Dr Ashish pargaie Orthopaedic resident Aiims rishikesh

1. PRINCIPLES OF ARTHROSCOPY
Presenter : Dr Ashish pargaie
Moderating SR : Dr Nikhil Goyal
Moderator Faculty : Dr Pradeep Kumar Meena

2. Learning Objectives:
 Instruments and equipment
 Anesthesia
 Documentation
 Advantages & disadvantages
 Indication & contraindication
 Basic arthroscopic techniques
 Complication

4. MEANING OF ARTHROSCOPY
• Greek: “Arthro”: Joint
“Skopein” : To look
 literally means; to look within the joint
 Offers;
high degree of accuracy
low morbidity
for
making diagnosis and offering treatment

5. Main monitor
Camera unit device
Video recording & image device
Power box for radiofrequency
instruments
Irrigatation pump
Light source device

6. INSTRUMENTS AND EQUIPMENTS

7. ARTHROSCOPE -
 Rigid optical instrument
 Optical characteristics : determined by diameter ,angle of inclination and field
of view
 diameter : 1.7-7 mm
 4 mm (most commonly used , especially for knee joint
 1.9 & 2.7 mm usefull for tighter joints like wrist & ankle

8. • Angle of inclination- is angle between axis of arthroscope and
line perpendicular to surface of lens , varies from 0-120◦ .
 25- 30◦ most commonly used
 70- 90 ◦ seeing around corners

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
• 2.7 mm scope has 90 * field 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.

10. TELEVISION CAMERAS
• McGinty and Johnson the first to introduce a television camera to the
arthroscopy system.
• Advantages
 More comfortable operating position for the surgeon
 Avoidance of contamination of the operative field by the surgeon’s face
 Involvement of the rest of the surgical team in the procedure

11.  Improvement offered by latest three chip technology
Decresae size of camera
Increase resolution of image
Cableless arthroscopic systems in which video signal is
transmitted from an arthroscope with its own light source

12. Figure : Rotation of arthroscope with 30-degree angle of inclination, which causes
scanning effect that increases field of view by about three times. Dotted circle shows
field of view and is compared at lower left with small circle that shows field of view of
0-degree arthroscope.

13. Figure : ROTATION OF ARTHROSCOPE WITH 70-DEGREE ANGLE OF INCLINATION. THIS SCANS A LARGE CIRCLE BUT
CREATES A BLIND AREA DIRECTLY AHEAD OF IT IN WHICH NOTHING CAN BE SEEN.

14. ACCESSORY INSTRUMENTS
• Basic instrument kit :
– Arthroscopes (30- and 70-degree)
– Probe
– Scissors
– Basket forceps
– Grasping forceps
– Arthroscopic knives
– Motorized meniscus cutter and shaver
– Electrosurgical
– Laser/ Radiofrequency instruments
– Miscellaneous epuipment

15. Arthroscopic instruments for shoulder procedures.

16. PROBE :
• The extension of the arthroscopist’s finger.
• Used –
• To feel the consistensy 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

17. • Most are right – angle
• 2 mm fixed tap size . This is used to measure length of structure
inside joint cavity .
• Use the elbow of the probes for palpation
• Magnification occurs with the arthroscope : closer it is the higher
the magnification
• So it can be placed close or far depending on the observer’s desire.

18. FIGURE - Arthroscopic probe used in exploring intraarticular
structures during arthroscopic triangulation techniques.

19. (A) Arthroscopic view of a right knee medial compartment with the 30 arthroscope in the lateral viewing portal
using a 5-mm probe and physician-applied valgus. Notice the normal relationship of the femur (F), meniscus
(M), and tibia (T), despite the relatively large physiologic gapping of the joint space.
(B) Arthroscopic view of a right knee lateral compartment with the 30 arthroscope in the lateral viewing portal
using a 5-mm probe and a physician-applied varus stress. Notice the abnormal separation of the meniscus
from the tibia, " drive-through " sign, and inflamed synovium of the posterior capsule consistent with
posterolateral corner insufficiency.

20. 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 ,usuallly with a rotating of jaw mechanism,
actually cut at an angle to shaft of the scissors.
• Useful in detaching difficult to reach meniscal fragments .

21. FIGURE - Commonly used arthroscopic instruments scissors

22. BASKET FORCEPS :
• One of the most commonly used arthroscopic intruments.
• 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 .
• 3-5 mm sizes with straight or curved shaft
• Usually used for trimming the peripheral rim of the meniscus

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

24. GRASPING FORCEPS
• Retrieve material from the joint generally loose bodies from the
joints .
• 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 serrrated forcep used for securing loose bodies
– doesn’t slip from it.

25. ELECTROSURGICAL LASERS
• Electrocautery : for cutting & hemostasis .
• Works in a non – electrolyte medium like distilled water , co2 or
glycine.
• Newer coated tip function in both NS / RL
• Laser: role under investigation .
• Co2 laser, YAG laser , excimer laser.

26. RADIOSURGICAL SYSTEM
• Radio frequency system used for tissue ablation, electrocautery & capsular
shrinkage.
• Monopolar: grounding pad & draw energy through the body
• Bipolar :b/w electrodes at the site of treatment
• Used for cuttting and haemostasis for arthroscopic synovectomies and
subacromial decompression .
• Complications include-
 articular cartilage damage,
 Osteonecrosis
 Tissue damage

27. KNIFE BLADES
• 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 : helpful in retrieving them
when broken

28. MOTORISED SHAVING SYSTEMS
Consisting of
• Outer hollow sheath
• Inner hollow rotating cannula with corresponding windows & diameter of
cutting tip usually 3-5.5 mm
• Principle: the window of inner sheath function as a two edges cylindrical
blade ,that spins within the outer hollow tube.
• Suction through the cylinder bring the fragment of soft tissue in window
and as the blade rotates , the fragments are amputated , sucked to the
outside , and collected in the suction trap.

30. IMPLANTS
• Suture anchors
• Meniscal repair devices
• Devices for tendon and ligament fixation
• Articular cartilage repair

31. SUTURE ANCHORS
• Used to attached ligaments and tendons to bone without bony
tunnel passage sutures
• Desirable characteristics
 Must fixed the suture to the bone
 permit an easy surgical technique
 Not cause long – term problems

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

34. IRRIGATION SYSTEMS
 Irrigation and distension
 Essential to all arthroscopic procedure
 Joint distension is maintained better with RL than NS.
 Inflow is via arthroscopic sheath : 6.2 mm diameter with the
cannula in separate portal with 68 mm of pressure of water
 Usually two 3-5 lit plastic bags of RL, interconnevted with a Y –
connector are suspended for use with the arthroscopy pump.
 Continuous irrigation :
 keep clear viewing
 maintain hydrostatic pressure and distension

35. IRRIGATION SYSTEMS

36. IRRIGATION SYSTEMS & ARTHROSCOPY SETUP

37. DISTENSION PRESSURE
• Optimal pressure required to distension the joint .
• Ingress = egress to maintain hydrostatic pressure & distention
within joint.
• For each foot of elevation of solution bag above joints = 22 mm
of hg pressure
• Varied according to joints 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

38. TORNIQUET
Contraindication
 history of thrombophlebitis
 significant peripheral vascular disease
Advantages
 increased visibility
Disadvantages
 blanching of the synovium
 difficulty to diagnosis synovial disorders
• Ischemic damages if prolonged toruniquet time ( 90 – 120 min)

39. LEG HOLDERS
 The biggest advantages of leg holders is that they permit application of stress primarily
to open the posteriomedial compartment for viewing or manipulation of the meniscus
and posterior horn meniscus 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

40. LEG HOLDERS

41. METHOD OF STERILIZATION
• Ethylene oxide ( best method)
• Low temprature sterilization process
• CIDEX is used for cold disinfection of equipments between sucessive
procedures during whole day
• Knives, forceps etc : by steam autoclaving
• Fibreoptic materials , camera , motorised instruments : by soaking in cidex
sol. For 10 min . Or STERIS for 30 min.

42. ANESTHESIA
ARTHROSCOPY can be performed under
• Local anesthesia
• Regional anesthesia
• General anesthesia

43. REGIONAL ANESTHESIA
• Usually used in lower extremities –
 epidural or spinal anesthesia
 femoral and sciatic block
 feature of peripheral blocks-
• immediate ambulation
• require experince anesthesiologst
• longer time to prepare
• generally use a 1:1 mixture of 1 % lignocaine and 0.25 % bupivacaine
• Upper extremities
 brachial block

44. GENERAL ANESTHESIA
Used –
• Not cooperative patient
• Allergy to local anesthesia
• Less experienced surgeon
• Increased pain (acutely injured knee)

45. INDICATION AND CONTRAINDICATIONS
• No absolute indication
• Diagnostic arthroscopy
 preoperative evaluation and confirmation of the clinial diagnosis
 documentation of specific lesions
• Contraindication:
 Risk of joint sepsis , remote infection
 Ankylosis around the joint
 Capsular disruption

46. POST – OP PAIN
• Oral NSAIDS or IM,IV administration
 Reduced swelling
 Increase ROM in early postoperative period
• 30 ml of 0.25 % bupivacaine +/- morphine 3 mg intrarticular or
subacromial flow
 Excellent post operative pain relief
 Cathers should be removed in 48 hours

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

48. INDICATION OF ARTHROSCOPY
 DIAGNOSTIC
 For pre operative evaluation &
 Confirmation of clinical diagnosis
 For documentation in medicolegal cases
 THERAPEUTIC
 Smoothening of torn cartilage
 Damaged ligaments reconstruction
 Loose bodies removal
 Joint effusion
 Biopsy procedures
 Fracture fixation
 Sports related injuries

49. ADVANTAGES OF ARTHROSCOPY
• Reduced postoperative morbidity
• Smaller incision
• Less intense inflammatory response
• Improved thrughness of diagnosis
• Absense of secondary effects
 neuromas, scars

50. • Reduced hospital cost
• Reduced complication rate
• Imroved follow-up evaluation : second – look
• Possibility of performing surgical procedures that are difficult
to perform through open arthrotomy

51. 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

52. 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

53. 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

54. TRIANGULATION TECHNIQUE
• Involves use of one or more instuments inserted through separate
portals and brought into the optical field of the arthroscope
• Tip of the instuments 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

55. • 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

57. MOST COMMON CONDITIONS FOUND
DURING ARTHROSCOPY
Acute or chronic injury
shoulder : rotator cuff tendon tears
impingement syndrome
recurrent dislocation
knee : meniscal (cartilage) tears
chondromalacia (wearing or injury of cartilage cushion)
ACL & PCL tear with instability

58.  Wrist : carpal tunnel syndrome
 Loose bodies of bone & or cartilage :
 example : knee
shoulder
elbow
ankle
wrist
• Some problems associated with arthritis also can be treated

59. knee arthroscopy: ACL repair

62. COMMONLY DONE ARTHROSCOPIC SURGERIES
• Rotator cuff injury
• Repair or resection of torn cartilage (meniscus) from knee or shoulder
• Reconstruction of anterior cruciate ligament in knee
• Removal of inflamed (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

63. COMPLICATIONS
• Damage to intraarticular structure : most common
• Damage to menisci and fat pad
• Damage to cruciate ligaments
• Damage to extraarticular structure
• Hemathrosis
• Thrombophelebitis
• Infection
• Torniquet paresis
• Synovial herniation and fistulas
• Instrument breakage

64. FOLLOW – UP AFTER AETHROSCOPIC 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 limb elevation also recommended

65. • Physiotherapy not required in all patients, should be individualised
• Sitting job can be resumed one week after surgery
• 3-4 weeks to recover fully for routine daily activities
• 3 months before one can confortably return to sports .

66. Elsevier, February 2022
LEVEL OF EVIDENCE Case series: IV

67. PURPOSE
• Determine the rate of intraoperative and early postoperative (90-
day) complications of multiligamentous knee reconstruction
surgeries
• Both medical and surgical and associated variables from the 15-
year experience of a single academic institution

68. METHOD
• Patients treated at a single academic institution between 2005 and
2019 who underwent multiligament knee surgery were identified
• Inclusion criteria :
– 2+ ligament reconstructions performed concurrently
– > 90 days postoperative follow-up.

69. • Exclusion criteria :
– Included revision ligamentous knee surgery.
– Patient demographics, mechanism of injury
– Associated injuries of patients with intraoperative and postoperative
complications
– Time from injury to multiligamentous knee reconstruction
– Surgical data:
• including tourniquet time
• procedure time,
• type of procedures performed were retrospectively recorded.

70. • Results :
– 301 knees in 296 patients met the eligibility criteria.
– There were 11 intraoperative complications in 9 knees (rate of 3%) and 136 postoperative
complications in 90 knees (rate of 30%)
– Shorter time from injury to date of surgery was associated with arthrofibrosis (P = .001)
– superficial wound infections (P = .015).
– Concurrent head injuries were associated with less complications (P = .029).
– Procedural time >300 minutes was associated with intraoperative blood transfusions (P >
.05),
– deep infections (P = .003)
– arthrofibrosis (P = .012).

71. Inside-out meniscal reair was associated with
•Superficial and deep infections (P = .006 and .0004).
•Tibial-based posterolateral corner (PLC) reconstruction was associated with
symptomatic hardware (P = .037)
• Arthrofibrosis (P = .019) in comparison with fibular-based PLC reconstruction.
•Posterior cruciate ligament (PCL) reconstruction was associated with deep infections
(P = .015),
•arthrofibrosis (P = .003),
• postoperative blood transfusions (P = .018).

72. Complications associated with
• Longer procedure times
• Inside-out meniscal repair
• Tibia-based PCL reconstruction
• Shorter time to surgery

73. THANK YOU