Principles of Arthroscopy and instruments
- 1. PRINCIPLES OF ARTHROSCOPY & Basics of Knee Scopy Moderator : Dr Shreyas M J Presenter : Dr R K Adhavan chidhambaram R K
- 2. MEANING OF ARTHROSCOPY ⮚ This word arthroscopy came from GREEK , o "arthro" (joint) o And o "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. ….
- 4. BASIC INSTRUMENTATION KIT ▪ Arthroscope : 30 degree;70 degree ▪ Fibreoptic cables ▪ Light sources ▪ Television cameras ▪ Probe ▪ Scissors ▪ Basket forceps ▪ Grasping forceps ▪ Arthroscopic knives ▪ Motorized shaving systems ▪Electrosurgical lasers & radio surgical instruments
- 5. ARTHROSCOPE ▪Optical instrument ▪Three basic optical systems have been used in rigid arthroscopes: ⮚ Classic thin lens system, ⮚ Rod-lens system, and ⮚ Graded index (GRIN) lens system.
- 8. ARTHROSC OPE: DIAMETER Varies from 1.7 to 7 mm. Most common size = 4mm Smaller scopes = Smaller and tighter joints (wrist, ankle)
- 9. ANGLE OF INCLINATION ▪ The angle between the axis of the arthroscope and a line perpendicular to the surface of the lens, varies from 0 to 120 degrees.
- 10. ▪ 25- and 30-degree arthroscopes = Most commonly used ▪ 70- and 90-degree arthroscopes = Posterior compartments of the knee
- 11. FIELD OF VIEW Refers to the viewing angle encompassed by the lens and varies according to the type of arthroscope. 1.9-mm scope= 65-degree field of view; the 2.7-mm scope= 90-degree field of view; 4.0-mm scope=115- degree field of view. Wider viewing angles make orientation by the observer much easier.
- 14. Image Quality
- 15. Barrel length • Standard 18cm
- 16. CAMERA HEADS A device that attaches to the arthroscope itself and is responsible for producing the image on the screen. Inside the camera head there are small computer chips that capture the actual image into a digital image. Camera heads are sterilized using ethylene oxide gas or hydrogen peroxide gas
- 19. LIGHT SOURCE WITH FIBRE OPTIC CABLES ▪ To illuminate the inside of the joint during the procedure. ▪ The light source consists of a box that houses the bulb (usually xenon or LED) that connects to the arthroscope via a sterile fiberoptic light cable.
- 21. MONITOR ▪ It is the device that projects the image created by the arthroscope and the camera head.
- 22. ARTHROSCOPY : EQUIPMENTS ASSEMBLY Arthroscope Fibreoptic cable Light source T. V. monitor POWER Irrigation fluid bags Y connector
- 23. PROBE
- 24. ▪ Most probes are right angled with a tip size of 3 to 4 mm, and this known size of the hook can be used to measure the size of intraarticular lesions.
- 25. SCISSORS ▪ Arthroscopic scissors are 3 to 4 mm in diameter and are available in both small and large sizes. ▪ The jaws of the scissors may be straight or hooked . ▪ The hooked scissors are preferred because the configuration of the jaws tends to hook the tissue and pull it between the cutting edges of the scissors.
- 26. BASKET FORCEPS ▪ The standard basket forceps has an open base that permits each punch or bite of tissue to drop free within the joint. ▪ Configuration- straight or hooked ▪ Available in angles of 30, 45 and 90 degree. ▪ 15 degree up biting and down biting curves are available Biting end Open base
- 27. GRASPING FORCEPS Single action Double action
- 28. KNIFE BLADES ▪ A variety of disposable blade designs are available: ▪ Hooked or retrograde blades; regular down- cutting blades, both straight and curved; and Smillie-type end- cutting blades.
- 31. MOTORIZED SHAVING SYSTEMS Consists of an outer, hollow sheath and an inner, hollow rotating cannula with corresponding windows . The window of the inner sheath functions as a two- edged, cylindrical blade that spins within the outer hollow tube.
- 33. ELECTROSURGICAL, LASER, AND RADIOFREQUENCY INSTRUMENTS Electrocautery has been used as an arthroscopic tool for cutting and hemostasis most often after arthroscopic synovectomy and subacromial decompression. It also has been used for both cutting and hemostasis in lateral retinacular release for malalignment of the patella. Reported complications of radiofrequency meniscal ablation include articular cartilage damage, osteonecrosis, and tissue damage caused by the irrigant.
- 44. CARE AND STERILIZATION OF INSTRUMENTS Arthroscopy equipment that is heat stable may be autoclaved for sterility. Heat- or moisture-sensitive equipment may be sterilized with a low-temperature hydrogen peroxide gas plasma.
- 45. IRRIGATION SYSTEMS Irrigation and distention of the joint are essential to all arthroscopic procedures. Joint distention is maintained by lactated Ringer solution/ Normal Saline during arthroscopy. It is physiological and results in minimal synovial and articular surface changes. The bag usually is placed 3 to 4 feet above the level of the joint, thus producing approximately 66 to 88 mm Hg of pressure. Addition of epinephrine (1 mg per liter of saline) significantly increases visibility.
- 46. DISTENTION PRESSURE For knee 60-80 mmHg For shoulder 30 mmHg less than systolic blood pressure. For elbow and ankle 40-60 mmHg
- 47. TOURNIQUET During arthroscopic procedures of the knee, ankle, elbow, and other distal joints, a tourniquet is almost always applied and is inflated as needed. Contraindication:- Thrombophlebitis and significant peripheral vascular disease
- 48. LEG HOLDERS ▪The biggest advantage of a leg holder is that it permits application of stress primarily to open the posteromedial compartment for better viewing, manipulation of the meniscus, and posterior horn meniscal surgery, especially in tight knees.
- 49. ▪ The lateral aspect of the distal thigh can be levered against the post for opening of the posteromedial compartment. ▪ The post does not confine or prevent the knee from being positioned in an almost unlimited number of positions,
- 50. ANESTHESIA Diagnostic arthroscopy can be performed with the patient under local, regional, or general anesthesia. Local anesthesia can be used for many arthroscopic procedures around the knee and ankle in a cooperative patient with intravenous sedation . Chondrotoxicity is known to occur with lidocaine and epinephrine. Combined spinal and epidural is best for knee and ankle.
- 51. CONTRAINDICATIONS ▪ When the risk of joint sepsis from a local skin condition is present or when a remote infection may be seeded in the operative site RELATIVE CONTRAINDICATIONS ▪ Partial or complete ankylosis around the joint ▪ Major collateral ligamentous and capsular disruptions of the joint
- 52. TRIANGULATION TECHNIQUE ▪ Triangulation involves the use of one or more instruments inserted through separate portals and brought into the optical field of the arthroscope, the tip of the instrument and the arthroscope forming the apex of a triangle.
- 53. KNEE In general, knee arthroscopy is performed for diagnosing and treating a variety of knee problems. The common indications are: ▪ Meniscal tears ▪ ACL tears ▪ PCL tears ▪ Removal of loose bodies ▪ Synovectomy (removal of diseased synovial tissue) in cases of: ⮚ Rheumatoid arthritis ⮚ Infections (pyogenic arthritis, tuberculous arthritis) ⮚ Pigmented villonodular synovitis ⮚ Synovial chondromatosis (multiple loose bodies)
- 54. Anatomy of knee joint
- 58. Positioning of the patient.
- 59. Positioning of the patient.
- 62. Anteromedial portal • Workhorse portal • Flexible position • ACL only- Higher and more medial • Meniscus- Just above the superior surface • Pre Patellar fat is partially shaved to give unhindered access.
- 63. Accessory Anteromedial portal • Anterior to the MCL • Used in meniscal repair/Meniscectomy with AM portal. • In Root Repair Used to park Sutures. • Knife blades held horizontal, cutting edge away from MCL.
- 64. Superolateral and Superomedial Portal • Made in Knee Extension. • Access to Patello femoral joint. • 2-3 cms proximal to the superolateral patellar surface. • Viewing portal for Patello Femoral tracking/ lesion
- 67. Accessory Portals • Central Transpatellar Tendon (Gillquist) Portal • Located 1cm inferior to the lower pole of the patella in the midline of the joint through the patellar tendon. • It is made with the knee in 90 degrees of knee flexion to keep the tendon under tension. • Used for ACL Avulsion # fixation, Meniscectomy and some uses as the primary viewing portal. • Others : Accessory Far Medial and Lateral Portals. Patel's Midpatellar Portals.
- 68. Take Home Message • Plan the portals: Surface marking in every case • Be Flexible with Portal Positioning: Depending on the surgery modify the working portals. • Be willing to change the Viewing portals “Swap”during the course of the surgery(Eg: Meniscus repair, medial portal to view the femoral entry point during ACL R) • Be ready to rectify and revise the portals during the surgery. • View should be ‘’Panoramic’’ and not too “Close Up”.
- 69. ARTHROSCOPIC EXAMINATION OF THE KNEE The knee should be divided routinely into the following compartments for arthroscopic examination 1. Suprapatellar pouch and patellofemoral joint 2. Medial gutter 3. Medial compartment 4. Intercondylar notch 5. Posteromedial compartment 6. Lateral compartment 7. Lateral gutter and posterolateral compartment
- 70. COMPLICATIONS Damage to Intraarticular structures Damage to Menisci and Fat pad Damage to Cruciate ligaments Damage to Extraarticular structures Blood vessels Compartment syndrome Nerves Ligaments and tendons
- 71. DAMAGE TO INTRAARTICULAR STRUCTURES � Most common complication of knee arthroscopy � Damage to the articular cartilage surfaces by the tip of the arthroscope or the operating instrument is the most common complication. � It leads to progressive chondromalacic changes and degenerative arthritis. Prevention : ⮚ The joint should be opened with leverage or traction first and the arthroscope allowed to slide into the space created. ⮚ Use of a leg holder or a leverage post during knee surgery, as well as traction or distraction devices during shoulder, hip, and ankle procedures, is helpful.
- 72. DAMAGE TO MENISCI AND FAT PAD ▪ The anterior horn of either meniscus of the knee can be damaged by incision or penetration if the anterior portals are located too inferiorly. ▪ Repeated penetration of the fat pad causes swelling of the pad and obstruction of view and may also result in hemorrhage, hypertrophy, or fibrosis of that structure.
- 73. DAMAGE TO CRUCIATE LIGAMENTS Occurs during meniscal excision when an intercondylar attachment is cut. When motorized instruments are debriding the intercondylar notch.
- 75. BLOOD VESSELS CAUSES:- ▪ Direct penetration or laceration ▪ From pressure caused by excessive fluid extravasation. ▪ Popliteal artery is at risk during meniscectomy when intercondylar attachments are cut, especially when arthroscopic knives are used. ▪ Extensive arthroscopic synovectomies have been associated with injury to the genicular arteries.
- 76. ANKLE � Anterior tibial artery is at risk during anterior approaches for ankle arthroscopy, especially with the anterocentral approach. ELBOW � Brachial artery may be damaged during establishment of either the anteromedial or anterolateral portal. � Fluid extravasation also may compress this vessel in the antecubital fossa.
- 77. SHOULDER � The axillary artery may be injured by an arthroscopic instrument plunging through the axillary pouch. � More often, axillary vessel occlusion is caused by fluid extravasation or excessive arm traction
- 78. COMPARTMEN T SYNDROMES CAUSE ▪ From fluid extravasations PREVENTION ▪ By using gravity inflow or lower pump pressures and ensuring adequate outflow, most of these complications can be avoided.
- 79. NERVES CAUSES • Direct trauma from a scalpel or sharp trocar • By traction from overdistraction • By mechanical compression or compression from fluid extravasation • By prolonged ischemia from excessive tourniquet use • By a poorly defined mechanism of injury to the anatomical nervous system that results in reflex sympathetic dystrophy
- 80. ▪ Saphenous nerve or sartorial branches of the femoral nerve are injured in knee arthroscopy. ▪ Axillary nerve in shoulder arthroscopy. ▪ Traction neurapraxia of the brachial plexus may occur when strong traction and distraction of the shoulder have been used. ▪ Neurovascular injury is the major risk of elbow arthroscopy.
- 81. PREVENTION � By marking portals appropriately � Making sure the scalpel penetrates the skin only � Using a hemostat to spread down to the joint capsule in proximity to a nerve � Routinely using blunt trocars. � Maintaining proper joint distention and distraction � Padding nerve and bony prominences, and � Proper patient positioning
- 82. LIGAMENTS AND TENDONS ▪ The medial collateral ligament may be injured by accessory medial portals around the knee, or it may be torn by severe valgus stress in an attempt to open up the medial compartment.
- 84. ADVANTAGES Reduced postoperative morbidity Smaller incisions Less intense inflammatory response Improved visualization Absence of secondary effects Reduced hospital stay
- 85. DISADVANTAGES Working through small portals with delicate and fragile instruments. Maneuvering the instruments within the tight confines of the intraarticular space may produce significant scuffing and scoring of the articular surfaces. Requires experienced surgeon Time consuming Requires special instruments Expensive
- 86. REFERENCES ▪ Campbell’s Operative Orthopaedics ▪ Atlas of knee arthroscopy ▪ Grey’s anatomy