BASIC_ARTHROSCOPIC__INSTRUMENTATION.pptx

Plasty

1. B A S I C A R TH R O S C O P I C INSTRUMENTATION

2. H I ST O R Y O F A RTHR O SCO P Y Q . Wh o i s c a lle d t h e F a t h er of S p o r t s M e d i c i n e Q. Who is credited with performing the first s u cc e s s f u l Ar t h r o s c o p y p r o c e d u r e? Greatest advantage ??

3. Danish physician Severin Nordentoft reported performing arthroscopy of the knee joint in 1912 at the Proceedings of the 41st Congress of the German Society of Surgeons at Berlin. He called the procedure (in Latin) arthroscopia genu , and used boric acid solution as optic media. ?? Living or Cadavers Professor Kenji Takagi in Tokyo has traditionally been credited with performing the first successful arthroscopic examination of knee joint, in 1919, for TB knee. He used a 7.3 mm cystoscope !! The Japanese surgeon Masaki Watanabe , receives a r t h r oscopy p r i m a r y c r ed i t for interventional f o r us i ng su r ge r y (SHOULDER specifically) as on modern lines. Introduced the concept of Triangulation ! Canadian doctor Robert Jackson is credited with bringing the procedure to the Western world ! T I M E L I N E

4. danish seurgeon was not given the credit ad the article awa not clear wheher performed on human or animal ..anald many other robert learned scopy from watanbe..and inteoduced to western world later by robert.. watanbe introduced the concept of triangulation..hand holding the instrument, hand with camera..teo jntersect each other..

5. O p e r a t i ng R o o m S e t up > 20 i n c h es

6. bottles has to be placed in particulr height to achive desired elivation television should at the height of ur eyes arthroscopy slab has many slabs..each slab has control unit( for shaver , control unit for light source, etc..) top of tower has monitor ( monitor should atleast to 20 inches)

7. 1 f o o t r a is e of 5 L f lu i d ab o v e t h e j o i n t le v el, r a is es p r e s s u r e b y 22 mm - H g ! J O I N T D I S T E N S I O N P R E SS U R E S K n ee : 6 - 80 mm - Hg Sh o u l d e r : 30 mm - Hg E l bo w / A n k l e : 40 - 60 mm - Hg Glycine 1.5% Glucose 5% Normal saline 0.9% Ringer lactate Demineralized water

8. all these liquids/ fluids has been used by many arhrscopy surgeon..extravasation of fluids could happen .. we push saline through sheath..inside the sheath we put in scope..scope is attached to camera..scope has attachement for light source..as camera doesnt has light.. most commonly used is RL( all over world .. based on article)..glycine and NS being used in INDIA..damage by glycine would be very less compared with NS..as glycine minimum tissue toxicity..as glucine is not conductive but saline is conductive of charge

9. Hip: 4 mm D; 180 mm L Knee, Shoulder: 4 mm D; 135 mm L E l bo w , W r i s t , Ank l e : 2 . 7 m m D , 67 m m L Small joints: 1.9 mm D, 67 mm L Optical Systems Classic thin lens Rod-lens system (Prof Hopkins, England) Graded index lens system (GRIN) - currently in use ARTHROSCOPE

10. we should never push the telescope IN..there lens placed SPACED from each other..if we push it hand, these lenses could get damaged..and arrangement could get changed arthroscope is actually telescope..parts of scope 1. eye peice 2.coupler 3.light post 4. telescope bar 5.Lenses - tip of telescope 6.fibre optic cabe attachemnt in light post standard arthrscopy - 4mm dia, 13.5 cm length.. in hipwe have to penetrate for longer distance..so its 18cm length.. 4 mm diameter..

11. Pi t oning The forward and backward movement of the arthroscope is called “pistoning.” Pitoning allows the surgeon to move closer or further away to visualize one particular area or to obtain a panorama of a larger field. Angulation Angulation is a sweeping motion that moves the arthroscope in a horizontal or vertical plane. Rotation - most important Rotation is the most valuable movement in arthroscopy. MCQ..as its directly linked to feild of view.. Using a 30 ° instead of a ° arthroscope permits a wider view of joint. With the 70 ° arthroscope, rotation occurs around a central blind.

12. The apparent field of view is the diameter seen at the ocular end of the arthroscope Th e a c tua l field o f view is t h e me a su r ed angle of view the arthroscope produces D i a m e t e r an d A n g l e o f I n c li n a t i o n 4 mm diameter: 115 o 2.7 mm diameter: 90 o 1.9 mm diameter: 75 o Angle of inclination INCREASES Field of view!!

13. wen 70 degree- in hip arthroscopy, if there is impingement, we just need to see the periphery..

14. A R T H R O S C O PE S H E A T H AND OBTURATOR SHEATH Diameters 4 mm scope: 5.5-6 mm 2.7 mm scope: 2.9 mm 1.9 mm scope: 2.2 mm Coupler S p i g o t joint Barrel s h e a th Ar t h r o s c o p e T o L i g h t s o u r c e

15. obturator aka trochar sheath diameter is generally larger than the scope as saline has to pass through it..4 mm scope has 5.5 mm sheath.. sheath parts - coupler , spigot joint , barrel sheath two thpes of sheath- 1.universal sheath - more of lens system exposed 2. Hooded sheath - less of lens part exposed

16. L i g h t s o u r c e a n d F i b ero p t i c C a b l e 1 c h i p / 3 c h i p Camera system was invented by McGinty and Johnson P o w e r : 300 - 350 W a tt s S o ur c e s : T u n g s t e n , H a l o g e n , X e n o n , mos t r e c e nt l y L E Ds T e m p e r a t u r e - minimum with LED light source Camera 30 c m L ength 4. 8 m m D iameter - core has optical fibre…Coating provides insulation ( as current doesnt dissipate and dage tissue..

17. camera - initially 1 chip camera..now 3 chip camera..high definition

18. forceps, Suture r ods ( s wi t ch i ng passe r s, s t i cks ) , Mechanical Instruments Probes, Punches, Grasping Knot pushers, Wissinger Cannulas Motorised Instruments Shavers and Burrs Electrosurgical Instruments Electrocautery, Radiofrequency, Laser Special Instruments ACL/PCL sets jigs, Tendon strippers, Meniscus repair sets, OATS Set, Shoulder set, Suture anchors, Screws and Buttons INSTRUMENTATION

19. M E C H A N I C A L I N S T R U M E N T S

20. Extension of surgeon’s finger: Palpates and manuvres ( pull meniscus etc) intra a r t i c u la r s t r u c t u r es M e a s u r e m e n t d ev i c e ( s c a l e ) graduated marking in shaft of probe - TOTAL 12cm Shaft.. horizontal limb has 4 mm TW O F O L D U S E 1 2 c m shaft

21. B a s k e t F o r c e p s Ca t c h e r A v a i l a b l e w i t h 1 5 o up an d d o w n b i t i n g o p t i o n s J A W S Biter Suture 1 2 c m shaft

22. if we take BITE with punch..dont withdraw the punch..do take BITE in sequential manner ..then take out punch..use probe / grabber to remove the tissues..

23. W i s s i n g e r R o d s 4 m m O D

24. cannula 1. WASH Cannula ( GREEN colour in pic) a - plastic and also rigid 2. PASSPORT button cannula ( LIGHT BLUE ) Flexiblw cannula SWITCHING STICKS - for switching / shuttle / changing portal intra-operatively.i.e. used for portal ahuttle..aka weissenger rod..how does this work ?

25. Indirect suture passers 1. antegrade indirect suthre passer 2. retrograde suture passer Direct auture psser

26. S i n g l e H o l e : M o s t c o mm o n l y u s ed . Double Hole: Best avoids suture twisting. But difficult to use so al mo s t di s c a r d e d . Double diameter knot pusher: Creates very good loop and knot s e c u r i t y bu t agai n di ff i c u l t to u s e . E n d s p li tt i n g kn o t pu s h e r : C r e at e s the s t r o n g e s t k n o t s . Le a r n i n g c u r v e . 1 2 c m shaft

27. 30 cm length and 5.5 mm diameter

28. Diameters available 3.5 mm 4.5 mm 5.5 mm 1 2 c m shaft Handpiece – Autoclavable Blades- Disposable M O T O R I Z E D I N S T R U M E N T S Lengths: 70 mm, 120 mm, 180 mm S h a v er w a s i n v e n t ed b y Johnson

29. Outer hollow sheath & inner cutting rotating cannula. Sheath sucks tissue inside for cutting by inner cannula. RPMs Cutting soft tissues: 1000-3000/min Burring Bone: 3000-9000/min SH A V ER B U RR The side-cutting shaver has a small window that does not allow exposure to the blade’s distal tip. The open-ended shaver is the most aggressive and has the distal tip of the blade exposed. The most commonly used is a combination of the 2 types, which is called a FULL-RADIUS RESECTOR. It has only partial exposure of the tip of the blade and the side-cutting window Teeth on barrel and on the blade

30. Electrocautery Haemostasis (Lateral retinacular release) Laser (YAG laser) Delivers high energy with precision Uses- Chondroplasty Drawbacks-Expensive Radiofrequency Can coagula t e and thermal shrinkage Drawbacks- Articular can cause cartilage damage, Osteonecrosis E L EC T R O S U R GI C A L I N S T R U ME N T S

31. S P E C I A L I N S T R U M E N T S

32. ETHOBOND Nonabsorbable braided Polyester suture The first of this type was FiberWire (Arthrex) which has a braided polyester coat around a central core of multiple small strands of UHMWPE. The OrthoCord design has a PDS core with a UHMWPE sleeve and leaves a lower profile after the PDS reabsorbs while retaining the outer sleeve strength. F I B E R W I R E Ultrahigh molecular weight polyethylene (UHMWPE)-containing sutures! FiberTape/ TigerTape are ultra-high strength, 2 mm width tapes . The tapes provide broad compression and increased tissue cut-through resistance making it an excellent choice for knotless rotator cuff repair ORTHOCORD This most recent addition is by DePuy-Mitek). OrthoCord combines both UHMWPE suture with a degradable suture. The size No. 2 combines 32% UHMWPE with 68% polydioxanone (PDS) and is coated with polyglactin. Mechanical irritation, Tissue abrasion, Impingement, Knots slip under load

33. Low c o s t , c l ear on po s t op era ti ve im a g i ng, fe w e r concerns about anchor migration, Lack of Osteolysis Potential for causing suture abrasion, chondral injury in improper placement Radiolucent (but not absorbable; plastic), Can be drilled through during a revision procedure (although not all plastic can be removed), Since they do not absorb they present the same concerns as a metal anchor A biocomposite not only degraded but offer the chance of osteoconductive ingrowth of bone into the space occupied by the anchor. Biocomposite materials are combinations of a degradable polymer (PLLA) with a bioceramic (β-TCP). JuggerKnot (Biomet) is made from a single strand of No. 1 braided UHMWPE suture. The “anchor” portion is created with a short sleeve of braided polyester suture in the middle of the suture and is inserted into the bone. Traction on the suture bunches up the “V”-shaped suture sleeve creating the anchor within the bone.

34. Extra time consumption and possible disadvantages of knots like theoretical risk of tissue irritation, potential postoperative joint clicking from large knots and surgeons knot-tying skill have given way to KNOTLESS REP A I R te c hn i q u e s! T H E M O D E R N W E A P O N A channel is located at the tip of the anchor that functions to capture the loop of suture after it has been ligament. tensioned p a ss e d The as the thro u gh the li ga men t is anchor is inserted into bone! Do u b l e s u t u r e l oo p Bet t er s t r en g t h KN OTL E S S A N C H OR

35. SIZES

36. M I SS E D I N S T R U M E N T S No s c i s s o r s ; No k n i v e s ? ?

37. > 30 min Cidex (Glutaraldehyde) Steris solution (Paracetic acid)

38. S L I D I N G NON-SLIDING NON L O C K I N G L O C K I N G PROXIMAL: Nicky’s knot ( E a s ie r bu t c a n l o o s e n ) MIDDLE: SMC knot, T e n n e s s e s li d er DISTAL: Roeder and Weston knots (Prevent slippage best but learning curve) F i v e o p en t h r o w s S u r g eo n ’ s s q u a r e k n o t K N O T T Y I N G A l l kn o t s s h o u l d be b a c k ed u p w it h t h r ee RH H A L s! Dun c a n l oo p

39. 2 types of knots 1. non sliding knots - its of less use in arthroscopy , since if we tighten the knot , knot doesnt goes through the cannula..ex.a.Surgeon square knot - five open throws 2. Sliding knots - most used in scopy , so that if we pull one end, knot passes down through the cannula..its of two types a. Non locking - problem with this type , after we so the knot , BACK presSURE from the tissue , can loosen the knot b. Locking - further clssified as I. Proximal locking II. middle locking III. Distal locking

40. non locking knot - Dunkan knot one end longer - LOOP Side..its in the anchor side shorter end - POST side..its in the tissue side Hold the POST and LOOP in same level with ur thumb..then u SURROUND the POST with ur loop 3 times..with first time over ur thumb..( additional to three turn) ..then pull the POST for SLIDING the knot . now pull the LOOP to tighten the knot… now u put simple knot ( called Half hitches ) and puss it with knot pusher ( if cannula present).do this for three times.. i.e . the POST is used for doing knots now..out of this three half hitches , there should be one reverse half hitches on alternating loops ( that is exchange LOOP nad POST in knot doing) make sure u do past pointing with knot pusher to tighten it RHHAL - Reverse Half Hitches On Alternating LOOPS..

41. non locking knot - Dunkan knot one end longer - LOOP Side..its in the anchor side shorter end - POST side..its in the tissue side

42. Hold the POST and LOOP in same level with ur thumb

43. first time loop over the thumb ( by LOOP SIDE over POST side )

44. then u SURROUND the POST with ur LOOP 3 times.

45. Insert LOOP side end into the THUMB LOOP..

46. With the kot pusher , kot has to be pushed further away from knot..it i s called past pointing

47. One side is POST (short ) and other side is LOOP ( long )

48. Insert Index finger of POST sid e hand b/w POST and LOOP

49. Take the LOOP side , rotate over the index finger…put it on the other side of POST…now it forms one turn

50. This is after 1 TURN of LOOP side over POST side

51. Then LOOP is rotated again over the POST 2 nd time…

52. This is after 2 nd turn

53. Now the free end of LOOP side is inserted b/w POST and LOOP

54. This step shows that the LOOP end is taken out b/w LOOP and POST..

55. After the LOOP end is taken out, your han d is pronated… Now we can see 3 holes…if we insert LOOP end in proximal mos t hole it is PROXIMAL LOCKING KNOT… Likewise in the Middle and DISTAL hole..

56. PROXIMAL LOCKING KNOT DISTAL LOCKING KNOT MIDDLE LOCKING KNOT

57. K n o t Fa i l u r e : S li ppa g e or di s p l a c e m e n t > 3 mm Knot Security : Ability to withstand slippage and maintain the tension. Depends on friction an d s l a c k be t w ee n th r o w s Loop Security : Refers to ability of the suture loop to withhold tissue and hold tension ( a f t er the kn o t i s t i e d an d t e n s i o n e d )

58. T H A N K Y O U

59. Most common complication of Arthroscopy is Haemarthrosis particularly after Synovectomies an d L a t e r a l re t i n a c u l a r re l e a s e!