Skip to main content

Advertisement

SpringerLink
Log in

The determination of safe zones for arthroscopic portal placement into the posterior knee by mapping the courses of neurovascular structures in relation to bony landmarks

  • Original Article
  • Published:
European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Purpose

Minimally invasive surgery in the posterior knee is high risk for iatrogenic injury to popliteal neurovascular neurovasculature structures. This study aimed to use reliable landmarks to define safe zones for arthroscopic portal placement into the posterior knee.

Methods

Distances were measured between bony landmarks and neurovascular structures within the popliteal fossa using 45 formalin-embalmed cadavers: small saphenous vein (SSV), medial (MCSN) and lateral (LCSN) cutaneous sural nerves, tibial nerve (TN), common fibular nerve (CFN), popliteal vein (PV) and artery (PA). The structures were measured in relation to medial (MEF) and lateral (LEF) femoral epicondyle, medial (MCT) and lateral (LCT) tibial condyle and the midpoint between the landmarks.

Results

The mean distance (mm) between MEF and structures was, male and female, respectively: SSV 37.6 + 12.5, 37.9 + 8.2; MCSN 39.2 + 14, 38.8 + 10.1; TN 39.4 + 10.2, 38.0 + 8.1; PV 38.4 + 12.9, 32.8 + 5.6; PA 38.4 + 12.1, 34.6 + 4.9. At midpoint and MCT all structures medialized between 5 and 28%. The mean distance between LEF and structures was, male and female, respectively: CFN 13.4 + 8.2, 8.4 + 9.1; LCSN 24.9 + 7.3, 18.4 + 10.4. At midpoint and LCT the CFN lateralized by 37–42% and the LCSN medialized by 8–9%.

Conclusions

Results suggest posteromedial portal placement can be safely established < 20 mm from the medial femoral epicondyle, tibial condyle or the midpoint between the two landmarks. Posterolateral portal placement is of higher risk, and entry point is 18 mm from the lateral femoral epicondyle, tibial condyle or the midpoint between the two landmarks in males and 12 mm in females. These landmarks will allow safe portal placement in 99% of cases.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

Raw data were generated at XXX. Derived data supporting the findings of this study are available from the corresponding author, XXX, on request.

Code availability

Not applicable.

References

  1. Ahn JH, Lee SH, Jung KH, Koo KH, Kim SH (2011) The relationship of neural structures to arthroscopic posterior portals according to knee position. Knee Surg Sports Traumatol Arthrosc 19(4):646–652

    Article  PubMed  Google Scholar 

  2. Blackmon JA et al (2013) Locating the sural nerve during calcaneal (Achilles) tendon repair with confidence: a cadaveric study with clinical applications. J Foot Ankle Surg 52(1):42–47

    Article  PubMed  Google Scholar 

  3. Boytim MJ, Smith JP, Fisher DA, Quick DC (1995) Arthroscopic posteromedial visualization of the knee. Clin Orthop Relat Res 310:82–86

    Google Scholar 

  4. Buyukdogan K, Laidlaw MS, Millar MD (2017) Meniscal ramp lesion repair by a trans-septal portal technique. Arthrosc Tech 6:1379–1386

    Article  Google Scholar 

  5. Cancienne JM, Werner BC, Burrus MT, Kandil A, Conte EJ, Gwathmey FW, Miller MD (2017) The transseptal arthroscopic knee portal is in close proximity to the popliteal artery. J Knee Surg 30(9):920–924

    Article  PubMed  Google Scholar 

  6. Chen H, Chang S, Pan J (2015) Recent progress in the diagnosis and treatment of posterior tibial plateau fractures. Int J Clin Exp Med 8(4):5640–5648

    PubMed  PubMed Central  Google Scholar 

  7. Dilworth B, Fehrenbacher V, Nyland J, Clark J, Green JW (2018) Lateral knee compartment portals: a cadaveric study defining a posterolateral viewing safety zone. Arthroscopy 34(7):2201–2206

    Article  PubMed  Google Scholar 

  8. Eisma R, Lamb C, Soames RW (2013) From formalin to thiel embalming: What changes? one anatomy department’s experiences. Clin Anat 26(5):564–571

    Article  CAS  PubMed  Google Scholar 

  9. Faucett SC, Gannon J, Chahla J, Ferrari MB, LaPrade RF (2017) Posterior surgical approach to the knee. Arthrosc Techn 6(2):e391–e395

    Article  Google Scholar 

  10. Fonkoue L, Behets CW, Steyaert A, Kouassi JK, Detrembleur C, De Waroux BLP, Cornu O (2019) Accuracy of fluoroscopic-guided genicular nerve blockade: a need for revisiting anatomical landmarks. Reg Pain Anesth Pain Med. https://doi.org/10.1136/rapm-2019-100451

    Article  Google Scholar 

  11. Garagozlo C et al (2019) The anatomical relationship between the sural nerve and small saphenous vein: an ultrasound study of healthy participants. Clin Anat 32(2):277–281

    Article  PubMed  Google Scholar 

  12. Hallgren A, Björkman A, Chemnitz A, Dahlin LB (2013) Subjective outcome related to donor side morbidity after sural nerve graft. BMS Surg 13:39

    Article  Google Scholar 

  13. Hohmann E, Keough N, Glatt V, Tetsworth K, Putz R, Imhoff A (2019) The mechanical properties of fresh versus fresh/frozen and preserved (Thiel and Formalin) long head biceps tendons: a cadaveric investigation. Ann Anat 221:186–191

    Article  PubMed  Google Scholar 

  14. Huelke DF (1957) A study of the formation of the sural nerve in adult man. Am J Phys Anthropol 15:137–145

    Article  CAS  PubMed  Google Scholar 

  15. Kennel L, Martin DMA, Shaw H, Wilkinson T (2018) Learning anatomy through Thiel- vs. formalin-embalmed cadavers: student perceptions of embalming methods and effects on functional anatomy knowledge. Anat Sci Educ 11(2):166–174

    Article  PubMed  Google Scholar 

  16. Keyurapran E, Phoemphunkunarak W, Lektrakool N (2016) Location of the neurovascular bundle of the knee during flexed and extended position: an MRI study. J Med Assoc Thai 99(10):1102–1109

    Google Scholar 

  17. Kim SJ, Song HT, Moon HK, Chun YM, Chang WH (2011) The safe establishment of a transeptal portal in the posterior knee. Knee Surg Sports Traumatol 19(8):1320–1325

    Article  Google Scholar 

  18. Makridis KG, Wajsifisz A, Agrawal N, Basdekis G, Dijan P (2013) Neurovascular anatomic relationships to arthroscopic posterior and transeptal portals in different knee positions. Am J Sports Med 41(7):1559–1564

    Article  PubMed  Google Scholar 

  19. McGinnis MD 4th, Gonzalez R, Nyland J, Caborn DN (2011) The posteromedial knee arthroscopy portal: a cadaveric study defining the safe zone for portal placement. Arthroscopy 27(8):1090–1095

    Article  PubMed  Google Scholar 

  20. Morin WD, Steadman JR (1993) Arthroscopic assessment of the posterior compartments of the knee via the intercondylar notch: the arthroscopist’s field of view. Arthroscopy 9(3):284–290

    Article  CAS  PubMed  Google Scholar 

  21. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174

    Article  CAS  PubMed  Google Scholar 

  22. Ogilvie-Harris DJ, Biggs DJ, Mackay M, Weisleder L (1994) Posterior portals for arthroscopic surgery of the knee. Arthroscopy 10(6):608–613

    Article  CAS  PubMed  Google Scholar 

  23. Ohishi T, Takahashi M, Suzuki D, Matsuyama Y (2015) Arthroscopic approach to the posterior compartment of the knee using a posterior transseptal portal. World J Orthop 6(7):505–512

    Article  PubMed  PubMed Central  Google Scholar 

  24. Ortigüela ME, Wood MB, Cahill DR (1987) Anatomy of the sural nerve complex. J Hand Surg Am 12(6):1119–1123

    Article  PubMed  Google Scholar 

  25. Pace JL, Wahl CJ (2010) Arthroscopy of the posterior knee compartments: neurovascular anatomic relationships during arthroscopic transverse capsulotomy. Arthroscopy 26(5):637–642

    Article  PubMed  Google Scholar 

  26. Pyun SB, Kwon HK (2008) The effect of anatomical variation of the sural nerve on nerve conduction studies. Am J Phys Med Rehabil 87(6):438–442

    Article  PubMed  Google Scholar 

  27. Sabat D, Jain A, Kumar V (2016) Displaced posterior cruciate ligament avulsion fractures: a retrospective comparative study between open posterior approach and arthroscopic single-tunnel suture fixation. Arthroscopy 32(1):44–53

    Article  PubMed  Google Scholar 

  28. Sora MC, Dresenkamp J, Gabriel A, Matusz P, Wengert GJ, Bartl R (2015) The relationship of neurovascular structures of the posterior medial aspect of the knee: an anatomic study using plastinated cross-sections. Rom J Morphol Embryol 56(3):1035–1041

    PubMed  Google Scholar 

  29. Thi C, Van Huy N, Nguyen NC, Thanh TH (2018) Applied anatomy of the common fibular nerve: a cadaveric study. Int J Med Pharm 6(1):6–10

    Google Scholar 

  30. Yasar E, Kesikburun S, Kilic C, Güzelkücük U, Yazar F, Tan AK (2015) Accuracy of ultrasound-guided genicular nerve block: a cadaveric study. Pain Phys 18(5):E899-904

    Google Scholar 

  31. Yoo JH, Chang CB (2009) The location of the popliteal artery in extension and 90 degree knee flexion measured on MRI. Knee 16(2):143–148

    Article  PubMed  Google Scholar 

Download references

Funding

Not applicable.

Author information

Authors and Affiliations

  1. Department of Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa

    Kelsi Greenwood, Reinette Van Zyl & Natalie Keough

  2. Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates

    Natalie Keough

  3. Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates

    Erik Hohmann

  4. School of Medicine, University of Pretoria, Cnr Bophelo and Dr Savage Road, Gezina, Pretoria, 0001, South Africa

    Erik Hohmann

Authors
  1. Kelsi Greenwood
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Reinette Van Zyl
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Natalie Keough
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Erik Hohmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Erik Hohmann.

Ethics declarations

Conflict of interest

The author(s) declare that they have no conflict of interests.

Ethics approval

Ethics approval was obtained from the from the Faculty of Health Sciences Research and Ethics Committee, University of Pretoria (Ethics reference number 82/2019 for review) (Ethics number: XXX/2019).

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Greenwood, K., Van Zyl, R., Keough, N. et al. The determination of safe zones for arthroscopic portal placement into the posterior knee by mapping the courses of neurovascular structures in relation to bony landmarks. Eur J Orthop Surg Traumatol 31, 1087–1095 (2021). https://doi.org/10.1007/s00590-020-02847-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00590-020-02847-4

Keywords

Search

Navigation