Basic Arthroscopy

OUTLINE

Sự phát triển của phẫu thuật nội soi có thể được coi là một trong những cột mốc quan trọng trong phẫu thuật chỉnh hình trong thế kỷ XX, cùng với phẫu thuật thay khớp và mổ mở và cố định bên trong của fracture.

The term arthroscopy comes from the Greek: “arthro” meaning joint and “skopein” meaning looking. Literally “look into the joint”, like looking into a keyhole instead of opening a door.

Over the past five decades, arthroscopy has dramatically changed the orthopedic surgeon's approach to the diagnosis and treatment of a wide range of joint pathologies. High clinical accuracy, combined with low morbidity, has encouraged the use of arthroscopy to aid in diagnosis, determine prognosis, and often to provide treatment. Arthroscopy should serve as a correction and not a substitute for thorough clinical evaluation; Arthroscopy is not a substitute for clinical skills.

Advances in arthroscopic and fiber optic systems and lens advancements, miniaturization and surgical instruments make advanced endoscopic techniques applicable to almost any joint in the body. including knees, shoulders, groin, ankles, elbows, wrists, hands and feet. Even spinal procedures are increasingly being performed with endoscopic techniques. Although many laparoscopic procedures have been shown to be superior to previous open techniques, surgical outcomes should not be sacrificed to expand indications for laparoscopic procedures.

HISTORY

The origins of endoscopy can be traced back to the time of the Roman Empire. In the ruins of Pompeii, evidence for the use of vaginal balls and proctoscopes was made.

In modern times, Philipp Bozzini (1773 – 1809), a German physician from Mainz, who first invented the primitive endoscope, the Lichicateiter, to examine body cavities such as the mouth, nasal cavity, rectum or female bladder. When the invention of

he was presented to the Rome Academy of Sciences (Italy) in 1806, however, the potential of his invention was not acknowledged.

In 1955, Masaki Watanabe, the father of modern arthroscopy, developed the concept of a triangle and removed the first tumor endoscopically. In 1960, he developed the modern generation of bronchoscopes.

In 1954, Harold Hopkins introduced the cold light fiberglass principle. In 1976, Lanny Johnson developed the first motorized planer.

In 1970, endoscopy became popular.

ESTABLISH

Endoscope tower

The endoscope tower is an upright trolley with various shelves on which electronic equipment for the arthroscopy procedure is placed. Wheels allow to move the tower to the optimal position during surgery. The modern endoscope tower has a modular design to fit any required setting. A screen is placed on top of the arthroscopy tower. A smaller screen can be placed on the opposite side of the main screen or on another articulating arm to allow views from other points of the room. The video camera unit and light source unit are usually located on the first shelf under the monitor, along with external hard drives or document system units; A printer can be placed on the bottom shelf. A power box for motorized instruments and a box for radio frequencies can be mounted on the arthroscopy tower or on separate trolleys. If used, the irrigation pump is usually placed on the endoscope tower.

Surgical site

Patient position and easy access to joint space determine the success of surgery. Patient position must consider the surgeon, anesthesiologist and nurse, comfort and the ability to convert the procedure from endoscopic to open. The arthroscopy tower is usually placed on the opposite side of the patient. The Mayo holder for sterile instruments can be inserted from the opposite side or from the foot of the table, according to the surgeon's preference. Multiple devices are available to optimize patient position: leg stands, side posts and traction units designed to attach to the standard operating table are available in different models for laparoscopic hip joint, knee, ankle, shoulder, elbow, and wrist and are described for each joint. Pillows and pads are used to protect fragile structures that can be damaged by prolonged compression or by traction.

Basic endoscopy kit

1. Endoscope 30°, 70°
2. Light source and light wire
3. Irrigation system
4. Auxiliaries
5. Camera
6. Probes
7. Drag
8. Tissue clamp
9. Tissue cutting
10. Endoscopic knife
11. Grinding cutting system
12. Electrosurgical instruments: laser or radio

EQUIPMENT CONSTRUCTION

Endoscopic Instruments

1. Camera head

• Structure

McGinty and Johnson were the first to introduce television cameras to the arthroscopy system. The advantages of this addition include a more comfortable surgical position for the surgeon, avoidance of contamination of the surgical site by the surgeon's face, and relaxation of the operating team members. The original camera was cumbersome and inconvenient, but small, solid-state cameras have been developed that can be connected directly to the arthroscope. In these camera systems, chip and circuitry improvements have allowed for reduced size and better digital resolution. Wireless endoscopy systems are also available, in which the video signal is transmitted to the monitor from an arthroscope containing its own miniature light source.

The camera head is the "brain" of the endoscope. It attaches to the lens to produce the image displayed on the screen. The inside of the camera head uses a technology of three small computer chips that allows for greater color resolution, and the digitization of the video signal has led to advancements in high-quality, more realistic images.

2. Preservation

The camera is sterilized with ethylene oxide gas or hydrogen peroxide gas.

Light source system

Endoscopy uses a light source to look into the joint. The light source consists of a box-shaped block containing a light-emitting diode that is connected to the lens via a sterilized light wire.

Xenon sources, because of their similarity to sunlight, color temperature, service life, and quick warm-up cycles when turned off and back on, are the gold standard for use in the operating room. However, energy-saving LED (light-emitting diode) technology is now replacing xenon light boxes. Xenon bulbs have a lifespan of about 30 hours, while LEDs have a lifespan of about 30,000 hours.

Light wire

To transmit light from the light source to the distal end of the scope, a light guide is interfaced between the light source and the scope. Light or wire guides consist of bundles of optical fibers to transmit light. Fiber optic guides are typically very flexible and easy to manipulate in a sterile field, but damage to individual fibers can create inadequate light transmission. Light wires are always sterilized and wrapped carefully to avoid breakage.

Video format

The National Television Systems Commission (NTSC), Alternating Line (PAL) and Sequential Coleur à Memire (SECAM) are television standards used around the world to broadcast signals from one point to another. . NTSC is the industry standard in the United States, Canada, some countries in the Far East, and most of Central and South America. PAL is the standard in the UK, found throughout Europe, Africa and Asia. The Advanced Television Systems Commission (ATSC) sets the global standard for high-definition video.

Lens

The arthroscope is an optical instrument. Three optical systems are used in a rigid lens: a thin flat lens system, a cylindrical lens system designed by Professor Hopkins in Reading, UK, and a converging lens system.

Over the past 30 years, the optical quality of endoscopes has improved dramatically. The Hopkins vertical lens system continues to provide the best image quality. Initially, the scope knee joint 4.0 mm was used at the ankle, but in some cases it was too large in diameter and had too long a swingarm and too large a cover to allow full view of the ankle joint without increasing the risk of injury. articular cartilage. Furthermore, the 4.0 mm lens may be too large to visualize the small spaces along the gully and the back of the ankle and into the subtalar and forefoot joints. A short 4.0 mm lens has been developed to better conform to the surface of the ankle joint without sacrificing the clear image of a longer lens. Recently, arthroscopy lenses have been produced with diameters of 1.9 mm; 2.3 mm; 2.5mm and 2.7mm. These smaller endoscopic lenses are available in short (67 mm) versions, which have the advantage of a shorter arm, excellent image quality, easy maneuverability, and interchangeable catheters for together. The body of the arthroscope is only 67 mm long for use in ankle and foot endoscopy. However, as the endoscopes have become smaller and shorter, they have become more fragile. Today, the image quality of smaller endoscopes is comparable to that of larger versions and matches the quality of the latest ultra-high-resolution or ultra-high definition camera systems.

Several characteristics determine the optical characteristics of a lens, the most important being diameter, tilt angle, and field of view. The angle of inclination is the angle between the axis of the lens and the line perpendicular to the surface of the lens, varying from 0 to 120°. The most commonly used 30° lens. The 70° lens has a wide field of view, which is useful for seeing around corners, such as the posterior compartments of the knee. The diameter of the lens has many types: type 1.9 mm; 2.7 mm for wrist, elbow; The 4mm type is the most common, for shoulders and knees.

1. Viewing angle

There are two different sizes for the market. The apparent field of view is the diameter seen at the eyepiece end of the lens and is enhanced by magnification through a video splicer. The similarity of the lens to the object affects the surgeon's perception of the field of view. The actual field of view is a measured angle of view that the arthroscope produces. This angle changes 90° to 115° for the current 4.0 mm (wide-angle) lens. In contrast, the 2.7mm wide-angle lens has a field of view from 75° to 90°. The term “wide angle glass” refers to the actual field of view rather than the clear field of view.

The angle of view is the angle of projection at the objective (far) end of the lens. The 30° angle of inclination, the most realistic and most commonly used, allows for excellent visualization in the ankle and foot joints, especially when using a wide-angle lens. The small 70° arthroscope allows the surgeon to see around corners but requires some experience as it is rarely used.

2. Transparency

Most current endoscopic lenses have a working distance of 0 to infinity and provide clear images whether the tissue is near the lens or further away. A focus ring allows fine adjustments to image quality. Once in focus, adjustments are rarely needed.

3. Move

Careful investigation is the synthesis of images obtained by moving the scope to different positions and using the scope's ability to rotate and tilt. The movements of the bronchoscope include:

1. Piston: the forward and backward movement of the bronchoscope is called the piston. The piston allows the PTV to move closer or farther to visualize a specific area or to get a panorama of a larger region.
2. Angle: is a sweeping motion that moves the scope in a horizontal or vertical plane. This movement can scratch delicate joint surfaces and must be done gently, except when a sapphire lens is used. Sapphire is an extremely hard optical glass that is resistant to scratches.
3. Rotation: is the most valuable movement in arthroscopy. Using a 30° scope instead of 0° allows for a wider view. Rotating 30° enhances visibility by creating overlapping circular images. With the 70° arthroscope, rotate around a central blind field.

4. Cone phenomenon for arthroscope movement

The top of the cone represents the tool port. The red line represents the range of the tool or anchor, and the eye shows the viewports from the side, posterior, and apex positions of the cone. Viewing from the tailgate or side gate can result in varying angles and positions of anchors or tools and difficult to measure. The view from the top of the cone can select a better anchor position or tool, and the angle can be determined based on the ratio of the cone height to the anchor tip distance from the radial center, tan (θ = angle of application) instrument with the superficial cortex).

Included supporting tools

Main trocar, trocar barrel and plastic trocars; gate switch, probe; drag; thread threading and thread catcher, thread pusher; tissue clamp, tissue cutting; endoscopic knife; cut meniscus and planing heads, grinding blades; high frequency electric burning; and other devices. These instruments are used in most common laparoscopic surgical procedures. Additional tools are available for special use.

1. Trocar

Cannula and barrel

The bronchoscope is inserted into the joint by a cannula or barrel, which should be 1-2 mm shorter than the bronchoscope when fully attached. The trocar barrel has a blunt tip, never a sharp one. The cannula tip is angled to match the angle of the lens scope. The end end of the sheath must have

Quick and secure connection mechanism for attaching a trocar or scope. This allows easy insertion and withdrawal of the bronchoscope with the barrel during surgery. Barrel with or without auxiliary port for liquid flow or suction. The amount of liquid that can be introduced through the barrel depends on the size of the barrel and the pressure applied to the fluid.

Endoscopes must be interchangeable to easily insert the scope and instrument (eg, planer) through any port without the need for repeat instruments, causing additional soft tissue trauma.

For systems that do not have multiple interchangeable cannulas, a disposable plastic cannula can be used to allow instrument exchange through a given portal.

Wissinger rod and switch

Conversion sticks are simple rods smaller in diameter than the cannula used and are particularly useful if the catheter comes out of the joint by accident or if the surgeon needs to switch from a lateral ported cannula to one without a lateral port. .

For a larger surgical cannula, a dilator is used prior to conversion. The Wissinger bar is designed to assist in setting up a portal on the opposite side of the joint from a previously established portal.

Probes

Các que dò có lẽ là được sử dụng nhiều nhất và là dụng cụ chẩn đoán quan trọng sau máy soi khớp. Nó được sử dụng trong cả nội soi chẩn đoán và phẫu thuật và là công cụ an toàn nhất mà người ta có thể sử dụng khi học các kỹ thuật tam giác. Que dò được xem như “ngón tay nối dài của phẫu thuật viên”. Tốt hơn là nên “nhìn và cảm nhận”, hơn là chỉ “nhìn”. Que dò cần thiết để sờ nắn các cấu trúc bên trong và lên kế hoạch tiếp cận một quy trình phẫu thuật. Que dò có thể được sử dụng để cảm nhận sự thống nhất của một cấu trúc, chẳng hạn như sụn khớp; để xác định độ sâu của vùng loét sụn; để xác định và sờ nắn cấu trúc lỏng lẻo trong khớp như phần meniscus tear, or bring loose pieces to the pick-up position; palpate cruciate ligament anterior and synovial joints, unfolding structures to reveal; lift the meniscus for observation; Probe holes and defects such as popliteal defects. Most probes have a square hook at the tip, a probe size of 3 to 4 mm and a known size of this hook can be used to measure the size of an intra-articular lesion. Care should be taken when using the tip of the probe; Most palpation with an intra-articular probe is actually done with the elbow of the transducer and not the tip or toe of the instrument.

Endoscopic scissors

Endoscopic scissors are 3 – 4 mm in diameter and are available in small and large sizes. The pull mouth can be straight or curved. A curved mouth is preferred because the hook holds the tissue to make it easier to cut the tissue. Scissors design options include right and left curved scissors and cutting angle. The difference between these two designs is based on the corner folding position. The body of the curved scissors is gently bent to accommodate the right and left positions, while the angled scissors, often with a rotating jaw mechanism, actually cut at an angle to the axis of the scissors. These sub-designs are useful for separating hard-to-reach debris.

Tissue cutting tools

Baskets or staples are one of the most common tools used in arthroscopy. Standard basket clamps have a hollow lower jaw and a movable cutter jaw to cut tissue into the hollow jaw below, allowing each click or bite of tissue to fall freely into the joint without the need for other tools to remove it. from joints and clean them. Small pieces of free-falling tissue in the joint through an open-base press or basket clamp can be irrigated or removed from the joint by suction. These tools are available in 3 – 5 mm sizes with straight or curved shafts. It is useful for trimming the periphery of the meniscus or can be used instead of scissors to cut across the meniscus or other tissue.

The wide, low profile basket is great for work with meniscus. The jaw configuration of the basket clamp can be straight or hook; again, hook configuration is preferred. The basket has angles of 30°, 45°, 90°, especially useful for trimming the anterior parts of the cartilage. A 15° opening jaw is suitable. As with other endoscopic instruments, the proper technique is to make small bites to avoid undue pressure on the joints and legs of the instrument and to avoid frequent fractures. However, the instrument is often too large to enter tight rear areas.

Tissue clamp

Tissue forceps are useful for removing materials from a joint, such as a articular stone or synovial membrane, or a meniscus fragment. Most tissue clamps have some type of clamp that closes on the handle to protect the tissue in the jaw. The jaws of the clamp can be single or double movable and can have regular alternating serrations. Dual movable clamps, in which both jaws are open, are particularly preferred for holding cartilaginous pieces because single types often allow it to slide slowly between the two jaws.

Endoscopic blade

Most endoscopes currently in use are disposable, single-use instruments. A variety of disposable blade designs: hook blade or reverse blade; regular down cutting blade, both straight and curved; and Smillie type end blade. The magnetic property is also useful in case the blade needs to be removed if it accidentally breaks inside the joint. These blades should be inserted through the trocar or encased in a retractable sheath so that the cutting part of the blade is only exposed when entering the area to be worked.

Grinding cutting system

The basic grinding system has a similar design, consisting of a hollow, outer shell and an inner, hollow rotating barrel with corresponding windows. The inner tube's window functions as a double-edged cylindrical blade, revolving in the outer hollow tube. When the system is operating, it will suck through the cylinder to bring the soft tissue pieces into the window, and when the blade rotates, the pieces are amputation, is sucked to the outside of the joint. The diameter of the cutting head is typically 3 – 5.5 mm, many of the tips are of variable size to allow entry into smaller or tighter joints. It is designed to cut or trim bone, remove synovial fluid, and scrape cartilage. Most systems use the foot pedal to control the motor, allowing speed and direction to change. The reverse rotation of the discontinuous blade often improves cutting efficiency and minimizes clogging with debris. Motor grinders have been developed for small joints with a grinder and a 2 mm planer. When the motorized planer is in use, the arthroscope outlet must be closed, not only to minimize excessive suction, but also to prevent accidental aspiration of potentially hazardous irrigation fluid.

contaminated back through the joint. Finally, the cutting head must always be positioned in the visual field and the position of the window must be set before activating the blade rotation.

High-rise combustion cutting system

High-frequency ablation is used as an endoscopic tool for routine cutting and hemostasis in arthroscopic surgery and decompression of the subarachnoid space. It is also used to amputate the outer patella. At much lower cost, radio frequency systems that have been reported to produce thermal energy similar to that of lasers have fallen out of favor. The two types available are unipolar and bipolar. Unipolar devices use a grounding pad and collect the energy transmitted through the body; With bipolar devices, energy is transferred between electrodes at the treatment site. Current controversies include the depth of tissue penetration, the number of dead cells, and the capabilities of temperature monitoring and control devices. Reported complications of RF ablation include cartilage damage, caseation bone and tissue damage caused by hot water escaping.

Other tools

A variety of implants, both metallic and biological, have been developed for use in endoscopic procedures, including suture anchors, meniscal repair devices, and tendon immobilization devices. and ligaments and meniscus repair.

Suture anchors are used to attach ligaments and tendons to bone without creating a bone tunnel for the suture. Instead, the suture is pierced through an eyelet in the anchor, which is inserted into the bone. According to Barber and Richards, the desirable feature of the anchor is that it should fix the suture to the bone, not pull on the bone, allow for an easy surgical technique (the ability to tie a knot to slip the joint), and not cause problems. long term topic; Other desirable features include biocompatibility, robustness, easy insertion and the ability to enable early recovery. The most frequently used suture anchor for endoscopic procedures shoulder. Synthetic or metal polyetheretherketone (PEEK) bio-anchors can be used; these are less likely to produce the bone resorption reactions associated with biological implants.

Meniscal repair devices, available in a variety of styles and materials, allow for total internal repair without the need for knots, accessory ports, or incisions. The first generation meniscal repair devices were solid flexible devices that were pierced through the tear to hold fragments of the meniscus. Today, fourth generation devices have a low profile, thread tension construction and provide much greater fixing strength.

Traction devices have been developed for use in the shoulders, elbows and ankles for better exposure. There has also been an explosion of tools in specific procedures, many of which are described in the appropriate surgical sections.

2. Storing and sterilizing tools

The heat-stable arthroscopic device can be autoclaved for sterilization. Equipment that is sensitive to heat or moisture can be sterilized with a low temperature hydrogen peroxide gas plasma. Low-temperature sterilization, gas sterilization, and activated glutaraldehyde have been shown to be less effective, with more potential side effects.

Irrigation system

1. Function

Irrigation and joint swelling to enlarge the surgical field are essential for all arthroscopic procedures. Capsular distension was better maintained with Ringer lactate than with normal saline. The constant inflow of water keeps the surgical field clean, while maintaining water pressure and enlarging the surgical field.

2. Endoscopic translation

Various liquids may be used for irrigation during endoscopy. Lactate Ringer is the most commonly used fluid because it is physiologically compatible with articular cartilage and is rapidly reabsorbed if leached from the joint. Glycine and physiological saline may also be used and an experimental liquid, synovial (Baxter), has been developed for use with or without an electric knife and has an appropriate pH and osmolarity. suitable for intraarticular structures. Today, Ringer Lactate is commonly used, with the exception of glycine or sorbitol which is preferred when electrocautery or RF (radio frequency) is required. According to Shinjo et al. determined that Ringer Lactate solution was better at maintaining the integrity of meniscal cells than isotonic sodium chloride solution. Glycine or sorbitol should be flushed from the joint with Ringer Lactate before wound closure.

3. Gravity

The inflow can be accomplished by gravity or by using a matching pump device. Gravity inflow is usually sufficient when fluid is introduced through a separate cannula, but may not be sufficient if fluid is passed through the sleeve of the bronchoscope because the flow rate and flow rate may not be high enough (eg. , use a 1.9 mm scope with a 2.2 mm sheath or with a 2.7 mm scope with a 2.9 mm sheath) to keep up with the escapes created by suction devices such as a planer system or 2.5 mm vacuum cleaner. Using gravity inflow through a dedicated cannula with an inner diameter of 3 mm (ID) at a bag height of 3 feet above the joint, a flow rate of 750 mL/min is produced. In contrast, when using the same cannula and gravity height as above, but with a 2.7 mm scope in the cannula, the flow rate was reduced to 75 mL/min. Using the 3.7 mm wider cannula (ID) with the same 2.7 mm scope produces a much higher rate of 500 mL/min. For comparison, a 4.5 mm cannula without a bronchoscope yields 924 mL/min; a standard 4 mm bronchoscope with a standard 4.5 mm (high flow) diagnostic cannula yields 110 mL/min. A 4.0 mm bronchoscope with 4.5 mm surgical cannula and extended irrigation unit yields 67 mL/min.

4. Maintain water pressure

Water entering through the trocar is maintained by the pump with a water pressure level according to the joint. If you don't have a pump, you can use a high mount, then hang 2 water bottles together via a Y-fork or a large pitcher. An elevation of about 0.9 - 1.2 m above the level of the joint to be arthroscopic can provide a water pressure of 66 - 88 mmHg. For each approximately 30.5 cm (1 foot) increase in the height of the sac, a pressure of 22 mmHg is created.

GARO

During endoscopic manipulation of knees, elbows, and ankles, it is always necessary to pump garo. garo helps to reduce bleeding during endoscopy for better vision. However, it also

This causes the synovial fluid to appear white, making it difficult to distinguish and diagnose disorders of the synovial joints. In addition, there is a possibility of ischemic damage to muscle and nerve tissue if the garo time is longer than 90-120 minutes. Garo is contraindicated in the presence of thrombosis and severe peripheral vascular disease.

In a randomized clinical trial, Kirkley et al. found no significant difference between patients with garo and those who did not. There was a trend toward early postoperative analgesia and slightly better independent biomechanical strength tests at 2 weeks in patients without garo, but visibility was assessed by surgeons. the price is three times better with the use of garo. The authors concluded that the use of a single garo at 300 mmHg did not significantly affect the overall functional outcome. In a randomized, prospective trial including 109 patients who had undergone knee arthroplasty with or without garo, Johnson et al. found no significant difference between the two groups with regard to display, duration, operative time, pain scores, pain relief requirements or complications. Because the use of a garo improves visibility, these authors recommend against the use of garo for knee surgery.

Endoscopic pump system

Several endoscopic fluid management systems are available on the market. They work through the use of a pump or gas device to pressurize an irrigation fluid into the joint. All systems have regulating devices to prevent over-inflating or over-inflating, but each works by a different mechanism.

The pump pressure should vary depending on the joint being arthroscopic and the type of pump used. When using a pressure flow system, the joint dislocation pressure at the knee joint is typically 45-60 mmHg. Visibility and hemostasis of the shoulder are usually best when the tension is maintained around 40 mmHg below systolic pressure. In healthy patients, hypotensive anesthesia can be used to reduce systolic blood pressure by about 100 mmHg, at a pump pressure of 55 to 60 mmHg usually providing safety and clear vision. In a randomized, double-blind study, Olszewski et al. found that the addition of epinephrine (1 mg/L saline) significantly increased visibility and decreased 50% need for gargoyle compared with the placebo group of patients who did not receive epinephrine. In patients with hypertension or heart problems, we do not use epinephrine. Karaoglu et al. also found that adding a small amount of epinephrine (50 µg/10 mL) to the local anesthetic mixture just prior to local injection of the bronchoscope improves endoscopic visibility.

Due to the possibility of fluid drainage, increased pressure at the elbow and ankle must be maintained at approximately 40–45 mmHg when gravity flow is used. Surgeons should be aware of individual variations related to different pump flow and sensing mechanisms. We do not use pumps to inflate small joints.

Surgeons must exercise extreme caution when using the pump device during arthroscopy. Disadvantages of these systems include mechanical problems, the need for equipment, specialized and expensive tubing, and the need for a team familiar with the operation of the equipment. Especially in the feet and ankles, the effusion can lead to a number of cavity problems with disastrous results afterward.

Instruments for posturing in endoscopy

1. Foot Holder

The greatest advantage of the foot retainer is that it allows the application of tension, mainly the opening of the posterior medial space for better visibility, the manipulation of the meniscus, and the surgery of the posterior meniscus, especially in the narrow knee joint. Because the thigh is supported by the foot retainer, the number of different positions the leg can be placed is somewhat limited. An alternative to a leg stand is a side retainer that is attached to the side rails of the operating table. The lateral outer edge of the lower thigh can be used against this retainer to open the posterior compartment.

2. Hand sling in wrist arthroscopy

Includes sterile pull tower with nylon finger holder. This allows for easy wrist flexion, rotation, and pivoting. This system allows adjustment of both traction and position of the wrist. In addition, it allows an easy transition to open surgery if necessary.

3. Leg traction in ankle and hip arthroscopy

4. Arm sling or head support in shoulder endoscopy

5. Pockets or cushions

Insensitivity

Diagnostic endoscopy can be performed under local, regional, or general anesthesia. Local anesthesia may be used during many knee and ankle arthroscopic procedures in a patient in cooperation with intravenous sedation. A combination of spinal and epidural is best for the knee and ankle joints.

Favorable

The advantages of laparoscopic surgery far outweigh the disadvantages. Some of the advantages of arthroscopic surgery over open joint surgery are as follows:

• Reduce the rate of complications after surgery
• Smaller incision
• Significant reduction in inflammatory response after surgery
• Clearly see lesions that open surgery may not be able to see
• Few side effects
• Reduce hospital stay
• Improved follow-up rating
• Ability to perform surgical techniques that are difficult or impossible to perform through open joint surgery.

Hard 

The disadvantages of arthroscopy are few but can be significant for the individual arthroscopic surgeon. Not all surgeons are capable of performing arthroscopic surgery, difficulties include:

• Manipulate through small ports with delicate and perishable tools.
  • Maneuvering instruments within the tight confines of space within the joint can create significant abrasion and damage to the joint surfaces.
  • Requires an experienced surgeon
  • Waste time
  • Requires special tools
  • Expensive.

• While these disadvantages can be significant, their benefits to patients are much greater.

Contraindications

• Contraindications of arthroscopy are few
• Main contraindications:

There is a risk of joint infection from a local skin condition or when a remote infection can be seeded at the surgical site.

Relative contraindications:

• Partial or complete stiffness of the joint.
• Big break lateral ligament and joint sheath.

Basic endoscopic techniques

Proficiency in endoscopic techniques requires a great deal of patience and persistence. The technique is best learned by assisting and performing surgical procedures alongside an experienced endoscopic surgeon during residency or graduate school or in practice.

If laparoscopic surgery is not progressing as expected, it is better to cancel the laparoscopy and switch to an open approach. Practicing surgeons should keep up with the literature, attend seminars, and observe these procedures being performed by highly skilled endoscopists. Orthopedic surgeons should perform procedures concurrently with their skill level, remembering that a skillfully performed procedure through open joint surgery is better than poorly performed arthroscopic surgery. .

Endoscopy steps:

1. After anaesthesia, small skin incisions are made at the skin sites that mark the portals to the joint.
2. A sterile solution is injected into the joint via the trocar, then the lens is inserted.
3. Examine the joint by shifting the lens in the joint.
4. If necessary, other instruments are brought in for the procedure, to repair lesions, or to clean up and remove objects that cause symptoms.
5. Then, sterile water is withdrawn, the incision is closed, and a bandage is applied.

Triangulation: triangulation involves the use of one or more instruments inserted through separate ports and into the field of view of the lens, the tip of the instrument, and the lens forming the top of an image. triangle. Instruments and lenses are inserted through separate ports which improve perception and have the most significant advantage, allowing independent movement of the lens and surgical instrument, which is essential for arthroscopy. To initiate the triangulation process, the arthroscope should be placed at a sufficient distance from the area

need exploration to give a wide view. When the device is positioned, the scope and the device will both move towards the intended area, reducing the field of view while increasing the magnification. A mistake often made by endoscopists is prematurely placing the scope too close to objects, thus losing the larger field of vision needed to maintain constant visual orientation. If the surgeon becomes disoriented and has difficulty in triangulation, aids can be inserted into the joint to make contact with the arthroscope's sheath. By sliding the instrument down the sheath to the tip of the scope, the surgeon can bring the instrument into view. With practice, the surgeon will develop a stereoscopic sensation that allows the instrument to be placed into view immediately.

SYMPTOMS

Performing arthroscopy is like walking through a minefield: the arthroscopic surgeon must maneuver his assistant carefully to avoid complications. Poor technique can lead to the most common complications in endoscopy. Most complications are preventable with good preoperative and surgical planning and attention to details of basic techniques. Familiarize yourself with regional anatomy and familiarize yourself with new techniques through learning centres, work with colleagues, videos, and keeping up with specialized journals allowing surgeons to gain valuable information from the experience of other colleagues. Before the surgical procedure, have all the records and notes available X-ray similarly beneficial. Additionally, before entering the operating room, reviewing the surgical procedure with the patient and asking the patient to write the word “wrong” on the nonoperative limb can reduce confusion that can occur one day after surgery. long art. The American Institute of Orthopedic Surgeons' Sign Your Site program and the Joint Committee's Global Protocol recommendations include preoperative verification of the surgical site, marking surgeon's surgical position and "time out" before the procedure is started for final verification and final checklist.

The overall complication rate for arthroscopy has been reported from 1 to 4.7%. The rate of complications is proportional to experience, time of procedure, time of garo, complexity of procedure, multi-ligament and ligament injury. rear cross, number of procedures and meniscus repair. Commonly reported complications are listed below.

Damage to structures in joints

Arthroscopy can damage structures in the joint such as articular cartilage, meniscus, border cartilage, ligaments and fatty tissue. This is the most common complication of knee arthroscopy. Injury to the articular cartilage surface by puncture of a lens or surgical instrument is the most common complication leading to progressive changes in the cartilage and osteoarthritis. Prevent these complications by prior to insertion, the joint must be expanded by lever or traction first and then the lens slides into the space created. The use of leg stands or lever posts in knee surgery, as well as traction or release devices in shoulder, hip, and ankle procedures, are helpful.

1. Injury to meniscus and adipose tissue

The anterior horn of either meniscus can be injured by port manipulation if the anterior portals are positioned too low. Repetitive manipulating the portals causes the hoffa fat tissue to swell and obstruct vision and can also lead to hemorrhage, hypertrophy, or fibrosis of that structure.

2. Injury to the cruciate ligament

This complication occurs when the meniscus is removed to the point where the intercondylar margin is attached, or when the area is resected with the intercondylar defect.

Injury to extra-articular structures

1. Blood vessels

It is usually caused by direct puncture or laceration, or from pressure caused by excessive effusion. In the knee, the popliteal artery is at risk of injury during meniscal ablation when cutting attachments to the intercondylar ridge, especially when using an endoscopic knife. Both the popliteal artery and vein can be injured during meniscal suture because the suture is placed posteriorly, drilling the tibial tunnel in posterior cruciate ligament reconstruction. Synovialectomy and joint release in ankylosing spondylitis can also damage blood vessels. In the ankle, the anterior tibial artery is at risk of injury when entering the anterior port for ankle arthroscopy, especially the portal right in the middle of the ankle. At the elbow, the brachial artery may be injured during entry to the anterior medial or anterolateral portal. The effusion can also compress the veins in front of the elbow. In the shoulder, it is more common that axillary blood vessels are compressed due to effusion and excessive hand pulling.

2. Nervous

Các thần kinh có thể bị tổn thương trực tiếp do dao hoặc đầu trocar nhọn, do kéo quá nhiều, do chèn ép cơ học hoặc do tràn dịch, hoặc do thiếu máu kéo dài vì garo quá lâu. Nhánh dưới bánh chè và nhánh xuống của thần kinh hiển có thể bị tổn thương khi vào cổng và rạch da lấy gân Hamstring trong nội soi gối. Trong nội soi vai, thần kinh nách có thể bị tổn thương khi dụng cụ nội soi xuyên qua hố nách hoặc kéo quá nhiều gây tổn thương đám rối thần kinh cánh tay tạm thời. Trong nội soi khuỷu tay, cổng phía trước có thể gây tổn thương thần kinh quay hoặc thần kinh gian cốt sau khi vào cổng trước ngoài, thần kinh giữa đối với cổng trước trong, cổng sau trong có thể gây tổn thương thần kinh trụ.

Neurological complications can be prevented by selecting appropriate port access routes, making sure the knife cuts only through the skin, using kelly pliers to remove tissue up to the joint capsule, using an obtuse trocar barrel, injecting water to stretch the capsule, and Stretch the joint before entering the trocar, palpate to identify clear skeletal and neurological landmarks if possible, and prescribe the correct patient position.

3. Tendons, ligaments

The medial collateral ligament can be injured by entering the posterior medial accessory portal or by manipulating the outside of the knee to open the internal cavity during knee arthroscopy.

Cavity compression

The cause is usually an effusion. Prevent by using gravity inflow or low pressure pump and ensure adequate water outlet. Most complications are preventable.

Other Complications

The knee arteries are often injured when the lateral patella is released, and the hamstring tendon can be injured by meniscalectomy or bursectomy.

1. Venous Thrombosis

Venous thromboembolism has a very variable incidence. Studies have found no specific risk factors for deep vein thrombosis. Risk factors may include: age > 50, duration of observation > 60 min. Prevention is by administering low-molecular heparin 12 hours before surgery and continuing 48 hours after surgery in at-risk patients.

2. Infection

Despite concerns about early infection, the actual number of infections reported after arthroscopy remains very low. Many studies have reported large numbers of cases, all with infection rates below 0.2%. Babcock et al. Note, however, that when such infections occur, they can cause significant morbidity. Risk factors include: intra-articular corticosteroid injection, too long garo, patient over 50 years old, failure to prepare the surgical site again before switching to open joint surgery, complicated procedure, and history of previous procedures and note that some outbreaks of infection reported after arthroscopy have been associated with disruptions in infection control or contaminated instruments.

The use of prophylactic antibiotics remains controversial. Preoperative antibiotic prophylaxis as recommended by the Ministry of Health of Vietnam: 1 g of cefazolin intravenously 1 hour before skin incision, patients over 80 years old can use 2 g.

3. Paralysis due to garo

Temporary paralysis may occur if garo lasts longer than 90-120 minutes. If you need a garage, you should deflate after 90-120 minutes. Careful monitoring of the garo pressure and checking the gauge accuracy helps to minimize these problems. Fortunately, varicose veins are usually mild and resolve on their own within a few days.

4. Hernia of bursa or synovial fistula

Small masses of fat and synovial tissue can herniate through the endoscopic port. Usually, the larger the port, the more likely this complication is to occur. Rarely, large cystic hernias filled with fluid have occurred. These fatty and synovial hernias are usually small and asymptomatic for several weeks and do not require specific treatment. If the hernia persists and symptoms persist, the hernia can be resected and carefully encapsulated.

Synovial fistulas are rare but have occurred following suture site reactions or suture site abscesses. To improve sealing, these ports should be sewn rather than closed with tape. Fistulas usually do not produce significant intra-articular infection, but the patient should be given antibiotics and the knee joint should be treated motionless for 7 to 10 days to allow the fistula to close naturally. Surgical closure is rarely required.

5. Tool break

Instrument fracture during endoscopy has a rate of 0.03%. If an instrument breaks, the surgeon will immediately close the outflow but the inlet must stay open to keep the joint inflated. If the broken instrument is in the market, it must be kept in view to find a way to remove it. If the broken piece is small, it can be sucked out or used a magnet.

SOME BASIC arthroscopic arthroscopy

Knee joint

Point

The basic indications of knee arthroscopy:

1. Meniscus tear.
2. Torn ligament front cross.
3. Torn cruciate ligament
4. Get the joint.
5. Synovectomy (removal of pathological synovial tissue) in the following cases:
   1. Arthritis low form.
   2. Bacterial infections (purulent arthritis, tuberculosis).
   3. PVNS (brown hair pigment pigment).
   4. Synovial chondrosarcoma (multiple joint stones).
6. Cutting and irrigating joints in osteoarthritis.
7. Damage and defects of articular cartilage:
   1. In-joint shaping.
   2. Reattach cartilage.
   3. Autologous cartilage graft.
8. Release the outer wing of the tea cake.
9. Knee patella syndrome after total knee replacement.
10. Assess the knee joint before performing partial knee replacement (UKR) or tibial elevation surgery (HTO).
11. Supportive endoscopy with tibial plateau fusion.

Patient Pose

The patient can be placed supine. When the patient is anaesthetized, a gauze and a foot retainer are applied if desired, and the limb from the ankle to the garo is prepared, as for an arthroscopy.

The patient can also be placed supine on a standard operating table with the knee joint positioned slightly past the lower transition point of the table. The end of the table is dropped so that both limbs dangle at 90 degrees. The opposite extremities should be well padded to prevent potential pressure problems. Bend the middle of the table and place a pad that also flexes the groin to relieve femoral nerve tension and at the same time flatten the lumbar spine. It is also helpful to use a good foot support for the nonsurgical limb.

Basic ports

1. External front gate

As the camera port, most of the internal structures of the knee joint can be seen: posterior cruciate ligament, anterior lateral meniscus, and periphery of the posterior horn of the medial meniscal.

Location of entrance: 1 cm above the joint line, 1 cm outside the lateral patellar tendon, 1 cm below the pole.

Tiến hành vào khớp bằng trocar ở tư thế gối gấp 70º. Đẩy từ từ liên tục cho đến khi qua được bao khớp. Gối duỗi ra đến khi còn 20º gấp thì đẩy trocar vào khoang chè đùi. Dấu hiệu vào khớp xác định khi di chuyển trocar qua lại dễ dàng và cảm nhận được sự va chạm với xương bánh chè. Nếu ở ngoài khớp thì không thể đẩy trocar qua lại được. Khi xác định trocar đã vào khớp thì xả nước vào và đưa camera vào dưới xương bánh chè.

Avoid entering the port at a position too low, close to the joint line, risking damage to the anterior meniscus and making it difficult to manipulate the lens. If the entrance is too high above the articular cleft line, it will be difficult to see the posterior meniscus horns and posterior structures. If it is right next to the patellar tendon, it will go straight into the hoffa fatty tissue, making it difficult to see and manipulate the lens in the joint.

3. Inner front gate

The location is similar to that of the anterolateral portal: 1 cm above the medial articular cleft line, 1 cm below the inferior patellar pole, and 1 cm medial to the medial margin of the patellar tendon. Opening this port allows an additional view of the external cavity and examination of structures in the external and internal compartments. It should be pre-positioned with a needle, usually just above the medial meniscus.

4. Inner tailgate

Entering the portal 1 cm above the medial posterior articular cleft line, located on the posterior border of the medial condyle, the “soft spot” was palpated between the semi-membranous tendon, the medial head of the calf muscle, and the medial ligament. The anterior capsule should be inflated with water, this small triangle can be easily palpated in the 90º flexed knee position. The pillow must be inflated with water, then the inner cavity will be like a balloon in the 90º flexed knee position.

This port is used to suture or remove the torn posterior horn of the inner meniscus, remove the joint stones that cannot be removed through the anterior portal, used in some cases of synovectomy, or manipulate the posterior border of the tibial plateau to tibial tunnel drilling in posterior cruciate ligament reconstruction.

4. Gate on the outside

The superior external port is useful for observing the movement of the patellar joint. Enter the lateral port of the quadriceps tendon and approximately 2.5 cm above the superior lateral patellar pole. This port allows assessment of patellar mobility, patellar morphology, for debridement of the patellar synovial fluid and release of the lateral wing.

5. Outer tailgate

The knee should be flexed to 90° and the joint should be maximally stretched. The landmark for the external posterior portal is at the point where a line drawn along the posterior edge of the femoral axis intersects a line drawn along the posterior border of the fibula. Or approximately 2 cm above the posterior lateral joint line at the posterior edge of the iliotibial band and the anterior edge of the biceps tendon.

This port is useful for assisting in the repair of lateral meniscus tears.

Technique

A systematic sequence of checks should be carried out from compartment to compartment and systematically performed on each pillow. In the knee joint is usually divided into the

the following compartments on laparoscopic examination: suprapatellar and femoral sulcus, medial sulcus, medial space, intercondylar sulcus, posterior medial space, external space, lateral sulcus and posterior lateral sulcus, medial and interstitial fis convex convex.

Shoulder

Point

Indications for basic shoulder arthroscopy include:

• Shoulder instability (recurrent shoulder dislocation)
• Catch-up syndrome
• Torn rotator cuff
• Viêm gân calci hóa
• Tear SLAP
• Torn long head of biceps
• Frozen shoulder (periarthritis of the shoulder joint)
• Get the joint stone
• Cut synovial fluid:

Inflammation in osteoarthritis

Infection (tuberculosis)

+ Tumor synovial cartilage (many joint stones).

Posture

Two basic positions for shoulder arthroscopy have been described: the supine position and the beach chair position. The side-lying position is probably more commonly used because of the better access to the back shoulders and the ease and safety of this position. The benefits of the beach chair are ease of surgical orientation and manipulation in the subarachnoid space and ease of conversion to open surgery. Complications such as stroke and death have been reported from episodes of beach chair hypotension; Blood pressure in the arms is lower than in the brain and is likely to be significantly lower if carotid artery disease is present. Because blood pressure measured in the calves of a patient in the beach chair position can be 40 mmHg higher than cerebral perfusion pressure, pressure should be monitored on the contralateral arm or with a cerebral perfusion monitor when possible. . We use hypotensive anesthetics and believe that cerebral perfusion is more reliably maintained in the lateral position than in the beach chair position.

1. Beach chairs

The use of beach chair pose and anesthesia in the anterior quadriceps muscle has several reported advantages: quicker and easier patient placement, reduced risk of neuropathic pain because no force is used traction, less distortion of the intra-articular anatomy, improved patient arm mobility, and an easier transition to open surgery because re-preparation is not required. The disadvantages of this technique are the difficulty of working from the posterior ports and the reduced cerebral perfusion during hypotensive anesthesia. As mentioned earlier, stroke complications and death can result from episodes of hypotension in the beach chair position.

A commercially available beach chair attachment is used to better control the patient's head, neck, and torso and increase access to the posterior shoulder. An auxiliary person may control the arm or a sterile arm positioner may be used.

2. Lying on your side

The patient is placed in the lateral position with the affected shoulder exposed and supported by a vacuum bean bag and kidney stand. A chest strap is used for extra support. The patient's head is supported by foam support and carefully protects the eyes and ears. An armpit roll is often required by anesthesiologists to improve ventilation.

Peripheral pulses and pulse oximetry should be evaluated to ensure that the axillary structure is not damaged. All pressure points should be cushioned, with a pillow under the lower leg protecting the peroneal nerve, the lateral ankle, and one or more pillows between the knee and the ankle. This upright lateral recumbent position can be adjusted by tilting the patient 20 to 30° backward, so that the pan parallel to the floor. This modification has been reported to have several advantages: (l) less traction, reduced risk of brachial plexus neurosis; (2) highlight tears of the alveolar margin cartilage because they are pulled out of their bed instead of aligning with them and (3) improve endoscopic access to the lower third of the alveolar and joint cover.

Using a commercially available sterile hand traction device, apply a pulling force of 4.3 – 5.9 kg. Overstretching with excessive weight should be avoided. The rule is that more than one weight hangs balanced. The amount of traction should only be used if a clear view is required. Most endoscopists use 30 – 60° flexion and 20 – 30° forward flexion and pay more attention to traction and length of the procedure. Vertical and axial traction can be applied to the shoulder, with most of the traction applied vertically to elongate the socket arm joint without dislocating it downwards. Complications after shoulder arthroscopy have been reported to range from 23 to 30%, largely due to neuropathic pain following excessive hand traction. The position of the arm for arthroscopy of the subarachnoid space and the sacroiliac joint is slightly different. Arms are brought down 20 – 45° flexed and 0° flexed. This position allows for a slight inferior subluxation of the brachii, opening up the space below the apex

Ports

Before entering the endoscopic portals, it is necessary to understand the anatomy around this area, in order to limit damage to the neurovascular structures.

1. Back gate

The posterior port is the first port in shoulder arthroscopy. It allows exploration of most positions in the shoulder joint and aids in access to other portals.

This port is located about 1.5 - 3 cm below and 1 cm inward from the posterior pole of the acrosis of the shoulder, located between the subscapular muscle and the small circular muscle.

2. Lower back gate, 7 o'clock gate

Davidson and Rivenburgh described a posterior accessory port at 7 o'clock for shoulder arthroscopy that allows direct access to the lower humeral alveolar capsule and avoids injury to nearby structures.

The inside-out portal was created using a toggle bar that was passed over the 3 o'clock portal and oriented posteriorly. The conversion rods are inserted through a small skin incision and placed in place. The 7 o'clock portal from the outside to the inside is established by making a small skin incision 2 - 3 cm below the posterior portal. A blunt end rod is then inserted into the lower arm socket joint under direct observation.

3. Front Gate

This port allows visualization of the posterior capsule and rotator and anterior to the brachial cruciate ligament and subscapular tendon.

The anterior portal is located slightly beyond the midpoint between the anterior poles of the scapular and crow's processes.

4. Gate 5 o'clock

This portal site is located along the inferior brachial fascia ligament at 5 o'clock along the alveolar margin, at the subscapular tendon-to-muscle transition.

This port allows evaluation of the inferior brachial cruciate ligament margin and suture closure

5. Upper Gate – Neviaser

This portal penetrates the trapezius muscle and through the abdomen of the supraspinatus. Note that the supraclavicular nerve is located approximately 3 cm medially.

This port is useful for suturing the rotator cuff tendons.

6. Outer Gate

The external portal is the first opening and the main portal to the subarachnoid space, located 3 cm lateral to the parietal margin, through the deltoid muscle.

7. Wilmington Gate

This port allows access to the socket and the upper margin cartilage.

The defined site was 1 cm anterior and 1 cm lateral to the posterior pole of the acrosis of the shoulder.

Shoulder arthroscopic examination

The examination begins with identifying the soft spot between the biceps tendon and below the shoulder. Into the socket arm joint cavity.

Move the lens in sequence. Endoscopic diagnosis and repair.

Into the inferior apical space

Ankle joint

Point

1. Diagnostic endoscopy

Pain difficult to diagnose the cause, swelling, stiffness, instability. Signs of a stiff or wobbly lock in the joint.

2. Interventional endoscopy

Facet joint trauma

Software injuries.

Soft tissue blockade after trauma. Catch bones.

Fibrosis in joints.

Loss of stability.

Endoscopic assisted bone fusion. Synovitis.

Get the joint.

Fibrous bands in joints. Tendonitis.

Bone buds.

Khuyết hỗng sụn xương. Hàn khớp.

Infective arthritis.

Patient Pose

The patient lies supine on the table. Garo is placed in the thigh or leg of the surgical limb. The surgical leg is then placed in a good foot support or on a bushing. The thigh should be secured in a slightly flexed position, with the end of the table flexed and the knee extended far enough to prevent the table from impeding the rear device. The opposite leg should also be well padded and flexed at the hip to prevent injury to the femoral nerve. Next, the stretcher is reinforced according to the manufacturer's specifications.

The image of the ankle, subtalar joint, and forefoot can be significantly improved using a stretcher. Stretchers are used to increase the space between the tibia and talus. Without stretching, certain areas of the ankle, such as the medial and posterior tibial ceilings, the talus arch, the posterior inferior tibialis ligament (PIT-FL), and the transverse tibial ligament (TTFL), seen very poorly. Stretching methods can be non-invasive or invasive.

With invasive stretching, two nails are placed, one in the lower tibia and the other in the calcaneus. Currently, invasive stretching is rarely used. It is replaced by continuous non-invasive stretching or by a technique in which stretching is applied only when needed. The zipper is tied to the patient's leg and the rest is tied to the surgeon's waist. Non-invasive traction up to 11.3 kg (25 lb) can be safely applied.

Ports

1. Inner front gate

This port is located just medial to the anterior tibial tendon. If necessary, an auxiliary anterior portal can be created approximately 1 cm anterior to the apex of the medial ankle.

2. Outside front gate

Depending on the disease of the ankle, the position of the anterior lateral port may vary. To treat anterior medial pathology, the anterior lateral portal is placed between the lateral branch of the superficial peroneal nerve and the third peroneal tendon as centrally as possible. For external pathology treatment, the front of this port can be placed more externally.

3. Gate between shaft

The mid-axial port is located between the anterior tibial tendon and the extensor tendon of the long toe. This port is similar to the central anterior portal, but has a lower risk of damage to neurovascular structures.

4. Outer tailgate

The outer tailgate is located right next to the Achilles tendon. With the ankle in the flexed position, it is located 1 cm above the top of the lateral ankle.

5. Central front gate

The central anterior portal is created at ankle level between the common extensor tendons of the long toe.

6. Tibia and ankle gates

For the debridement and drilling of tarsal arch lesions, a trans-ankle port can be used, combined with ankle stretch to create more work space, but this portal has the disadvantage of being cause cartilage damage to the inner ankle opposite the injury. Drilling through the tibia or through the ankle with the use of a special guide system, which facilitates the placement of the gate and the K-nail, is useful for lesions in the ceiling of the tibia.

Ankle arthroscopy examination

An arthroscopic examination of the ankle had 21 points (including: deltoid ligament, medial sulcus, medial talus, medial tarsal center, lateral talus, tibi-fifacial junction, lateral sulcus, anterior sulcus, medial tibial center. talon, medial talus, lateral talus, reflective capsule of the long flexor tendon, transverse tibial ligament, posterior inferior tibial ligament, medial groove, medial talus, center of talus, lateral talus, face talus, lateral groove, posterior groove) were performed to ensure systematic evaluation. After completing the endoscopic evaluation, the surgeon determines the pathology and provides appropriate treatment.

Hip joint

Point

Treatment of femur acetabulum and torn meniscus. Get the joint.

1. Cartilage disease.
2. Osteoarthritis disease. Avascular necrosis (AVN). Synovial disease.

Loss of stability.

Snapping hip inside and out.

Infective arthritis.

Patient Pose

1. Middle Pose

The patient lies supine on a bone table or on a table usually with scissors. Multi-side padding on the side of the tree. Surgical groin in neutral position, slightly closed and neutral rotation. Mild flexion can relax the capsule and facilitate stretching, but can create additional traction on the sciatic nerve and pull it closer to the joint, making it more susceptible to injury. Apply traction to the surgical limb and confirm elongation of the joint by fluoroscopy.

2. Side tilt posture

Place the anesthetized patient in a supine position on the groin with the affected groin on top. An osteopathic table or a specialized stretching device may be used. A label stopper side pad is inserted. The bar should be placed as far as possible on the surgical leg to protect the pudendal nerve and to improve traction vectors in the groin. The foot of the affected leg is placed in a leg support to apply traction. Shape the groin from 20 – 45° and stretch it. Place the groin in a light, flexed, and externally rotated position. Use the C-arm to assess traction and to guide the tool. Apply enough traction to create a space large enough to accommodate the 5 mm scope and instrument.

Ports

1. Front Gate

Location: is the intersection of the line passing through the apex of the great trochanter and the descending extension of the anterior superior iliac spine.

2. Outside front gate

Location: 1 cm above and anterior to the anterior margin of the great trochanter.

3. Outer tailgate

Location: 1 cm posterior to and above the great trochanter, the junction between the anterior superior iliac spine and the anterior margin of the great trochanter.

arthroscopic examination of the hip

Enter the front and rear gates first, then the front and rear gates. Enter the central cavity, observe the acetabulum, the marginal cartilage, and the femoral head. Resection of the marginal or fragmented cartilage. After visualizing the central compartment, remove traction and flex the hip 45°, allow the capsule to relax and examine the external spaces. The anterior and external anterior portals can be redirected to the femoral neck.

Elbow joint

Point

Basic indications of endoscopy elbow joint:

1. Remove joint stones.
2. Cut joints, remove bone buds.
3. Joint release.
4. Inflammation of the bone cartilage detachment (OCD).
5. Cut the fascia.
6. Remove the tip
7. Removal of the elbow synovial sac (Kerr).
8. Infective arthritis.
9. Combine bones.
10. Release the outer condyle.

Patient Pose

Elbow arthroscopy can be performed in the supine, prone, or supine position on the operating table. A garo is used to control bleeding and is placed as high as possible on the arm to avoid crowding the surgical area.

1. Lie on your back

With the patient lying supine, the hand and forearm are placed in a suspension device with sterile, waterproof socks connected to a rope and pulley system weighing 2.27 to 4.53 kg ( 3 – 6 lb) for balance suspension. The patient is positioned so that the arm hangs freely from the table, with the shoulder neutral and 90° flexed. Elbows are bent at 90°. The surgeon sits in a wheelchair with the elbows across the chest so that the elbows can be easily moved to the sides.

2. Lie on your stomach

With the patient lying prone, improves joint mobility, makes joint manipulation easier, improves access to the posterior aspect of the joint, and provides a fuller view of internal structures. The patient is placed on the chest roll, an armrest parallel to the operating table. Shoulders and upper arms are raised on a sandbag placed on an armrest. Without using traction, the arm is placed in a neutral rotated shoulder position and 90°. Elbows bent 90° with hands facing the floor. The surgeon stands to operate, with the operating table at chest level to avoid contamination of the hands. Monitors and other devices are placed facing the surgeon.

3. Lie on your side

Placing the patient in a lateral position allows easy access to the posterior compartment and maintains the patient's mobility for anesthesia and maintenance of anesthesia during the procedure. The patient is kept in the lateral position with the aid of a bean bag and a kidney tree. The arm is placed on an attachment to the bed. The support bar should be small enough to exit the surgical site and allow the elbow to hang freely at a 90-degree flexion angle with unobstructed access to the front and rear ports. Takahashi et al. backing traction for support.

Ports

1. External Gate

The outer port is in the soft-touch position outside. This portal is located at the center of the triangle formed by the lateral condyle, the rotator cuff, and the apex of the elbow process. The elbow is inflated initially through this port.

2. Outside front gate

The anterior external port, traditionally the primary diagnostic port, is often the first to be established after the elbow bulges. External front ports may include: 

(1) the traditional distal anterior portal 2–3 cm inferior and 1 cm anterior to the lateral condyle, (2) the mesio-medial anterior portal and 1 cm anterior to the rotator cuff and (3) anterior lateral portal 2 cm mesial and 1 cm anterior to the lateral condyle. The proximal anterolateral portal provides the safest distance from the radial nerve but can make measurements in the central joint space more difficult than in the medial anterolateral portal.

3. Inner front gate

The medial anterior portal is located 2 cm inferior and 2 cm anterior to the medial condyle. It allows penetration into the central cavity of the elbow joint.

4. Gate in the near

This port is located 2 cm above and anterior to the medial condyle. It is imperative that the location of the ulnar nerve be palpated before establishing this or any other internal portal. This port allows a better view of the entire elbow joint compared to the traditional front port

5. Outer tailgate

The posterior external portal is located 2–3 cm above the apex of the ulnar process and just outside the border of the triceps along the superior lateral condylar margin. The lateral brachial cutaneous nerve and the posterior brachial branch of the anterior brachial nerve may be injured if the incision is deep.

6. Back gate

The tailgate is placed 2–3 cm above the apex of the elbow and approximately 2 cm inward of the outer tailgate, with the supine position and the elbow at a 45-degree flexion.

Elbow arthroscopic examination

Inject water to inflate the joint capsule.

Enter the anterior, anteromedial portal, into the elbow joint space.

Observe the elbow joint, the cone and the pulley groove. Examine the medial capsule to the articular surface, the anterior bundle of the ulnar ligament.

Forearm supine, apply lateral flexion force at elbow flexion 30-90°, check for internal instability.

Observe the joint capsule and its attachment point to the inferior humerus, and examine the pit of the scapula (fragments, bony shoots, and adhesions).

Enter the medial anterior port, observe the rotator cuff and rotator cuff joints and the annular ligament. Inner curvature allows a better view of the crest. Observe whether the anterolateral capsule is thick or not, then bring the bronchoscope back to the parrot's apex.

Enter the external port, check the rotator cuff concave surface on the occipital head, bring the lens forward and slightly extend the elbow to examine the occipital face (cartilage ulcer, osteochondrosis), return the instrument to the posterior midline. two-sided joints.

Check the joint between the elbow and the pulley. Follow the joint face forward to observe the apex of the medial posterior elbow process (cartilage ulcer, osteophyte).

Continue the bronchoscope forward and observe the position of the external posterior port entry.

Enter the external posterior port, observe the elbow fossa, the apex of the elbow and posterior to the pulley, the posterior bundle of the ulnar collateral ligament, and be careful of the ulnar nerve.

Wrist joint

Point

Endoscopy diagnoses and supports the treatment of wrist joint diseases.

TFCC tear, inferior radial joint instability, wrist instability. Grind bone, remove brooch.

Cut the dorsal synovial cyst. Cut the synovial membrane, irrigate the joint. Joint release.

Hỗ trợ kết hợp xương gãy đầu dưới xương quay, xương thuyền.

Posture

The patient lies supine with the surgical limb on the arm support table. The operating table is angled so that the surgeon stands above the armrest near the patient's head, while the assistant stands across the arm inside the patient's armpit. An unsterilized vapor garo is placed in the prepared arm and hand and the forearm is suspended in an upright position.

Stretching is necessary to facilitate exploration and to provide sufficient space for the procedure during wrist arthroscopy. There are different ways of stretching. A dedicated sterile or non-sterile pull tower is a popular choice. Alternatives include using horizontal traction with pulley systems and system weights as well as non-sterile traction rigs.

The arm is placed in the form position and is fixed to the towing tower. Soft nylon finger gabions are used to secure the index and middle fingers to the pyramidal bone during most procedures. Soft gabions have increased surface area and better force distribution than wire devices. In the case of poor or fragile skin, adding fingers in the basket can reduce the force exerted on the skin. To improve the investigation of ulnar diseases, we will frequently use the index and ring fingers. In general, 5 to 10 pounds of traction is enough for most tricks.

Ports

The wrist endoscope ports can be arranged as radial, medial, mandibular, and palmar rotator cuff ports. Previously, endoscopic ports were described according to their relationship to the six extensor tendon compartments of the wrist. There are 11 commonly used endoscope ports. These include five rotator cuffs, four medial wrists, and two mandibular rotator cuffs. In addition, two palm face ports are also becoming increasingly popular.

Precise port placement allows complete wrist arthroscopy while minimizing treatment-induced damage to the wrist joint and surrounding structures. Incorrect port placement can lead to damage to the vascular nerve structures and articular cartilage. Marking the tailgate by hand helps to avoid distortion and misplacement of the gates.

The crank wrist ports include 3 – 4, 4 – 5, 6-R, 6-U, and 1 – 2 ports. The crank wrist ports allow for smoother visibility of the wrist joints, while the crank ports The middle wrist will see uneven joints. The ports are named for the distance between the extensor tendon compartments. Ports 3–4 divide the third and fourth extensor tendon spaces.

The 6-R and 6-U ports are named for their relationship to the ECU, with 6-R on the rotating side and 6-U on the cylinder side. Palpation between these compartments will reveal the soft points of the wrist, providing entry points for the least amount of joint damage.

Technique

The water pump inflates the joint capsule.

Starting with ports 3 – 4, enter the rotator cuff joint, examine the radial bromance and capsule. The keel above and the rotator cuff below. The proximal margin of the radial facet is then evaluated as the peripheral ligament, the major rotator cuff, and the long radial ligament. The ulnar side is the rotator cuff ligament, also known as Testut's ligament. Next, the proximal surface of the lunate and the distal surface of the radial bone, TFCC, can be evaluated.

The RMC port, located about 1 cm from the crank 3 to 4 wrist gate, enters the middle carpal compartment. Endoscopic evaluation in this area begins with a look at the convexity of both the bones (above) and the synovial joint (below). The meniscus ligament is not present distal to the lunate joint and, therefore, the joint is best viewed from this position. The distal surfaces of the lunate and pyramidal bones were subsequently evaluated, as was the proximal concavity of the hook bones. The pyramidal lunate joint is also clearly seen from this angle. In the far row, the hook joint can also be checked. Further, the hook tower joint can use an auxiliary port. The trapezius joint can be observed when the lens is pushed toward the rotator cuff and early degenerative joint changes can be observed.

After completion of mid-rotator cuff diagnostic endoscopy, a port proximal to the inferior radial joint can be placed, the radial and ulnar radial surfaces, as well as the proximal TFCC, can be evaluated. Through pronation of the wrist, the articular margin of the ulna can be seen. Evaluated as helpful for DRUJ debonding, debridement, excision, or capsulotomy.

POSTOPERATIVE

Patients after arthroscopy can be discharged after a few days or the same day. Change the wound dressing every 3 days until healed and sutures removed. For diagnostic laparoscopy, just rest for 2 days and then do joint physical therapy. For therapeutic endoscopy, 2 weeks rest with splints or specialist physiotherapy is required.