arthroscopy general principles

1. General Principles of
Arthroscopy
Chairperson-
Dr. Chetan D.M.
Presenter-
Dr. Utkarsh Dwivedi

2. 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.

4. INDEX
 Instruments and equipment
 Anesthesia
 Documentation
 Advantages & Disadvantages
 Indications & contraindications
 Basic arthroscopic techniques
 Complications

5. INSTRUMENTS AND EQUIPMENTS

6. 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 mm
 4mm is the most commonly used, especially for knee joint.
 1.9 & 2.7 mm useful for tighter joints like wrist & ankles.

7.  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 used
 70-90* is for seeing around corners or postero-lateral corners
of the knee joint

9.  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 view
 Wider 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.

11. ARTHROSCOPY EQUIPMENTS ASSEMBLY

13. FIRBREOPTIC LIGHT SOURCES
 LIGHT 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.

15. FIBREOPTIC CABLE ASSEMBLY

16. TELEVISION CAMERAS
 First introduced by McGinty and Johnson
 More comfortable
 Avoidance of contamination by the surgeon’s face
 Improvement offered by latest three chip technology-
 Decrease size of camera
 Increase resolution of image
 Cableless arthroscopic systems in which video signal is
transmitted from an arthroscope with its own light
source

18. BASIC INSTRUMENT KIT
 Arthroscopes
 30 and 70 degrees
 Scissors
 Probes
 Basket forceps
 Grasping forceps
 Arthroscopic knives
 Motorized meniscus cutter and shaver
 Laser/radiofrequency instruments
 Miscellaneous epuipment

19. PROBE
 The extension of the arthroscopist’s finger. Used-
 To feel the consistency of a structure
 To determine the depth
 To identify and palpate loose structures
 To maneuver loose bodies into more accessible grasping
position
 To probe fossae & recess
 To maneuver intraarticular structure
 To elevate meniscus

20.  Most are right-angled
 2 mm fixed tip size. This is used to measure length of
structures inside joint cavity.
 Use the elbow of the probes for palpation
 Magnification occurs with the arthroscope; the closer it is
the higher the magnification.
 So it can be placed close or far depending on the observer’s
desire.

22. SCISSORS
 3-4 mm in diameter
 JAWS : 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.

26. BASKET FORCEPS
 One of the most commonly used arthroscopic
instruments.
 Open base that permits the tissue to drop free within
the joint & don’t 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 shaft
 Usually used for trimming the peripheral rim of the
meniscus

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

29. GRASPING FORCEPS
 Retrieve 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 teeth
 Usually double side serrated forcep is used for securing loose bodies as
it doesn’t slip from it.

32. ELECTROSURGICAL LASERS
 ELECTROCAUTERY :For cutting & hemostasis
previously.
Now a days only to obtain hemostasis after A’scopic
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

35. 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.

36. 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.

38. MOTORISED SHAVING SYSTEMS
 Consisting of
 Outer hollow sheath
 Inner 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.

41. 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.

42. IMPLANTS
 Suture anchors
 Meniscal repair devices
 Devices for tendon and ligament fixation
 Articular cartilage repair

43. SUTURE ANCHORS
 Used to attach ligaments and tendons to bone without
bony tunnel passage of sutures
 Desirable characteristics
 Must fix the suture to the bone
 Permit an easy surgical technique
 Not cause long-term problems

46. MENISCAL REPAIR DEVICES
 Allow an all-inside meniscal repair without the need
for arthroscopic knot-tying
 3 categories
 Arrows
 Darts
 Meniscal screws

49. IRRIGATION SYSTEMS
 Irrigation and distension
 Essential to all arthroscopic procedures
 Joint 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 viewing
 Maintain hydrostatic pressure and distension

51. DISTENSION PRESSURE
It 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 pressure
Varied according to joint as follows :
 Knee 60 -80 mm of hg
 Shoulder 30 mm of hg below systolic pressure
 Elbow 40 – 60 mm of hg
 Ankle 40 – 60 mm of hg

53.  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.

54. TORNIQUET
 Contraindications
 History of thrombophlebitis
 Significant peripheral vascular disease
 Advantages
 Increased visibility
 Disadvantages
 Blanching of the synovium
 Difficult to diagnosis synovial disorders
 Ischemic damage if prolonged touniquet time (90-
120min)

55. LEG HOLDERS
 The 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.
 Disadvantages
 Obstruct the operations in lateral compartment
 Use in case of medial compartment disease

58. 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.

59. ANESTHESIA
 Arthroscopy can be performed under
 Local Anesthesia
 Regional Anesthesia
 General Anesthesia

60. REGIONAL ANESTHESIA
 Usually used in lower extremities-
 Epidural or spinal anesthesia
 Femoral and sciatic blocks
 Features of peripheral blocks-
 Immediate ambulation
 Require experience anesthesiologist
 Longer time to prepare
 Generally use a 1:1 mixture of 1% lignocaine and 0.25%
bupivacaine.
 Upper extremities
 Brachial Block

61. GENERAL ANESTHESIA
Used in cases of-
 Not cooperative patients
 Allergy to local anesthetics
 Less experienced surgeon
 Increased pain (acutely injured knee)

62. POST-OP PAIN
 Oral NSAIDs or IM,IV administration
 Reduce swelling
 Increase ROM in early postoperative period
 30mL of 0.25% bupivacaine +/-Morphine 3 mg
intraarticular or subacromial flow
 Excellent postoperative pain relief
 Catheters should be removed in 48 hours

63. DOCUMENTATION
 Drawings and documentation are very essential
 35-mm reflex camera photos
 Digital video recordings

64. INDICATIONS OF ARTHROSCOPY
 DIAGNOSTIC
 -For preoperative evaluation &
 confirmation of clinical diagnosis
 -For documentation in medicolegal
 cases
 THERAPEUTIC
•Smoothening of Torn cartilage
•Damaged ligaments reconstruction
•Loose bodies removal
•Joint effusions
•Biopsy procedures
•Fracture fixation
•Sports Related Injuries

65. ADVANTAGES OF ARTHROSCOPY
 Reduced postoperative morbidity
 Smaller incision
 Less intense inflammatory response
 Improved thoroughness of diagnosis
 Absence of secondary effects
 Neuromas, scars

66.  Reduced hospital cost
 Reduced complication rate
 Improved follow-up evaluation : second-look
 Possibility of performing surgical procedures that are
difficult to perform through open arthrotomy

68. DISADVANTAGES OF ARTHROSCOPY
 Skill and temperament to perform arthroscopic
surgery
 Need to maneuver within the tight confines of the
intraarticular space
 Time-consuming procedures in cases of inexperienced
surgeons and follows a steep learning curve
 Expensive equipment

69. INDICATIONS AND CONTRAINDICATIONS
 No absolute indications
 Diagnostic arthroscopy
 Preoperative evaluation and confirmation of the clinical
diagnosis
 Documentation of specific lesions
 Contraindications
 Risk of joint sepsis, remote infection
 Ankylosis around the joint
 Capsular disruption

70. 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.

71. BASIC ARTHROSCOPIC TECHNIQUES
 Patience and persistence
 Techniques are mostly self-taught
 Artificial models or amputated specimens for initial
practice
 Perform arthroscopic procedures in the company of
an experienced arthroscopist.
 It has a steep Learning curve
 Keep in mind that open arthrotomy is to be preferred
over poorly performed arthroscopic procedures

72. 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.

73.  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

75. MOST COMMON CONDITIONS FOUND
DURING ARTHROSCOPY
Acute or Chronic Injury
 Shoulder: Rotator cuff tendon tears, impingement
syndrome, and recurrent dislocations
 Knee: Meniscal (cartilage) tears, chondromalacia
(wearing or injury of cartilage cushion), and anterior
cruciate ligament tears with instability
 Wrist: Carpal tunnel syndrome
 Loose bodies of bone and/or cartilage: for example,
knee, shoulder, elbow, ankle, or wrist
 Some problems associated with arthritis also can be
treated.

76. 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.

77. COMPLICATIONS
 Damage to intraarticular structures: most common
 Damage to Menisci and Fat Pad
 Damage to Cruciate Ligaments
 Damege to Extraarticular structures
 Hemathrosis
 Thrombophlebitis
 Infection
 Tourniquet Paresis
 Synovial Herniation and Fistulas
 Instrument Breakage

78. FOLLOW-UP AFTER ARTHROSCOPIC
SURGERIES
RECOVERY TIME DEPENDS UPON MANY FACTORS:
 severity of disease
 Type 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.

79. 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..

80. THANK YOU FOR LISTENING