Dr Dilshan Munidasa NHSL Arthroscopy Basics Dr Dilshan Munidasa NHSL

BASIC INSTRUMENTATION KIT Arthroscope : 30 degree 70 degree Fibreoptic cables light sources Accessory instruments Television cameras Probe Scissors Basket forceps Grasping forceps Knife blades Motorized shaving systems electrosurgical lasers & radio surgical instruments

ARTHROSCOPY : EQUIPMENTS ASSEMBLY irrigation fluid bags y connector T. V. monitor POWER camera light source Arthroscope Fibreoptic cable

MONITOR It is the device that projects the image created by the arthroscope and the camera head.

Certain features determine the optical characteristics of an arthroscope. Most important are the diameter, angle of inclination, and field of view. The angle of inclination, which is the angle between the axis of the arthroscope and a line perpendicular to the surface of the lens, varies from 0 to 120 degrees. Angle of inclination

The 25- and 30-degree arthroscopes are most commonly used The 25- and 30-degree arthroscopes are most commonly used. The 70- and 90-degree arthroscopes are useful in seeing around corners, such as the posterior compartments of the knee

TROCAR AND SHEATH Sheath Blunt trocar Sharp Trocar

Field of view refers to the viewing angle encompassed by the lens and varies according to the type of arthroscope. The 1.9-mm scope has a 65-degree field of view; the 2.7-mm scope, a 90-degree field of view; and the 4.0-mm scope, a 115-degree field of view. Wider viewing angles make orientation by the observer much easier.

Viewing angle 0 ° Straight view not recommended 30 ° Increase the field of vision (90 )

70 ° For viewing special regions

ACCESSORY INSTRUMENTS The basic instrument kit consists of the following: arthroscopes (30- and 70-degree); probe; scissors; basket forceps; grasping forceps; arthroscopic knives; motorized meniscus cutter and shaver; electrosurgical, laser, and radiofrequency instruments; and miscellaneous equipment. These instruments are used in performing most routine arthroscopic surgical procedures. Additional instruments are available and are occasionally used in special circumstances.

PROBE The probe has become known over the years as “the extension of the arthroscopist’s finger.

PROBE cont….. The probe is essential for palpating intraarticular structures and in planning the approach to a surgical procedure. The probe can be used to feel the consistency of a structure, such as the articular cartilage Determine the depth of chondromalacic areas Identify and palpate loose structures within the joint, such as tears of the menisci Maneuver loose bodies into more accessible grasping positions Palpate the anterior cruciate ligament and determine the tension in the ligamentous and synovial structures within the joint Elevate a meniscus so that its undersurface can be viewed Probe the fossae and recesses

Most probes are right angled with a tip size of 3 to 4 mm, and this known size of the hook can be used to measure the size of intraarticular lesions.

SCISSORS Arthroscopic scissors are 3 to 4 mm in diameter and are available in both small and large sizes. The jaws of the scissors may be straight or hooked . The hooked scissors are preferred because the configuration of the jaws tends to hook the tissue and pull it between the cutting edges of the scissors.

BASKET FORCEPS The standard basket forceps has an open base that permits each punch or bite of tissue to drop free within the joint. It is useful in trimming the peripheral rim of the meniscus, or it can be used instead of scissors to cut across meniscal or other tissue. Configuration- straight or hooked Available in angles of 30, 45 and 90 degree. 15 degree up biting and down biting curves are available. Biting end Open base

GRASPING FORCEPS Single action Grasping forceps are useful to retrieve material from the joint, such as loose bodies or synovium, or to place meniscal flaps and other tissues under tension while cutting with a second instrument. The jaws of the grasping forceps may be of single- or double-action design and may have regular serrated interdigitating teeth. Double action

KNIFE BLADES A variety of disposable blade designs are available: hooked or retrograde blades; regular down-cutting blades, both straight and curved; and Smillie-type end-cutting blades. These blades should be inserted through cannula sheaths or encased within a retractable sheath mechanism so that the cutting portion of the blade is exposed only when it enters the field of arthroscopic vision.

MOTORIZED SHAVING SYSTEMS Consists of an outer, hollow sheath and an inner, hollow rotating cannula with corresponding windows . The window of the inner sheath functions as a two- edged, cylindrical blade that spins within the outer hollow tube. Suction through the cylinder brings the fragments of soft tissue into the window, and as the blade rotates, the fragments are amputated, sucked to the outside, and collected in a suction trap.

MOTORIZED SHAVING SYSTEMS USES.. Designed for meniscal cutting or trimming, for synovial resection, and for shaving of articular cartilage.

ELECTROSURGICAL, LASER, AND RADIOFREQUENCY INSTRUMENTS Electrocautery has been used as an arthroscopic tool for cutting and hemostasis most often after arthroscopic synovectomy and subacromial decompression. It also has been used for both cutting and hemostasis in lateral retinacular release for malalignment of the patella. Reported complications of radiofrequency meniscal ablation include articular cartilage damage, osteonecrosis, and tissue damage caused by the irrigant.

Irrigation system

IMPLANTS Suture anchors Meniscal repair devices Devices for tendon and ligament fixation and articular cartilage repair. Suture passes

CARE AND STERILIZATION OF INSTRUMENTS Arthroscopy equipment that is heat stable may be autoclaved for sterility. Heat- or moisture-sensitive equipment may be sterilized with a low-temperature hydrogen peroxide gas plasma.

JOINT IRRIGATION Irrigation and distention of the joint are essential to all arthroscopic procedures. Joint distention is maintained by lactated Ringer solution or N saline during arthroscopy. It is physiological and results in minimal synovial and articular surface changes. Usually, two 5-L plastic bags of N saline, interconnected with a Y-connector. The bag usually is placed 3 to 4 feet above the level of the joint, thus producing approximately 66 to 88 mm Hg of pressure. Addition of epinephrine (1 mg per liter of saline) significantly increases visibility.

DISTENTION PRESSURE For knee 60-80 mmHg For shoulder 30 mmHg more than systolic blood pressure. For elbow and ankle 40-60 mmHg

TOURNIQUET During arthroscopic procedures of the knee, ankle, elbow, and other distal joints, a tourniquet is almost always applied and is inflated as needed. Advantages : Increased visibility Disadvantages : Blanching of the synovium, which makes differentiation and diagnosis of various synovial disorders difficult, and The possibility of ischemic damage to muscle and nervous tissue with prolonged tourniquet time of more than 90 to 120 minutes.

SHOULDER COMPLICATIONS The axillary artery may be injured by an arthroscopic instrument plunging through the axillary pouch. More often, axillary vessel occlusion is caused by fluid extravasation or excessive arm traction

SHOULDER Indications for shoulder arthroscopy 1. Shoulder instability (recurrent dislocation of shoulder) 2. Impingement syndrome (pain on lifting the arm) 3. Rotator cuff tears 4. Calcific tendonitis tendinitis (calcium deposition in the rotator cuff) 5. SLAP tears 6. Tears of long head of biceps tendon 7. Frozen shoulder (periarthritis) 8. Removal of loose bodies 9. Synovectomy for: Inflammatory conditions like RA Infections (like TB) Synovial chondromatosis

PATIENT POSITIONING

PORTALS

Before making arthroscopic portals, a thorough understanding of the local anatomy is necessary to prevent damage to neurovascular structures

POSTERIOR PORTAL Primary entry portal for shoulder arthroscopy. It allows examination of most of the joint and assists in the placement of subsequent portals . This portal is located 1.5 to 3.0 cm inferior and 1.0 cm medial to the posterolateral tip of the acromion. Between the infraspinatus and teres minor muscles.

POSTEROINFERIOR 7-O’CLOCK PORTAL

ANTERIOR PORTAL Observation of the posterior capsule and the rotator cuff and for an anterior view of the glenohumeral ligaments and the subscapularis tendon. Anterior portal is made slightly lateral to a point halfway between the anterolateral tip of the acromion and the coracoid process.

ANTEROINFERIOR 5-O’CLOCK PORTAL Along the leading edge of the inferior glenohumeral ligament at the 5-o’clock position along the glenoid rim. The portal travels through the subscapularis and lateral to the conjoined tendon. Allows appropriate access to the leading edge of the inferior glenohumeral ligament.

SUPERIOR PORTAL This portal penetrates the trapezius muscle and passes through the supraspinatus muscle belly. The suprascapular nerve and artery lie approximately 3 cm medial to the superior portal at its closest point Useful for passage of suture retrieval devices for rotator cuff repair.

LATERAL PORTAL The lateral portal is the primary operative portal for the subacromial space. It is located 3 cm lateral to the lateral border of the acromion and passes through the deltoid muscle.

PORTAL OF WILMINGTON Providing access to the glenoid and superior labrum. The location is 1 cm anterior and 1 cm lateral to the posterior acromial angle.

Arthroscopic knot tying Dr Dilshan Munidasa NHSL

Knot tying principles More complex than open knotting Suture management is more important than memorizing knot configuration. Understand the path of the sutures within the cannulas

Surgical technique Preparation Selection of right knot Suture handling Knot configurations

Knot tying terms Limbs – suture ends Post limb – around witch loops of knots are passed around Loop limb (Non post )– the limb that that is passed around the post Throw (Half Hitch ) – single loop of a knot Over hand throw- over the post Underhand throw – under the post reversing throw – loop opposite direction knot Post switching – alternating the post The post is not always the same , it can be changed with every throw

The post is not always the same , it can be changed with every throw

Preparation - Requirements Sutures and post or hook against which knots are tied Suture retrieving device - suture grasper ,crochet hook, suture retriever Knot pusher – two holes or one hole To check suture twist before tying To tie sliding knots To tie non sliding knots Water tight canula

Ideal knot Provide good tissue tension Ability to hold tension till tissue healing occurs Smallest bulk of knot Ease of tying

Knot types Non sliding Sliding Stacked half hitches / Square knot Revo knot Sliding Sliding non locking – Duncan loop Sliding Locking – Weston Knot , SMC Knot

Sliding vs non sliding knot Sliding – gives good tissue tension but could loosen easily Non sliding – poor tissue hold but does not loosen easily (square knot) Sliding followed by non sliding is good combination Locking sliding not – danger of premature locking

Suture handling Tips and tricks Good view of knot tying field Untangle twist Check whether suture slides freely Ensure that both suture limbs being tied exit the joint through the same passage, with no soft tissue bridge between the limbs The tip of the cannula is kept close to the area where the knot is to be seated Having a third portal allows the uninvolved sutures to be passed out of the joint clear of the tying process Have mental picture of suture orientation as ‘left’ and ‘right’, ‘anterior’ and ‘posterior’, or similar Place assistants finger between separated limbs and place a haemoastat on post limb

Tips and tricks - Suture anchor Make proper orientation of limbs Avoid over penetration – friction at edge of the hole For a sliding knot, leaving the non-post limb protruding about half the overall suture length farther than the post limb from the cannula For non-sliding knots, the post and non-post limbs should be about equal

Loosening could occur if the knots are not locked

Proper orientation of the suture anchor is necessary to avoid suture twist at the anchor

Tips and tricks : knot pusher For sliding knots, the knot pusher should be placed on the post limb Subsequent throws are best placed on non post limb For non sliding knots the knot pusher is placed on non post limb Choose the post limb as the one that passes through the tissues Once a throw is seated, the knot pusher should be used to ‘pastpoint’ to gain additional tightness within the knot

Pass pointing

Non sliding knots

Staked half hitches s– square knot Maintain equal lengths Tag the post limb with clamp Throw overhand loop around the post Pull the knot down to the target with knot pusher on non post Keep continuous tension on post, tension and release on non post Switch the knot pusher to other strand (original non post) Throw under hand half hitches

Revo - Non sliding knot

Revo knot + two opposite half hithes

Sliding knots

Sliding non locking knots

Duncan loop

Duncan loop Identify post and place a clamp Make non post limb length twice as post suture Wrap the loop strand over the thumb, creating a loop Wrap the loop over both limbs four times Pass the free end of the loop back through the loop formed around the thumb Remove the slack of the knot slide the knot

Duncan loop

SMC Knot

Sliding locking knot – SMC knot Identify post and mark with clamp Slide the suture making non post limb twice as post limb Begin the knot by passing the loop strand over the tumb Then pass loop strand over both limbs Pass loop strand over the post limb only Pass the free end under the post between the first two throws and leave a loop of suture Remove the slack of the knot Advance the knot by pulling on the post and pushing the knot with a knot pusher Lock the knot by pulling on the loop, the loop now become post Throw additional two half hiches

Sliding locking - Weston

Nickys knot

Tenesee slider