Knee arthroscopy without the use of the tourniquet could enhance the use of the Y sign for determining optimal placement of the anteromedial portal

Abstract

Gulan et al. conducted a study, designed as case series, to identify an anatomical landmark that could facilitate optimal anteromedial portal placement during knee arthroscopy, thus helping less experienced surgeons not to damage the meniscus or the cartilage and shorten the learning curve [2]. The authors determined the relationship of the optimal position of the intramuscular needle for the anteromedial portal placement and the subcutaneous venous joining or the curve of a single vein at the medial patellar tendon border in 70 patients undergoing knee arthroscopy. The authors used elevation of the leg for 4 min for exsanguination and, afterwards, inflation of the thigh tourniquet in all patients. Arthroscopic illumination of the anteromedial part of the knee was performed to visualize the subcutaneous veins before determining the position of the anteromedial portal. The authors reported the veins in this area were visible in all patients. Venous joining of the two veins was described in 70% of cases and addressed as the Y sign, while a single vein curve was described in 30% of the cases. According to the authors, the venous joining or the venous curve was found just adjacent to the optimal position for the anteromedial portal. We believe that the described Y sign can indeed be helpful for less experienced surgeons performing knee arthroscopy. Although the authors managed to visualize the Y sign in 70% of the patients, they also acknowledged that their findings might not be generalizable to all patients undergoing knee arthroscopy [2]. It is our opinion that the visibility of the Y sign could be improved if the tourniquet was not used. The tourniquet use was described as a possible cause of serious complications, of which pulmonary embolism and deep vein thrombosis are the most wellknown [3]. In recent literature, there is evidence supporting safe and efficient arthroscopic procedures both on the knee and the ankle, without the use of the tourniquet [1, 4]. A meta-analysis from Zhang et al. in 2013 included five randomized controlled trials regarding the effect of the tourniquet use on arthroscopic visualization and operative time in knee arthroscopy, concluding that the tourniquet use is no longer advisable for routine arthroscopic knee surgery [5]. In addition, a systematic review and meta-analysis of 16 randomized controlled trials by Wang et al. from 2019 showed that the arthroscopic surgery of the knee without the tourniquet resulted in less postoperative blood loss and less consumption of analgesics [4]. Furthermore, there was no difference when compared to the tourniquet use regarding arthroscopic visualization, postoperative pain scores, postoperative quadriceps muscle strength and operation time. Thus, the authors suggested that the current evidence was in favor of not using the tourniquet as a routine procedure during arthroscopic surgery of the knee. Therefore, not using the tourniquet in knee arthroscopy could have multiple benefits, not only by avoiding the possible complications, but also by enhancing visibility of the subcutaneous veins and facilitating the positioning of the anteromedial portal, thus helping less experienced surgeons during their training in knee arthroscopy.