demonstrated. T h e tips of the forefinger and long finger have b e e n e n t e r e d in the gap. B e t w e e n the two is the ilio-tibial band.

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51 Access to lateral compartment. Note the remarkable exposure provided by this manoeuvre. In this example the posterior half of the meniscus has been removed. The structure seen is the posterior capsule.

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Termination of operation 52A Closing the incision. I n t e r r u p t e d sutures are used. T h e y are inserted in a special way to avoid showing catgut within the joint, thought to be a cause of postoperative e f f u s i o n : the needle picks u p the capsule, then picks up the synovial m e m b r a n e in such a m a n n e r so that t h e suture does not appear within the joint.

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52 Termination of operation. In closing the skin the knee should b e in the s a m e degree of flexion as when the incision was m a d e .

53 Termination of operation. A t the end of the o p e r a t i o n , and b e f o r e the tourniquet is released, a compression, or Jones, b a n d a g e is applied to control capillary ooze f r o m the divided synovial m e m b r a n e at the periphery of the joint. It consists of three thick layers of sheet cottonwool of high quality in terms of elasticity and compressibility. Interposed between each layer are two layers of 15 cm (6 inch) b a n d a g e of nonstretch material. A total of some 12 metres is required. T h e bandage should be applied by the surgeon who p e r f o r m s the o p e r a t i o n ; not by an inexperienced assistant. T h e completed b a n d a g e should have the consistency of a 'ripe m e l o n ' .

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Exercise therapy 54

54 After treatment: exercise therapy. It will be indicated later that haemarthrosis is the most important c o m m o n complication of the operation. It is for this reason that immediate quadriceps exercises are not advised. O n the first t h r e e to f o u r days patients practise hourly, or preferably m o r e o f t e n , calf and anterior c o m p a r t m e n t exercises in the f o r m of plantar and dorsiflexion of t h e foot. This is much in the interests of avoiding d e e p vein thrombosis but to some extent it slackens the compression b a n d a g e which the patient may feel tight. It has the advantage that it involves the patient in his own recovery at the earliest stage.

N o t e f r a c t u r e - b o a r d bed. It is essential that the mattress is firm so that the patient can turn over without flexing the knee. A soft mattress is a source of pain in turning with the possible increased danger of haemarthrosis.

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55 After treatment: exercise therapy. On the third or fourth day quadriceps exercises begin in the form of straight-leg raising. This is essential exercising in the simplest f o r m not requiring the patient to learn anything new. It can with advantage be taught on the sound limb as soon as the patient has overcome the immediate effects of operation.

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56 After treatment: exercise therapy. T h e next stage is to load the straight-leg raising, increasing the resistance to be o v e r c o m e , by attaching a weight to the foot starting with a half to o n e kilogram and increasing, depending on progress, to two to f o u r kilograms.

57 Resumption of weightbearing. When weightbearing is resumed on, say, the tenth day when the skin stitches are removed, a normal heel-andtoe gait is taught. A single stick (cane) is not permitted. The compression bandage is retained. It possibly prevents effusion but in any event gives a sense of security. The patient is permitted to walk short distances and then to sit. T o stand about is to induce effusion.

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Haemarthrosis 58 Complications: haemarthrosis. Transient pain localised to the site of operation is to be expected on commencing exercise therapy in the form of straight-leg raising and quadriceps drill. Persistent severe pain results from some local cause and warrants investigation. It is usually caused by haematoma between: 1 Skin and capsule; 2 Capsule and synovial membrane; or 3, most important of all, within the joint in the form of a haemarthrosis. 1 And 2 are usually caused by failure to ligate or coagulate sizeable vessels. The treatment is evacuation of the clot under strict aseptic precautions. 3 Is caused by either capillary ooze and necessitates no more than aspiration and the re-application of the compression bandage, or, more uncommon, but much more important, haemorrhage from a sizeable artery.

59 Haemarthrosis of arterial origin. T h e inferior medial geniculate artery lies well below the joint line and should not be divided at o p e r a t i o n . The inferior lateral geniculate artery is located at the periphery of the meniscus and is almost invariably divided at o p e r a t i o n . 52

60 Haemarthrosis of arterial origin. Lateral meniscus of normal conformation to show section of inferior lateral geniculate artery. N o haemarthrosis resulted f r o m division of the artery.

61 Haemarthrosis of arterial origin. In a large congenital discoid lateral meniscus the geniculate artery may b e of even greater dimensions. N o haemarthrosis resulted f r o m division of the artery.

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62 Haemarthrosis of arterial origin. If the inferior lateral geniculate artery is divided as in 60 and 61, the ends retract and no h a r m results. It is w h e n incomplete division occurs, such as a slice out of the wall, that the danger of a pulsating haemarthrosis occurs.

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63 Haemarthrosis of arterial origin: securing haemostasis. If this complication is uncommon when it does occur it poses the impossible problem of finding the bleeding point. A suture on a round-bodied needle, entered blindly at the joint line, readily stops the bleeding.

Patellar plexus injury 64 Complications: injury to patellar plexus. T h e superficial sensory nerves which m a k e up the patellar plexus seem particularly sensitive to injury. T h e s a p h e n o u s nerve pierces the d e e p fascia on the medial side between the t e n d o n s of sartorius and gracilis. B e f o r e doing so it gives off the infrapatellar branch which passes forward about a finger's b r e a d t h below the joint line to form the patellar plexus in association with branches of the medial, lateral and intermediate cutaneous nerves. S o m e of the branches are invariably cut in knee incisions leading to t e m p o r a r y areas of anaesthesia.

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65 Complications: neuroma of infrapatellar branch of saphenous nerve. It has been indicated that an incision on the medial side of the joint should not extend m o r e than a finger's b r e a d t h below the joint line. A n a t o m y is not an exact science: the nerve must frequently be cut without u n d u e consequences. W h e n a n e u r o m a occurs following meniscectomy it is probably because t h e nerve has been w o u n d e d , r a t h e r than cut, and becomes a d h e r e n t to the scar. W h e n this complication occurs the scar is excised, the n e u r o m a isolated and the nerve traced in a proximal direction and divided with a sharp scalpel. This m e a s u r e ensures that a f u r t h e r n e u r o m a is not a d h e r e n t to the cutaneous scar.

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Reference and further reading Smillie, I.S., Injuries of the Knee Joint (5th edition). Churchill Livingstone, Edinburgh, London & New York, 1978.

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Index Numbers in medium type refer to page numbers; those in bold refer to figure and caption numbers. '

A Access to lateral compartment 4 1 - 4 3 , 4 8 - 5 1 Adhesive 'skin' covering, 20, 16 A f t e r treatment 47, 54 Allis tissue forceps 20, 16 Antero-central attachment, division of 20, 23 Antiseptic, re-application of 11, 15 Arteries, inferior lateral geniculate 52, 59 Arteries, inferior medial geniculate 52, 59 Arthroscopic surgery 38, 42

B Bucket-handle tear 17, 21 Bursa, gastrocnemio-semimembro 40, 46

Capillary ooze 46, 53 Capsule, division of 17, 21 Complications 51, 58 Complications, H a e m a t o m a 51, 58 Complications, Haemarthrosis 51, 58 Compression bandage 46, 53 Cottonwool 46, 53

D Draining limb 9, 13

E Effusion, dealing with 27, 27 E n d , operating table 9, 13 Esmarch bandage 9, 13 Exercise therapy 47, 54 Extra synovial fat, arteries in 19, 21 Exercises, anterior compartment 47, 54 Exercises, calf 47, 54 Exercises, quadriceps 48, 55

Fracture - board bed 47, 54

H Haemarthrosis, arterial origin 52, 60 61

I Incision, site of 16, 20 Incision, site of 14, 15, 18, 19 Inferior lateral geniculate artery 52, 59 Inferior lateral geniculate artery, wound of 54, 62 Inferior medial geniculate artery 52, 59 Infrapatellor branch of saphenous netve, neuroma 57, 65 Infrapatellor branch of saphenous nerve, wound of 57, 65 Ilio-tibial band 42, 49

J Jones bandage 46, 53

L Lateral compartment, access to 41, 48 Lateral meniscus, congenital discoid 53, 61 Loaded straight-leg raising 56, 59

Meniscus lesions, cystic degeneration 39, 40, 43, 45 Meniscus tears, bucket-handle 17, 21 Meniscus tears, horizontal cleavage 35, 38 Meniscus tears, parrot-beak 41, 47 Meniscus tears, retained posterior segment 38, 42 Michel clips 16, 20 Mosquito forceps 36, 40 Muscles, gracilis 56, 64 Muscles, sartorius 56, 64

N Nerves, infrapatellar branch of saphenous 14, 18, 56, 64 Nerves, intermediate cutaneous 56, 64 Nerves, lateral cutaneous 56, 64 Nerves, medial cutaneous 56, 64 Nerves, saphenous 56, 64 Neuroma 57, 65

O Operating table, height of 12, 16 Orientation, loss of 29, 30 M Martin's meniscus forceps 22, 24 Mattress 54, 57 Meniscus clamp 22, 24 Meniscus knife, chisel 1, 9 Meniscus, defining the periphery 21, 24 Meniscus knives 1, 9 Meniscus knives, maintenance 5, 11 Meniscus knives, mode of use 2 - 3 , 10, 11 Meniscus knives, hone 5, 11 Meniscotomes, bad design 6 - 8 , 12 Meniscotomes, mode of use 2 - 3 , 10,11 Meniscus clamp, mode of use 23, 25 Meniscus, congenital discoid lateral 53, 61 62

P Peripheral synovial attachments, division of 2 - 3 , 10 Popliteal cyst 40, 46 Pneumatic tourniquet 9, 13 Postero-central attachment, division of 4, 11, 32, 35 Posterior incision 35, 39 Posterior incision, site 35, 40

Q Quadriceps exercises 47, 54

R Retractors 24, 25, 25, 26, 26

S Sandbag 9, 10, 13, 14 Saphenous vein 37, 41 Subcapsular veins 18, 22 Surgeon, position of 12, 16 Surgeon's gown, length of 12, 16 Surgeon's knees, use of 12, 16

T Termination of operation 45 - 4 6 , 5 2 - 5 3 Tibial rotation, effect of 30, 31, 31, 32, 33, 34

Torn meniscus, exercising 33, 36 Tourniquet 9, 13

V Veins, saphenous 37, 41 Veins, subcapsular 18, 22

W Weight-bearing arc 33, 35, 36, 39 Weight-bearing, resumption of 50, 57 Worn joint 34, 37

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