Thank you for attending this course and for tuning into this talk on tips and tricks for making it easier treating discoid lateral menisci even in the very small knee. These are my disclosures none of which are relevant to this talk. I'd like to first highlight this paper done by the group in Dallas where they looked at 261 lateral meniscus tears in patients under 16 years old. 75% of those tears were of discoid morphology and that was true 97% of the time in kids under age 13. And if you look at the distribution on their graph there the red lines indicating discoid menisci, a hundred percent of lateral meniscus tears in kids 10 and under were discoid and this represents a group of very small knees. Therefore it's important to be able to effectively move around very small knees and I'm going to focus on tips and tricks in each of these three categories patient positioning, equipment, and interoperative techniques. Starting with patient positioning. Because discoid menisci are almost universally on the lateral side we access the lateral compartment by positioning in the figure of four position in order to create a varus force to open up the knee. Unfortunately children have greater flexibility including hip external rotation which can block our ability for figure of four to open up the lateral side of the knee so there's a few positioning tips that can help with that. First cheating the patient to the ipsilateral side of the bed helps remove any sort of block or impediment to the figure of four position. Second using a removable or breakaway post as noted in that picture is helpful for again removing equipment that can get in the way of the figure of four position putting a varus force on the knee. Although not used in this picture you can see where the red arrow is one could use an ipsilateral hip bump in order to prop that hip up and further give space in order to have the figure of four position create a varus force on the knee. And it's important with any as with any surgery after you're done positioning checking to make sure that you can get to the appropriate positions and in this case checking to make sure that varus force is able to be applied after you position and before you prep and drape. Interoperatively it's really important to have a full complement of biters and shavers. A full complement of biters includes standard size straight and angled biters and really important in small knees would be would be having available some skinny straight and angled biters. Curved biters to the right and left are really helpful as well as well as 90 degree biters to the right and the left. Back biters are also very helpful in working on the anterior horn of the meniscus. Similarly shavers come in multiple sizes curved and straight and it's important to have several different options available. Most manufacturers create a long 2.7 millimeter scope which is somewhat of a hybrid between the 4.0 millimeter standard arthroscope and the 2.7 millimeter short small joint arthroscope. It has the diameter of the small joint arthroscope but with the length of the standard arthroscope and it can be very helpful in extremely small knees. Also interoperatively it can be very helpful to lift the operative foot onto a padded mayo stand which can help counteract the hip external rotation and affect a greater amount of various force onto the knee and open up the lateral compartment. I like to create my medial working portal in the figure 4 position first by localizing with a spinal needle and making sure I like my trajectory towards the parts of the meniscus that we're going to be working on. This tends to be more central for posterior work and more medial on the anterior medial aspect of the knee for work on the anterior aspect of the meniscus but it's always reasonable to consider using both such as an accessory portal in order to work on all parts of the meniscus. I also like to create my portal in this position because it allows the skin capsule and fat pad all to be opened in the same trajectory in the position that you're going to be working on the knee. Once you're in the knee and beginning to work, this is a trick I learned from Ben Hayworth, you can start your saucerization by starting your biter right at the junction between the normal anterior horn tissue and the central tissue that's going to be resected. You can see that's identified here by the blue arrow and then you start your resection working from this point straight back towards the popliteal hiatus and then once you've created this channel you can work from within the meniscus which creates a greater space than you had before in order to affect a complete saucerization. Finally once you've done some work through the medial portal I find it extremely helpful to switch and view from the medial portal and work through the lateral portal. Most importantly this allows you to probe the anterior horn the meniscal capsular junction of the anterior aspect of the lateral meniscus to identify any instability. You can also work through this lateral portal with back biters in order to contour the anterior horn of the meniscus and you can also view from the medial portal to effectively work on an outside in repair if needed. In conclusion I like to have all of these things ready and available if I need them. I like to think of these tricks again in three categories, patient positioning, equipment availability, and intraoperative techniques and although you don't frequently need all or most of these it's important to have them in your armamentarium for maneuvering around these small knees. Thanks for your attention and thanks again for tuning into our course.

discoid lateral menisci

small knees

patient positioning

equipment

intraoperative techniques