1. Joint Preservation Surgery for Medial Compartment Osteoarthritis
Deepak Goyal, M.B.B.S., M.S.(Ortho.), D.N.B.(Ortho.), M.N.A.M.S., Anjali Goyal, M.B.B.S., M.D.(Pathol.), D.I.C.P.(Histopathol.), Nobuo Adachi, M.D. 
Arthroscopy Techniques 
Volume 6, Issue 3, Pages e717-e728 (June 2017)
DOI: /j.eats
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2. Fig 1
Patient selection while performing a joint preservation surgery for medial compartment osteoarthritis (MCOA). (BMI, body mass index; MRI, magnetic resonance imaging; PCL, posterior cruciate ligament.)
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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3. Fig 2
The special instruments required for the joint preservation surgery apart from the instruments used in a routine arthroscopy and osteotomy procedure. (1) Curved lamina spreader. (2) Straight lamina spreader (J. J. International Instruments, Kerala, India). (3) Osteotomy gauze (Anujay Engineering, Ahmedabad, India). (4) A series of thin and long osteotomes (J. J. International Instruments, Kerala, India).
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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4. Fig 3
Arthroscopy pictures of the left knee, viewing from the anterolateral portal. Assessment of the chondral lesion while performing the arthroscopy part of the joint preservation surgery. The medial meniscus is normal in this case, whereas a large degenerative lesion is seen at the medial femoral condyle articular surface.
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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5. Fig 4
Arthroscopy pictures of the left knee, viewing from the anterolateral portal. Cartilage lesion preparation while performing the arthroscopy part of the joint preservation surgery. A sharp curette is used to sharply demarcate and stabilize the degenerated cartilage from the healthy surrounding cartilage of medial femoral condyle. The scrapping is performed till all the unhealthy cartilage and the calcified cartilage are removed.
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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6. Fig 5
Arthroscopy pictures of the left knee, viewing from the anterolateral portal. Assessment of bone marrow access after microfracture (hollow black arrows) while performing the arthroscopy part of the joint preservation surgery. The degenerative lesion is scrapped and then microfracture is performed as part of the cartilage repair technique. The freshly bleeding microfracture holes (solid black arrows) indicate a good access to subchondral bone marrow and its autogenous stem cells.
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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7. Fig 6
Vertical incision on the medial surface of the proximal tibia over the pes complex while performing the osteotomy part of the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. After exposure of pes complex, an “S”-shaped incision is put on the medial surface of the proximal tibia (black arrows). The upper arm of “S” is in the center of the proximal part of the medial surface of the tibia. The center of “S” is along the upper border of the pes tendons, whereas the lower vertical arm of “S” is along the anterior border of the tibia, just medial to the pes tendon insertion. Solid blue arrow, tibial tuberosity; solid white arrows, arthroscopy portals.
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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8. Fig 7
Exposure of the medial surface of the proximal tibia while performing the osteotomy part of the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. Two large Hohmann retractors along the posterior border of the tibia to protect the medial structures such as the medial collateral ligament and the pes tendons (black arrows). These retractors also protect the posterior structures. Also note a small Hohmann retractor proximal to the tibial tuberosity (blue arrow) protecting the patellar tendon (white arrow).
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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9. Fig 8
Guide pin insertion while performing the osteotomy part of the joint preservation surgery. Left knee peroperative C-arm anteroposterior view, the patient lying supine with the leg straight on the table and the hip internally rotated. The C-arm is introduced to the surgical field from the lateral side of the left knee while the surgeon is standing on the right side of the patient. A guide pin is passed from the medial side aiming just superior to the proximal tibiofibular joint. A small retractor is retracting the patellar tendon (while arrow), whereas the large retractor is retracting the pes-medial collateral ligament complex (black arrow). Note that the anterior and posterior borders of the medial tibial plateau are overlapping with each other.
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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10. Fig 9
Osteotomy plane demarcation while performing the osteotomy part of the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. A motorized saw is used to put an osteotomy cut (solid black arrows) on the medial surface adjacent to the guide pin and parallel to the medial articular surface. Note that the posteromedial structures are retracted safely using the Hohmann retractor (empty black arrows), whereas the patellar tendon is retracted anteriorly using a small Hohmann retractor (white arrow), just above the tibial tuberosity (blue arrow).
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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11. Fig 10
Biplanar osteotomy demarcation while performing the osteotomy part of the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. Because the tibia tuberosity comes in the plane of osteotomy cut (solid black arrows), a biplanar osteotomy is recommended. A 10-mm osteotome (hollow white arrow) is used to angulate the osteotomy toward proximal direction so that a biplanar osteotomy passes just above the tibia tuberosity (blue arrow), whereas the patellar tendon is safely retracted using a small Hohmann retractor (solid white arrow). Note that the posteromedial structures are kept retracted using large Hohmann retractors (hollow black arrows).
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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12. Fig 11
Gradual opening of osteotomy while performing a joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. Stacking of long thin osteotomes helps in a gradual opening of the osteotomy (solid black arrows). A simultaneous opening of biplanar osteotomy (hollow white arrow) takes place just above the tibial tuberosity (blue arrow). Note that the posteromedial structures are continuously retracted using large Hohmann retractors (hollow black arrows) and the patellar tendon is continuously retracted using a small Hohmann retractor (solid white arrow).
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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13. Fig 12
Measuring the osteotomy opening using the osteotomy gauze while performing the joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. An osteotomy gauze (Anujay Engineering, Ahmedabad, India) not only helps in a gradual opening of the osteotomy (hollow white arrow) but also helps in measuring the size of opened-up osteotomy (solid black arrows). Note that the posteromedial structures are continuously retracted using large Hohmann retractors (hollow black arrows) and the patellar tendon is continuously retracted using a small Hohmann retractor (solid white arrow) just above the tibial tuberosity (solid blue arrow).
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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14. Fig 13
Fixation of an osteotomy plate. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. Osteotomy plate fixation using 2 proximal cancellous screws and 2 distal cortical screws (Hib Surgicals, Mumbai, India). Note that the posteromedial structures are continuously retracted using large Hohmann retractors (hollow black arrows).
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
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15. Fig 14
Suturing of the pes complex while performing a joint preservation surgery. Left knee, viewing from the medial side, the patient lying supine with the leg straight on the table and the hip internally rotated. The pes complex (hollow black arrows) is brought back to its original insertion site near the tibial tuberosity (solid blue arrow) and the anterior border.
Arthroscopy Techniques 2017 6, e717-e728DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions