1. Dr Dilshan Munidasa NHSL
Arthroscopy Basics
Dr Dilshan Munidasa
NHSL

2. 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

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

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

6. 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 degrees.
Angle of inclination

7. 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

8. TROCAR AND SHEATH
Sheath
Blunt trocar
Sharp Trocar

9. 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.

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

11. 70 °
For viewing special regions

14. 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.

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

16. 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

17. 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.

18. 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.

19. 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

20. 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

21. 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.

22. 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.

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

24. 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.

25. Irrigation system

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

28. 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.

29. 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.

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

31. 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.

32. 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

33. 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

34. PATIENT POSITIONING

35. PORTALS

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

37. 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.

38. POSTEROINFERIOR 7-O’CLOCK PORTAL

39. 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.

40. 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.

41. 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.

42. 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.

43. 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.

44. Arthroscopic knot tying Dr Dilshan Munidasa NHSL

45. 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

46. Surgical technique Preparation Selection of right knot Suture handling
Knot configurations

47. 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

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

49. 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

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

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

52. 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

53. 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

54. 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

55. Loosening could occur if the knots are not locked

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

57. 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

58. Pass pointing

59. Non sliding knots

60. 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

62. Revo - Non sliding knot

63. Revo knot + two opposite half hithes

65. Sliding knots

66. Sliding non locking knots

67. Duncan loop

68. 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

69. Duncan loop

80. SMC Knot

82. 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

83. Sliding locking - Weston

85. Nickys knot

86. Tenesee slider