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.
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
8.
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.
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.
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
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.
21.
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.
23.
24.
25.
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.
28.
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.
30.
31.
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
33.
34.
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.
37.
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.
39.
40.
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
44.
45.
46. MENISCAL REPAIR DEVICES
Allow an all-inside meniscal repair without the need
for arthroscopic knot-tying
3 categories
Arrows
Darts
Meniscal screws
47.
48.
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
50.
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
52.
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
56.
57.
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.
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
67.
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
74.
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..