General Principles of Arthroscopy

Pumsak Thamviriyarak, MD.Orthopaedics Department

Khonkaen Hospital

Campbell’s Operative Orthopaedics ed.11

OutlinesO Instruments and equipmentO AnesthesiaO DocumentationO Advantages & DisadvantagesO Indications & contraindicationsO Basic arthroscopic techniquesO Complications

Instruments and equipment

Arthroscope O Optical instrumentO Optical characteristics

O Diameter : 1.7-7 mmO 4mm is the most commonly used

O Angle of inclinationO 0-120 degreesO 30 degrees is the most commonly usedO 70-90 degrees : seeing around corners

or posterior compartmentO Field of view

Angle of inclination and field of view

ArthroscopeO 2 designs

O Operating arthroscopeO Operative instrument in line with the

arthroscpoeO Large-diameter sheath

O Viewing arthroscpoeO 2 portalsO Triangulation techniquesO Smaller size

Fiberoptic Light Sources

O Direct viewing via arthroscope :150 watts

O Television systemsO Demand more light intensity

O 300-350 wattsO Tungsten, Halogen, Xenon

Fiberoptic Light Sources

O Fiberoptic lightingO A bundle of specially prepared glass

fibersO Fragile : develop by using liquid light

guides (glycerin)O Length of cable: 8 inches lost for each

foot of cable

Television camerasO First introduced by McGinty and

JohnsonO More comfortableO Avoidance of contamination by the

surgeon’s faceO Improvement

O Decrease sizeO Increase resolutionO Recording deviceO Controls the light source

Basic instrument kitO Arthroscopes

O 30 and 70 degrees O ScissorsO Basket forcepsO Grasping forcepsO Arthroscopic knivesO Motorized meniscus cutter and

shaverO Miscellaneous epuipment

Accessory Instruments

ProbeO The extension of the arthroscopist’s finger

O To feel the consistency of a structureO To determine the depthO To identify and palpate loose structuresO To maneuver loose bodies into more

accessible grasping positionO Etc.

O Most are right-angledO 3-4mm tip sizeO Use the elbow of the probes to palpation

Scissors O 3-4 mm in diameterO Jaws : straight or hooked

O Hooked scissors are preferredO Pulling the tissue rather than pushing

away

O Right and left curved

Basket ForcepsO One of the most commonly usedO Open base that permits the tissue to

drop free within the jointO Subsequently removed from the joint by

suctionO 3-5mm sizes with straight or curved

shaftO Straight or hooked jawsO Usually used for trimming the peripheral

rim of the meniscus

Grasping ForcepsO Retrieve material from the jointO Grasping tissue to cutting

Knife BladesO Should be inserted through cannula

sheathsO Exposed only when it enters the

arthroscopic field

Motorized Shaving Systems

O Consisting ofO Outer hollow sheathO Inner rotating cannula with

corresponding windows

Motorized Shaving Systems

O Avoid oversucking : create bubbles in the jointO Decrease intensity of suctionO Increase inflow rateO Closed outflow from the arthroscope

ImplantsO Suture anchorsO Meniscal repair devicesO Devices for tendon and ligament

fixationO Articular cartilage repair

Suture anchorsO Attach ligaments and tendons to

bone without bony tunnel passage of sutures

O Desirable characteristicsO Must fix the suture to the boneO Permit an easy surgical techniqueO Not cause long-term problems

Meniscal repair devicesO Allow an all-inside meniscal repair

without the need for arthroscopic knot-tying

O 3 categoriesO ArrowsO DartsO Meniscal screws

Device for tendons and ligaments fixation

O Bone-to-bone or soft tissue-to-bone fixation

O Biodegradable or nonbiodegradable

Miscellaneous Equipment

O Sheaths and trocarsO Blade No.11O Switching sticks

Care and Sterilization of Instruments

O Fiberoptic arthroscopes and cablesO Best method is

O Gas (ethlyene oxide) :1 hourO Low-temperature sterilization process

(steris) :30 minO Most commonly used

O Activated glutaraldehyde (Cidex)

O Knives, graspers, basket forceps, cannulasO Steam autoclave

Irrigation SystemsO Irrigation and distension

O Essential to all arthroscopic proceduresO NSS or RLS

O InflowO Arthroscopic sheath: 6.2mm diameterO Cannula in separate portal

O Continuous irrigationO Keep clear viewingO Maintain hydrostatic pressure and

distension

Irrigation Systems

Irrigation SystemsO Optimal pressure in the joint

O Knee : 60-80 mmHgO Shoulder : 30 mmHg below systolic

BPO Elbow and ankle : 40-60 mmHg

O Each foot elevate from the level of the jointO Produced 22 mmHg pressure

O Outflow site should be closed during suctionO Potentially contaminated fluid into the

joint

Tourniquet O Contraindications

O History of thrombophlebitisO Significant peripheral vascular disease

O AdvantagesO Increased visibility

O DisadvantagesO Blanching of the synovium

O Difficult to diagnosis synovial disordersO Ischemic damage if prolonged touniquet

time (90-120min)

Leg holdersO Advantages

O Open the posteromedial compartment for viewing or manipulation of the meniscus

O DisadvantagesO Obstruct the operations in lateral

compartment

O Use in case of medial compartment disease

Leg holders

Anesthesia O Arthroscopy can be performed under

O Local AnesthesiaO Regional AnesthesiaO General Anesthesia

Local AnesthesiaO Knee or ankle arthroscopyO Cooperative patientsO Can be supplemented with DiazepamO The most cost-effectiveness

Regional AnesthesiaO Lower extremities

O Epidural or spinal anesthesiaO Peripheral blocks

O Immediate ambulationO Require experience anesthesiologistO Longer time to prepare

O Upper extremitiesO Brachial Block

General AnesthesiaO Not cooperative patientsO Allergy to local anestheticsO Less experience surgeonO In case that need tourniquet to

control bleeding

Postoperative painO Oral NSAIDs or IM,IV administration

O Reduce swellingO Increase ROM in early postoperative

periodO 30mL of 0.25% bupivacaine +/-

Morphine 3 mg intraarticular or subacromial flowO Excellent postoperative pain reliefO Catheters should be removed in 48

hours

Documentation O DrawingO 35-mm reflex cameraO Digital video recordings

Advantages of Arthroscopy

O Reduced postoperative morbidityO Smaller incisionO Less intense inflammatory responseO Improved thoroughness of diagnosisO Absence of secondary effects

O Neuromas, scarsO Reduced hospital costO Reduced complication rateO Improved follow-up evaluation : second-lookO Possibility of performing surgical procedures that

difficult to perform through open arthrotomy

Disadvantages of Arthroscopy

O Temperament to perform arthroscopic surgery

O Need to maneuver within the tight confines of the intraarticular space

O Time-consuming procedures in early of surgeon experience

O Expensive equipment

Indications and Contraindications

O No absolute indicationsO Diagnostic arthroscopy

O Preoperative evaluation and confirmation of the clinical diagnosis

O Documentation of specific lesionsO Contraindications

O Risk of joint sepsis, remote infectionO Ankylosis around the jointO Capsular disruption

Basic Arthroscopic Techniques

O Patience and persistenceO Techniques are mostly self-taughtO Artificial models or amputated specimens

for initially practiceO Perform arthroscopic procedures,

triangulation practice in the company of an experienced arthroscopist

O Learning curveO Keep in mind that open arthrotomy when

poorly performed arthroscopic procedures

Triangulation Technique

O One or more instruments inserted through separate portals

O Tip of the instrument and arthroscope forming the apex of a triangle

O If disoriented and difficulty in triangulationO Instrument may be brought into the

joint to contact the sheath and sliding to the tip

O Stereoscopic sense and two-handed ability

Complications O Damage to intraarticular structures: most

commonO Damage to Menisci and Fat PadO Damage to Cruciate LigamentsO Damege to Extraarticular structuresO HemathrosisO ThrombophlebitisO InfectionO Tourniquet ParesisO Synovial Herniation and FistulasO Instrument Breakage

Thank you