Five days later, she returns to the emergency department complaining of continuing knee pain. She says the knee gives way when she puts weight on it. The physical findings are unchanged, and she is discharged home with a follow-up appointment with orthopedics in 3 days. At the follow-up visit, she complains of persistent knee pain in the medial aspect of the knee joint.
Physical examination is difficult because of pain and swelling, and it reveals mild joint effusion with no gross instability. She has pain on the medial side with valgus stress, but there appears to be a hard end point. There is no posterior sag, and the Lachman test is negative. She is given a hinged brace and is instructed to undergo a physical rehabilitation program. Three weeks after the initial evaluation, she returns to the orthopedics clinic with continuing knee problems. Mild knee effusion persists, but she has less pain and swelling, allowing a more complete examination.
The examination reveals less limitation of range of motion and a hint of positivity on the Lachman test. The knee is diffusely tender, and the pain seems out of proportion with the maneuvers used during the examination. She requests more pain medication. You suspect internal derangement of the knee. Which imaging test should you order to further evaluate this patient? The case presented above represents a typical scenario for the presentation of acute knee pain and illustrates the diagnostic challenges.
Knee pain is a common reason for emergency room visits, and it accounts for approximately 1. The anterior drawer test is done to evaluate the anterior cruciate ligament. The upper hand grasps the distal thigh, and the lower hand, with the thumb on the tibial tubercle, pulls the tibia forward. An end point is considered soft when the ligament is disrupted and the restraints are the more elastic secondary stabilizers.
Some authors contend that in skilled hands a thorough history, physical examination, and radiographic examination are sufficient to diagnose trauma-related intra-articular knee disorders. A number of studies 4—8 have shown that using MRI in the initial evaluation not only identifies key lesions, but also may eliminate the need for an invasive diagnostic procedure ie, arthroscopy. For example, MRI can reveal fracture, stress fracture, insufficiency fracture, and transient patellar dislocation—conditions that may satisfactorily explain knee symptoms.
Skip to main content. In-office arthroscopy has been available for use since the early s. This allows the surgeon another tool to diagnose patients with intra-articular pathology that has been missed on previous advanced imaging. It can also be potentially beneficial for patients with intra-articular pathology who are unable to have an MRI for medical reasons or as a result of claustrophobia.
Another potential use is in patients with continued knee pain following return to activity after a previous meniscal surgery, a situation that occurs commonly and one where advanced imaging is often nondiagnostic. This would allow the surgeon a less expensive, more readily available way to visualize the previous repair, without having to bring the patient back for a diagnostic arthroscopy.
Additionally, in-office arthroscopy can be valuable to assess the knee joint prior to the use of an allograft, such as an osteochondral or meniscal allograft. In these cases, a diagnostic arthroscopy is often required before authorization of the procedure. In-office arthroscopy is not without limitations. Because of the smaller size of the needle, the visualization is not as clear as a true operative diagnostic arthroscopy. Additionally, if the patient either has a hemarthrosis or one is created during the process of in-office arthroscopy, visualization can be severely limited as the surgeon is unable to run fluid through the knee to clear it out.
Immediate swelling and bruising usually indicates significant trauma and may require X-Ray to rule out tibial plateau fractures, bone bruises or an MRI to investigate the integrity of the ligaments. In Helfet's test the knee is locked, and cannot rotate externally while extending, and the Q angle cannot reach normality with extension. Just as in standard arthroscopy, the knee can be manipulated using varus force or a figure-of-4 position to visualize the lateral and medial compartments, respectively. Arthrosc J Arthrosc Relat Surg. Contents Editors Categories Share Cite. Menu Menu Presented by Register or Login. The patient's knee should be marked and appropriate signed consent obtained.
Also, in patients with previous surgery, scar tissue can limit the excursion of the small-bore needle. These are all situations to keep in mind during patient selection for in-office arthroscopy. In-office arthroscopy presents minimal risk, especially when compared with diagnostic arthroscopy in the outpatient setting. The needle used is no larger than a similar arthrocentesis needle.
Compared with the higher risks of a diagnostic arthroscopy and the associated anesthesia, in-office arthroscopy offers a cost-effective, safer alternative. Previous studies have also demonstrated the potential cost savings for in-office arthroscopy.
In-office arthroscopy offers the surgeon another diagnostic tool that can be valuable in a multitude of clinical settings. The authors report the following potential conflicts of interest or sources of funding: A. Step-by-step guide for the use of diagnostic in-office arthroscopy. The patient is supine with the affected leg manipulated to improve visualization. A varus force is placed to visualize the medial compartment, and a figure-of-4 position is used for the lateral compartment. National Center for Biotechnology Information , U.
Journal List Arthrosc Tech v. Arthrosc Tech. Published online Dec Karan A.
Patel , M. Hartigan , M. Makovicka , M.
Dulle, III , P. Author information Article notes Copyright and License information Disclaimer. Anikar Chhabra: ude. Received Apr 14; Accepted Aug 9.
Published by Elsevier. Associated Data Supplementary Materials Video 1 Step-by-step guide for the use of diagnostic in-office arthroscopy. ICMJE author disclosure forms. Abstract Arthroscopy is currently the gold standard for diagnosing intra-articular knee pathology. Technique Preoperative Workup and Patient Setup Standard preoperative workup should be conducted based on the patient's presenting symptoms.
Open in a separate window. Equipment Needed Mi-Eye 2 Topical antiseptic and local anesthetic of the surgeon's preference Multiple or mL syringes filled with sterile saline Dressing of surgeon's preference. Fig 1. Portals The lateral, medial, and inferior border of the patella should be palpated and drawn out along with the patellar tendon.
Fig 2. Diagnostic Arthroscopy Remove the Mi-Eye 2 tray from its sterile packing. Fig 3. Fig 4. Fig 5. If further evaluation of the patellofemoral joint is necessary, standard superolateral or superomedial portals can be used. Discussion In-office arthroscopy has been available for use since the early s. MRI, magnetic resonance imaging. Footnotes The authors report the following potential conflicts of interest or sources of funding: A. Supplementary Data Video 1: Step-by-step guide for the use of diagnostic in-office arthroscopy.
Click here to view. References 1. Phelan N. Knee Surg Sports Traumatol Arthrosc. Crawford R. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: A systematic review. Br Med Bull. Behairy N.
Accuracy of routine magnetic resonance imaging in meniscal and ligamentous injuries of the knee: Comparison with arthroscopy. Int Orthop. Esmaili Jah A. Accuracy of MRI in comparison with clinical and arthroscopic findings in ligamentous and meniscal injuries of the knee.
Acta Orthop Belg. Kohl S. Accuracy of cartilage-specific 3-tesla 3D-DESS magnetic resonance imaging in the diagnosis of chondral lesions: Comparison with knee arthroscopy.