Editors: McKeon, Brian P., Bono, James V., Richmond, John C. (Eds.) Arthroscopic procedures are a welcome alternative to total joint replacement and, with millions of procedures performed each year, the field of knee arthroscopy is rapidly advancing as instrumentation and. Sections on the knee, shoulder, elbow, hip, wrist, and ankle provide in-depth Arthroscopy will be an invaluable textbook and reference for orthopaedic. From the reviews: "Each chapter in this book on arthroscopic management of knee disorders . serve as a concise and practical reference for all professionals.
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“This is a contribution from the European Romanian team on pathology, imaging, and scoping of knee trauma. This is a good book for orthopaedic surgeons. Below are books that ESSKA has published with Springer. ESSKA members Knots in Orthopaedic Surgery – Open and Arthroscopic Techniques Akgun, U. Find Arthroscopy books online. Get the best Arthroscopy books at our marketplace. MRI-Arthroscopy Correlations: A Case-Based Atlas of the Knee, Shoulder.
An introductory section describes the history of arthroscopy, explains general principles, and provides information on instrumentation, electronic equipment, anesthesia, pain control, and prevention of complications.
A special chapter focuses on the operative report, with description of an electronic form that can be used by every surgeon to store operative records or participate in European multicenter ESSKA studies. The authors include the most renowned arthroscopic surgeons in Europe. Arthroscopy will be an invaluable textbook and reference for orthopaedic surgeons, general orthopaedic physicians, sports traumatologists, residents, and physical therapists.
Pietro S. After graduating from the University of Milan, Dr. Randelli specialized in Orthopaedics and Traumatology and in completed his Masters in Pediatric Orthopaedics and Traumatology. He has surgical experience of more than procedures, including primarily shoulder and knee arthroscopy and total knee, hip, and shoulder replacement. He has more than publications to his name, including numerous articles in peer-reviewed journals.
Series: AANA Advanced Arthroscopy
Medicine Orthopedics. Various instruments are passed through the other portal to perform the surgery. An arthroscopy takes about 20 minutes to perform. Bigger operations, such as ligament reconstructions take about 90 minutes. How long will I be in hospital for? While a knee arthroscopy only takes about 30 minutes to do you will need to come into hospital hours early to be checked in and sort out your paperwork. After the operation you will need to be observed for a couple of hours to ensure that you have recovered from the anaesthetic What happens when I leave hospital?
You will need someone to pick you up from the hospital and stay with you on the night of your surgery. You will probably feel a bit sleepy and might need some pain killers.
You will be given written instructions on how to look after your wound, what warning signs to look out for and what to do with your dressings. You will also be given a sheet of exercises to get you started after your operation. A physiotherapist may visit you while you are in hospital to teach you these exercises. You should keep the wounds dry until you are seen by your specialist. Will I need crutches or a brace? An assistant surgeon, if available, stands proximal to the surgeon, and the scrub nurse stands distal to the surgeon with her instrument trolley further distal to her.
Proximal to the tower is the Mayo stand which holds all the arthroscopic instruments. A separate table may be utilized adjacent to the scrub nurse instrument trolley for graft preparations. The operation bed and surgeon should be within the confines of the laminar flow ceiling.
Arthroscopic tower 1. From top the bottom, the components are: Arthroscopic tower 2. The top console is the fluid pump management system, and the bottom console is the radiofrequency ablation system.
The patient should be supine on the operation table.
Placement of this side support must facilitate two functions: The operation table may have to be lowered or the surgeon may place his left foot onto a stool. Therefore, the surgeon must check both positions before instructing the attendant to secure the side support in place. If a sandbag is used, it should be securely taped down to the table to prevent movement during the surgery. A properly applied tourniquet is a great aid to visualization during the surgery, especially during femoral drilling for Anterior Cruciate Ligament ACL reconstruction.
A thick wad of cotton should be applied first to the thigh, and it is important that the width of the applied cotton is larger than the width of the tourniquet. This allows the even distribution of pressure from the tourniquet to the thigh. The tourniquet itself should be tightly applied over the cotton such that it will not admit even one finger.
A crepe bandage is then secured over the lower half of the tourniquet and the lower edge is folded inwards beneath the lower edge of the tourniquet. Positioning of this more proximal foot rest should be slightly less than full knee flexion.
If the knee were fully flexed during positioning, the foot rest will not be able to hold the knee properly after draping adds bulk to the entire set-up. An upright image is maintained by adjusting the scope handle. Arthroscopic instruments. From top to bottom, they are: The diagram on the left illustrates the correct way of directing the angle of visualization to the posterior part of the knee. The diagram on the right is the wrong way.
An arthroscopic debrider, commonly called a shaver, is used to debride damaged tissues. The author routinely uses a 4.
When using this for cartilage or menisci, the shaver edge is first used to debride the damaged tissue, and the shaver gradually moved towards normal tissue with a controlled gradual movement to achieve a smooth tissue edge.
When used carefully, there is no risk of accidentally debriding normal tissue. The next important instrument is the radiofrequency ablation probe, or commonly called a wand. The wand delivers electrical energy to its tip, generating intense localized heat that coagulates tissues. There are two modes, cutting and coagulation.
Successful Knee Arthroscopy: Techniques
The cutting mode delivers a continuous high-frequency current, which heats the tissue so strongly that the cells are explosively destroyed, severing the tissue. The coagulation mode delivers high-frequency current in pulsed mode, delivering a lower energy such that the tissue dries out without being severed.
The wand is a useful instrument for shrinking synovial tissue, smoothing out a rough meniscal edge or cartilage edge with fibrillations, and dissecting tissue off bone, for example when preparing the lateral femoral condyle in ACL surgery. The most commonly used arthroscopic fluid is 0. For standard arthroscopy cases such as cartilage or meniscal debridement and wash-out, a fluid management pump is not required.
The author uses a fluid management pump for ACL surgeries, in particular for the drilling of the femoral tunnel.
This is because hyperflexion of the knee for drilling of the femoral tunnel may decrease the tourniquet effectiveness due to the extreme positioning. A standard knee arthroscopy starts with the positioning and set-up as detailed in the previous section. The first portal to be established is the anterolateral portal.
Correspondingly, the anteromedial portal is at the same level and situated as close to the medial edge of the patella tendon as possible. Taking in mind that the tibial plateaus are dish-shaped, the height of the portal at the inferior pole of the patella allows access to the posterior part of the tibiofemoral articulation.
Furthermore, a wrong injection into synovium will cause marked synovial swelling that will severely obstruct visualization. Following incision, a straight arterial haemostat is inserted through the synovial tissue with a controlled force and the tip of the haemostat felt to touch the trochlear.
A controlled insertion is important to avoid inadvertent damage to the trochlear cartilage. The haemostat is then opened to dilate the track.
The scope trocar is inserted in the same direction, and similarly felt to contact the trochlear, before the knee is extended and the trocar driven beneath the patella into the suprapatellar pouch. Following visual confirmation of placement in the suprapatellar pouch, fluid irrigation can be started.
Where there is a lot of synovial debris, a washout of the suprapatellar pouch will first be performed using the irrigation. A diagnostic arthroscopy starts with examination of the suprapatellar pouch with the knee in extension. Pathology that can be observed at this stage includes loose bodies, synovitis or plicae.
The lens is directed upwards and the undersurface of the patella cartilage inspected. Following inspection of the suprapatellar pouch, the lens is taken over the medial side of the medial femoral condyle while the knee is allowed to flex over the side of the table. The medial gutter can be inspected at this juncture.
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The medial femoral condyle should be inspected in its entirety, followed by the anterior horn of the medial meniscus and the ACL. Frequently though, the fat pad posterior to the patellar tendon can interfere with visualization and it is at this point that a 21G hypodermic needle can be inserted through the surface marking of the anteromedial portal.
The direction of the needle should be checked and confirmed to be able to give a direct line of access to the posterior horn of the medial meniscus. A stab incision is then made and the track dilated with a straight haemostat.
The author routinely use a 4. There is often a rudimentary ligament at the anterior aspect of the tibiofemoral articulation which can be safely excised. Adequate visualization is achieved when the anterior horn of both medial and lateral menisci are easily visualized together with the intermeniscal ligament. With the knee at different angles of flexion, the direction of the portal changes slightly due to the difference in position of the skin relative to the capsule and synovium.
With experience, primarily through development of muscle memory, the surgeon is able to quickly locate the right direction of entry without forcefully creating another tract. Additional tracts through the capsule or synovium should be avoided as these are all potential sites for joint fluid extravasation and represents unnecessary additional tissue damage. To enhance easy insertion of instruments and changing of the scope through different portals, the track should be adequately dilated using the haemostat.
With the scope in the anteromedial portal, the wand should be inserted through the anterolateral portal and used to shrink the synovium around the opening of the tract and vice versa.
By slowly varying the angle of flexion using his hip, the surgeon will be able to find an angle of best access. Sometimes, this maneuver does not suffice to allow access to the posterior horn in muscular young adult male patients or patients with post-traumatic knee arthritis and joint stiffness.
A method of improving access is by needling the MCL from within. An 18G spinal needle is inserted from the anterolateral portal. The spinal needle is directed towards the body of the medial meniscus, inferior to it.
The curved tip is pointed inferiorly to avoid injury to the meniscus. It is important to apply a sustained gradual force and avoid sudden excessive valgus forces to avoid creating an iatrogenic MCL tear. This technique is sufficient to open up the medial compartment for visualization and instrument access.
A similar method is needling the MCL from outside the skin and observing the needle penetrating the joint below the meniscus [ 3 ]. Both techniques work well but doing it from within avoids puncture marks on the skin and is more accurate in avoiding the meniscus. To visualize just the posterior root of the medial meniscus, the scope can be inserted from the anterolateral portal and driven through the notch. This can easily be done in patients with a lax ACL and a wide notch.
In patients with an intact ACL, a trans-patellar tendon portal is sometimes required in order for the scope to adopt the right direction to penetrate the notch.
This position allows work to be done on the posterior horn of the lateral meniscus, with the scope inserted from the anteromedial compartment and the instruments inserted from the anterolateral compartment.
Following an arthroscopic inspection of the whole joint, the required work is then performed. Standard knee arthroscopies are often done as a debridement procedure in middle-aged patients with knee osteoarthritis.
Menisci damage is classified according to the morphology fraying, tear, horizontal cleavage and location within the white-white, white-red, or red-red zone. Routine debridement procedures involve debriding damaged cartilage or menisci down to a stable and smooth rim with a combination of the shaver and wand.
Degenerated menisci involving the white-white zone can be safely debrided. However, if the meniscal damage involves the red-red zone, an attempt should be made to repair the meniscus wherever possible and biologically feasible. Intra-articular loose bodies or prominent osteophytes, especially patellar osteophytes, can also be removed. They can be excised with a combination of the arthroscopic scissors and the shaver.
Boggy synovial hypertrophy can be downsized as synovitis is also often an important contributor of pain. At the completion of the procedures, the knee is repeatedly washed out using the arthroscopic fluid to remove debris and inflammatory cytokines.
The wounds are closed with non-absorbable sutures to achieve a water-tight closure, and generous local anesthetic can be infiltrated around the wounds. A bulky post-operative dressing is applied.
A lateral release is a commonly performed step of routine knee arthroscopy for patients who have tight lateral retinaculum causing a lateral patellar tilt.
Patients will commonly have anterior knee pains after walking or running, and examination will show reduced medial translation of the patella and lateral patellar facet tenderness. This should be corroborated by a skyline x-ray view of the knee showing abnormal lateral patellar tilt. Patients with these findings will then do well with a simple lateral release.
This step is usually performed at the end of the arthroscopy, because there will be fluid extravasation into the subcutaneous tissues once the lateral release is done. A hook radiofrequency ablation tip is inserted through the incision and used to incise the retinaculum longitudinally about 1—1. It is important that only the retinaculum be ablated and released, without ablating the more superficial subcutaneous layer.
Another method of doing this is to insert the radiofrequency hook through the anterolateral portal. The patella should be checked for increased medial mobility and the knee taken through flexion to check for an adequate release.
Static quadriceps contractions, straight leg raise, and active flexion of the knee is encouraged from immediately after surgery. Cartilage repair or restoration is a group of surgical techniques of treating cartilage lesions in suitable cases [ 4 ].
Generally, these are middle-aged patients with fairly localized Outerbridge grade 3—4 degenerative cartilage wear, usually over the medial femoral condyle or beneath the patella facet.
The Arthroscopy Book
Patients with Outerbridge grade 1—2 cartilage wear can usually be satisfactorily treated with debridement. Young active patients with very localized cartilage lesions will benefit from Autologous Cartilage Implantation ACI , where the first stage involves arthroscopically harvesting cartilage from the anterior non-weightbearing surface of the medial or lateral trochlear.
The cartilage chondrocytes are then cultivated in the laboratory. For most patients, the most basic method of treating cartilage lesions is microfracture, known as a marrow stimulation technique.
The idea is to allow the release of mesenchymal stem cells from within the marrow into the cartilage defect, forming a blood clot. It is important to create vertical wall edges wherever possible. This allows more effective trapping of the resultant blood clot within the defect. An arthroscopic awl is then used to create subchondral punctures in the bone to allow the escape of fat globules from within the marrow.
Patients who had microfracture alone do not require protected weight-bearing after surgery. In fact, weight-bearing is beneficial because it compresses the femoral condyles against the tibia, closing off the cartilage defect and allowing formation of a contained blood clot.Meniscal Allograft Transplantation: Toe-touch weight bearing with two crutches is allowed.
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Medicine Orthopedics. Two minutes is allowed to lapse for the hardening of the glue, and the knee is then ranged carefully to check for the stability of the mesh. A final check arthroscopy can then be done, assessing the final position of the new graft. When using the all-inside devices, the needle itself can be used as a reduction device since there is usually little room to admit another instrument to hold the meniscus in place.
Abstract Knee arthroscopy is one of the most common arthroscopic procedures required of an orthopedic surgeon. Preparation of the wall of the lateral femoral condyle should show the Ridge and the entire wall inferior, posterior and superior to the Ridge.