47 cb principle of arthroscopy

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47 cb principle of arthroscopy

  1. 1. General Principles of Arthroscopy Pumsak Thamviriyarak, MD. Orthopaedics Department Khonkaen Hospital Campbell’s Operative Orthopaedics ed.11
  2. 2. OutlinesO Instruments and equipmentO AnesthesiaO DocumentationO Advantages & DisadvantagesO Indications & contraindicationsO Basic arthroscopic techniquesO Complications
  3. 3. Instruments and equipment
  4. 4. ArthroscopeO Optical instrumentO Optical characteristics O Diameter : 1.7-7 mm O 4mm is the most commonly used O Angle of inclination O 0-120 degrees O 30 degrees is the most commonly used O 70-90 degrees : seeing around corners or posterior compartment O Field of view
  5. 5. Angle of inclination and field of view
  6. 6. ArthroscopeO 2 designs O Operating arthroscope O Operative instrument in line with the arthroscpoe O Large-diameter sheath O Viewing arthroscpoe O 2 portals O Triangulation techniques O Smaller size
  7. 7. Fiberoptic Light SourcesO Direct viewing via arthroscope :150 wattsO Television systems O Demand more light intensity O 300-350 watts O Tungsten, Halogen, Xenon
  8. 8. Fiberoptic Light SourcesO Fiberoptic lighting O A bundle of specially prepared glass fibers O Fragile : develop by using liquid light guides (glycerin) O Length of cable: 8 inches lost for each foot of cable
  9. 9. Television camerasO First introduced by McGinty and Johnson O More comfortable O Avoidance of contamination by the surgeon’s faceO Improvement O Decrease size O Increase resolution O Recording device O Controls the light source
  10. 10. Basic instrument kitO Arthroscopes O 30 and 70 degreesO ScissorsO Basket forcepsO Grasping forcepsO Arthroscopic knivesO Motorized meniscus cutter and shaverO Miscellaneous epuipment
  11. 11. Accessory Instruments
  12. 12. ProbeO The extension of the arthroscopist’s finger O To feel the consistency of a structure O To determine the depth O To identify and palpate loose structures O To maneuver loose bodies into more accessible grasping position O Etc.O Most are right-angledO 3-4mm tip sizeO Use the elbow of the probes to palpation
  13. 13. ScissorsO 3-4 mm in diameterO Jaws : straight or hooked O Hooked scissors are preferred O Pulling the tissue rather than pushing awayO Right and left curved
  14. 14. Basket ForcepsO One of the most commonly usedO Open base that permits the tissue to drop free within the joint O 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
  15. 15. Grasping ForcepsO Retrieve material from the jointO Grasping tissue to cutting
  16. 16. Knife BladesO Should be inserted through cannula sheathsO Exposed only when it enters the arthroscopic field
  17. 17. Motorized Shaving Systems O Consisting of O Outer hollow sheath O Inner rotating cannula with corresponding windows
  18. 18. Motorized Shaving Systems O Avoid oversucking : create bubbles in the joint O Decrease intensity of suction O Increase inflow rate O Closed outflow from the arthroscope
  19. 19. ImplantsO Suture anchorsO Meniscal repair devicesO Devices for tendon and ligament fixationO Articular cartilage repair
  20. 20. Suture anchorsO Attach ligaments and tendons to bone without bony tunnel passage of suturesO Desirable characteristics O Must fix the suture to the bone O Permit an easy surgical technique O Not cause long-term problems
  21. 21. Meniscal repair devicesO Allow an all-inside meniscal repair without the need for arthroscopic knot-tyingO 3 categories O Arrows O Darts O Meniscal screws
  22. 22. Device for tendons and ligaments fixationO Bone-to-bone or soft tissue-to-bone fixationO Biodegradable or nonbiodegradable
  23. 23. Miscellaneous EquipmentO Sheaths and trocarsO Blade No.11O Switching sticks
  24. 24. Care and Sterilization of InstrumentsO Fiberoptic arthroscopes and cables O Best method is O Gas (ethlyene oxide) :1 hour O Low-temperature sterilization process (steris) :30 min O Most commonly used O Activated glutaraldehyde (Cidex)O Knives, graspers, basket forceps, cannulas O Steam autoclave
  25. 25. Irrigation SystemsO Irrigation and distension O Essential to all arthroscopic procedures O NSS or RLSO Inflow O Arthroscopic sheath: 6.2mm diameter O Cannula in separate portalO Continuous irrigation O Keep clear viewing O Maintain hydrostatic pressure and distension
  26. 26. Irrigation Systems
  27. 27. Irrigation SystemsO Optimal pressure in the joint O Knee : 60-80 mmHg O Shoulder : 30 mmHg below systolic BP O Elbow and ankle : 40-60 mmHgO Each foot elevate from the level of the joint O Produced 22 mmHg pressureO Outflow site should be closed during suction O Potentially contaminated fluid into the joint
  28. 28. TourniquetO Contraindications O History of thrombophlebitis O Significant peripheral vascular diseaseO Advantages O Increased visibilityO Disadvantages O Blanching of the synovium O Difficult to diagnosis synovial disorders O Ischemic damage if prolonged touniquet time (90-120min)
  29. 29. Leg holdersO Advantages O Open the posteromedial compartment for viewing or manipulation of the meniscusO Disadvantages O Obstruct the operations in lateral compartmentO Use in case of medial compartment disease
  30. 30. Leg holders
  31. 31. AnesthesiaO Arthroscopy can be performed under O Local Anesthesia O Regional Anesthesia O General Anesthesia
  32. 32. Local AnesthesiaO Knee or ankle arthroscopyO Cooperative patientsO Can be supplemented with DiazepamO The most cost-effectiveness
  33. 33. Regional AnesthesiaO Lower extremities O Epidural or spinal anesthesia O Peripheral blocks O Immediate ambulation O Require experience anesthesiologist O Longer time to prepareO Upper extremities O Brachial Block
  34. 34. General AnesthesiaO Not cooperative patientsO Allergy to local anestheticsO Less experience surgeonO In case that need tourniquet to control bleeding
  35. 35. Postoperative painO Oral NSAIDs or IM,IV administration O Reduce swelling O Increase ROM in early postoperative periodO 30mL of 0.25% bupivacaine +/-Morphine 3 mg intraarticular or subacromial flow O Excellent postoperative pain relief O Catheters should be removed in 48 hours
  36. 36. DocumentationO DrawingO 35-mm reflex cameraO Digital video recordings
  37. 37. Advantages of ArthroscopyO 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
  38. 38. 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
  39. 39. Indications and ContraindicationsO 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 infection O Ankylosis around the joint O Capsular disruption
  40. 40. Basic Arthroscopic Techniques O Patience and persistence O Techniques are mostly self-taught O Artificial models or amputated specimens for initially practice O Perform arthroscopic procedures, triangulation practice in the company of an experienced arthroscopist O Learning curve O Keep in mind that open arthrotomy when poorly performed arthroscopic procedures
  41. 41. Triangulation TechniqueO One or more instruments inserted through separate portalsO Tip of the instrument and arthroscope forming the apex of a triangleO If disoriented and difficulty in triangulation O Instrument may be brought into the joint to contact the sheath and sliding to the tipO Stereoscopic sense and two-handed ability
  42. 42. ComplicationsO 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
  43. 43. Thank you

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