ARTHROSCOPY

SHOULDER

• An arthroscope is an optical instrument. • Three basic optical systems have been used in rigid arthroscopes: • (1) the classic thin lens system,• (2) the rod-lens system designed by Professor Hopkins of Reading,

England, and • (3) the graded index (GRIN) lens system

the optical characteristics of an arthroscope• 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 120 degrees.• The 25- and 30-degree arthroscopes are most commonly used. • The 70- and 90-degree arthroscopes are useful in seeing around

corners,

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

Principle• 1) Instrumentation• 2)Operation room• 3)Anaesthesia• 4) Portal Placement• 5) Arthroscopic Knot Typing

1) Instrumentation

Arthroscopy cart:

• a high-definition (HD) flat-screen monitor and a tablet suspended by a moveable arm are placed on the top;• an integrated control unit that combines the HD video camera, the

“xenon bright” LED light source, and the image management console is placed on the second shelf, • followed by the irrigation pump, the motorized instruments unit, a

radiofrequency generator, and the footswitches

Fluid Management• In general, fluid pressure within the glenohumeral joint is kept close

to 30–40 mmHg;• it can increase to between 40 and 70 mmHg in the subacromial space

to allow for an adequate visualization. • Maintaining the mean arterial pressure between 70 and 90 mmHg,• or the systolic blood pressure at 100 mmHg, improves the

visualization.

• The liquids utilized must have osmotic, ionic, and pH biologically compatible properties to not cause tissue damage. • We use 3 L bags of sterile saline solution with one vial of

noradrenaline added to help control any bleeding.

Irrigation Systems

•1) a gravity system •2)an automatic pump system.

Hand tools

Permanent Skin Marker

• A dermographic pen is utilized to draw landmarks of the underlying bone structures on the patient’s skin

Needles• An 18 gauge spinal needle• is used to correctly identify the arthroscopic entry points on the skin • and trajectories leading into the joint

Cannulas• made of plastic or metal; • equipped with a blunt trocar that facilitates the penetration through

the soft tissue to reach the joint. • We prefer to use a metal cannula to create the arthroscopic portals. • We use plastic cannulas with different calibers throughout the

remainder of the surgery:• 8.0 mm operative cannulas and 5.5 mm outflow cannulas

Switching Sticks

• There are generally two switching sticks per arthroscopic kit• two switching sticks are inserted, • one in the cannula and • the other in the sheath of the arthroscope

Dilators

• Dilators are metal instruments • that are utilized to dilate the arthroscopic portals in order to facilitate

the passage of the cannulas.• They are cannulated so they can easily slide over the switching stick,

which acts as the guide .

Probe• The probe is an instrument with a curved end which represents the

“extension of the surgeon’s finger.” • It is inserted into the joint through an arthroscopic portal.

Chisel Dissector

• Available in various sizes,• the chisel dissector is characterized by a flat and sharp end. • It is primarily used in instability surgery and enables the surgeon• to loosen scar adhesions and• to adequately mobilize the capsulolabral complex from the glenoid

neck

Rasp• An instrument utilized to abrade bone surfaces and/or capsular tissue

to create bleeding

Cutting Instruments • 1)Punches • Punches are a particular type of basket scissors;• they can be straight, curved, or angled (upturned, right, left) with

antegrade or retrograde bite • The use of basket punches in shoulder surgery is currently limited

because of the widespread utilization of motorized or radiofrequency tools

2)Scissors and Suture Cutters • The scissors can be straight or curved. • They are frequently utilized to cut soft tissue, such as the rotator cuff

(i.e., during an interval slide procedure), the capsule (i.e., during an arthroscopic capsular release), or the long head of the biceps (tenotomy), as an alternative to radiofrequency instruments. • They can also be used to cut the suture strands after a knot has been

tied. • Suture cutters were designed to facilitate arthroscopic cutting of high-

resistance braided sutures, such as FiberWire, and are available in a closed and open end

Grasping Instruments• 1)Suture Retrievers • Suture retrievers are used to recover and manage the suture • strands.• The jaw creates a closed loop which allows the suture to slide freely

during suture extraction

• 2)Graspers • Graspers can be blunt, serrated, or hook shaped. • A fundamental requirement of these forceps is the ability to provide

an atraumatic grasp that does not compromise the integrity of the structure. • They can be used for tissue grasping and/or reduction,• foreign and loose body removal, • minor arthroscopic biopsies, and• suture retrieval and management

3)Suture Passers

• The role of suture passers is• to allow for the passage of suture strands through the soft tissue

(tendons or capsulolabral tissue). • They are divided into two types: direct and indirect

Powered Instruments

• The shaver is an instrument equipped with a handpiece in which single-use blades, with different shapes and functions, can be inserted. • The control unit is inserted in the arthroscopic tower, and it is

controlled by footswitch placed near the surgeon’s feet or by buttons on the handpiece. • The shaver has a suction tube; the suction is managed either directly

by the surgeon with a control on the handpiece or by an assistant who adjusts the suction by manually clamping the tube. • The suction serves to remove loose tissue or bone fragments in the

joint which were generated by the shave

2.Operation Room

lateral decubitus position • < 10–15 lbs longitudinal traction• position of the arm• 45° to 70° of abduction• 20° to 30° of forward flexion

Hennrikus et al. (Am J Sports Med 23:444, 1995.)

positionlateral decubitus position • continuous traction

allows easier GH & subacromial arthroscopy

beach-chair position• more convenient for regional

anesthesia and converting to open procedures

beach-chair position• Anatomical• Convert to Open surgery• Move arm• Less Nerve injury• Complication ; stroke & death• The disadvantage of this technique

is difficulty in working from posterior portals and decreased cerebral perfusion when hypotensive anesthesia is induced

beach-chair position• Anatomical• Convert to Open surgery• Move arm• Less Nerve injury

Anaesthesia• Interscalene block• GA

Portal Placement and Related Anatomy• Arthroscopic portals can be made in

i. the glenohumeral, ii. subacromial, and iii. acromioclavicular joints.

• The glenohumeral joint portals can be made posteriorly, superiorly, and anteriorly; • the subacromial joint portals are placed anteriorly, posteriorly, and

laterally; and • the acromioclavicular joint can be approached from the subacromial

space anteriorly or posteriorly

• The axillary and suprascapular nerves are the two structures at most risk during shoulder arthroscopic portal placement. • Nassar et al. found that the distance

between the acromioclavicular joint and the axillary nerve is 7.9 cm for men and 6.37 cm for women. • Bigliani et al. found the suprascapular

nerve to be located 1.8 cm from the posterosuperior labrum and 2.5 cm from the superior glenoid tubercle. • Posterior portals seem to be at lower risk

than anterior portals.

Landmarks• First, the scapular spine, the posterolateral, and the antero-lateral

corners are identified and palpated with the first three fingers and then marked with a dermographic pen. • Then, the anterior and posterior profiles of the distal clavicle are

identified, and the acromioclavicular joint is drawn.• Finally, the coracoid process is identified, and the coracoacromial

ligament is drawn between the coracoid process and the antero-lateral corner of the acromion .

• An intra-articular injection of 20 ml of a diluted solution of epinephrine/norepinephrine (1:80,000 ) performed with a spinal needle before surgery is a useful tool to facilitate joint access and reduce bleeding during the procedure • The needle is inserted through the soft spot of the shoulder, which is • located 2 cm inferiorly and 1–2 cm medially to the postero-lateral

edge of the acromion.

SUBACROMIAL BURSA:

GLENOHUMERAL JOINT:

2

2 – Glenoid & Posterior Labrum

3

3 – Inferior Recess

1

1 – LHB (SLAP, tear)

4

4 – Humeral Head, Bare area, Posterior Cuff

55 – Anterosuperior Cuff

6

6 – Rotator Interval (pulley, LHB in groove, SGHL)

7

7 – Subscap, MGHL, anterior labrum88 – AnteroInferior labrum, IGHL

9

9 – CAL & Acromion

10

10 – Rotator Cuff - Bursal side

10 Point Shoulder ArthroscopyLennard Funk

Sutures

• An arthroscopic suture should possess good handling characteristics, good strength, and good loop and knot security and be biocompatible.• If degradation should occur, the suture should not create a significant

inflammatory response• Polydioxanone (PDS) is perhaps the most common biodegradable

monofilament suture use

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