Arthroscopy
Author: Satish Kale, FRCS.ED
Introduction
Arthroscope is a term that comes from two Greek words, arthro- meaning joint, and -skopein, meaning to examine. Arthroscopy refers to examination of the inside of a joint with an arthroscope.
Not long ago, before arthroscopy came into its own, orthopaedic surgery involved major incisions to expose and treat joint pathology, followed by a prolonged and painful rehabilitation needed to recover from the trauma due to pathology compounded by the pain from the surgical procedure itself. Smaller incisions, contrary to popular belief may be minimally invasive but are not necessarily minimally traumatic. Arthroscopy is the exception, a minimally access surgical procedure, not only allowing excellent visualization with minimal soft tissue trauma but also giving the surgeon the advantage of tackling almost everything through camera. The real winner is the patient.
Historical Aspects
Arthroscopy has a most interesting history of evolution. Medical endoscopy has been described as early as the 1800s. Bozzini, in 1806, presented his “Lichtleiter” to the Rome Academy of Medicine. Unfortunately, it was scorned by that scientific body and very little progress was made until 1853 when A.I. Désormaux developed the “gazogene endocystoscope”. This instrument used turpentine burned in a combustion chamber to transmit the light into the bladder by mirrors. In 1918, Prof Kenji Takagi of Tokyo University did the first arthroscopy in a cadaveric knee using a cystoscope! Dr. Eugene Bircher is the first to be credited for performing and publishing the first ever arthroscopy on live patients.
Watanabe was the first to develop the concept of triangulation, bringing instruments into the knee from different directions to treat the pathology that was seen. In 1955, he performed the first recorded operative procedure under arthroscopic control, which was the removal of a solitary giant cell tumor from a knee joint. In 1961, he removed a loose body and in 1962 he performed the first partial meniscectomy under endoscopic control. Robert W. Jackson, MD from Canada, was the first foreign doctor to visit Watanabe in 1964. He also gave the first instructional course on arthroscopy at the American Academy of Orthopaedic Surgeons in 1968 and wrote the first textbook (in English) on “Arthroscopy of the Knee” in 1976, with Mr. David Dandy.
Though initially used in diagnosis and management of tuberculosis, the art and practice of arthroscopy now spans treatment of joint disease and trauma alike. During the past two decades, arthroscopic procedures have been replacing traditional, more invasive orthopaedic surgical procedures. Today arthroscopy has broken all barriers and is being used not only in the conventional areas probed hitherto but also tighter and smaller joints from the hip to the wrist, not to mention recent procedures in the treatment of the first metatarsophalyngeal joint osteoarthritis!
Current Arthroscopic Techniques
There has been a phenomenal increase in the volume and diversity of arthroscopic procedures worldwide. As the ease of working with uncomplicated equipment grows steadily, by eliminating intra-operative glitches such as camera fogging, hand fatigue, suction clogs, and awkward instrumentation, operative time and thus health care costs for such procedures have taken a nose dive.
The surgeon’s comfort has steadily increased by development of more ergonomic designs and light weight instrumentation. Autoclave sterilization has been the focus of other innovations, since sterilization costs and time elapsed between uses are both reduced when steam can be used instead of gas or chemical sterilization. Poor visibility, previously a serious drawback has now being upturned by newer camera systems. Fiber-optic bundles are being used for both lighting and viewing in some systems, and improvements in colour, brightness, and resolution has put arthroscopy at the cutting edge of orthopaedic surgery.
Recent Advances in Instrumentation and Equipment
The development of newer and better arthroscopes has enhanced our ability to see within joints and bursae. A major advantage of arthroscopic surgery is the ability to record the procedure in real time. This helps patients to better understand their injuries and their prognosis for recovery. Modern documentation systems not only allow printing of photographs, but also DVD or VHS recording.
Computerised pumps are used to regulate the water flow and thus maintain the joint pressure during the arthroscopic procedure. Shavers available now are single use and disposable and come in many different sizes and shapes. Motorised shavers allow the surgeon to remove large amounts of tissue in a short amount of time. Tissue vaporisers and underwater cautery have been instrumental in ushering in an era of bloodless arthroscopic surgery. Specialised instrumentation has been developed for specific and frequent procedures such as anterior and posterior cruciate ligament reconstruction, meniscal repair, or osteochondral transplantation.
‘Needle arthroscopes,’ which are even narrower in diameter than ordinary arthroscopes, are already being used in diagnosis and some procedures. These diagnostic scopes has an outside diameter of 1.2mm (18 gauge needle) and requires only one portal. These are designed for use in a diagnostic environment such as an office or outpatient service under local anaesthesia. This system can be used in addition to MRI or alone.This scope is primarily being used in the knee and shoulder. However, the wrist, elbow, ankle and other small joints are presently being investigated. These pilot data suggest that in knee Oosteoarthritis (OA), needle arthroscopy can accurately detect meniscal and cartilage abnormalities and also detect most synovial abnormalities but may often underestimate the severity.
New applications are in development, including studies with laser arthroscopes to ‘re-bond’ injured tissues, rather than simply remove them, and even smaller, digital imaging devices to replace and improve on current television-camera imaging.
Another new and somewhat controversial device currently used in arthroscopic fixation are bioabsorbable implants. The biggest advantage is the ability to view the surgical repair on X-ray, MRI, or a CT-scan without any metal obstruction or scatter. This is useful for standard post-op evaluations and is especially important when the patient becomes symptomatic after surgery or returns with a related injury. The downside is the current costs of bioabsorbable implants which can be 25 to 50 percent greater than that of their metal counterparts.
Another significant trend in post-arthroscopy management is the use of leave-in catheters or take-home pain pumps that automatically and continuously deliver local anesthetics directly into the surgical site for the first 48 post-op hours. The pumps are tamper resistant and feature sterile ‘closed’ integrated tubing for reducing contamination risk.
Knee Arthroscopy
Nowadays knee arthroscopy as a diagnostic procedure has evolved from an inpatient procedure to one performed as a day-care procedure under regional or even local anaesthesia.
Meniscal repair
Since the meniscus is paramount to effective shock-absorbing function of the knee joint, it is always recommended to preserve the meniscus rather than debride it. Various techniques are now available for arthroscopic meniscal repair. The Bio-absorbable Meniscal Arrows are made up of copolymers ( 96% poly-L, 4 %Poly–D Lactic acid) which provides high strength microstructure. After the tear is reduced into position with the help of a probe ,the arrow is introduced through the cannula to fix the tear.
Arthroscopic Meniscal Transplantation
The indication for this procedure is a patient with meniscectomy or a severely injured meniscus, skeletally mature with stable ligaments and a normal femorotibial alignment. This technique involves use of deep frozen cadaver allograft tissue thoroughly thawed to eliminate crystalline water content. The original meniscal remnants are debrided except for the peripheral border. With a hand gouge and burr a trough is prepared to receive the allograft bone. The allograft bone is fixed to the tibial bone trough by means of pull out sutures.
Chondral injuries
According to recent research, up to 10 to 12% of individuals present with chondral injuries. Those which are symptomatic or in the weight-bearing zone manifest as swelling and knee pain. The natural history of untreated lesions is progression and increasing disability. These are classified by the modified Outerbridge classification into grades 1 to 4 depending on the severity. In Outerbridge grades 2 and 3 lesions, with a properly tracking patella, debridement removes fibrillation and provides a stable rim of chondral tissue. Recent studies suggest that bipolar radiofrequency probes are superior to mechanical shavers for articular cartilage debridement. This procedure is a valuable technique particularly in adolescents and young adults
Autologous chondrocyte implantation (ACI) beneath a periosteal patch covering the lesion is increasing being used across dedicated centres across the globe. The choice of procedure depends on the characteristics of the lesion, patient’s symptoms, age and activity level. Though Autologous chondrocyte transplantation is presently claimed to have a durable outcome, long term results are not yet clear.
With bony defects co-existing with chondral injuries, osteochondral autograft transplant is used in which a bone cone graft capped with healthy hyaline cartilage is harvested from the non weight bearing region of the intercondylar notch and transplanted into the defect. This can effectively delay total knee replacement in the relatively young patient. For larger defects the technique of “mosaicplasty” is used involving insertion of multiple plugs of osteochondral grafts into the defect.
PCL Reconstructions
Though anterior cruciate ligament reconstruction has been widely practiced using the arthroscope. Increasingly posterior cruciate reconstruction is being attempted rather successfully by the new genre of knee surgeons and arthroscopic reduction and retrograde fixation is being done for large fractured bony fragments which get avulsed with the posterior cruciate ligament.
Intra-articular Fractures
Tibial plateau fractures needing condylar elevation techniques to reconstruct the joint congruity and patellar fractures without major separation and comminution can be reduced under arthroscopic guidance and fixed percutaneously with cannulated screw. It allows clear visualization of the reduction and facilitates early mobilization of the knee.
Hip Arthroscopy
Inspite of recent advances the application of hip arthroscopy in its scope as a routine procedure remains small. Of particular application in athletes, the current indications for hip arthroscopy include symptomatic acetabular labral tears, intra-articular loose bodies, femoroacetabular impingement, chondral lesions and osteochondritis dissecans. It can be used in pelvic and acetabular fixation to assess the congruity of reduction of the fracture surfaces and avoid metalwork from impinging onto articular surfaces. In rare cases, hip arthroscopy can be used to “buy time”in patients with mild-to-moderate hip osteoarthritis with associated mechanical symptoms. The procedure is presently not widely available as it requires specialist equipment and has a steep learning curve. Complications are not uncommon occurring in slightly less than 5% of patients.
Ankle Arthroscopy
In selected patients with advanced and symptomatic ankle arthritis, arthroscopic debridement and arthrodesis is rapidly become the procedure of choice amongst arthroscopic surgeons. Selected patients though, include those with only mild angular deformity and avascular necrosis not greater than 30% of the talus. The advantages of the arthroscopic technique include a high fusion rate, decreased time to fusion and good wound healing without the need for external fixation devices.
Arthroscopic curettage and drilling are being increasingly performed for both, primary and revision treatment of an osteochondral defect in the dome of the talus. Autologous chondrocyte implantation (ACI) is also being used in the ankle for osteochondritis dissecans though the long term benefits and results are still unclear.
Ankle fractures have a high incidence of concomitant occult intra-articular injury with syndesmosis disruption and a high risk of articular surface injury to the talar dome. Arthroscopy is a valuable tool in identifying and treating such lesions following ankle trauma. These that would otherwise remain unrecognised are being increasingly diagnosed and treated. This procedure also helps to prognosticate the functional outcome of these injuries. Arthroscopy is an acceptable modality to obtain accurate reduction and fixation of a juvenile Tillaux fracture.
Recent studies suggest that, with the patient in the prone position, arthroscopic equipment may be introduced into the posterior aspect of the ankle without gross injury to the posterior neurovascular structures.
Shoulder Arthroscopy
In arthroscopic trans-humeral rotator cuff repair, the results now being achieved are comparable to a standard open procedure. Many sophisticated instrument systems and techniques have been developed for performing arthroscopic Bankart repair. Thermal modification of the joint capsule and ligamentous tissues, is a recent introduction. Arthroscopic thermal capsulorrhaphy is one such procedure for treating joint instability. This helps to avoid large incisions and iatrogenic shoulder joint trauma. Relatively low-temperature heat is directed to the supportive structures tightening a previously stretched and attenuated shoulder capsule. Beside electro-thermic procedures, several suture-anchor system for labrum fixation have been developed in the last years. Compared to open procedures the arthroscopic shoulder stabilization has many advantages.
Newer techniques use Surtec – a bioabsorbable fixation device which has spikes with concentric ribs contributing to its high pullout strength. After the preparation of the glenoid neck the guide wire is introduced to shift the capsule superiorly. Over the guide wire the Surtech is passed and impacted into place. Knotless suture anchor fixation can be achieved by use of a suture anchor made of a titanium body with two nitinol arcs which prevent anchor pullout. Bioknotless suture is bioabsorbable anchor made of poly-L- Lactic acid.
There are very few studies that directly compare the arthroscopic versus open treatment of particular disorders. However, the benefits of arthroscopy have been well studied for the surgical repair of Bankart lesions. In 1993, Green and Christensen were able to show that arthroscopic repair of Bankart lesions was associated with a significant decrease in operative time, blood loss, and postoperative narcotic use compared with the open procedure. In addition, the use of arthroscopic Bankart repair significantly decreased the length of hospital stay and the time lost from work. In a prospective randomised study, Fabbriciani et al compared the outcomes of patients undergoing open versus arthroscopic treatment of Bankart lesions. While there was no difference in the general outcome, the arthroscopic group demonstrated a significantly better range of motion of the shoulder.
Elbow Arthroscopy
Arthroscopic synovectomy is a reliable procedure to alleviate pain in rheumatoid arthritis. A preoperative radiographic Grade of 1 or 2 is a good indication. The fundamental of arthroscopy is visualization and access. Visualization and access to the ulnohumeral and radiocapitellar articulation is rather difficult presently. Recent modifications have included use of a joint jack or a distractor to widen the ulnohumeral joint space for enhanced visualization.
Wrist Arthroscopy
Acute nondisplaced scaphoid fractures have traditionally been managed with cast immobilization. Prolonged casting has been implicated in post-fracture muscle atrophy, joint stiffness and disuse osteopenia. Arthroscopic assisted fixation offers an advantageous compromise between traditional cast immobilization and open reduction for scaphoid fractures with minimal soft tissue dissection, a lower risk of damaging the bone’s already tenuous blood supply, avoids division of the stabilizing important radioscaphocapitate ligament and allows adequate visualization of the fracture and stable fixation. This technique allows for faster and early rehabilitation and an earlier return to work. Nondisplaced fractures presenting with delayed or fibrous union without evidence of avascular necrosis, cyst formation, or bony sclerosis may also be considerations for this technique.
Imaging techniques may offer a pointer for diagnosing occult fractures and distal radioulnar subluxation, but are unsatisfactory for diagnosing dynamic ulnocarpal impingement, tears of the triangular fibrocartilagenous complex (TFCC) and lunotriquetral ligament and joint mice. Therefore, prior to surgical intervention arthroscopy is recommended for patients with persistent ulnar wrist pain that interferes with their daily activity. Triangular fibrocartilagenous complex (TFCC) tears can be eminently treated via the arthroscope. Carpal detachment injury should be considered when no abnormalities of the TFCC and ligaments are observed with ongoing wrist symptoms. Arthroscopic findings suggested that a portion of TFCC that was originally attached to the ulnar side of the triquetrum may get detached. Resection of meniscus homologue-like tissue which arose from TFCC with a shaver, may improve symptoms
Injuries to the scapholunate complex present the surgeon with both diagnostic and treatment dilemmas. Arthroscopy is considered the gold standard for complete evaluation of scapholunate interosseous ligament injury and often is performed as a first step before repair or reconstruction.
Several reports have shown the superiority of endoscopic carpal tunnel release over open surgery, in particular relating to earlier recovery of hand strength and return to work. A significant reduction in scar tenderness (pillar pain) contracture and symptoms of stiffness is of particular importance for those who do heavy manual work.
Arthroscopy of the Temporomandibular joint
Temporomandibular joint (TMJ) arthroscopy is an effective therapeutic modality for patients with TMJ internal derangements, with reoperation required for only 20% of patients. It is effective in reducing pain and increasing mandibular motion in patients with anterior unreduced disc displacement especially in patients the duration of symptoms being less then 6 months. It is recommended as a simple alternative to more invasive TMJ procedures.
Conclusion
In conclusion, Arthroscopy has introduced some potential advantages compared with open procedures. These include shorter surgery times, less morbidity, less postoperative pain, shorter hospital stays, less blood loss, and a decreased risk of complications. In addition, the ever widening uses of arthroscopic procedures contribute to the overall reduction in healthcare costs.
The meeting attracted over 220 delegates from all over the globe, including Germany, Iceland, Spain and the US, making it the second largest orthopaedic event to be held in Britain. This impressive level of attendance was particularly poignant for the organisers of the meeting, for whom panic had set in, when the rather inclement weather conditions threatened to close motorways, airports and rail lines. Despite these minor set backs the meeting ran smoothly and Professor Cobb, the Chair of the meeting, seemed to be incredibly happy with the outcome stating: “The Great Debate certainly lived up to its name and succeeded in stimulating us all to reflect on our current practice and the direction we wish to take, whether it be conservative or invasive.”
Delegates of varying seniority were evenly split between trainees and consultants, this mixture made for interesting and surprising results especially when delving into the more controversial technologies such as navigation and arthroscopy. The knee sessions kicked off the debate on Friday morning with issues on opening wedge versus closing wedge osteotomy expounded as well as their impact on the ACL deficient knee. Interestingly delegates registered they would like to learn more about what has seemingly become a lost art in British orthopaedics. The place of uni-compartmental knee arthroscopy was debated with Medial UKA’s revealing themselves as the most popular choice for the future. Specialist subjects such as joint biomechanics and arthroplasty were also dissected.
The hip sessions which began on Friday afternoon focused on a variety of different topics such as the advantages of navigation in hip arthroplasty, by the end of the session a surprisingly high number of delegates said they would like to use navigation during hip resurfacing admitting that it would improve levels of accuracy. Unsurprisingly the resurfacing versus replacement issue was perhaps the most heated, with parties ranged on both sides of the argument.
The most rewarding aspect of the meeting was arguably the interactive element. On arrival at the venue, each delegate was given a handset which allowed them to vote on numerous issues throughout each of the sessions. This anonymous system allowed everybody to air their views and to feel a part of the proceedings despite varying levels of seniority. Mike Tuke, Managing Director of Finsbury Orthopaedics commented: “The result of this Old English style of debate was that the audience got the chance to learn from the experts, who invariably don’t all agree, and to form a broad opinion. We felt that the meeting offered a unique and exciting opportunity to teach people in an informative and interesting way.”
Although it has not yet been announced whether or not the meeting will be repeated, with such tremendous feedback, there seems to be no doubt that it would be a great shame to cut the Great Debate off in its prime. For more information on this event or to read more about the issues discussed, log on to 
Once prototype designs are created they are converted into product models which should then be shown to clinicians. In the case of HiVac™ 7 a number of different design ideas were shown to nurses, surgeons and Procurement Personnel to guide the development programme. During this stage some ideas were rejected but others were highlighted as significant improvements over products currently being used.
For example, the HiVac™ 7 product is made from a transparent material. This allows clinicians to view the mix quality during mixing but is also strong enough to reliably resist the high levels of force that it would be subjected to during cement delivery. When shown to clinicians, this feature was viewed as being beneficial as clarity allows the user to maintain control over the mix and ensure consistent cement quality for the patient.
Whenever possible, it is useful to allow the various groups to use the prototype models. For example, to ensure that HiVac™ 7 was easy and simple to use, a number of different designs were evaluated by users. Different mixing handles, bases and paddle ideas were assessed to produce a final design that most Theatre Staff agreed was significantly easier to use than many existing products. Ease of use was highlighted as being a key element for new products as it gave confidence to those that operate the product, made training of new staff easier and should result in more consistent results for the patient.
Features to enhance product reliability should also be tested at this stage of the development programme. For example, positive feedback was given by users on the coloured snap point of the HiVac™ 7 mixing rod. This new idea was viewed by users as improving a significant area of weakness and product failure that occurs with a number of existing mixing devices.
Health & Safety related product features were also discussed at this stage. The HiVac™ 7 prototypes were of a closed design reducing the potential for users to be exposed to polymethylmethacrylate fumes during mixing. Even though all modern vacuum mixing systems reduce fumes to below Health & Safety guidelines 1 the closed system concept was well received by users.
Prototype designs were also shown to surgeons. Mix quality and cement strength were highlighted as being a key concern with this group. To enhance the mechanical properties of cement the HiVac™ 7 device was designed to operate at 550mmHg. The application of a vacuum during mixing reduces the air content in bone cement which up to a point makes the cement stronger and more likely to survive the extreme loading that it is subjected to post implantation. The vacuum level of 550mmHg was chosen due to previous test work 2 conducted by Queens University Belfast which demonstrates that this vacuum level is optimum. This paper demonstrates that the higher vacuum levels used by many existing mixing devices produce cement with very low levels of porosity leading to the cement suffering from excessive shrinkage. This has been shown to produce micro cracks in the cement mantle which can weaken the fatigue life of the cement. In addition excessive shrinkage has been shown to produce voids at the cement stem interface 3 which could increase the chance of aseptic loosening.
In addition to mix quality a number of surgeons were interested in the feel of the cement delivery gun and the pressure that it could generate during cement delivery. To enhance gun performance the HiVac™ 7 prototypes were designed with a narrow bore mixing & delivery tube. Surgeons suggested that this design feature would allow them to generate enough pressure in the cement delivered to the femur to create effective micro interlock which is important for secure fixation of the implant. In addition surgeons liked the lightweight manoeuvrable gun which contrasts favourably with the bulkier caged guns used with some existing mixing systems.
Prototype product designs were also discussed with Procurement personnel. This group of customers were keen to purchase all mixing devices from one company which helps to streamline the purchasing process. With this in mind a triple mix version of HiVac™ 7 was proposed which would cover the requirement for up to 120g of mixed cement for revision hip procedures. Although the demand for a triple mix was suggested to be modest, Procurement staff were keen to have this option to cover all surgical requirements.
Functionality testing is critical to ensure that the product is going to perform as intended. For HiVac™ 7 this included destructive testing on components to ensure that the device is robust enough to function without failure. This also has to include the testing of components that have been sterilised as the sterilisation process can affect the strength of individual components. In addition, materials had to be tested to ensure that the components of the device were compatible with the aggressive characteristics of bone cement.
Mechanical testing of cement mixed in the new system was also an important step in the HiVac™ 7 project. The cement has to be tested to ensure that when delivered to the patient it is at least equal to the criteria set out in the international standard for bone cement ISO5833. In addition cement fatigue testing is conducted as this is viewed as a key performance indicator for long term cement survival. The importance of this was illustrated by the launch of the Boneloc bone cement in the early 1990’s. This cement was sold on a number of key benefits and passed the basic ISO requirements. However later test work revealed that it suffered from poor fatigue properties 4. Had Boneloc been tested for fatigue failure prior to launch, the large amount of early implant failures 4 reported as a result of the Boneloc failure could have been avoided.
In addition packaging has to be assessed to ensure that during transit the sterility of the product is not compromised and that the product is not damaged. Also the product has to be aged tested to ensure that when launched the shelf life marked on the product is reliable.
During the final stages of initial product development the packaging design also needs to conform to the regulatory requirements of the markets that the product will be sold into. For example the information on the packaging for the HiVac™ 7 product had to be translated into 21 languages to reflect the regulatory requirements of those particular markets.
Once the product has passed all of its testing and conforms to the regulatory requirements of the market place it is ready for production. The launch stock of a new product faces rigorous Quality testing before being released, ready for sale.
As part of a new product launch, detailed briefing and product training will need to be given to the relevant sales team. Product training needs to be comprehensive as new products often involve different techniques and methods which need to be fully understood before being passed on to users. In addition comprehensive product support programmes need to be in place to give users confidence and to ensure that the products are used correctly. In the case of the HiVac™ 7 the product support package included;
