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1. BASIC PRINCIPLES OF ARTHROSCOPY BY : Dr. NIHARIKA MODERATOR : Dr. VAMSI KRISHNA 1

2. HISTORIC DEVELOPMENT Fathers of Arthroscopy: Japanese surgeon Takagi Swiss surgeon Bircher 2

3. Instrumentation Arthroscope : 3

4. Viewing Angle: 0 degrees,30 degrees and 70 degrees 0 degrees scope It must be angled in order to change the field of view Retracting and advancing the scope narrows or widens the image Not recommended for arthroscopic surgery 4

5. 30 degrees scope Viewing angle is directed 30degrees relative to barrel axis Portion of joint accessible is tripled simply by rotating the scope The visual field is 90 degrees 70 degrees scope Very oblique viewing angle does not permit visualization along optical axis Absolutely required for inspection of the posterior joint areas 5

6. Barrel length Length of 18cm Short barrel : hindrance in certain procedures Diameter Determined by dimensions of lens system ,the fiberoptics and the metal barrel. 1.7 to 4mm 6

7. Image quality Mainly adequate brightness and uniformly illuminated Aging: Physiological aging process More used ,faster it ages Accelerated by frequent Flash sterilizations Hazy murky image or localized scratches 7

8. SHEATH COMPONENTS 1.COUPLER 2.SIGOT PLANE 3.SHEATH BARREL 8

9. VEDIO CAMERA 1.TUBE CAMERA ADVANTAGES Brilliant image with good depth of field and excellent color reproduction DISADVANTAGES Heavy weight ,relatively large size and delicate tube 9

10. 2.ONE CHIP CAMERA Based on semiconductor chip Adapts to variety of lighting Provides balanced ,high quality image 3. THREE CHIP CAMERA 3 chips separately detect and process each of the primary colours Contains built in digital image processor. 10

11. Requirements of arthroscopic camera Ergonomic design Mechanism of coupling the camera to scope Zoom lens Adjustable sharpness Built in control functions Contro l unit Camera cable sterilization 11

12. LIGHT CABLE 1.FIBREOPTIC CABLES Transmit light through bundled optical glass fibers Constant stresses causes fiber damage Easier to maintain and sterilize 150-180 cm 12

13. 2.FLUID CABLES Plastic tubes filled with fluid that transmits light 40-50% more efficiently than fiberoptic cables Less flexible and difficult to handle Not autoclavable Blue wavelength light is particularly transmitted 13

14. TRIANGULATION A principle in which probe and arthroscope are held so that their tips form apex of an imaginary triangle 14

15. SURGICAL INSTRUMENTS 5 principal types of instruments Mechanical instruments Motorized instruments Electrosurgical instruments Lasers Special instruments 15

16. BASKET FORCEPS Also known as punch or cutting forceps Various types and degree of angulation Contain jaws for excision of tissue Indication s Division of tissue bridges Removal of degenerative tissue Division of synovial bands and scar tissue Piecemeal removal of soft loose bodies 16

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18. Disadvantages Piecemeal removal Retained tissue fragments Poor control of resection dept h 18

19. GRASPING FORCEPS Used for removing loose bodies, blood clots and tissue fragments Indications Meniscal fragments Loose bodies Osteophytes Grasping of sutures for arthroscopic repair (1.5mm and shaft length 60-80mm) 19

20. MOTORIZED INSTRUMENTS COMPONENTS Control unit Connecting cable Hand piece Blades suction 20

21. Clogging of shaver blades Drawing large tissue fragments into cutter Suction set too low Disproportion between the instrument diameter and cutting window Constantly pressing shaver against tissue to be removed If shaver gets clogged Switch on oscillating mode Check suction Check fluid inflow Check the tip of attachement 21

22. Drive unit with blades Resection of tissue Retrieval of loose bodies Notch plasty Smoothening of bone tunnels Abrader Drive with saw Removal of bone blocks Osteotomy Windowing of bone Drive with drill Harvesting bones K wire insertion Fibrocartilage induction 22

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24. ELECTROSURGICAL INSTRUMENTS High frequency electric current divides tissue by heating the cellular fluid to more than 100 degrees High vapor pressure explosively disrupts the cells and tissue. Electrocoagulation with high frequency modulated or unmodulated Indications Meniscal resection Lysis of adhesions Selective hemostasis Resection of scar tissue 24

25. ADVANTAGES Small size No dulling Minimal postoperative bleeding Selective hemostasis Malleability Multidirectional cutting Variable cutting action DISADVANTAGES Bubble formation Iatrogenic cartilage damage Short circuiting Skin burns Monitor interference Muscle contraction 25

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27. SPECIAL INSTRUMENTS Chisels Files Rasps Curettes Screwdrivers Irrigation cannulas 27

28. ANESTHETIC TECHNIQUES General anesthesia Regional anesthesia Local anesthesia 28

29. POSITIONING Accessibility of all joint compartment Convenience Options of converting to open surgery Simple positioning devices Free tourniquet access 29

30. DISTENSION MEDIUM REQUIREMENTS Sterile No synovial irritation Non toxic Provides good visibility No side effects Easy to use Low cost 30

31. GAS MEDIUM A dvantages Good visibility Good depth of field Rapid distension Facilitates differentiation between old and acute tears D isadvantages Difficult to evaluate cartilage and synovial membrane Loose bodies Risk of emphysema Gas leakage Lens fogging Costly Risk of embolism 31

32. FLUID DISTENSION Ringer lactate Isotonic saline Non electrolytic solution Disadvantages Storage requirements Fluid leakage Extra-articular fluid collection Contaminated irrigating fluid 32

33. IRRIGATION SYSTEM Channeling distension fluid into joint and removing it again PUMP SYSTEM Inflow tubing is connected to special roller pump Pressure or volume controlled Excellent irrigation , maintains clear visual field High cost 33

34. GRAVITY FLOW SYSTEM distension pressure can be increased or decreased by raising or lowering the level of suspension Slow infusion Types of irrigation Inflow through cannula and outflow through sheath Inflow through sheath ,outflow through cannula Inflow and outflow through sheath 34

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36. INDICATIONS FOR ARTHROSCOPY Meniscal tears ACL tears PCL tears Removal of loose bodies Synovectom y Mosaicplasty Autologous cartilage implantation Diagnostic Synovial biopsy 36

37. Rotator cuff tear Subacromial decompression Frozen shoulder Suprascapular nerve entrapement Labral tears Shoulder instability Removal of loose bodies 37

38. TECHNIQUE FOR CREATING ARTHOSCOPIC PORTAL POSITION: knee joint flexed upto 70degrees IDENTIFICATION First patellar apex, patellar tendon and lateral femoral condyles are identified. The patellar apex provides key landmark for portal placement Anterolateral portal is considered standard viewing port Portal is placed lateral to the patellar tendon at the level of patellar apex. 38

39. SKIN INCISION A transverse incision of 6mm is made with 15 blade, the inside the knife is rotated 90 degrees and lateral joint capsule is cut vertically INSERTION OF SHEATH: Sheath with blunt obturator is inserted into the joint, when the sheath and obturator enters the fibrous capsule the tissue resistance declines. The knee is extended and the sheath is gradually advanced into medial portion of superior recess. 39

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52. THANK YOU 52