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General Principles of Arthroscopy

Chairperson-Dr. Chetan D.M. Presenter- Dr. Utkarsh Dwivedi

WHAT IS ARTHROSCOPY?This word arthroscopy came from GREEK , "arthro" (joint) and "skopein" (to look).

The term literally means to look within the joint simply as if you see a room through a key hole instead of opening doors. .It offers a high degree of accuracy combined with low morbidity for making diagnosis and offering treatment.

INDEXInstruments and equipmentAnesthesiaDocumentationAdvantages & DisadvantagesIndications & contraindicationsBasic arthroscopic techniquesComplications

INSTRUMENTS AND EQUIPMENTS

ARTHROSCOPE-

It is a rigid optical instrument.Optical characteristics of an arthroscope are determined by diameter, angle of inclination and field of view.Diameter : 1.7-7 mm4mm is the most commonly used, especially for knee joint.1.9 & 2.7 mm useful for tighter joints like wrist & ankles.

Angle of inclination-is angle between axis of arthroscope and a line perpendicular to surface of the lens, varies from 0-120*.25-30* is the most commonly used70-90* is for seeing around corners or postero-lateral corners of the knee joint

Field of view-refers to viewing angle encompassed by lens and varies according to type of arthroscope.1.9 mm scope has a 65* field of view.2.7mm scope has 90* filed of viewWider viewing angles make orientation by observer much easier.

Two designs- -Viewing -Operating, developed by O'Conner allows direct viewing , with a channel for the placement of operative instruments in line with the arthroscope.

ARTHROSCOPY EQUIPMENTS ASSEMBLY

FIRBREOPTIC LIGHT SOURCESLIGHT SOURCES : 300 350 watts required.

Tungsten, halogen & xenon sources.

Can produce low & high intensity output.

FIBREOPTIC CABLE :-Fragile ,should be handled carefully.-One end connected to light source & another to Arthroscope.Works on the principle of Total internal refraction.-Length of cable also important as some amount of transmitted light is lost for each foot of cable.

Now-a-days breakage of Fibreoptic cable has been eliminated with introduction of liquid (glycerin) light guides.

FIBREOPTIC CABLE ASSEMBLY

TELEVISION CAMERASFirst introduced by McGinty and JohnsonMore comfortableAvoidance of contamination by the surgeons faceImprovement offered by latest three chip technology-Decrease size of cameraIncrease resolution of imageCableless arthroscopic systems in which video signal is transmitted from an arthroscope with its own light source

BASIC INSTRUMENT KITArthroscopes30 and 70 degrees ScissorsProbesBasket forcepsGrasping forcepsArthroscopic knivesMotorized meniscus cutter and shaverLaser/radiofrequency instrumentsMiscellaneous epuipment

PROBEThe extension of the arthroscopists finger. Used-To feel the consistency of a structureTo determine the depthTo identify and palpate loose structuresTo maneuver loose bodies into more accessible grasping positionTo probe fossae & recessTo maneuver intraarticular structureTo elevate meniscus

Most are right-angled2 mm fixed tip size. This is used to measure length of structures inside joint cavity.Use the elbow of the probes for palpationMagnification occurs with the arthroscope; the closer it is the higher the magnification. So it can be placed close or far depending on the observers desire.

SCISSORS3-4 mm in diameterJAWS : straight / hooked -hooked scissors preferred as jaws hook tissue & pull it between cutting edges of scissors rather than pushing materials as in straight scissors.

CURVES : right / left

ANGLES : right / left, usually with a rotating of jaw mechanism, actually cut at an angle to shaft of the scissors. -useful in detaching difficult-to-reach meniscal fragments.

BASKET FORCEPSOne of the most commonly used arthroscopic instruments.Open base that permits the tissue to drop free within the joint & dont require instrument to be removed from the joint & cleaned with each bite. The debris is subsequently removed from the joint by suction.3-5mm sizes with straight or curved shaftUsually used for trimming the peripheral rim of the meniscus

Basket forceps specialized for meniscus are wide, low-profile baskets with hooked configuration.Shaft : straight / curvedJaws : straight / hookedBasket in assortment of 30 , 45 , 90 degree.Also as 15 degree up & down biting.

GRASPING FORCEPSRetrieve material from the joint generally loose bodies from knee joint.Grasping tissue to cutting used to retrieve material from the joint, or to hold other tissue under tension to facilitate cutting.Rachet closure system for better hold.Jaws : single / double action with regular serrated interdigitating teeth / 1 2 sharp teethUsually double side serrated forcep is used for securing loose bodies as it doesnt slip from it.

ELECTROSURGICAL LASERSELECTROCAUTERY :For cutting & hemostasis previously.Now a days only to obtain hemostasis after Ascopic synovectomy & subacromial decompression.Works in a non-electrolyte medium like distilled water, Carbon dioxide or glycine.Newer coated tip function in both NS / RL.LASER :role under investigation.CO2 laser ,YAG laser, excimer laser

RADIOSURGICAL SYSTEM

Radiofrequency systems are used for tissue ablation, electrocautery, & capsular shrinkage.Monopolar uses a grounding pad & draw energy through the body.Bipolar in it energy is transferred b/w electrodes at the site of treatment.They are used for cutting and haemostasis for arthroscopic synovectomies and subacromial decompression.Complications include- articular cartilage damage, osteonecrosis, tissue damage.

KNIFE BLADES

These should be inserted through cannula sheaths and cutting portion be exposed only when it enters the arthroscopic field.Available varities are- hooked or retrograde blades, regular down-cutting blades-straight and curved.Magnetic properties of blades are helpful in retrieving them when broken.

MOTORISED SHAVING SYSTEMSConsisting ofOuter hollow sheathInner hollow rotating cannula with corresponding windows & dia. of cutting tip usually 3 5.5 mm.

principle : the window of inner sheath function as a two edged cylindrical blade ,that spins within the outer hollow tube. Suction through the cylinder brings the fragment of soft tissue in the window and as the blade rotates ,the fragments are amputated ,sucked to the outside ,and collected in the suction trap.

Special blade, for meniscal cutting or trimming, Synovial resection, and for shaving of articular cartilage. Special abraders & burrs for arthroscopic acromioplasty & cruciate Ligament reconstructions.

Both clockwise & anticlockwise rotation. Reversing the rotation improves cutting efficiency & minimises Clogging with debris.

IMPLANTSSuture anchorsMeniscal repair devicesDevices for tendon and ligament fixationArticular cartilage repair

SUTURE ANCHORS

Used to attach ligaments and tendons to bone without bony tunnel passage of suturesDesirable characteristicsMust fix the suture to the bonePermit an easy surgical techniqueNot cause long-term problems

MENISCAL REPAIR DEVICESAllow an all-inside meniscal repair without the need for arthroscopic knot-tying3 categoriesArrowsDartsMeniscal screws

IRRIGATION SYSTEMSIrrigation and distensionEssential to all arthroscopic proceduresJoint distension is maintained better by RL than NS.Inflow is via arthroscopic sheath: 6.2mm diameter with the cannula in separate portal with 68mm of pressure of water.Usually two 5 Lit plastic bags of RL , interconnevted with a Y-connector are suspended for use with the arthroscopy pump. Continuous irrigation is needed to-Keep clear viewingMaintain hydrostatic pressure and distension

DISTENSION PRESSUREIt is optimal pressure required to distend the joint.Ingress = egress to maintain hydrostatic pressure & distention within joint.For each foot of elevation of solution bag above joint = 22 mm of hg pressureVaried according to joint as follows :Knee 60 -80 mm of hgShoulder 30 mm of hg below systolic pressureElbow 40 60 mm of hgAnkle 40 60 mm of hg

type of pump (arthrex AR 6450 , stryker 1.5L high flow pump , arthro FMS4 ,& acutex inteliject )all maintained a pressure of 60 mm of hg accurately.

Sensor mechanism to check over distention.Distention is essential for arthroscopic viewing as it pushes synovial folds & other soft tissues out of the way in viewing area, expands internal capacity of joint, allowing greater maneuverability of arthroscope, defining proper portal entry points like posteromedial & posterolateral portals in knee.

TORNIQUETContraindicationsHistory of thrombophlebitisSignificant peripheral vascular diseaseAdvantagesIncreased visibilityDisadvantagesBlanching of the synoviumDifficult to diagnosis synovial disordersIschemic damage if prolonged touniquet time (90-120min)

LEG HOLDERSThe biggest advantage of leg holders is that they permit application of stress primarily to open the posteromedial compartment for viewing or manipulation of the meniscus and posterior horn meniscuc surgery.The post does not confine knee and offers unlimited number of positions for the knee to be placed.DisadvantagesObstruct the operations in lateral compartment

Use in case of medial compartment disease

METHOD OF STERILIZATION

Ethylene oxide(best method)

Low temperature sterilization process

CIDEX is used for cold disinfection of equipments between successive procedures during whole day.

Knives, forceps etc.: by steam autoclaving.

Fibreoptic materials, camera, motorised instruments: by soaking in CIDEX sol. For 10 min. or in STERIS for 30 min.

ANESTHESIA

Arthroscopy can be performed underLocal AnesthesiaRegional AnesthesiaGeneral Anesthesia

REGIONAL ANESTHESIAUsually used in lower extremities-Epidural or spinal anesthesiaFemoral and sciatic blocksFeatures of peripheral blocks-Immediate ambulationRequire experience anesthesiologistLonger time to prepare Generally use a 1:1 mixture of 1% lignocaine and 0.25% bupivacaine.Upper extremitiesBrachial Block

GENERAL ANESTHESIA

Used in cases of-

Not cooperative patientsAllergy to local anestheticsLess experienced surgeonIncreased pain (acutely injured knee)

POST-OP PAIN

Oral NSAIDs or IM,IV administrationReduce swellingIncrease ROM in early postoperative period30mL of 0.25% bupivacaine +/-Morphine 3 mg intraarticular or subacromial flowExcellent postoperative pain reliefCatheters should be removed in 48 hours

DOCUMENTATION

Drawings and documentation are very essential

35-mm reflex camera photos

Digital video recordings

INDICATIONS OF ARTHROSCOPYDIAGNOSTIC-For preoperative evaluation & confirmation of clinical diagnosis-For documentation in medicolegal casesTHERAPEUTICSmoothening of Torn cartilageDamaged ligaments reconstruction Loose bodies removal Joint effusionsBiopsy proceduresFracture fixationSports Related Injuries

ADVANTAGES OF ARTHROSCOPY

Reduced postoperative morbiditySmaller incisionLess intense inflammatory responseImproved thoroughness of diagnosisAbsence of secondary effectsNeuromas, scars

Reduced hospital costReduced complication rateImproved follow-up evaluation : second-lookPossibility of performing surgical procedures that are difficult to perform through open arthrotomy

DISADVANTAGES OF ARTHROSCOPY

Skill and temperament to perform arthroscopic surgeryNeed to maneuver within the tight confines of the intraarticular spaceTime-consuming procedures in cases of inexperienced surgeons and follows a steep learning curveExpensive equipment

INDICATIONS AND CONTRAINDICATIONSNo absolute indicationsDiagnostic arthroscopyPreoperative evaluation and confirmation of the clinical diagnosisDocumentation of specific lesionsContraindications Risk of joint sepsis, remote infectionAnkylosis around the jointCapsular disruption

HOW IS ARTHROSCOPY PERFORMED?

Under anesthesia make small incision in the skin around joint. Eg. Anteromedial and anterolateral entry points in the knee jnt.

A sterile fluid is pumped into joint and then the arthroscope is inserted. Examine joint by images from arthroscope

If necessary, other instruments inserted for procedure i.e. repair any damage or remove material that causes symptoms.

Afterwards, the fluid is drained out, cuts are closed & dressed.

BASIC ARTHROSCOPIC TECHNIQUESPatience and persistenceTechniques are mostly self-taughtArtificial models or amputated specimens for initial practicePerform arthroscopic procedures in the company of an experienced arthroscopist.It has a steep Learning curveKeep in mind that open arthrotomy is to be preferred over poorly performed arthroscopic procedures

TRIANGULATION TECHNIQUE

Involves use of one or more instruments inserted through separate portals and brought into the optical field of the arthroscope, the tip of the instruments and arthroscope forming apex of a triangle

When the instrument is located, the scope and instrument are advanced together towards the intended area, reducing the field of vision and increasing the magnification.

If disoriented and difficulty in triangulation the instrument may be brought into the joint to contact the sheath and sliding to the tip

Stereoscopic sense and two-handed ability are developed gradually

MOST COMMON CONDITIONS FOUND DURING ARTHROSCOPYAcute or Chronic InjuryShoulder:Rotator cuff tendon tears, impingement syndrome, and recurrent dislocationsKnee:Meniscal (cartilage) tears, chondromalacia (wearing or injury of cartilage cushion), and anterior cruciate ligament tears with instabilityWrist:Carpal tunnel syndromeLoose bodies of bone and/or cartilage:for example, knee, shoulder, elbow, ankle, or wristSome problems associated with arthritis also can be treated.

COMMONLY DONE ARTHROSCOPIC SURGERIES

Rotator cuff surgery

Repair or resection of torn cartilage (meniscus) from knee or shoulder

Reconstruction of anterior cruciate ligament in knee

Removal of inflamed lining (synovium) in knee, shoulder, elbow, wrist, ankle

Release of carpal tunnel

Repair of torn ligaments

Removal of loose bone or cartilage in knee, shoulder, elbow, ankle, wrist.

COMPLICATIONSDamage to intraarticular structures: most commonDamage to Menisci and Fat PadDamage to Cruciate LigamentsDamege to Extraarticular structuresHemathrosisThrombophlebitisInfectionTourniquet ParesisSynovial Herniation and FistulasInstrument Breakage

FOLLOW-UP AFTER ARTHROSCOPIC SURGERIESRECOVERY TIME DEPENDS UPON MANY FACTORS:severity of diseaseType of surgery.

Supports for 3 to 7 days, weight bearing on the operated leg as tolerated.Analgesics Rest, ice packs, and elevating the limb also recommended.

Physiotherapy not required in all patients, should be individualised.

sitting job can be resumed one week after surgery.

3 weeks to recover fully for routine daily activities.

3 months before one can comfortably return to sports..

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