Post on 14-Apr-2017
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
THANK YOU