SEMINAR (14-11-09)

TOPIC : ARTHROSCOPY PRINCIPLES

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MODERATOR :DR. S. AGARWAL (M.S.)

SPEAKER : PRIYANK GUPTA

TOPIC :ARTHROSCOPY PRINCIPLES

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CHANGE :the golden rule of lifeSo the same here

From invasive to less invasive……

& now the pendulum is swinging ….from open to close arthroscopic techniques .

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So What the Arthroscopy is ?

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. ….

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What joints are being scoped ?

But not that much of Elbow

MAJOR – Knee Shoulder

MINOR – Wrist, Ankle & Hip

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BASIC INSTRUMENTATION KIT

Arthroscope : 30 degree 70 degreeFibreoptic cableslight sourcesAccessory instrumentsTelevision camerasProbeScissorsBasket forcepsGrasping forcepsKnife bladesMotorized shaving systemselectrosurgical lasers & radio surgical instruments

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ARTHROSCOPY : EQUIPMENTS ASSEMBLY

Arthroscope

camera

Fibreoptic cable

light source

T. V. monitor

POWER

irrigation fluid bags

y connector

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ARTHROSCOPE

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.

ADVANTAGES : tip of instruments is directly in the field of vision, & only portal is required for the passage of two instruments. as it requires a large dia. Sheath so it is impractical for small joints.

Now due to triangulation technique through the viewing A'scopy made it more popular.

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ARTHROSCOPE : characteristics

ANGLE OF INCLINATION : - angle b/w axis of a’scope & a line perpendicular to surface of lens -from 0 – 120 degrees., -25 – 30 degree most commonly used, -70 & 90 degree used to see corners, e.g. post. Compartment of knee through the intercondylar notch.

DIAMETER : 1.7 – 7 mm, -4 mm is m.c. size, -1.9 & 2.7 mm useful for tighter joints like wrist & ankles.

FIELD OF VIEW : viewing angle encompassed by lens& varies according to type of arthroscope. e.g. 1.9 mm A’scope has 65 degree of view. wider viewing angle make orientation by observer much easier.Rotation of 70 & 90 degree arthroscope produces an extremely large field of view but may create a central blind area directly in front of the scope.

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PROBE

Better termed as extension of A’scopist’s finger.

Usually probes are right angled & tip size of 3 – 4 mm to measure size of defects.

FUNCTIONS : -To palpate intraarticular structures.-To feel consistency.-To determine depth.-To probe fossae & recess-To maneuvered intraarticular structure.

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light sources & Fibreoptic cables

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 A'scope.-Length of cable also important as 8” of

transmitted light is lost for each foot cable.

Now-a-days breakage of Fibreoptic cable has been eliminated with introduction of

liquid (glycerin) light guides.

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Scissors

3 – 4 mm in dia.

JAWS : straight / hooked -hooked scissors preferred as jaws hook tissue & pull it b / w cutting edges of scissors rather than pushing material from jaw 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.

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Basket forceps & Grasping forceps

BASKET /PUNCH BIOPSY FORCEPS : has an open base that permits each punch or bite of tissue to drop free within joint & don’t require instrument to be removed from the joint & cleaned with each bite.Shaft : straight / curvedJaws : straight / hookedBasket in assortment of 30 , 45 , 90 degree.Also as 15 degree up & down – biting.Useful for trimming meniscal rim.

GRASPING FORCEPS : 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

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Motorized shaving systems

Consist of outer hollow sheath & inner hollow rotating canula with corresponding windows & dia. of cutting tip usually 3 – 5.5 mm.

principle : the window of inner sheath function as a two edgedcylindrical 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.

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.

Care must be taken to prevent oversucking.

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electrosurgical lasers & radio surgical instruments

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 laserRADIOFREQUENCY SYSTEM :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.

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Irrigation systems

Usually normal saline or lactated ringer solution ( preferred coz it is physiological & causes minimal changes in synovial & articular surfaces). Two 5 L plastic bag interconnected with y-connector.

Inflow may directly pass through arthroscope or via separate Portal by means of a canula.

For adequate flow 6.0 – 6.2 mm should be used with scope

Older intraarticular electrocautery system requires non-electrolytic system like glycine.

Continuous irrigation is by pump through canula or through arthroscopic sheath.

Preferred as it keeps the fluid clear for optimal viewing.

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Distention 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 pressureVaried according to joint as follows :

Knee 60 -80 mm of hgShoulder 30 mm of hg below systolic pressureElbow 40 – 60 mm of hgAnkle 40 – 60 mm of hg

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 pointsLike posteromedial & posterolateral portals in knee.

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TOURNIQUET

According to recent studies its routine use is not recommended.

No significant differences in outcome between patients with or without tourniquet but visibility was 3 times better with tourniquet use.

Contraindication : history of Thrombophlebitis, - significant peripheral vascular Ds.

Advantages : increased visibility, -no significantly increased postoperative morbidity -with tourniquet times of <90 – 120 minutes.

Disadvantages : blanching of the synovium, -difficulty in diagnosing synovial disorders, -possibility of ischemic damage to muscles & nervous tissue with prolonged tourniquet time of

>90 – 120 minutes.

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ACESSORY EQUIPMENTS

•Part holders

•Meniscal repair devices-arthrotek staple , t – fix ,dart etc.

• Non -biodegradable suture anchors-corkscrew, harpoon, revo , minitac etc.

• Biodegradable suture anchors-biocockscrew , biophase ,bone button etc.

• Non -biodegradable ligament fixation material-endobutton ,advantage , profile

• Biodegradable ligament fixation matterial-bilok screw , smartscrew acl ,biocryl etc.

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DOCUMENTATION

DOCUMENTATION OF PROCEDUREVERY NECESSORY

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METHOD OF STERLISATION

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.

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INDICATIONS !!!!!!

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

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Sports Related Injury

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Cricket too …..!!!!

Knee injuries Throwing – shoulder injuries

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CONTRAINDICATIONS

In a minimaly deranged joints where conservative method may response

When risk of joint sepsis from a local skin infection.

Partial or complete ankylosis. Relative contraindication

Major collateral ligament & capsular disruption

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Which anesthesia used for Arthroscopy ?

Can be performed under general, local or regional-spinal anesthesia.

Spinal anesthesia preferred

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What are the advantages of Arthroscopy?

No major surgery, Tiny scar – no scar related problems

Short hospital stay ,Early return to activity

OVERALL COST REDUCED

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Now the other side?????

Very few

Technically demanding

Specialized equipments required

Needs excellent psychomotor co-ordination

ADVANTAGES FAR OUTWEIGH DISADVANTAGES

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What are the possible complications of Arthroscopy ?

COMPLICATION RELATED TO SURGERYDamages to related structures.Hemarthrosis (most common postop.)ThrombophlebitisINFECTION – as for any surgery but very less -around 10- 15 % with conventional open surgery -its <1% for ArthroscopyTourniquet paresisSynovial herniation & fistulasInstrument breakage

COMPLICATIONS RELATED TO ANESTHESIA

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How is arthroscopic surgery performed?

AS OPD BASIS: 30 minutes to an hour

Under anesthesia make small cuts in the skin around joint.

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.

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Triangulation technique

BASIS FOR OPERATIVE ARTHROSCOPY

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

Separates the arthroscope from operating instruments, allowing the viewing arthroscope to be enlarged and increasing the field of view.

Improves depth perception, and most significantly permits independent movement of arthroscope & surgical instruments.

ONLY DISADVANTAGE technically demanding and requires psychomotor orientation.

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Inflammationsynovitis is an inflammation of the lining in the knee, shoulder, elbow, wrist, or ankle

Acute or Chronic InjuryShoulder: 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 syndromeLoose bodies of bone and/or

cartilage: for example, knee, shoulder, elbow, ankle, or wrist

Some problems associated with arthritis also can be treated.

Most frequent conditions found during arthroscopy

meniscal (cartilage) tears,

rotator cuff tear

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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.

combined arthroscopic and standard surgical procedures

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RECOVERY TIME DEPENDS UPON MANY FACTORS:severity of ds. And type of surgery.

As OPD basis

supports for 3 to 7 days, weight bearing on the operated leg as tolerated. Rest, ice packs, and elevating the limb also recommended. Physiotherapy not required in all patients, should be individualised.

drive at least a week before patients can depending on operated.

sitting job at one week after surgery.

3 weeks to recover fully for routine daily activities.

3 months before one can comfortably return to sports..

NOW WHAT AFTER ARTHROSCOPIC SURGERY?