Principles of arthrotomy & arthrocentesis

A summarised guide on these often frequently carried out proceduresv - arthrocentesis & arthrotomy. Quite useful for orthopaedic residents, GPs and med students

1. PRINCIPLES OF ARTHROTOMY & ARTHROCENTESIS Bassey , A E M.B., B.S. D ep’t of Orthopaedic & Trauma S urgery UATH, Abuja

2. OUTLINE - ARTHROTOMY INTRODUCTION DEFINITION STATEMENT OF IMPORTANCE INDICATIONS DIAGNOSTIC THERAPEUTIC PRE-OPERATIVE CONSIDERATIONS INTRA-OPERATIVE CONSIDERATIONS POST-OPERATIVE CARE/REHABILITATION COMPLICATIONS EARLY LATE CURRENT TRENDS

3. INTRODUCTION This is an incision into a joint to expose its interior Although many of its roles have been usurped by minimally-invasive techniques, arthrotomy still remains a very useful tool in the management of joint diseases, moreso , in resource-constrained settings. Every orthopaedic surgeon of worth should therefore be well-grounded in its principles.

4. INDICATIONS DIAGNOSTIC Assessment of joint trauma Biopsy THERAPEUTIC Incision & drainage Debridement/removal of loose bodies Ligament reconstruction Fracture fixation Disarticulation Joint replacement Tumour excision

5. PRE-OPERATIVE CONSIDERATIONS Indication is first met Consent – written, informed consent

6. INTRA-OPERATIVE CONSIDERATIONS Anaesthesia – depends on site Prophylactic antibiotics Tourniquet (where feasible) Approach Shoulder Anterior ( deltopectoral ) approach Posterior approach Elbow Posterolateral approach Posteromedial approach Wrist Dorsal approach Hip Anterior approach (children) Lateral approach (adults) Knee Medial parapatellar approach Lateral parapatellar approach Ankle Anteromedial approach Anterolateral approach

7. TECHNIQUE – KNEE ARTHROTOMY Anaesthesia – GA, SAB, epidural, femoral block Position – supine with sandbag underneath the hip Tourniquet Skin preparation Incision – midline longitudinal incision extending from 5cm above superior pole of patella to the tibial tuberosity

8. TECHNIQUE – KNEE ARTHROTOMY Procedure – deepen incision thru subcut and deep fasciae Develop medial flap to expose quadriceps tendon, medial border patella and medial border ligamentum patellae Incise medial aspect of knee joint capsule longitudinally and adjacent to patella Retract patella laterally for better view Closure is done in layers

9. TECHNIQUE – SHOULDER ARTHROTOMY Anaesthesia – GA Position – Supine Skin preparation Incision – Starts at coracoid process extending inferolaterally along deltopectoral groove. 10 to 15cm long

10. TECHNIQUE - SHOULDER ARTHROTOMY Deepen incision thru subcut and deltopectoral fascia Retract p. major med, deltoid lat and cephalic vein medially or laterally Retract conjoint tendon medially with great care – MC nerve! Incise fascia lat to conjoint tendon to expose articular capsule

11. POST-OP CARE/REHABILITATION Wound care Splintage and elevation of limb Analgesia Antibiotics? Physical therapy Muscle strengthening ROM exercises

12. COMPLICATIONS Early Haemorrhage / haemarthrosis Septic arthritis Nerve damage Late Stiffness Chronic joint pain Fibrous adhesions Scars/contractures

13. CURRENT TRENDS Use of arthroscopy offers folllowing benefits Decreased metabolic response to trauma Decreased complication rate Decreased hospital stay Earlier return to work Improved ability to perform some surgical procedures e.g. partial meniscectomy

14. OUTLINE - ARTHROCENTESIS INTRODUCTION DEFINITION STATEMENT OF IMPORTANCE INDICATIONS DIAGNOSTIC THERAPEUTIC CONTRAINDICATIONS PREPROCEDURAL CONSIDERATIONS TECHNIQUE POSTPROCEDURAL CARE SYNOVIAL FLUID ANALYSIS MACROSCOPIC EXAMINATION MICROSCOPIC EXAMINATION CHEMISTRY CYTOLOGY COMPLICATIONS CONCLUSION

15. INTRODUCTION It is the sterile, surgical puncture of a joint with aspiration of fluid for diagnostic and/or therapeutic purposes It is an indispensable component of the management of joint diseases. In fact, the diagnosis of diseases such as septic arthritis and crystal arthropathy can only be made when arthrocentesis has been carried out

16. INDICATIONS Diagnostic Septic arthritis Tuberculous arthritis Cyrstal arthropathy – gout, pseudogout Therapeutic Septic arthritis (repeated aspiration) Haemathrosis Done prior to corticosteroid injection

17. CONTRAINDICATIONS These are generally relative, Overlying cellulitis Bleeding diathesis

18. PREPROCEDURAL CONSIDERATIONS It is an aseptic procedure Consent – verbal consent would suffice Equipment – Personal protective equipment – surgical gloves, face mask Solution for skin prep – povidone -iodine, alcohol Sterile gauze 1% lidocaine (administered with 25 or 27 gauge needle. Ethyl chloride spray is an alternative) 5-, 10- or 20ml syringe depending on size of joint and volume of effusion Lighting

19. PREPROCEDURAL CONSIDERATIONS Equipment (cont’d) Needles Large joints (shoulder, knee) – 21-18 gauge needle, 1.5in Medium joints (wrist) – 21 gauge, 1in Small joints (MCP) – 25 gauge, 1in Plaster Sterile sample bottle ( heparinized )

20. TECHNIQUE Prior to skin prep identify landmarks and mark needle insertion point Anaesthesia – 1ml 1% lidocaine Positioning – joint to be aspirated should rest on a stable, immobile surface Skin prep – ensure solution dries before start Blind vs. image-guided aspiration

21. APPROACH Considerations: These are designed such that the articular capsule bulges toward the inserted needle If on aspiration the tap is dry it may be that the needle isn’t in the joint space or the fluid is too viscous or the needle is blocked by debris. This is ameliorated by withdrawal and repositioning of the needle or changing it. Specific approaches Shoulder Anterior: Patient is seated Arm adducted and externally rotated

22. APPROACH Shoulder Anterior approach Patient seated Arm adducted and ext rotated Coracoid palpated & needle inserted 1.5in laterally & inferiorly Posterior approach: Needle inserted inferior to acromion

23. APPROACH Elbow Elbow is at 90 o Palpate olecranon , lateral epicondyle and radial head Insert needle laterally in triangle formed by the 3 structures above

24. APPROACH Wrist Wrist is kept neutral & in line with forearm Palpate dimple overlying radio-carpal joint Insert needle perpendicular to limb

25. APPROACH Hip Anterior Patient supine Palpate femoral artery just below inguinal lig Needle entry is 1in lateral to art & inf to ing lig Lateral Patient supine Palpate greater troch Needle insertion just ant to tip of great troch , parallel to couch & inclined 45 o cephalad

26. APPROACH Knee Parapatellar Patient supine Leg fully extended (flexion of up to 15 o is permissible) Medial point of entry is 2-3 o’clock Lateral point of entry is 9-10 o’clock Insert needle perpendicular to knee

27. APPROACH Ankle Patient supine Ankle at 90o or slightly plantarflexed Medial to tibialis anterior tendon is a palpable dimple which is the point of needle insertion

28. APPROACH MCPJ Finger is slightly flexed Needle inserted dorsally, lat or med to extensor tendons MTPJ Similar technique as for MCPJ

29. POST PROCEDURAL CARE Apply gauze over puncture site Rest the drained joint for 48hrs

30. SYNOVIAL FLUID ANALYSIS Macroscopic examination Colour : straw- coloured , bloody, purulent Turbidity: clear, turbid Microscopic examination Microscopy: gram stain, AFB Culture/sensitivity Chemistry Crystal analysis: monosodium urate (gout), calcium pyrophosphate dihydrate ( pseudogout ) Glucose, protein, lactate dehydrogenase Cytology malignancy

31. COMPLICATIONS Early Haemarthrosis Infection Cartilage damage Late Adhesion Recurrence of effusion

32. CONCLUSION Arthrocentesis and arthrotomy are frequently performed procedures, often being carried out in tandem in the management of joint pathology. Despite the emergence of advanced technologies in current orthopaedic practice, the principles guiding the use of these techniques are still very valid today.

33. THANK YOU

34. REFERENCES Apley’s System of Orthopaedics & Fractures, 9 th Ed, pg 323 Chapman’s Orthopaedic Surgery, 3 rd Ed, pp 3568-3569 Essential Orthopaedics & Trauma, Dandy D, Edwards D, 5 th Ed, pg 83 http://www.orthobullets.com/approaches/12028/knee-medial-parapatellar-approach http://www.rileywilliamsmd.com/elbow/arthrotomy http://www.wisegeek.com/what-are-the-different-reasons-to-perform-a-arthrotomy.htm http://emedicine.medscape.com/article/2094114-overview http://www.anwresidency.com/simulation/guide/arthro.html http://www.wheelessonline.com/ortho/aspiration_of_the_hip_joint