47 cb principle of arthroscopy
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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
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