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1. General Principles of
Arthroscopy
Presented by: Dr. Parameshwor Poudel
2nd year Resident
Moderator : Asso.Prof Dr Kaushal Singh
National Medical College, Birgunj

2. Learning objectives
• Instruments and Equipment
• Anesthesia
• Documentation
• Advantages and Disadvantages
• Indication and Contraindication
• Basic Arthroscopic techniques
• Complications
• Special arthroscopic portals

3. Instruments : Arthroscope
• Optical Instrument
• Optical Characteristics
• Diameter: 1.7-7mm, 4mm is most commonly used
• Angle of inclination: angle between axis of arthroscope and line
perpendicular to surface of lens
• 0-120 degrees
• 25 and 30 degrees is most commonly used
• 70-90 degree: seeing around corners and posterior compartment

4. • Field of view: viewing angle of lens
• 1.9 mm scope : 65 deg field of view
• 2.7 mm scope : 90 deg field of view
• 4.0 mm scope: 115 deg field of view
• rotation of arthroscope scans larger surface area
• 70 deg arthroscope produce large field but with central blind area

5. Angle of inclination and field of view

6. Arthroscope
• Optical systems :
• classic thin lens system
• rod lens system
• graded index (GRIN) lens system

7. Fiberoptic Light Sources
• Direct viewing via arthroscope : 150 watts
• Television System
• Demand more light intensity
• 300-350 watts
• Tungsten, Halogen, Xenon
• Fiberoptic lighting
• A bundle of specially prepared glass fibers
• Fragile: developed by using liquid light guides (glycerin)

8. Television Cameras
• First introduced by McGinty and Johnson
• More comfortable
• Avoidance of contamination by the surgeon face
• Improvement
• Decrease size
• Increase resolution
• Recording device
• Controls the light source

9. Basic instrument kit
• Arthroscopes-30 to 70 degrees
• Probe
• Scissors
• Basket forceps
• Grasping forceps
• Arthroscope knives
• Motorized meniscus cutter and shaver
• Miscellaneous equipment

10. Probe
• The extension of the orthoscopists finger
• To feel the consistency of a structure
• To determine the depth
• To identify and palpate loose structure
• To maneuver loose bodies( grasping position)
• Most right-angled
• 3-4mm tip size
• Use the elbow of the probes

11. Scissors
• 3-4 diameter
• Jaws: straight or hooked
• Hooked scissors are preferred
• Hooked scissors pull the tissue
rather than pushing away
• Right and left curved
• angled scissor with rotating type
jaw mechanism cut at angle to
shaft

12. Basket Forceps
• One of the most commonly used instruments
• Open base that permits the tissues drop free with joint
• which is subsequently removed from the joint by suction
• types:
• 3-5mm sizes with straight or curved shaft
• Straight or hooked jaws, hooked is preferred
• up biting / down biting curves present
• Used for trimming the peripheral rim of the meniscus

13. Basket Forceps

14. Grasping Forceps
• Retrieve material from the joint
as loose bodies , synovium
• Grasping tissue to cut and secure
tissue within jaws
• may be single, double action
• double action forceps have
both jaw open and prevents
tissue from slipping

15. Knife Blades
• single use and disposable
• types:
• hooked blades, regular down cutting blades ,
straight / curved , smillie type end cutting blades
• Should be inserted through cannula sheaths
• cutting portion of blade is exposed only when
it enters in the arthroscopic field

16. Motorized Shaving Systems
• Consists of :
• Outer hollow sheath
• Inner rotating cannula with corresponding windows
• window of inner sheath acts as cylindrical blade spins within hollow
tube
• tissue get suctiones from window and blade cuts it
• diameter of cutting tip is 3-5.5 mm
• cutting tip should be positioned within visual field

18. • electrosurgical , laser, radiofrequency instruments
• used for cutting and hemostasis
• various monopolar and bipolar devices are used
• effects :
• depth of tissue penetration
• amount of cell death
• ability of devices to monitor

19. Implants
• Suture anchors
• Meniscal repair devices
• Devices for tendon and ligament fixation
• Articular cartilage repair

20. Suture anchors
• Attach ligament 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
• biocompatibility
• adequate strength
• easy insertion early rehabilitation

21. Meniscal Repair devices
• Allow an all inside meniscal
repair without the need for
arthroscopic knot-tying
• 3 categories: Arrows, Darts,
Meniscal screws

22. Device for tendon and ligament fixation
• Bone to bone or soft tissue to bone fixation
• Biodegradable or non biodegradable

23. Miscellaneous Equipment
• Sheaths or trocars
• Blade no 11 use to pass trocar
• Switching sticks are rods placed
through canulla to maintain portal
while cannula is changed

24. Care of Sterilization of Instrument
• heat stable instruments autoclaved
• heat or moisture sensitive equipment is sterilized with low temp
H2O2 gas plasma
• other:
• Gas ethylene oxide:1 hour
• Activated Glutaraldehyde(cidex)

25. Irrigation System
• Irrigation and distention
• distension maintained by RL
• Inflow :Arthroscopic sheath 6.0/6.2 diameter or cannula in separate
portal
• after inflow and outflow cannula is established jt is lavaged till fluid is
clear
• jt disgtension is increased by elevating fluid bag
• 1 feet increase in height of fluid from joint raises pressure by 22
mmHg
• Continuous irrigation id done for hydrostatic pressure and distention

26. Irrigation System

27. Tourniquet
• Contraindication
• History of thrombophlebitis
• Peripheral vascular disease
Advantages: increased visibility
Disadvantages: ischemic damage if prolonged, difficult to diagnosed
synovial

28. Leg holders
Advantages
• Open posteromedial compartment for viewing meniscus
Disadvantages
• Obstruct operation in lateral compartments
• may fix distal femur resulting in the fractures around knee,
ligamentous injury
• lateral post can be used for pull unobstructed knee flexion

30. Anesthesia
• Local anesthesia
• Regional Anesthesia
• General Anesthesia

31. Postoperative Pain
• Oral, IV, IM NSAIDS ( reduce swelling)
• Increase ROM in early postop period
• 30ml of 0.25% bupivacaine,+/_ morphine IA
Documentation
• examination of operative joint done using digital photographs , video
clips.

32. Advantages of arthroscopy
• Reduced postop morbidity
• Smaller incision
• Less intense inflammatory response
• Improved visualization
• Absence of secondary effect like neuromas and scar
• Reduced complication rate and hospital stay
• Improved follow-up evaluation
• performing surgical procedure that is difficult or impossible to
perform through open arthrotomy

33. Disadvantages of Arthroscopy
• Temperament to perform arthroscopic surgery
• Need to maneuver within the tight confines of the intraarticular space
• Time consuming
• Expensive equipment

34. Indication and Contraindication
• No absolute indication
• Diagnostic Arthroscopy
• Preoperative evaluation, confirmation of diagnosis
• Documentation of specific lesions
Contraindication
• not used in a minimally damaged joint
• Risks of joint sepsis
• Ankylosis around joint
• lysis or adhesion around joint
• Capsular disruption

35. Basic Arthroscopic Techniques
• Patience and persistence
• Techniques are mostly guided
• Artificial model or amputated specimen for practice
• Learning curve

36. Triangulation Technique
• One or more instrument inserted through separate portals and
brought into optical field of operative field
• Tip of the instruments and arthroscope forming the apex of a triangle
• separation of instruments and arthroscope increases the field of
depth perception
• triangulation also permits
• independent movement of arthroscope
• wide field of vision

37. • If surgeon is disoriented and difficulty in triangulation, instrument is
brought to arthroscope tip through sheath
• and it brings the instrument in field of vision
• Stereoscopic sense and two handed ability develops over time .

38. Complications
• Damage to intraarticular structures
• Damage to menisci and fat pad
• Damage to cruciate ligaments and extra articular structure
• Hemarthrosis
• Thrombophlebitis
• Infection
• Tourniquet paresis
• Synovial herniation
• Instrument breakage

39. ankle arthroscopy portals
• done for soft tissue or bony impingement , OCD talus
• short barrel scope 4 mm , with working length 14 cm used
• 30 deg , 70 deg scope used
• non invasive , invassive distraction done
• portals :
• anterior portal (medial , lateral)
• posterior portal (medial, lateral)
• transtalar portal
• transmalleolar portal

41. knee arthroscopy portals
primary portals
• anterolateral and anteromedial portal
• knee flexed , adjacent to patellar tendon over jt line
• superomedial and superolateral portal
• knee extended, adjacent to patellar tendon
secondary portals
• Posteromedial portal
• 1 cm above joint line behind MCL
• posterolateral portals
• 1 cm above joint line between LCL and biceps tendon

42. • Transpatellar portal
• 1 cm distal to patella splitting
patellar tendon
• proximal superomedial portal
• 4 cm proximal to patella
• far medial and far lateral portals
• placed according to need

43. shoulder arthroscopy portals
primary portals
• Posterior Portal
• 1st portal placed
• 2 cm inferior, 1 cm medial to posterolateral
corner of acromion
• pass between infraspinatus , teres minor
or through substance of infraspinatus
• directed anteriorly towards tip of coracoid
• anterior portal
• lat to coracoid , ant. to AC joint
• passes between pect.major , deltoid

44. • lateral portal
• 1-2 cm distal to lateral edge of acromion
• passses through deltoid
secondary portals
• anteroinferior (5 o clock portal)
• inferior to coracoid
• posteroinferior (7 o clock portal)
• placed form posterior portal under direct supervision

45. • Nevasier (supraspinatus portal )
• medial to lateral acromion
• pass through supraspinatus muscle
• Port of wilmington (posterolateral portal)
• anterior to posterolateral corner of acromium
• placed under direct supervision
• diagnostic scope/arthroscope
• done with 30 deg scope through posterior portal

46. reference
• campbells operative orthopaedics, 14th edition

47. THANK YOU