The Knee Exam
Observation:
1. Make sure that both knees are fully exposed. The patient should be in either a gown or shorts. Rolled up pant legs do not provide good exposure!
2. Watch the patient walk. Do they limp or appear to be in pain? When standing, is there evidence of bowing (varus) or knock-kneed (valgus) deformity? There is a predilection for degenerative joint disease to affect the medical aspect of the knee, a common cause of bowing. Varus Knee Deformity, more marked on the left leg. 3. Make note of any scars or asymmetry. Chronic/progressive damage, as in degenerative joint disease, may lead to abnormal contours and appearance. Is there obvious swelling as would occur in an effusion? Redness suggesting inflammation? 4. Is there evidence of atrophy of the quadriceps, hamstring, or calf muscle groups? Knee problems/pain can limit the use of the affected leg, leading to wasting of the muscles.

While both legs have well developed musculature,
the left calf and hamstring are bulkier than the right. 5. Look at the external anatomy, noting structures above and below the knee itself: 1. Patella 2. Patellar tendon 3. Quadriceps/Hamstring/Calf muscles 4. Medial and lateral joint lines. 5. Femur and Tibia 6. Tibial tuberosity


Ballotment (helpful if the effusion is large) 1. Slightly flex the knee which is to be examined.
2. Place one hand on the supra-pateallar pouch, which is above the patella and communicates with the joint space. Gently push down and towards the patella, forcing any fluid to accumulate in the central part of the joint.
3. Gently push down on the patella with your thumb.
4. If there is a sizable effusion, the patella will feel as if it's floating and "bounce" back up when pushed down.

Removal of pregnancy within the fallopain tube using laparoscopic keyhole surgery. A segment of the tube together with the pregnancy within is removed video.

Pancreatic pseudocyst drainage was the first therapeutic application of EUS. The cyst is punctured under ultrasound guidance, contrast injected, and a guidewire inserted. Initial dilation to 8mm is performed over the wire The EUS scope is then exchanged over the wire for a forward viewing endoscope.... A second dilation to 18mm is performed. This enables entry of the endoscope into the cyst perform cystoscopy, debridement if necessary, and insertion of multiple large bore double pigtail stents. The curved linear array-or CLA—echoendoscope has oblique viewing optics located proximal to an oblique scanning transducer. The accessory exits from the shaft of the echoendoscope at an ablique angle, adjustable between 15 and 30 degrees. There are several technical limitations using this echoendoscope. The oblique angle of exit results in a weekend transfer of force when advancing the accessory, difficult deployment of larger bore accessories, and in instrument tunneling effect relative to the bowel wall. There is the potential loss of access during endoscope exchange. A novel CLA echoendoscope was developed by the Olympus Corporation that shifts the orientation of endoscopic and ultrasound views from oblique to forward viewing. The channel is therapeutic at 3.7mm Note that the working channel is located adjacent to the ultrasound transducer at the endoscope tip. The accessory exits the working channel in the axis of the shaft. Shown here are balloon inflation and deployment of a Dormia basket. We report on the use of the prototype forward viewing echoendoscope in six consecutive patients who were referred for pancreatic cyst drainage. Here you see endoscopic view-indistinguisable from that of a gastroscope-showing a bulge where the cyst impinges against the posterior gastric wall. Power Doppler is switched on and highlights multiple vessels interposed in the wall This allows selection of a safe vessel-free window for a cyst puncture A 19 G needle is advanced into the cyst lumen. A sample of contents is aspirated for fluid analysis. A guidewire under ultrasound guidance into the cyst. An 18mm balloon is coaxially thread over the wire and advanced across the cyst wall, Note that resistance is encountered, but the forward transfer of force overcome this. The dilation is performed under forward viewing endoscopuc and ultrasound guidance. As the balloon is maximally inflated we see the cystgastrostomy open up. The balloon is then deflated while simultaneously advancing the scope into the cyst cavity. Cystoscopy isnow performed showing the cyst contents to be filled with pasty wall-adherent necroses. Pulsed power Doppler is switched on we can see and hear arterial flow vessels within the wall of the cyst. This identifies sensitive areas at bleeding risk when performing debridement In this case vigorous water jet irrigation is performed through an accessory water irrigation channel built into the echoendoscope. This issued to clear nonadherent debris. Our experience has shown that it is not necessary to actively remove wall-adherent debris using extraction tools as such Dormia or Roth net basket to achieve cyst resolution. Three large bore 10 Fr double pigtail stents are now inserted into the cyst under direct endoscopic guidance. The first stent is delivered over a guide catheter. The second stent. And the third stent All three stents are deployed. Finally, a nasocystic catheter is inserted for maintenance irrigation. In another patient we used the Cook Cystome to perform cystgastrostomy. We have found the Cystotome easy to delivery through the forward viewing echoendoscope. As shown, we advance the Cystotome into the cyst while applying diathermy. This is performed under and endoscopic guidance, entering the cyst at a near perpendicular orientation. After entry, the Cystotome is removed and cyst fluid gushes from the cystagastrotomy site.

Resection of a glioblastoma multiforme, a very malignant, aggressive brain tumor.

Scleral fixated IOLs in case of inadequacy of capsular support and scleral sutured capsular tension rings when adequate zonular support is inavailable have been recently used in cataract surgery. In these techniques, polypropylene suture is used and the suture ends over the sclera after the knot ha...s been formed, may erode the conjunctiva and become exposed. Thus, the erosion may lead to the development of endophtalmitis. In order to prevent the aforementioned complication, scleral flaps, otologous cornea, duramater or fascia lata patches have been used to cover the knot and rotation of the knot into the tissues has been described.

A 49-year old female patient complainig of cough. X-ray and chest CTscan showed a 2.5cm nodule in the left upper lobe. Transthoracic biopsy was consistent with adenocarcinoma. PET-Scan and CT Scan showed no mediastinal disease. The procedure was performed through three incisions.

Removal of the superficial lobe is performed on a child presenting with a mass

Single tooth implant

A LASAG Yag laser is in thermal mode, 1.5 Joules/pulse to treat the trabecular meshwork between the cornea and iris for glaucoma. The view is of the inside anterior eyeball.

Percutaneous Endoscopic Colostomy

Stephen has sharing his experience with the others.

Dealing with choking

removal of a "toxic" phaeochromocytoma

How to infuse a local anesthetic into a wound.

How to test radial & ulnar artery circulation

Closed Rhinioplasty Exposing The Nasal Structures

Lembert Suture for the intestine

foot cast used in Toe Fractures

A video discussing the Liver Cancer Treatment with Radiofrequency Ablation

A case of soft tissue Sarcoma of the thigh presenting as a long standing mass that recently showed rapid gross and fluctuation. Patient 34 years old presented with sever pain and inability to walk. Abscess like symptoms