BASIC ARTHROSCOPIC
INSTRUMENTATION
HISTORY OF ARTHROSCOPY
Greatest advantage ??
Q. Who is called the Father of Sports Medicine
Q. Who is credited with performing the first
successful Arthroscopy procedure?
Danish physician Severin Nordentoft reported performing
arthroscopy of the knee joint in 1912 at the Proceedings of
TIMELINE
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.
Professor Kenji Takagi in Tokyo has traditionally
?? Living or Cadavers
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 primary credit for using
arthroscopy for interventional surgery
(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 !
> 20 inches
Operating Room Setup
1 foot raise of 5 L fluid above the joint
JOINT DISTENSION PRESSURES level, raises pressure by 22 mm-Hg !
Knee: 60-80 mm-Hg
Shoulder: 30 mm-Hg
Elbow/ Ankle: 40-60 mm-Hg
• Glycine 1.5%
• Glucose 5%
• Normal saline 0.9%
• Ringer lactate
• Demineralized water
ARTHROSCOPE Optical Systems
Hip: 4 mm D; 180 mm L
• Classic thin lens
Knee, Shoulder: 4 mm D; 135 mm L • Rod-lens system
Elbow, Wrist, Ankle: 2.7 mm D, 67 mm L (Prof Hopkins, England)
Small joints: 1.9 mm D, 67 mm L • Graded index lens system
(GRIN)
Pitoning
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
Rotation is the most valuable movement in arthroscopy.
q Using a 30° instead of a 0° arthroscope permits a
wider view of joint.
q With the 70° arthroscope, rotation occurs around
a central blind.
The actual field of view is the measured
angle of view the arthroscope produces
The apparent field of view is the diameter Angle of inclination
seen at the ocular end of the arthroscope INCREASES
Field of view!!
Diameter and Angle of Inclination
4 mm diameter: 115o
2.7 mm diameter: 90o
1.9 mm diameter: 75o
ARTHROSCOPE SHEATH Coupler
AND OBTURATOR Spigot
joint
Barrel
sheath
SHEATH Diameters
4 mm scope: 5.5-6 mm
Arthroscope
2.7 mm scope: 2.9 mm
1.9 mm scope: 2.2 mm To Light source
Light source and Fiberoptic Cable
Power: 300-350 Watts
Sources: Tungsten, Halogen,
Xenon, most recently LEDs
Temperature !!!
Camera
300 cm L and 4.8 mm D
Camera system was invented
by McGinty and Johnson
1 chip/ 3 chip
INSTRUMENTATION
Mechanical Instruments
Probes, Punches, Grasping forceps, Suture passers,
Knot pushers, Wissinger rods (switching sticks),
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
MECHANICAL INSTRUMENTS
TWO FOLD USE
Extension of surgeon’s finger:
Palpates and manuvres intra
articular structures
Measurement device (scale)
12 cm
shaft
Basket Forceps Suture
JAWS
Catcher
Biter
12 cm
shaft
Available with 15o up
and down biting options
Wissinger Rods
4 mm OD
Single Hole: Most commonly used.
Double Hole: Best avoids suture
twisting. But difficult to use so
almost discarded.
Double diameter knot pusher:
12 cm Creates very good loop and knot
shaft security but again difficult to use.
End splitting knot pusher: Creates
the strongest knots. Learning curve.
30 cm length and 5.5 mm diameter
MOTORIZED INSTRUMENTS
Lengths: 70 mm, 120 mm, 180 mm
Diameters available
• 3.5 mm
• 4.5 mm
• 5.5 mm
12 cm Handpiece – Autoclavable
shaft
Blades- Disposable
Shaver was invented by
Johnson
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. BURR
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
RPMs
Cutting soft tissues:
1000-3000/min
SHAVER
Burring Bone:
3000-9000/min
Outer hollow sheath & inner cutting rotating cannula.
Sheath sucks tissue inside for cutting by inner cannula.
ELECTROSURGICAL INSTRUMENTS
Electrocautery
Haemostasis
(Lateral retinacular release)
Laser (YAG laser)
Delivers high energy with precision
Uses- Chondroplasty
Drawbacks-Expensive
Radiofrequency
Can coagulate and can cause
thermal shrinkage
Drawbacks- Articular cartilage
damage, Osteonecrosis
SPECIAL INSTRUMENTS
The first of this type was FiberWire Mechanical irritation, Tissue abrasion,
(Arthrex) which has a braided Impingement, Knots slip under load
polyester coat around a central core of FiberTape/ TigerTape are ultra-high strength,
multiple small strands of UHMWPE. 2 mm width tapes. The tapes provide broad
compression and increased tissue cut-through
resistance making it an excellent choice for
Ultrahigh molecular weight polyethylene knotless rotator cuff repair
(UHMWPE)-containing sutures!
FIBERWIRE
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%
ETHOBOND polydioxanone (PDS) and is coated with polyglactin.
Nonabsorbable The OrthoCord design has a PDS core with a UHMWPE
braided Polyester suture sleeve and leaves a lower profile after the PDS reabsorbs
while retaining the outer sleeve strength.
JuggerKnot (Biomet) is made from a single strand
A biocomposite not only degraded but
of No. 1 braided UHMWPE suture. The “anchor”
offer the chance of osteoconductive
portion is created with a short sleeve of braided
ingrowth of bone into the space
polyester suture in the middle of the suture and is
occupied by the anchor.
inserted into the bone. Traction on the suture
Biocomposite materials are combinations bunches up the “V”-shaped suture sleeve creating
of a degradable polymer (PLLA) with a the anchor within the bone.
bioceramic (β-TCP).
Radiolucent (but not absorbable;
plastic), Can be drilled through during a
Low cost, clear on postoperative imaging, fewer revision procedure (although not all
concerns about anchor migration, Lack of Osteolysis plastic can be removed),
Potential for causing suture abrasion, chondral injury in Since they do not absorb they present
improper placement the same concerns as a metal anchor
THE MODERN WEAPON
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
REPAIR techniques!
Double suture loop
KNOTLESS ANCHOR Better strength
A channel is located at the tip of
the anchor that functions to
capture the loop of suture after it
has been passed through the
ligament. The ligament is
tensioned as the anchor is
inserted into bone!
SIZES
MISSED INSTRUMENTS
No scissors; No knives ??
Cidex (Glutaraldehyde)
Steris solution (Paracetic acid)
> 30 min
NON Duncan loop
LOCKING
Five open throws
Surgeon’s square knot
L PROXIMAL: Nicky’s knot
NON-SLIDING (Easier but can loosen)
SLIDING O
C MIDDLE: SMC knot,
Tennesse slider
K
KNOT TYING I DISTAL: Roeder and
N Weston knots (Prevent
All knots should be backed slippage best but learning
up with three RHHALs! G curve)
Knot Failure: Slippage or displacement > 3 mm
Knot Security: Ability to withstand slippage
and maintain the tension. Depends on friction
and slack between throws
Loop Security: Refers to ability of the suture
loop to withhold tissue and hold tension
(after the knot is tied and tensioned)
THANK YOU
Most common complication of
Arthroscopy is Haemarthrosis
particularly after Synovectomies
and Lateral retinacular release!
