Arthroscopy (Dikis 2024).pptx

Arthroscop y Ashley M. Dikis, DPM, FACFAS 01 03 Recognize the proper instrumentation, indications, and contraindications for arthroscopy Identify the symptomatology and findings of ankle joint pathology 02 Identify the portals for ankle arthroscopy “See, playing Call of Duty is preparing me for my f...

Arthroscop y Ashley M. Dikis, DPM, FACFAS 01 03 Recognize the proper instrumentation, indications, and contraindications for arthroscopy Identify the symptomatology and findings of ankle joint pathology 02 Identify the portals for ankle arthroscopy “See, playing Call of Duty is preparing me for my future.” —Jeff Dikis, DPM 01 Introduction INTRODUCTION Arthroscopy is a minimally invasive method for joint access that offers superior visualization in order to manage intraarticular pathology. A history lesson: 1912: First arthroscopy (knee) 1931: Burman ○ Ankle “too narrow” John Buckholz, Harold Vogler, Richard Lundeen, David Gurvis, and Leonard Janis First podiatric course 1984 02 Why and Why Not? Indications: The Why Primary soft tissue pathology Hemorrhagic and chronic synovitis Fibrous bands and meniscoid lesions Soft tissue impingement Arthrofibrosis Osseous and osteochondral pathology Osteophytosis Avulsion injuries Synovial/intra-articular biopsies Arthrodesis (ankle and subtalar joints) Assist fracture reduction Lateral ankle instability Syndesmotic instability Gutter and soft tissue impingement status post total ankle replacement Pathology Soft tissue pathology Often has negative x-ray findings History of trauma MRI to assist with diagnosis and planning Intraarticular injection Pathology Synovitis Initially red and inflamed; more acute ○ Hemorrhagic synovitis White and fibrosed; more chronic ○ Atrophic synovitis Pigmented villonodular synovitis Pathology Fibrous band / Meniscoid lesion Well-defined fibrocartilaginous bodies attached to periarticular structures Not synovial in origin Nonspecific joint pain, popping, clicking or grinding Pathology Bassett’s ligament and lesion Distal fascicle of the anteroinferior tibiofibular ligament with secondary chondromalacia and mechanical erosion of the articular surface of the lateral talar shoulder due to impingement Typically occurs following trauma Chronic anterior ankle pain Pathology Arthrofibrosis Severe scarring Significant limitation in movement, but still adequate for access Pathology Osteophytes Intra versus extraarticular ○ Talar extension can be intraarticular or extraarticular, depending on how far distal it originates. Recall how far distal the ankle joint capsule extends Pathology Osteochondral lesions ○ Defect/injury to the articular cartilage ○ Can carry significant morbidity Pathology Synovial chondromatosis Rare, benign disorder Excise wherever possible Recurrence anticipated Pathology Additionally… Septic arthritis Foreign body Avulsion fracture Joint preparation for arthrodesis Contraindications: The Why Not Limited range of motion Severe edema Tenuous vascular states Localized infection Arthrofibrosis with severe DJD 03 Procedure & Instrumentation Instruments Camera & light source Monitor Fluid source Arthroscope Cannula Trocar Obturator 18-gauge needle Suction Hand instruments Instruments Camera & light source Monitor Fluid source Arthroscope Cannula Trocar Obturator 18-gauge needle Suction Hand instruments Instruments Camera & light source Monitor Fluid source Arthroscope Cannula Trocar Obturator 18-gauge needle Suction Hand instruments NSS or Lactated Ringers Instruments Foot & Ankle: 2.7/2.9mm and 4.0mm Camera & light source Monitor Fluid source Arthroscope Cannula Trocar Obturator 18-gauge needle Suction Hand instruments Instruments 30° and 70° Camera & light source Monitor Fluid source Arthroscope with lens Cannula Trocar Obturator 18-gauge needle Suction Hand instruments Instruments Camera & light source Monitor Fluid source Arthroscope Cannula Trocar Obturator 18-gauge needle Suction Hand instruments Ingress & Egress Cannula with scope placed through it Instruments Camera & light source Monitor Fluid source Arthroscope Cannula Trocar Obturator 18-gauge needle Suction Hand instruments Instruments Camera & light source Monitor Fluid source Arthroscope Cannula Trocar Obturator Assists in confirming lateral portal 18-gauge needle placement Care taken to avoid damaging Suction articular surface Hand instruments Instruments Camera & light source Monitor Fluid source Arthroscope Cannula Trocar Obturator Fluid management is of paramount 18-gauge needle importance in order to maximize Suction visualization, protect structures and Hand instruments control temperature Instruments Camera & light source Monitor Fluid source Chondral picks Arthroscope and osteotomes Cannula Trocar Obturator 18-gauge needle Suction Hand instruments Probe Instruments Camera & light source Monitor Fluid source Arthroscope Graspers Cannula Trocar Obturator 18-gauge needle Suction Hand instruments Curettes Instruments Camera & light source Monitor Fluid source Arthroscope Cannula Trocar Obturator 18-gauge needle Suction Hand instruments Power Shaver Burr Radiofrequency (ablation) Portals Appropriate portal placement is critical ○ Avoiding important structures ○ Maximizing access and visualization A thorough understanding of topographical anatomy is key Portals: Ankle Anteromedial* Anterolateral* Anterocentral Posteromedial Posterolateral Accessory Portals: Ankle Anteromedial ○ First portal Medial to the tibialis anterior tendon Portals: Ankle Anterolateral ○ Transillumination ○ Protect intermediate dorsal cutaneous nerve 1. 2. 3. 4. 5. 6. 7. Joint line TA Medial malleolus EDL Lateral malleolus Portal (AM) Portal (AL) Access Positioning Leg holder Insufflation 10-15ml of NSS or LR Notch of Harty Access Distraction Invasive vs Noninvasive Disadvantages ○ Risk of neurovascular damage ○ Ligamentous disruption / traction ○ Inability to manipulate ankle positioning Procedure 1. Insufflate or distract 2. #15 or #11 blade through the skin ○ Anteromedial portal 3. Curved hemostat ○ Dissection gently down to capsule 4. Trocar / Obturator ○ Sharp – initial entry into capsule, careful not to plunge deep and damage cartilage ○ Ankle in dorsiflexion Procedure 5. Switch trocar/obturator for camera 6. Perform brief evaluation to confirm visualization of horizon 7. Create anterolateral portal 8. Insert power or hand instrumentation 9. Optimize inflow/outflow 10.Perform 21-point survey 11.Address pathology Addressing Pathology Debridement ○ Limited or extensive Irrigation ○ Septic arthritis Removal of foreign body or osseous loose body Microfracture ○ OCD Retrograde drilling Fracture reduction Additional considerations… Subtalar arthroscopy ○ Debridement ○ Os trigonum excision ○ Preparation for arthrodesis Small joint arthroscopy ○ First MPJ Tendoscopy Summary Indications Contraindications Common pathology Portals Procedure Experience REFERENCES 1. McGlamry's comprehensive textbook of foot and ankle surgery (2020). 2. R. Ferkel. Arthroscopy of the Foot and Ankle (2017). 3. Grambart, S. “Arthroscopy” [PowerPoint] (2021). 4. Jentzsch et al. “Correlation Between Arthroscopy Simulator and Video Game Performance: A Cross-Sectional Study of 30 Volunteers Comparing 2- and 3-Dimensional Video Games” Arthroscopy (2016). THANKS! 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