Knee Arthroscopy: Patient

Positioning, Room Set-Up,

and Equipment

Austin V. Stone, Brady T. Williams, Kevin Shinsako, and

Rachel M. Frank

Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
4 Room Set-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
5 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Abstract collaboration with anesthesiologists to estab-

Knee arthroscopy can be performed with a lish both primary and contingency plans. Knee
variety of subtle variations based on institu- arthroscopy is typically performed under gen-
tional differences and surgeon preferences; eral anesthesia with or without adjuncts of
however, the general principles are the same. local or regional anesthetics. After appropriate
A successful procedure is predicated on appro- identification of patient, procedure, and opera-
priate planning and preparation. This includes tive extremity, the patient is positioned supine
on the operative table. The use of either a post
or an arthroscopic leg holder allows for appro-
priate intraoperative limb positioning, includ-
A. V. Stone
Division of Sports Medicine, Department of Orthopaedic ing the application of valgus stress for medial
Surgery and Sports Medicine, University of Kentucky, compartment visualization. Bony prominences
Lexington, KY, USA and potential areas of nerve compression are
B. T. Williams well padded. The arthroscopic tower is posi-
Department of Orthopaedic Surgery, University of tioned in a manner that allows for convenient
Colorado, Aurora, CO, USA visualization by the surgeon while also allo-
e-mail: Brady.williams@cuanschutz.edu
wing for passage of tubing and cords off the
K. Shinsako · R. M. Frank (*) surgical field. The arthroscopic tower typically
Division of Sports Medicine, Department of Orthopedic
Surgery, University of Colorado, Aurora, CO, USA contains video processing units, arthroscopic
e-mail: Kevin.shinsako@cuanschutz.edu; pump, shaver and ablation controllers, and
Rachel.frank@cuanschutz.edu

© Springer Nature Switzerland AG 2023 1

S. L. Sherman et al. (eds.), Knee Arthroscopy and Knee Preservation Surgery,
https://doi.org/10.1007/978-3-030-82869-1_8-1
2 A. V. Stone et al.
additional vendor-specific equipment. The
most common set-up includes a 30-degree
arthroscope and arthroscopic instruments
including probes, biters, and graspers. The
remainder of the room set-up and instrumenta-
tion can be tailored based on surgeon prefer-
ences and procedure-specific requirements.
For example, an additional back table is used
for extensive graft preparation or a 70-degree
arthroscope is used for better visualization of
the posterior aspect of the knee. Again, a suc-
cessful procedure is dependent on appropriate
preoperative planning, which includes identi-
fying case-specific equipment needs and ensur-
ing they are present prior to beginning the case.
Keywords
Knee · Arthroscopy · Positioning · Equipment
1 Introduction
Proper patient positioning, room set-up, and nec-
essary equipment are critical to a successful oper-
ation. The surgeon should communicate with the
operative team and ensure that the goals and
nature of the operation are clearly understood.
The most important portion of the procedure is
confirmation of the correct patient, operative
extremity, and surgical procedure. While the
exact nature of preoperative identification varies
by institution, the operative extremity should be
clearly marked by the surgeon or “credential pro-
vider,” confirmed by the patient before anesthesia
administration, and placed in an area that will be
visible to the operative team after surgical prep-
ping and draping. Prior to the commencement of
any procedure, a Universal Precautions Time-Out
should be performed, which identifies the correct
patient, operative extremity, and procedure.
2 Anesthesia
The selection of anesthesia is dependent upon
several factors including the nature of the planned
operation, the health of the patient, the comfort of
the anesthesiologist, and the surgeon preference.
Local, regional, or general anesthesia may be used
alone or in concert to achieve the desired effect
and duration based on the aforementioned factors.
Exclusive use of local anesthesia for performing
knee arthroscopy is uncommon, but may be used in
select cases where the patient desires a rapid recov-
ery or has medical comorbidities that prevent safe
use of general anesthesia. Preoperative planning
with the anesthesia team is important for contin-
gencies such as a difficult airway management.
Local anesthesia may be most effectively used for
short procedures, which require minimal manipu-
lation of the leg and have minimal discomfort.
Examples of potential procedures include diagnos-
tic arthroscopy, synovial biopsy, small loose body
removal, or limited partial meniscectomy. With the
introduction of micro-instrumentation, limited
arthroscopy can be performed in the office setting
under local anesthesia. Typically, a combination of
lidocaine and bupivacaine with or without epineph-
rine is used. Local anesthetics offer the advantages
of low morbidity, low cost, and rapid recovery.
Regional anesthesia may be used alone or in
conjunction with general anesthesia for periopera-
tive pain control. Regional anesthesia options
include spinal, epidural, and peripheral nerve anes-
thesia. Patients who have medical comorbidities or
sensitivities to general anesthesia can often tolerate
knee arthroscopy with these options. Potential
complications include nerve palsy, delayed motor
recovery, spinal puncture, and spinal headache. A
contingency plan should be reviewed with the
anesthesiologist prior to the operation.
General anesthesia is most commonly used for
knee arthroscopic procedures. Newer medications
allow for a safer, faster recovery that is well tol-
erated. Complete muscle relaxation is possible if
needed. Patients better tolerate tourniquet use and
bony procedures with general anesthesia.
3 Patient Positioning
The patient is positioned supine on a standard
operating table. Arm boards may be used for
positioning and ease of access for the anesthesiol-
ogist and allow for complete coverage during
Knee Arthroscopy: Patient Positioning, Room Set-Up, and Equipment
draping. The arms should be in a neutral position,
and the nerves should be protected from compres-
sion. The use of a tourniquet is based on surgeon
preference.
One of two positions is most often used:
(1) Supine with a lateral post or (2) supine with an
arthroscopic leg holder. If the lateral post is used, the
patient should be supine with the hips placed
slightly off-center to the operative side and the
post placed such that a valgus force can be applied
to the knee during arthroscopy to improve medial
compartment visualization. The post is placed just
proximal to the knee joint, and the fulcrum is set at
the distal femur. While many lateral post options
exist, a retractable post (Fig. 1) that can be collapsed
intraoperatively offers the benefit of more flexible
positioning and easier figure-four positioning for
lateral compartment access.
The second position utilizes an arthroscopic
leg holder and a well-leg holder. The arthroscopic
leg holder is placed proximally on the thigh and
can encompass the tourniquet if used. An example
of the arthroscopic leg holder is shown in Fig. 2.
The patient should be positioned in the bed with
the hips close to the retractable foot of the bed
with the feet extending over the end of the bed.
The leg holders are secured to the central portion,
which remains stationary. The head of the bed
may be removed to provide easier access for the
anesthesiologist. When placing the operative leg
holder while using a tourniquet, the valve of the
tourniquet should be free from compression to
allow for full inflation. The well leg is placed in
a padded leg holder with the leg primarily
Fig. 1 Photograph
highlighting the correct
position of a lateral leg post.
The post is positioned over
the distal femur such that a
valgus torque can be
applied to the knee for
intraoperative medial
compartment visualization.
(a) Post raised for ease of
resistance to valgus stress.
(b) Post lowered for figure-
four position
3
externally rotated to avoid excessive hip flexion
and compression on the lateral femoral cutaneous
nerve. The well leg should be placed in a manner
that does not compress the common peroneal
nerve as it courses around the fibular neck. Prior
to dropping the foot of the bed, the bed should be
reflexed to have the femur parallel to the floor.
This position reduces the possibility of excessive
traction on the femoral nerve from the weight of
the leg compressing the soft tissue and resulting in
relative hip extension. The resultant position
allows for full access around the knee and is useful
for more complex arthroscopic procedures such as
inside-out meniscal repair, ligament reconstruc-
tion, and meniscal transplantation.
4 Room Set-Up
The room is set up in a standard fashion with the
anesthesiologist at the head of the bed and suffi-
cient room on either side and at the foot of the bed
for staff and equipment. An arthroscopic tower is
placed to the left or right of the bed depending on
room organization and surgeon preference. The
arthroscopic tower contains video processing
units, arthroscopic pump, shaver and ablation
controllers, and additional vendor-specific equip-
ment. The tower should be positioned close to the
patient to facilitate passing of camera and equip-
ment cords and the pump tubing (Fig. 3). Suffi-
cient cord and tubing length should remain sterile
to avoid difficulty during the case. Foot control
4 A. V. Stone et al.
Fig. 2 The patient is positioned supine on the operating
table. The well leg is positioned in a holder. The operative
extremity is positioned within an arthroscopic leg holder,
and the foot of the bed is dropped to allow the operative leg
to hang free. Arthroscopic tower and suction device are
positioned near the head of the bed, and the monitor will be
lowered to an appropriate level for viewing after draping
pedals should also be placed on the ground and
within surgeon reach prior to start of the case.
Screens may be mounted to arthroscopic
towers, boom arms, stands, or operating room
walls. Generally, screens should be mounted in
such a way that they are flexible to accommodate
a wide range of patient positions and set-ups.
These should generally be positioned at the head
of the bed for knee arthroscopy and at a comfort-
able height for the surgeon. Additional monitors
may be used to aid in teaching or to improve
visualization for surgical assistants.
For less complex procedures, most of the
arthroscopic equipment is often contained on the
Mayo stand and the back table is used to store less
Fig. 3 Mayo stand prepared with the necessary arthro-
scopic tower equipment prior to the start of the case includ-
ing arthroscopic camera, light cord, pump tubing and
cassette, suction tubing, and arthroscopic shaver. Addi-
tional foot pedals and controls are appropriately positioned
on the floor prior to the start of the case
frequently used instrumentation. For larger, more
complex cases, where graft preparation and mul-
tiple surgical trays are necessary, one or more
back tables may be utilized. A second back table
dedicated to graft preparation is highly valuable if
room allows. A second Mayo stand placed over
the patient is helpful to place arthroscopic shavers
and additional devices, so the risk of iatrogenic
injury to the patient is minimized. If shavers or
devices are placed directly on the drapes overly-
ing the patient, an errant press of the foot pedal
can result in compromise of the sterile field and,
worse, injury to the patient.
5 Equipment
Arthroscopic equipment continues to evolve from
its humble beginnings as a repurposed endoscope
[1]. Modern arthroscopy can now be performed
with cameras millimeters in diameter, and the
sophistication of procedural instruments allows
Knee Arthroscopy: Patient Positioning, Room Set-Up, and Equipment 5

Tissue removal can be accomplished in several

ways. Arthroscopic biters come in a variety of
shapes and sizes and may be used to cut meniscal
tissue, debride an anterior cruciate ligament
stump, release adhesions, or perform a biceps
tenotomy. Arthroscopic shavers and burrs like-
wise are available in several diameters and con-
figurations to address cartilage or meniscal
lesions, perform extensive debridement, or
remove bone. It is important to recognize that
the disposable portion of the instrument is depen-
dent upon the manufacture of the shaver handle
Fig. 4 Mayo stand outfitted with a variety of commonly
and control, so the compatibility should be veri-
utilized tools and instruments for conducting knee arthros-
copy including (a) marking pen, (b) 11-blade scalpel, (c) fied prior to any procedure.
18-gauge spinal needle, (d) arthroscopic probe, (e) hemo- Additional tools include arthroscopic graspers,
stat, (f) arthroscopic graspers, (g) arthroscopic biters, and suture and tape graspers (commonly called “crab
(h) pituitary rongeur.
claws”), curettes, and electrocautery devices. Addi-
tional instruments may be repurposed for arthro-
for the treatment of a broad range of pathologies.
scopic tasks, such as a pituitary rongeur, which can
Since the instrumentation is so extensive, this
aid in loose body or tissue removal. Curettes may
section will focus on the most commonly used
be open or closed and are valuable for cartilage
arthroscopic instruments (Fig. 4).
debridement and biopsies. Suture graspers come in
The arthroscope is commonly described by the
varying sizes depending on the joint and width of
camera’s angle of inclination. A 0-degree arthro-
the suture or tape. Electrocautery devices may use
scope has the lens angled straight ahead, while
radiofrequency ablation or coblation technologies
30-degree and 70-degree arthroscopes have the
and require a manufacturer-specific control box.
lens at the respective angles to the horizontal. A
The surgeon should select the appropriate instru-
30-degree arthroscope is most commonly used in
mentation for the case and ensure availability and
knee, shoulder, and elbow arthroscopy, while a
compatibility to best execute the procedure.
70-degree arthroscope is often preferred for hip
arthroscopy. A 70-degree arthroscope offers the
advantage of a broad view of tight spaces and
6 Conclusion
should be employed when deemed advantageous.
Arthroscopic working portals or additional
Proper preoperative planning in room and equip-
portals are often established using an “outside-
ment set-up can lead to improved ease and effi-
in” technique, and so, an 18-gauge spinal needle
ciency of arthroscopic procedures. Patient
should be standard equipment to determine opti-
positioning should be considered to facilitate the
mal portal placement for the intended procedure.
surgical procedure while maximizing patient
Portals can then be established with an #11 blade
safety. Clear communication between the surgeon
knife, a hemostat, or a trocar or switching stick.
and the surgical team leads to improved operative
An arthroscopic cannula can be inserted if desired
safety and efficiency.
in any portal to be used as a working portal or an
outflow portal. These cannulas may be reusable or
disposable depending on the available arthro-
References
scopic system and surgeon preference. An arthro-
scopic probe is a useful diagnostic tool and 1. Jackson RW. A history of arthroscopy. Arthroscopy.
typically has a tip 4 mm in length. 2010;26:91–103.