Part XIV - ARTHROSCOPY

Chapter 47 - General Principles of Arthroscopy

Barry B. Phillips

Progress in arthroscopic surgery has been especially rapid in the past 10 years. The arthroscope has
dramatically changed the orthopaedic surgeon's approach to the diagnosis and treatment of a variety of
joint ailments. A high degree of clinical accuracy, combined with low morbidity, has encouraged the use
of arthroscopy to assist in diagnosis, to determine prognosis, and often to provide treatment. It should be
emphasized that arthroscopic procedures should serve as adjuncts to and not as replacements for thorough
clinical evaluation; arthroscopy is not a substitute for clinical skills.

Progressive improvements in the lens systems of arthroscopes and fiberoptic systems, in miniaturization,
and in the accessory operative instruments have made possible advanced operative arthroscopic
techniques for multiple joints of both the upper and lower extremities. Although many arthroscopic
procedures have proven superior to previous open techniques, surgical results should not be sacrificed to
expand the indications for arthroscopic procedures.

Instruments and Equipment

ARTHROSCOPE

An arthroscope is an optical instrument. Three basic optical systems are used in rigid arthroscopes: (1) the
classic thin lens system, (2) the rod-lens system designed by Professor Hopkins of Redding, England, and
(3) the graded index (GRIN) lens system ( Fig. 47-1 ). In the classic thin lens system, the lenses are thin
in comparison to their diameters, and air spaces separate the conventional lenses. The light and images
are transmitted through the relay lens system to an ocular lens, which then transmits the image to the
observer's eye. In the rod-lens system designed by Hopkins, the lenses are thick compared to their
diameter and the air space between successive lenses is relatively small. This system provides a number
of advantages in construction and performance, and most modern arthroscopes use this optical system. In
the graded index lens system, the entire instrument consists of a slender rod of glass. The Watanabe No.
24 arthroscope (1.7 mm diameter) and Dyonics needle scope use this type of basic optical lens system.

The so-called fiberoptic arthroscopes generally consist of a rod-lens system surrounded by multiple light-
conducting glass fibrils. These two systems are enclosed in a specially treated rigid metal sheath.

Certain features determine the optical characteristics of an arthroscope. Most important are the diameter,
angle of inclination, and field of view. The angle of inclination, which is the angle between the axis of the
arthroscope and a line perpendicular to the surface of the lens, varies from 0 to 120 degrees. The 25- and
30-degree arthroscopes are most commonly used. The 70- and 90-degree arthroscopes are useful in seeing
around corners, such as the posterior compartments of the knee through the intercondylar notch, but have
the disadvantage of making orientation by the observer quite difficult.

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Figure 47-1 Three basic optical systems used in rigid arthroscopes. A, Thin lens system. B, Rod-lens system designed by
Hopkins. C, Graded index (GRIN) lens system. (From Johnson LL: Arthroscopic surgery, St Louis, 1986, Mosby.)

Figure 47-2 Rotation of arthroscope with 30-degree angle of inclination, which causes scanning effect that increases field of
view by about three times. Dotted circle shows field of view and is compared at lower left with small circle that shows field of
view of 0-degree arthroscope. (From Shahriaree H: O'Connor's textbook of arthroscopic surgery, Philadelphia, 1984, JB
Lippincott.)

Field of view refers to the viewing angle encompassed by the lens and varies according to the type of
arthroscope. The 1.9-mm scope has a 65-degree field of view; the 2.7-mm scope, a 90-degree field; and
the 4.0-mm scope, a 115-degree field of view. Wider viewing angles make orientation by the observer
much easier. Rotation of the forward oblique viewing (25- and 30-degree) arthroscopes allows a much
larger area of the joint to be observed ( Fig. 47-2 ). Rotation of 70- and 90-degree arthroscopes produces
an extremely large field of view but may create a central blind area directly in front of the scope ( Fig. 47-
3 ).

Finally, arthroscopes vary in diameter from 1.7 to 7 mm, with 4 mm being the most common size. The
smaller 1.9- and 2.7-mm scopes are useful for the smaller and tighter joints such as the wrist and ankle,
respectively. Small-diameter, flexible arthroscopes are being developed for use in smaller, less accessible
spaces, as well as for diagnostic procedures performed in the office under local anesthesia, but the quality
of image and field of view provided by these instruments need improvement.

Two arthroscopic instrument designs are available, one for viewing and one for operating. The operating
arthroscope, developed by O'Connor, allows direct viewing, with a channel for the placement of operative
instruments in line with the arthroscope. The advantages of this system are that the tip of the instrument is
directly in the field of vision, and only one portal is required for the passage of two instruments. Because
it requires a large-diameter sheath (7.5 mm), it is impractical for smaller joints. The development of
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triangulation techniques through the viewing arthroscope has reduced the operating arthroscope to a
historical curiosity.

FIBEROPTIC LIGHT SOURCES

Initial light sources consisted of 150-watt incandescent bulbs; these were adequate for direct viewing
through the arthroscope, but the introduction of television systems to arthroscopy demanded more light
intensity. To meet this demand, tungsten, halogen, and xenon arc light sources that produce 300 to 350
watts were developed.

Figure 47-3 Rotation of arthroscope with 70-degree angle of inclination. This scans large circle but creates blind area directly
ahead of it in which nothing can be seen. (From Shahriaree H: O'Connor's textbook of arthroscopic surgery, Philadelphia,
1984, JB Lippincott.)

The development of fiberoptic lighting also eliminated many problems associated with older methods.
The fiberoptic cable consists of a bundle of specially prepared glass fibers encased in a protective sheath.
One end of the bundle or cable is attached to a light source that is remote from the operative field and
usually has the capability for low- and high-intensity output; the other end is attached to the arthroscope,
which is surrounded by fiberoptic fibrils.

The glass fibers are quite fragile, and the cables should be handled carefully. Bending them, coiling them
tightly, or placing heavy instruments on them tends to break the fibers and reduce the intensity and
quality of light transmission. The length of the cable also affects light transmission because 8 inches of
the transmitted light is lost for each foot of cable. In the newer systems, light-carrying capacity has been
increased, and the problem of fiberoptic breakage has been eliminated with liquid (glycerin) light guides.

TELEVISION CAMERAS

McGinty and Johnson were among the first to introduce a television camera to the arthroscopy system.
The advantages of this addition included a more comfortable operating position for the surgeon,
avoidance of contamination of the operative field by the surgeon's face, and involvement of the rest of the
surgical team in the procedure. Early cameras were bulky and inconvenient, but small, solid-state cameras
have been developed that can be sterilized either by gas or Cidex soaking and connected directly to the
arthroscope. In these camera systems, improvements are being made in the chip and electronic circuitry to
allow reductions in size and better resolution. Additional features are available, including controls to the
light source and to recording devices.

Video-dedicated systems are now available that eliminate the eyepiece and directly connect the camera to
the arthroscopic lens system. Such systems eliminate the fogging problem that can occur when moisture
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collects between the arthroscope and the camera at the C-mount adapter. Suction ports have been added to
the C-mount adapter to help clear the water vapor. The C-mount adapter allows rapid interchange of
arthroscopes with different lens obliquities; this is an advantage not shared by the video-dedicated
arthroscopes. Recent improvements in camera systems include RGB and super VHS capabilities, which
improve color and resolution. Also being developed are “cableless” arthroscopic systems in which the
video signal is transmitted to the monitor from an arthroscope that contains its own miniature light source.
Cameras using three-chip technology allow even greater color resolution, and digitalization of the video
signal also has resulted in advancements in high-quality imaging.

ACCESSORY INSTRUMENTS

The following instruments are used in performing most routine arthroscopic surgical procedures.
Additional instruments are available and are occasionally used in special circumstances. Each surgeon has
personal preferences regarding the type, design, and manufacturer of each instrument. The basic
instrument kit consists of the following:

Arthroscopes, 30 degree and 70 degree

Probe

Scissors

Basket forceps

Grasping forceps

Arthroscopic knives

Motorized meniscus cutter and shaver

Electrosurgical and laser instruments

Miscellaneous equipment

Figure 47-4 Arthroscopic probe used in exploring intraarticular structures during arthroscopic triangulation techniques.

Probe

The probe is perhaps the most used and important diagnostic instrument after the arthroscope. The probe
has become known over the years as “the extension of the arthroscopist's finger.” It is used in both
diagnostic and operative arthroscopy and is the safest instrument that one can use in learning triangulation
techniques ( Fig. 47-4 ). The probe is essential for palpating intraarticular structures and in planning the
approach to a surgical procedure. A tactile sensation soon develops regarding what is normal and what is
abnormal. It is better to “see and feel” rather than to just “see” alone. The probe can be used to feel the
consistency of a structure, such as the articular cartilage, to determine the depth of chondromalacic areas,
to identify and palpate loose structures within the joint, such as tears of the menisci, to maneuver loose
bodies into more accessible grasping positions, to palpate the anterior cruciate ligament and determine the
tension in the ligamentous and synovial structures within the joint, to retract structures within the joint for
exposure, to elevate a meniscus so that its undersurface can be viewed, and to probe the fossae and
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recesses, such as the popliteal hiatus within the joint. Most probes are right-angled with a tip size of 3 to 4
mm, and this known size of the hook can be used to measure the size of intraarticular lesions.
Magnification occurs with the arthroscope, and the closer the arthroscope the greater the magnification.
Care should be taken when using the tip of the probe, and much of the palpating with the probe within the
joint is actually done with the elbow of the probe rather than the tip or toe of the instrument.
Scissors

The arthroscopic scissors are 3 to 4 mm in diameter and are available in both small and large sizes. The
jaws of the scissors may be straight or hooked ( Fig. 47-5 ). The hooked scissors are preferred because the
configuration of the jaws tends to hook the tissue and pull it between the cutting edges of the scissors,
rather than pushing the material away from the jaws, which can occur with the straight scissors. Optional
accessory scissors designs include right and left curved scissors and angled cutting scissors. The
difference between these two designs is based on the location of the angulation. The shank of the curved
scissors is gently curved to accommodate right and left positioning, whereas the angled scissors, usually
with a rotating type of jaw mechanism, actually cut at an angle to the shaft of the scissors.

Figure 47-5 Commonly used arthroscopic scissors. A, Hooked scissors. B, Angled rotary scissors.

These accessory designs are useful in detaching difficult-to-reach meniscal fragments.

Basket Forceps

The basket or punch biopsy forceps is one of the most commonly used operative arthroscopic instruments
( Fig. 47-6 ). The standard basket forceps has an open base that permits each punch or bite of tissue to
drop free within the joint and does not require removing the instrument from the joint and cleaning it with
each bite. Small fragments of tissue that drop free within the joint through the open-floor punch or basket
forceps can be irrigated out or subsequently removed from the joint by suction. This instrument is
available in 3- to 5-mm sizes with a straight or curved shaft. It is useful in trimming the peripheral rim of
the meniscus, or it can be used instead of scissors to cut across meniscal or other tissue. Wide, low-profile
baskets are excellent for meniscal work. The configuration of the jaws of the basket forceps may be
straight or hooked; again, the hooked configuration is preferred. Baskets are available in an assortment of
angles, including 30, 45, and 90 degrees, which are especially useful for trimming the anterior portions of
the meniscus. They also are available in 15-degree down-biting and 15-degree up-biting curves to make it
easier to get around the femoral condyle during resection of the posterior meniscal horn. As with other
arthroscopic instruments, the proper technique is to make small bites to avoid excessive pressure on the
joints and pins of the instrument and prevent frequent breakage.

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Figure 47-6 Arthroscopic basket or punch forceps. A, Standard straight jaw forceps. B, Hooked jaw forceps. C, Acuflex rotary
punch forceps. D, Acuflex ducklet.

Hinged, jawed suction punches are available to cleanly bite small bits of meniscus or other small tissues
and suction them from the joint through a channel in the shaft of the punch. This prevents fragments of
tissue from floating in the joint and blocking vision and ensures removal of all free fragments from the
joint. This instrument, however, often is too large to reach tight posterior areas.
Grasping Forceps

Grasping forceps ( Fig. 47-7 ) are useful for retrieving material from the joint, such as loose bodies or
synovium, or for placing meniscal flaps and other tissues under tension while cutting with a second
instrument. Most grasping forceps have some type of ratchet closure on the handle to secure the tissue
within the jaws. The jaws of the grasping forceps may be of single- or double-action design and may have
regular serrated interdigitating teeth or one or two sharp teeth to better secure the grasped tissue. The
double-action grasping forceps, both jaws of which open, are especially preferred for securing an
osteocartilaginous loose body because the single-action types frequently allow it to slip from between the
jaws.
Knife Blades

Most arthroscopic knives currently used are disposable, single-use instruments ( Fig. 47-8 ). A variety of
disposable blade designs are available: hooked or retrograde blades, regular down-cutting blades, both
straight and curved, and Smillie-type end-cutting blades. Magnetic properties also are helpful in retrieving
the blade if it is inadvertently broken inside the joint. These blades should be inserted through cannula
sheaths or encased within a retractable sheath mechanism so that the cutting portion of the blade is not
exposed as it enters through the entry portal, but only when it enters the field of arthroscopic vision.
Motorized Shaving Systems

The motorized shaving systems are all basically of similar design, consisting of an outer, hollow sheath
and an inner, hollow rotating cannula with corresponding windows ( Fig. 47-9 ). The window of the inner
sheath functions as a two-edged, cylindrical blade that spins within the outer hollow tube. Suction through
the cylinder brings the fragments of soft tissue into the window and, as the blade rotates, the fragments
are amputated, sucked to the outside, and collected in a suction trap. Numerous cutting tips have been
developed for specific situations and functions. The diameter of the cutting tip usually is 3 to 5.5 mm, and

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many of the tips have variable sizes to allow access to smaller or tighter joints. Special blades have been
designed for meniscal cutting or trimming, for synovial resection, and for shaving of articular cartilage.
Special burrs and abraders have been designed for arthroscopic acromioplasty and anterior cruciate
ligament reconstructions. Most systems use a foot pedal to control the motor and allow both clockwise or
counterclockwise rotation. Some systems have hand controls and automatically alternate directions.
Reversing the rotation of the cutting blade intermittently often improves cutting efficiency and minimizes
clogging with debris. Motorized shavers have been developed for small joints with a 2-mm shaver and
burr. Most systems have both reusable blades and disposable blades. Cannulas should be used for passage
of these instruments into the joint to minimize damage to the articular cartilage surfaces and intervening
soft tissues.

Figure 47-7 Arthroscopic grasping forceps.

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Figure 47-8 A variety of disposable or arthroscopic knives are available. End-cutting, side-cutting, and retrocutting designs, as
well as “banana blades,” help ensure the best cutting angle.

When using motorized shavers, care must be taken to prevent “oversucking.” This occurs when the
outflow through the shaver exceeds the inflow of the irrigating solution, and turbulence from the suction
creates bubbles in the joint. To prevent this, the intensity of the suction may be decreased, the rate of
inflow may be increased, or the window of the cutting instrument may be closed to allow the inflow to
again distend the joint. When cutting is resumed, keeping the window filled with the tissue being shaved
minimizes the likelihood of oversucking.

While using the motorized shaver, the outflow from the arthroscope should be closed, not only to
minimize the chance of oversucking but also to prevent inadvertent suction of potentially contaminated
irrigating fluids back through the joint. Finally, the cutting tip should always be within the visual field,
and the position of the window should be located before the rotary motion of the blade is activated.
Electrosurgical and Laser Instruments

Electrocautery has been used as an arthroscopic tool for cutting and hemostasis. Early reports suggested
that electrosurgical knives used for meniscectomy resulted in less postoperative pain and effusion than
standard mechanical techniques. Later investigators found electrocautery to be quite slow for
meniscectomy and in some cases to result in significant injury to the remaining meniscal tissue. Today
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electrocautery is used primarily for obtaining hemostasis after arthroscopic synovectomy and subacromial
decompression. It also has been used for both cutting and hemostasis in lateral retinacular release for
malalignment of the patella.

Figure 47-9 Motorized handpieces come in large joint and small joint sizes. Each handpiece is available with a variety of
disposable blades and burrs that vary in size, cutting angle, and aggressiveness.

Early systems required a nonelectrolytic solution, which necessitated evacuating the knee of saline or
lactated Ringer solution. The joint could then be distended with either distilled water, a carbon dioxide
gas medium, or glycine. Newer, coated tips have been developed that function in both normal saline and
lactated Ringer solution.

Laser instrumentation is in an early stage of development, and investigators are attempting to determine
its usefulness in arthroscopic procedures. Current systems include the CO2 laser system, the YAG laser,
and the excimer laser. The CO2 laser requires a CO2 medium in the joint. The holmium Nd:YAG laser and
excimer laser can function in a fluid environment such as saline. The excimer laser is a pulsed laser that
emits high-energy light in the ultraviolet range. Its cutting is extremely precise with minimal thermal
damage to surrounding tissues. These more recent devices cut more precisely and deliver higher energy,
but their expense is still a disadvantage.

Although the laser may not replace the current motorized instruments for meniscectomy, investigation
continues into its use in the treatment of articular cartilage lesions. Some early work suggests that low-
power stimulation may promote cellular activity and proliferation, but long-term clinical trials are not yet
available. Recent evidence suggests that laser use may cause osseous damage, thus propagating further
damage to the joint. The Arthroscopy Association of North America recognizes lasers as an alternative to
mechanical arthroscopic techniques but notes the lack of proven advantages of laser technique over other
techniques, even though cost effectiveness may be a consideration.
Miscellaneous Equipment

A variety of sheaths and trocars are required for arthroscopic surgery, and they must accommodate the
arthroscope and accessory equipment being used. When possible, sharp instruments should be placed
through sheaths to protect the soft tissues of the skin portals. The motorized instruments can be used with
or without a sheath. The initial perforation through the capsular and synovial tissue may be made with a
no. 11 blade and blunt trocar or with a sharp trocar carefully passed through the appropriate instrument
sheath. Some systems allow cannulas to be interchanged for inflow, arthroscope, and motorized shaver
systems. Disposable plastic cannulas with sealed ends reduce fluid extravasation.

As arthroscopic surgery procedures have advanced to more joints, additional instruments have been
developed. “Switching sticks” are simple rods placed through the cannula to maintain the portal while the
cannula is exchanged for a larger or smaller one. The Wisinger rod was designed to assist in establishing
a portal on the opposite side of a joint from a previously established portal. Traction devices have been
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developed for use in shoulder and elbow arthroscopy, and Guhl has designed a distraction device to apply
traction to the ankle for better exposure ( see Chapter 48 ). There also has been an explosion of
procedure-specific instruments, many of which are described in the pertinent operative sections in
Chapters 48 and 49 .

CARE AND STERILIZATION OF INSTRUMENTS

Because most fiberoptic arthroscopes and cables will not tolerate steam autoclaving, the best method of
sterilizing them is by gas (ethylene oxide) or by a low-temperature sterilization process (Steris), which,
like gas sterilization, is both sporicidal and bactericidal. Gas sterilization takes hours, whereas the Steris
process is completed in 30 minutes, allowing resterilization of fragile equipment during a busy operative
day. Currently, most arthroscopists use activated glutaraldehyde (Cidex) for cold disinfection (i.e.,
nonsporicidal) of equipment between successive procedures during the course of a day. Experience with
thousands of diagnostic and operative arthroscopic procedures has proved that this is effective and safe.
Instruments such as knives, graspers, basket forceps, and cannulas should be sterilized by steam
autoclaving after each procedure, but light cables, motorized instruments, fiberoptic scopes, and cameras
should be soaked for 10 minutes in a glutaraldehyde solution or placed in Steris for 30 minutes after each
procedure.

IRRIGATION SYSTEMS

Irrigation and distention of the joint are essential to all arthroscopic procedures. Joint distention is
maintained by normal saline or lactated Ringer solution during arthroscopy. The inflow may pass directly
through the arthroscopic sheath or through a separate portal by means of a cannula. For adequate flow, a
6.0- or 6.2-mm sheath should be used with the scope. We routinely use lactated Ringer solution because it
is physiological and results in minimal synovial and articular surface changes. Some intraarticular
electrocautery systems require the use of a nonelectrolytic solution. In these circumstances the knee must
be evacuated of either saline or lactated Ringer and distended with glycine. Newer systems function in
saline or lactated Ringer and do not require changing of the medium.

We prefer continuous irrigation by means of an arthroscopic pump through a cannula inserted in the
suprapatellar bursa or through a 6.2-mm arthroscopic sheath ( Fig. 47-10 ). Continuous irrigation keeps
the fluid clear for optimal viewing, and the ingress of fluids must accommodate the egress to maintain
hydrostatic pressure and distention within the joint. With many systems, the inflow and outflow may be
changed alternately to improve viewing and distention.

Usually, two 5 L plastic bags of lactated Ringer solution, interconnected with a Y-connector, are
suspended for use with the arthroscopic pump. Once the inflow and outflow cannulas are established, the
joint is lavaged until the fluid is clear. When a pump is not used, joint distention is increased by elevating
the fluid bag, using a large-diameter tubing, or decreasing the size and number of outflow portals. For
each foot of elevation of the solution bag above the level of the joint, 22 mm Hg of pressure is produced.
Usually the bag is placed 3 to 4 feet above the level of the joint, thus producing approximately 66 to 88
mm Hg of pressure. Arthroscopic pumps should be used carefully, and the tightness of muscle
compartments and soft tissue spaces, such as the popliteal fossa, should be monitored closely. Pump
pressures should be varied according to the joint being treated and the type of pump being used. When
using a pressure inflow system, generally joint distention pressures in the knee should be 60 to 80 mm
Hg. Vision and hemostasis in the shoulder usually are best when the distension pressure is maintained
approximately 30 mm Hg below the systolic blood pressure. In healthy patients hypotensive anesthesia
may be used to reduce systolic pressure to approximately 100 mm Hg, at which level pump pressure of 70
to 80 mm Hg usually provides safe distention and clear vision. Olszewski et al., in a prospective, double-
blinded, randomized study, found that the addition of epinephrine 1 mg/L saline significantly increased
visibility and reduced the need for tourniquet inflation by 50% compared with the placebo group of
patients who had not received epinephrine. Because of the increased likelihood of extravasation,
distention pressures in the elbow and ankle should be maintained at approximately 40 to 60 mm Hg. The
surgeon should be aware of individual variations of different pump flow and sensor mechanisms. The
sensor mechanisms must be appropriately calibrated and positioned to provide proper distention in the
compartment to be examined.
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Figure 47-10 Arthroscopic pump allows more constant fluid flow and joint distention pressure. Inflow may be through
arthroscope sheath or separate inflow sheath.

As mentioned previously, a constant outflow site (e.g., through the arthroscope or some other site) should
be closed when suctioning or using motorized instruments with suction to prevent the introduction of
potentially contaminated fluid into the joint.

Proper positioning of the inflow cannula within the joint is essential. A subsynovial location allows large
amounts of the irrigating solution to be injected extrasynovially, which may obliterate the viewing area of
the joint. Moving the cannula about freely in the joint or directly viewing its location with the arthroscope
ensures that its tip is properly positioned.

Distention is essential for arthroscopic viewing of any joint. Proper distention pushes folds of synovium
and other soft tissues out of the way in the viewing area and expands the internal capacity of the joint,
allowing greater maneuverability of the arthroscope. It also may be important in defining proper portal
entry points into many joints. Distention is especially crucial in making posteromedial and posterolateral
entries into the knee for comprehensive examination of these joint compartments.

TOURNIQUET

During arthroscopic procedures of the knee, ankle, elbow, and other distal joints, a tourniquet is always
applied and is inflated as needed. Injection of a local anesthetic agent with epinephrine at the portal sites,
adequate intraarticular hydrostatic pressure, and epinephrine 1 mg/L saline often minimizes intraarticular
bleeding. In healthy patients hypotensive anesthesia can be helpful in reducing bleeding; a 30 mm Hg
gradient should be maintained between pump pressure and systolic blood pressure. Many arthroscopists
now perform major operative procedures on the knee without inflating the tourniquet. Contraindications
to the use of a tourniquet include a history of thrombophlebitis and significant peripheral vascular disease.
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Advantages of tourniquet use are increased visibility, with no significantly increased postoperative
morbidity with tourniquet times of less than 90 to 120 minutes. The disadvantages of routine tourniquet
use include blanching of the synovium, which makes differentiation and diagnosis of various synovial
disorders difficult, and the possibility of ischemic damage to muscle and nervous tissue with prolonged
tourniquet time of more than 90 to 120 minutes. Many of the commercial leg holders used in knee
arthroscopy require the tourniquet to be placed within it. These holders may function quite satisfactorily
whether or not the tourniquet is inflated.

LEG HOLDERS

The biggest advantage of a leg holder is that it permits application of stress primarily to open the
posteromedial compartment for better viewing, manipulation of the meniscus, and posterior horn
meniscal surgery, especially in tight knees ( Fig. 47-11 ). A surgical assistant may provide similar stresses
but is subject to such factors as inconsistency and fatigue. Significant valgus stress applied to the knee
firmly gripped in a leg holder may allow significant distraction of the medial compartment to easily
permit most operative procedures within this compartment. A leg holder has disadvantages, especially for
operations in the lateral compartment or in the patellofemoral joint. It obstructs the placement of the
arthroscope and other instruments in the superomedial and superolateral portals and makes it more
difficult to flex the joint without dropping the end of the table or placing the leg in the figure-four position
for work in the lateral compartment. Because the thigh is firmly held by the leg holder, the number of
different positions in which the leg can be placed is somewhat limited. An alternative to using an
encompassing leg holder is to use a lateral post attached to the siderail of the operating table. The lateral
aspect of the distal thigh can be levered against this post for opening of the posteromedial compartment.
The post does not confine or prevent the knee from being positioned in an almost unlimited number of
positions, including flexion or the figure-four position; therefore it has advantages over many of the
expensive commercial leg-holding devices.

Figure 47-11 Commercial leg holder that clamps to side rail of operating table.

Furthermore, the routine use of a leg holder, especially one that incorporates a tourniquet within the
confines of the holder, may present other difficulties. In such an arrangement wide fluctuations in the
tourniquet pressures may occur when stress is applied to the leg; however, we have had no specific
complications related to this. Also, the leg-holding device may fix the distal femur so securely that the
applied stress can result in fractures about the knee or tearing of the ligamentous structures; such
occurrences have been reported.

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Thus, if the clinical evaluation suggests medial compartment meniscal pathology, a leg holder can be of
significant assistance. On the other hand, if a patellofemoral joint or a lateral compartment problem is
anticipated, a valgus stress post may be chosen to make viewing of these compartments easier. For
endoscopic repair of the anterior cruciate ligament, a lateral post should be used or the end of the table
should be flexed to allow full, unobstructed knee flexion.

Anesthesia

Diagnostic arthroscopy can be performed with the patient under local, regional, or general anesthesia.
Some intraarticular operative procedures can be performed using regional and local anesthetics.

Local anesthesia can be used for many arthroscopic procedures about the knee and ankle in a cooperative
patient. Yoshiya et al. reported good results with the use of local anesthesia during 201 arthroscopic
surgeries of the knee, including diagnostic arthroscopy, meniscectomy, lateral retinacular release,
chondroplasty, loose body removal, and excision of synovial plica. The local anesthetic was
supplemented with diazepam or pentazocine as needed for sedation and pain relief.

Regional anesthesia also can be used in certain circumstances. Epidural and spinal anesthesias have been
used successfully for arthroscopic procedures in the lower extremity; however, with prolonged tourniquet
use patients may experience “tourniquet pain.” Some of our patients also have had problems with spinal
headaches after spinal anesthesia when they were mobilized quickly. Skyhar et al. reported successful use
of interscalene blocks for shoulder arthroscopy, and Galinat et al. reported 100 shoulder arthroscopies
performed with interscalene blocks; procedures included debridement, subacromial decompression, and
shoulder stabilization. There were no complications, although nine patients required general anesthesia
because of incomplete blocks.

General anesthesia is used or indicated more often in an acutely injured knee, when pain is an important
factor, when significant intraarticular surgery is anticipated, or when the patient is notcooperative or is
especially apprehensive. Allergy to local anesthetics, of course, requires that a general anesthetic be
administered. Arthroscopic surgeons who are less experienced and who are unfamiliar with all the
techniques probably are best advised to select a general anesthetic. If the need for a tourniquet to control
bleeding is anticipated, as in partial or complete synovectomies or excision of adhesions, general
anesthesia is recommended. Most arthroscopic procedures performed at this clinic are done with general
anesthesia.

If a local anesthetic is chosen, the tourniquet is not inflated. Yoshiya et al. reported the use of a 1:1
mixture of 1% lidocaine and 0.25% bupivacaine. Usually, 50 ml of the mixture was injected
intraarticularly before the procedure. When a long procedure was expected, a small amount of
epinephrine was added to the mixture to help maintain hemostasis and to increase the duration of action
of the anesthetic agents. These authors recommend care with the use of bupivacaine so as not to exceed
its maximum dosage (2 ml/kg of body weight). At each anticipated portal an additional 5 ml of this
mixture was injected. There was only one report of nausea and no other reports of toxic reactions or
central nervous system or cardiovascular complications.

Postoperative pain may be diminished by the use of oral nonsteroidal antiinflammatory medication
preoperatively and postoperatively or by intramuscular or intravenous administration intraoperatively.
The use of nonsteroidal antiinflammatory medication also has been shown to reduce swelling and
increase range of motion in the early postoperative period. The use of oral corticosteroids has not proved
effective. Beneficial analgesic effects have been documented for 30 ml of 0.25% bupivacaine with
epinephrine, with or without the addition of 3 mg of morphine. Use of a continuous flow subacromial or
intraarticular pain pump has been shown to give excellent postoperative pain relief for arthroscopic
shoulder procedures. Less benefit has been evident with knee cases. These catheters should be
meticulously cared for and should be removed in 48 hours.

13
Documentation

Carefully constructed drawings can be made to depict the pathology and the operative procedure
performed. These are perhaps the most practical and can be attached to the patient's record for easy
reference.

A 35-mm reflex camera can be used to photograph the inside of the joint and to document the pathology
and operative procedure. Video recordings can be made of the actual pathology and the surgical
procedure as it is performed. The videotapes serve as excellent teaching guides for patients, students,
residents in training, and practitioners wishing to learn arthroscopic techniques ( Fig. 47-12 ).

Video printers that allow the production of color prints without interruption in the arthroscopic procedure
are the best method for recording important information that may become part of the patient's permanent
record. The image is produced by a computer from the video system using a thermal transfer technique.

Digitalized first-generation pictures may be taken, catalogued, and stored on compact disks for later
retrieval and slide production.

Any 35-mm reflex camera with a lens adapter between the camera and the arthroscope can produce clear
pictures of intraarticular findings. A focal length of 100 mm usually will provide the best overall image
size and clarity. The normal ground-glass viewing screen is removed from the camera and replaced with a
clear-glass focusing screen. To make high-quality 35-mm slides, a high-intensity light source should be
available. Film with higher ASA numbers offers the advantage of requiring less light but has the
disadvantage of producing a grainier picture. The surgeon interested in documenting arthroscopic findings
with 35-mm slides should use his own light source and experiment with avariety of films with various
ASA numbers and different camera settings.

Figure 47-12 Documentation of findings using videotape.

The use of a camera intraoperatively often is time consuming and introduces the possibility for a break in
sterile technique. To minimize this, the camera may be attached to a separate arthroscope and placed on a
sterile table. It can then intermittently be brought to the operative table for use after the surgeon has
donned an additional pair of sterile gloves. Alternatively, cameras can be gas autoclaved, but this allows
the camera to be used in only one case each day. The camera also may be placed in a sterile plastic sheath
and attached to an arthroscope. This eliminates the need for an additional pair of gloves, but the
possibility for contamination still exists. Even though 35-mm cameras produce excellent still shots,
14
capturing arthroscopic procedures or inserting another instrument into the joint at the time of photography
often is difficult.

Although recording intraarticular findings and intraoperative procedures on videotape can produce
dynamic views of the structures within the joint, editing and storing tapes can be quite expensive and time
consuming. The current solid-state cameras produce good video prints and videotape recordings.

Advantages

The advantages of arthroscopic procedures far outweigh the disadvantages. Among the advantages when
compared with arthrotomy are the following:

Reduced postoperative morbidity. The patient can return to sedentary work almost immediately
and to more vigorous work activities within 1 to 2 weeks after most arthroscopic procedures.

Smaller incisions. Diagnostic arthroscopic and operative procedures can be carried out through
multiple small incisions about the joint, which are less likely to produce disfiguring scars.

Less intense inflammatory response. The small incisions through the capsule and synovium result
in a much less intense inflammatory response than does the standard arthrotomy. This results in
less postoperative pain, faster rehabilitation, and faster return to work.

Improved thoroughness of diagnosis. Most investigators report that diagnoses based purely on
clinical grounds are incomplete in a significant percentage of patients. Curran and Woodward
reported in 1980 that their total clinical accuracy rate was only 71%, but this increased to 97%
when diagnostic arthroscopy was added.

Absence of secondary effects. The secondary effects of arthrotomy about the joints, such as
neuroma formation, painful disfiguring scars, and potential functional imbalance (e.g., of the
extensor mechanism of the knee), are eliminated by arthroscopic techniques.

Reduced hospital cost. Most arthroscopic procedures can be performed on an outpatient basis. If
hospitalization is required, a 1- or 2-day stay is generally the maximum compared with several
days required for arthrotomy procedures.

Reduced complication rate. Only infrequent complications of arthroscopic procedures have been
reported.

Improved follow-up evaluation. The minimal morbidity associated with arthroscopy allows the
effects of a previous operative procedure such as meniscal repair to be reevaluated if persistent
symptoms warrant further evaluation. These are often referred to as “relook” or “second-look”
procedures.

Possibility of performing surgical procedures that are difficult or impossible to perform through
open arthrotomy. A number of surgical procedures are more easily performed with arthroscopic
techniques than through open arthrotomy incisions. For example, partial meniscectomy usually is
possible using arthroscopic techniques, whereas trimming and contouring of the inner posterior
edge of a meniscus by open means is extremely difficult. In addition, many repairable menisci are
accessible only with arthroscopic techniques and cannot be satisfactorily viewed through
arthrotomy.

Disadvantages

The disadvantages of arthroscopy are few, but they may be significant to the individual arthroscopic
surgeon. Not every surgeon has the temperament to perform arthroscopic surgery because it requires
working through small portals with delicate and fragile instruments. The need to maneuver the
instruments within the tight confines of the intraarticular space may produce significant scuffing and
15
scoring of the articular surfaces, especially by an inexperienced surgeon. The procedures can be
extremely time consuming early in one's experience with arthroscopy. Also, the specialized equipment
required is extensive and expensive.

Although these disadvantages can be quite significant, the advantages to the patients generally far
outweigh them.

Indications and Contraindications

Although the original indication for arthroscopy was the so-called problem case, it is now obvious that
arthroscopy is useful for a large variety of joint problems, including trauma and other disorders. No
absolute indications for arthroscopic procedures can be given. Diagnostic arthroscopy is indicated for
preoperative evaluation and confirmation of the clinical diagnosis before an arthroscopic or open surgical
procedure. It also may be indicated for the documentation of specific lesions when medicolegal issues,
worker's compensation insurance, or other secondary gains may be a factor. Arthroscopy provides an
important method of evaluating and studying the pathophysiology of certain diseases.

The contraindications are few. Arthroscopy should not be used in a minimally deranged joint that will
respond to the usual conservative methods of treatment. Furthermore, the surgeon should not consider
arthroscopy before a careful history, thorough physical examination, and standard noninvasive diagnostic
procedures have been performed. Arthroscopy is contraindicated when the risk of joint sepsis from a local
skin condition is present or when a remote infection may be seeded in the operative site. Partial or
complete ankylosis about the joint is a relative contraindication, although the use of arthroscopy for lysis
of adhesions about the knee, shoulder, elbow, and ankle has been reported. Major collateral ligamentous
and capsular disruptions of the joint that will permit excessive extravasation of fluids into the soft tissues
are relative contraindications to arthroscopy. In this situation, the capsule should be allowed to “stick
down” or should be repaired primarily before any arthroscopic procedure.

Basic Arthroscopic Techniques

Proficiency in arthroscopic techniques requires a great deal of patience and persistence. The techniques
are mostly self-taught and require mastering a surgical skill different from other orthopaedic surgical
techniques. The instruments are small and delicate and must be maneuvered in tight, confined spaces.
Everything is magnified, and, because the arthroscope is monocular and two dimensional, depth
perception is a matter of experience rather than observation.

Although artificial models and amputation specimens may be used initially for practice, rarely is the
realism sufficient and the specimens plentiful enough for the surgeon to develop proficiency. A better
method is to perform arthroscopic procedures and practice triangulation principles in the company of an
experienced arthroscopist.

Many surgical procedures, such as anterior cruciate ligament reconstruction or acromioplasty, can be
performed using both arthroscopic and open techniques. Opening the joint allows evaluation of the
arthroscopic portion of the procedure. As experience is gained, more and more of the procedure can be
done arthroscopically.

Patients' expectations from the use of arthroscopic techniques have placed tremendous demands on
practicing orthopaedic surgeons. A surgeon should not be persuaded by these pressures to perform a
difficult arthroscopic procedure for which he has yet to develop sufficient skills. If an arthroscopic
procedure is not progressing as expected, it may be wise to abort the procedure and return to an open
method that has given good results in the past. As arthroscopic procedures become better defined and
results continue to improve, the number of arthroscopic procedures is increasing steadily. There is a steep
learning curve to successfully completing complicated procedures, such as shoulder stabilization or
rotator cuff repair. The practicing surgeon should keep up with the literature, attend work shops, and is
16
encouraged to observe these procedures being performed by highly skilled arthroscopists. Orthopaedic
surgeons should perform procedures concurrent to their levels of skill and keep in mind that a skillfully
performed procedure through an open arthrotomy is preferable to a poorly performed arthroscopic
procedure.

TRIANGULATION TECHNIQUE

Triangulation involves the use of one or more instruments inserted through separate portals and brought
into the optical field of the arthroscope, the tip of the instrument and the arthroscope forming the apex of
a triangle. The principle of triangulation is the basis for operative arthroscopy. Triangulation separates the
arthroscope from the operating instrument, allowing the viewing arthroscope to be enlarged and
increasing the field of view. The angle of inclination can be varied to allow improved visual access to
more areas of the joint. Separating the instruments from the arthroscope improves depth perception and,
perhaps the most significant advantage, permits independent movement of the arthroscope and the
surgical instrument, which is essential for operative arthroscopy.

The only disadvantage of triangulation is the necessity of mastering the psychomotor skills to bring two
or more objects together in a confined space while using monocular vision (which eliminates the
convergence that provides depth perception with binocular vision). Diagnostic proficiency in simple
triangulation with a probe is the critical skill, and, once this is mastered, additional skills may be
developed. Triangulation of more than one instrument into the optical field of the arthroscope is
occasionally required. If available, a straight-ahead lens (0 degree) arthroscope makes the learning of
triangulation techniques easier. The more angled the fore-lens of the arthroscope, the more difficult the
orientation and triangulation procedures.

Thorough recognition of the intraarticular anatomy (e.g., recognizing the intercondylar notch and the
anterior cruciate ligament or dividing the menisci into thirds and directing the instruments toward that
known structure) increases triangulation skills. To begin triangulation, the arthroscope should be at a
distance from the area to be probed to give a wide field of vision. When the instrument is located, the
scope and the instrument are advanced together toward the intended area, reducing the field of vision
while increasing the magnification. A mistake commonly made by beginning arthroscopists is placing the
scope too close to objects, thus losing the larger field of vision necessary to maintain constant visual
orientation.

If the surgeon becomes disoriented and has difficulty in triangulation, he may bring the accessory
instrument into the joint to contact the sheath of the arthroscope. By sliding the instrument down the
sheath to the arthroscope tip, he may bring the instrument into the field of vision. With practice, a surgeon
develops a stereoscopic sense that allows him to place the instrument into the field of view immediately.

After this stereoscopic sense develops, the surgeon begins to master the ability to change from one portal
to another with both arthroscope and instruments and to locate optimum accessory portals.

Complications

Complications during or after arthroscopy are infrequent and fortunately are usually minor. Most are
preventable with good preoperative and intraoperative planning and attention to the details of basic
techniques. Familiarity with local anatomy and gaining familiarity with new techniques through learning
centers, operating with colleagues, videos, and staying current with specialty journals allow the surgeon
to gain valuable information from the experiences of other colleagues. Before operative procedures,
having all office notes and roentgenograms available is similarly beneficial. Also, before entering the
operating room, reviewing the surgical procedure with the patient and having the patient write the word
“wrong” on the nonoperative extremity can alleviate possible confusion on a long operative day. In 1986
Small reported a retrospective survey of 395,566 arthroscopies with an overall complication rate of
0.56%. At that time the highest complication rates occurred in the newer procedures, such as meniscal
repair (2.4%), anterior cruciate ligament procedures (1.8%), and anterior staple capsulorrhaphy of the
shoulder (5.3%). A later and more accurate prospective study by Small in 1988 found a complication rate
17
of 1.68% in 10,262 procedures. The most common complications in this study were hemarthrosis
(60.1%), infection (12.1%), thromboembolic disease (6.9%), anesthetic complications (6.4%), instrument
failure (2.9%), reflex sympathetic dystrophy (2.3%), ligament injury (1.2%), and fracture or neurological
injury (0.6% each).

DAMAGE TO INTRAARTICULAR STRUCTURES

Damage to intraarticular structures probably is the most common complication. Scuffing of the articular
cartilage surfaces by the tip of the arthroscope or the operating instrument occurs most often when the
arthroscopist is inexperienced, when the joint is tight, or when the procedure is long and particularly
difficult. Forcing the arthroscope or other instruments between articular surfaces, such as the femoral and
tibial condyles or the humeral head and glenoid cavity, may severely score their surfaces and lead to
progressive chondromalacic changes and degenerative arthritis. The joint should be opened with leverage
or traction first and the arthroscope allowed to slide into the space created. Using a leg holder or a
leverage post during knee surgery, as well as traction or distraction devices during shoulder, hip, and
ankle procedures, is helpful. Once the arthroscope has been inserted between the articular surfaces,
distraction should be maintained. If distraction is released and the scope is then retracted, the articular
cartilage will be severely scored. Finally, a poorly placed portal frequently makes instrument passage and
maneuvering more difficult. It is better to change the portal site or make an accessory portal than to scuff
the articular surface by forcing the instrument.

DAMAGE TO MENISCI AND FAT PAD

The anterior horn of either meniscus may be damaged by incision or penetration if the anterior knee
portals are located too inferiorly ( Fig. 47-13 ). If the portals are too close to the patellar tendon, they may
traverse the fat pad. Repeated penetration of the fat pad causes swelling of the pad and obstruction of
view and may also result in hemorrhage, hypertrophy, or fibrosis of that structure.

Figure 47-13 Ideal placement of cannula. If positioned too high, angle of obliquity is such that posterior horn cannot be seen;
if too low, cannula can go through meniscus and limit view or mobility. Ideal placement is directly in slot between femur and
tibia. (From Johnson LL: Diagnostic and surgical arthroscopy, St Louis, 1981, Mosby.)

DAMAGE TO CRUCIATE LIGAMENTS

Either cruciate ligament may be damaged during meniscal excision when an intercondylar attachment is
cut. With ligament reconstructions, the intact cruciate is susceptible to injury when motorized instruments
are debriding the intercondylar notch.

18
DAMAGE TO EXTRAARTICULAR STRUCTURES

Blood Vessels

Damage to the blood vessels about the joint may be the most serious and devastating arthroscopic
complication. Vascular injury most often occurs from direct penetration or laceration but may occur from
pressure caused by excessive fluid extravasation. Small's 1986 report included 12 vascular injuries, all in
knee surgery; no vascular complications were reported in his 1988 study. The popliteal artery is at risk
during meniscectomy when intercondylar attachments are cut, especially when using the arthroscopic
meniscotome or other arthroscopic knives. Both the popliteal artery and vein have been damaged during
meniscal repairs as the sutures are placed posteriorly. Most surgeons now recommend a posteromedial or
posterolateral incision, with exposure of the capsule and placement of a suitable retractor to protect the
popliteal vessels. The vessels also are vulnerable if there is uncontrolled penetration during establishment
of the posteromedial or posterolateral knee portals. Extensive arthroscopic synovectomies have been
associated with injury to the genicular arteries, with subsequent arteriovenous fistula or pseudoaneurysm
formation.

The anterior tibial artery is at risk during anterior approaches for ankle arthroscopy, especially with the
anterocentral approach. Likewise, posteromedial portals are not recommended because of the proximity
of the posterior artery. During elbow arthroscopy, the brachial artery may be damaged during
establishment of either the anteromedial or anterolateral portal. Fluid extravasation also may compress
this vessel in the antecubital fossa. In shoulder arthroscopy the axillary artery may be injured by an
arthroscopic instrument plunging through the axillary pouch. More often, axillary vessel occlusion is
caused by fluid extravasation or excessive arm traction.

Major superficial veins may be lacerated when portal selection is improper. In the knee the saphenous
vein may be penetrated by poor posteromedial portal location; in the shoulder the cephalic vein may be
penetrated by poor anterior portal site selection.
Nerves

Nerve injuries may be caused by direct trauma from a scalpel or sharp trocar, by traction from
overdistraction, by mechanical compression or compression from fluid extravasation, by prolonged
ischemia from excessive tourniquet use, or by a poorly defined mechanism of injury to the anatomical
nervous system that results in reflex sympathetic dystrophy. Many of these complications can be avoided
by marking portals appropriately, making sure the scalpel penetrates the skin only, using a hemostat to
spread down to the joint capsule when in close proximity to a nerve, and routinely using blunt trocars.
Maintaining proper joint distention and distraction, padding nerve and bony prominences, and proper
patient positioning also greatly reduce the chances of nerve complications. Familiarity with techniques
and anatomy allows proper portal placement and improves surgical technique, thus minimizing tourniquet
time.

Sensory and motor nerves near the joint also may be damaged. The inferior branches of the saphenous
nerve or sartorial branches of the femoral nerve are the most commonly injured cutaneous nerves. The
location of each of these numerous cutaneous branches varies, and therefore occasional injury to one may
be unavoidable, especially if multiple portals are used. In most instances the hypesthesia produced is of
minor consequence and causes no problem. Occasionally a painful neuroma may require subsequent
resection. In Small's report, 229 nerve injuries were reported during knee arthroscopies. Thirty saphenous
nerve injuries and six peroneal nerve injuries were reported in 3034 meniscal repairs. Increased
experience with meniscal repairs, as well as improved techniques (especially posteromedial or
posterolateral exposures) dramatically lowered the incidence of nerve injury to one saphenous nerve
injury in 310 meniscal repairs in Small's second series.

During shoulder arthroscopy the branches of the axillary nerve that course along the deep surface of the
deltoid may be injured if either anterior or posterior portal sites are too far inferior. Traction neurapraxia
of the brachial plexus may occur when strong traction and distraction of the shoulder have been used. In

19
1986 Small reported one axillary nerve injury and three brachial plexus injuries in 14,329 shoulder
arthroscopies. In 1988 there were no nerve injuries in 1184 shoulder procedures.

Arthroscopy of the smaller joints, elbow, and ankle, requires even greater attention to detail and general
principles than the more familiar knee arthroscopy. A thorough understanding of local anatomy and
precise marking of tendons and neurovascular structures are essential. Exact portal placement and proper
distention before blunt entry into the joint decrease nerve vulnerability. Careful use of less aggressive
motorized shavers is important when working in close proximity to neurovascular structures.
Ligaments and Tendons

The tibial collateral ligament may be injured by accessory medial portals about the knee, or it may be torn
by severe valgus stress in an attempt to open up the medial compartment This is a real possibility if a
rigid leg holder is used and a strong valgus stress is applied. Small reported 160 knee ligament injuries in
1986, 143 of which involved a leg holder. Three femoral fractures were reported, but surprisingly none
involved the use of a leg-holding device. By 1988 the frequency of this complication had decreased
dramatically.

Superior portals through the lateral parts of the rotator cuff during shoulder arthroscopy should be
avoided. These portals pass through the tendinous portions of the rotator cuff and may result in significant
fraying and rupture of the supraspinatus or infraspinatus tendons, or they may produce sufficient scarring
to result in significant impingement and subacromial problems. During ankle arthroscopy, the tibialis
anterior, peroneal, and extensor digitorum longus tendons should be avoided. Finally, the patellar tendon
may be injured by rough and repeated passages of the arthroscope or instruments through the Gilquist or
transpatellar tendon portal. If this technique is used, the incision in the tendon should be made vertically
to minimize trauma to the tendon.

Extravasation of irrigating solutions into the soft tissues about the joint is common; it rarely causes any
serious problems, but the potential for serious complications should be recognized. As already mentioned,
this is especially common about the shoulder, where the portals traverse much more tissue and often pass
through a connecting bursa. Excessive extravasation may put significant pressures on the neurovascular
elements within the axilla, which may result in vascular compromise within the extremity or a significant
neurapraxia. Noyes and Spievack showed that significant extravasation of fluids is possible during
arthroscopy of the knee. They found that rupture of the suprapatellar pouch is not infrequent and that
localization of the fluids about the superficial femoral artery can easily dissect all the way to the femoral
triangle. They also noted that a rupture of a semimembranosus bursa with extravasation was not
uncommon; this resulted in dissection of fluids into the soft tissues and compartments of the calf. They
pointed out that the extravasation of fluids in knee arthroscopy may very well be subtle and significant in
prolonged arthroscopic procedures. They recommended that tense distention of the knee be avoided if a
flexed position is required and great caution be taken if a pressure inflow system is used.

HEMARTHROSIS

Hemarthrosis is the most common postoperative complication, most frequently following lateral
retinacular releases and synovectomies. The superior lateral geniculate vessels usually are cut in lateral
retinacular releases, and the inferior lateral geniculate vessels may be lacerated just anterior to the
popliteal hiatus during lateral meniscectomy and synovectomy. Small in 1988 reported the incidence of
hemarthrosis as just over 1%. The incidence increased to 4.6% during lateral retinacular releases.
Persistent unexplained hemarthrosis is an indication for appropriate vascular studies and hematological
clotting studies to help determine appropriate treatment.

THROMBOPHLEBITIS

Thrombophlebitis is potentially the most dangerous postoperative complication; fortunately, it is not

common following routine arthroscopic procedures. The incidence was 0.17% in Small's 1986 evaluation
of reported complications and 0.13% in 1988 in all arthroscopic procedures in the lower extremities.
Stringer et al. reported deep venous thrombosis in 4.2% of 48 patients evaluated with venography after
20
knee arthroscopy; none had pulmonary emboli. In a 1998 report, Schippinger et al., using ultrasound,
phlebography, and lung scans preoperatively and 5 weeks postoperatively in 101 patients, revealed 8
cases of deep vein thrombosis, 4 of which were silent and 4 which were symptomatic. Nine emboli were
detected, of which 8 were silent. All patients had been given 5000 IU low molecular weight heparin 12
hours before surgery. The authors found a tendency toward development of deep vein thrombosis when
several preoperative risk factors were present. There was no correlation with surgical time, tourniquet use,
or anesthetic. Demers et al. studied 184 patients using sonography 1 week after arthroscopy; no
prophylaxis was given. Thirty-three patients (17.9%) were diagnosed with deep vein thrombosis, 20 were
symptomatic, and most were proximal or extensive. Deep vein thrombosis significantly increased with
tourniquet time more than 60 minutes. Some reports suggest that the use of a tourniquet reduces the
incidence of thrombophlebitis, whereas others suggest thatthe incidence is increased by the use of a
tourniquet and a leg holder. Poulsen et al. associated an increased risk of deep venous thrombosis with
tourniquet time exceeding 60 minutes, age over 50 years, and a previous history of deep venous
thrombosis. Minimizing operative and tourniquet times, avoiding postoperative immobilization, and using
thromboprophylaxis may be beneficial in patients at risk for thromboembolic complications.

INFECTION

Despite the early fears of infection, the actual number of reported infections has remained extremely low.
Numerous investigators have reported large series, all with infection rates of less than 0.2%. This low
incidence is undoubtedly the result of several factors, including limited incisions, young and healthy
patients, short operating time, and irrigation and dilutional effects of the irrigating solutions. The use of
prophylactic antibiotics is still controversial. Citing the development of septic arthritis in nine patients
after knee arthroscopy, D'Angelo and Ogilvie-Harris suggested that the use of prophylactic antibiotics
may be cost beneficial, considering the unpredictability of this complication and its serious consequences.
Routine use of postoperative intraarticular steroids has been associated with an increased incidence of
postoperative infection.

AIDS AND ARTHROSCOPY

Surgeons should be aware of the possibility of transmission of HIV and should follow guidelines for safe
surgical procedures recommended by the American Academy of Orthopaedic Surgeons. Use of
waterproof gowns, double gloves, goggles or face shields, and waterproof boots covered by disposable,
waterproof shoe covers should be routine. Care should be taken when using sharps, especially during
arthroscopic meniscal repair, to prevent accidental needle sticks. Hospital guidelines for procedures in
case of needle sticks should be readily available to operating room personnel. It has been proved by
Matava and Horgan that arthroscopic effluent can be HIV positive; two of the six serial aliquots obtained
while arthroscoping an AIDS patient were found to be HIV positive.

TOURNIQUET PARESIS

Temporary paresis in the extremity has been observed after tourniquet use to control bleeding in
diagnostic or operative arthroscopy, usually following prolonged procedures. If a tourniquet is required, it
should be deflated after 90 to 120 minutes. Carefully monitoring the tourniquet pressure and testing the
accuracy of the tourniquet gauges minimize these problems. Fortunately, tourniquet paresis usually is
mild and resolves within a few days.

SYNOVIAL HERNIATION AND FISTULAE

Small globules of fat and synovial tissue may herniate through any of the arthroscopic portals. Usually the
larger the portal, the greater the chance of this complication. A large fluid-filled cystic herniation rarely
may occur. These fat and synovial herniations are usually small, become asymptomatic over several
weeks, and do not require any specific treatment. If a herniation persists and remains symptomatic,
excision of the herniated part with careful closure of the capsule may be required.

Synovial fistulae are rare, but they have occurred following suture reactions or stitch abscesses. Fistulae
more commonly are associated with posteromedial knee and ankle portals. To improve closure, these
21
portals should be sutured routinely rather than closed with adhesive strips. Fistulae usually do not produce
significant intraarticular infections, but the patient should probably receive antibiotics, and the knee
should be immobilized for 7 to 10 days to allow the fistula to close spontaneously. Surgical closure rarely
is required.

INSTRUMENT BREAKAGE

Arthroscopic instruments occasionally may break within the joint. In a survey of over 9000 cases,
Mulhollan reported a 0.03% incidence of broken instruments with 0.01% requiring arthrotomy for
removal of the broken part. Small reported incidences of 0.1% in 1986 and 0.05% in 1988. Basket forceps
may be broken if one attempts to bite too large a fragment of meniscus or other tissue. The rotational pin
holding the biting jaw may break or become dislodged, allowing the jaw to fall free within the joint. A
similar breakage may occur with the scissors. Cutting instruments with disposable blades, especially
knives, not only may break but may become detached from the handle and be dropped free within the
joint. Newer instruments have shear pins within the cutting mechanism that will break before actual
instrument failure.

If an instrument breaks, the surgeon should immediately close the outflow cannula, but the inflow should
be left open to keep the joint distended. Stopping the outflow reduces turbulence, and holding the joint
still helps prevent the fragment from falling out of sight into another part of the joint. If the broken
instrument is in the visual field, total attention to keeping it in view and removing it is essential. Broken
instruments tend to gravitate into the medial or lateral gutters of the knee, to hide beneath the menisci, or
to drop by gravity into the posterior or most dependent part of the joint. If the fragment cannot be located
by thorough examination and probing of the joint, a roentgenogram of the joint should be made. If the
broken piece is located, a suction apparatus or a magnet may be introduced through an accessory portal to
stabilize and remove the small broken fragment, or an additional grasping instrument can be inserted
through a third portal to secure and extract the piece.

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