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Arthroscopy

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Abstract

Arthroscopy is particularly useful in those cases where lameness is associated with little or no clinical or radiographic evidence of pathology. This chapter covers general indications for diagnostic arthroscopy, the surgical team, patient preparation, general arthroscopic procedure, the arthroscopic image, visible intra-articular structures and their appearance, and complications and problems.

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Figures

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15.1 Patient positioned in lateral recumbency for elbow arthroscopy. The medial side of the elbow is clipped and is positioned near the edge of the table to allow rotation and abduction.
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15.2 Multi-arm positioning device used to immobilize the limb and hold it in position. (Courtesy of Dr Fritz)
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15.3 Preparation of a patient for stifle arthroscopy. The dog is covered with an impermeable sheath with a hole for the limb to allow free mobility.
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15.4 Arthroscopy of a left elbow joint. (a) A plastic sheath is attached to the clipped elbow region. (b) Insertion of instruments through the cover and manipulation of the limb with the cover in place are possible.
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15.5 Causes of inadequate arthroscopic visibility. (a) Fogging of the eyepiece of the arthroscope. (b) Poor positioning of the arthroscope such that the view is obstructed by synovium. (c) Scratch on the lens (arrowed).
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15.6 The monitor, patient and surgical team are in line, which facilitates a comfortable operating position with ease of instrument manipulation and a good view of the monitor.
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15.7 The viewing direction is altered by rotating the light post. The camera remains in a fixed position with the top pointing dorsally/cranially depending on the joint being examined. Note the notch on the border of the image (insert), which highlights the direction in which the arthroscope is pointing.
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15.8 Normal canine stifle joint showing normal smooth cartilage of the femoral condyle, part of the cranial cruciate ligament (white arrow) and part of the medial meniscus (black arrow).
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15.9 Primary lesions. (a) Fissure of the medial coronoid process of the elbow (arrowed). (b) Large medial coronoid process fragment of the elbow, which has caused cartilage erosions. (c) OCD flap and subchondral defect in a shoulder.
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15.10 Secondary lesions. (a) Small medial coronoid process fragment (black arrow) and superficial secondary cartilage lesions (white arrows) of the elbow; cartilage pitting due to fibrillation. A hyperplastic synovial villus (arrowhead) is visible protruding into the joint space. (b) Fibrillation (black arrows) and focal full thickness cartilage lesions (white arrows). (c) Severe erosions with multiple small islands of fibrocartilage (arrowed).
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15.12 Secondary and concomitant pathological changes that do not require treatment. (a) Elbow diagnosed with moderate incongruity and medial coronoid fragmentation: the trochlear notch shows a depression without cartilage, filled with a small amount of pannus. (b) Elbow diagnosed with severe incongruity and medial coronoid fragmentation: the trochlear notch shows a deep depression without cartilage, covered with hypervascular pannus. (c) Sound elbow: the trochlear notch is covered with normal smooth cartilage. (d) Elbow diagnosed with moderate incongruity and medial coronoid disease: pannus and irregular cartilage covering the radial head. (e) Elbow diagnosed with moderate incongruity and medial coronoid disease: pannus and irregular cartilage covering the step. (f) Elbow with medial coronoid disease: pannus with clear blood vessels covering the medial part of the trochlear notch of the ulna. (g) Stifle diagnosed with a partial rupture of the cranial cruciate ligament: red, inflamed synovial membrane at the distal pole of the patella. (h) Stifle diagnosed with a partial rupture of the cranial cruciate ligament, transition of synovial membrane to cartilage at the proximal site of the patellar groove: zones covered with pannus. (i) Stifle with a partial cruciate ligament showing severe inflammation and local hypertrophic synovial membrane. (j) Shoulder diagnosed with OCD: biceps tendon covered with hypertrophic synovial membrane. (k) Shoulder diagnosed with a calcified body at the caudal edge of the glenoid: chronic inflammation caused fibrillation of the joint capsule and intracapsular ligaments. (l) Shoulder with chronic osteoarthritis: partial tear of the medial glenohumeral ligament.
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15.13 Osteophytes. (a) Shoulder: caudodistal part of the humeral head. (b) Shoulder: caudal border of the glenoid cavity. (c) Elbow: lateral ridge of the humeral condyle. (d) Stifle: lateral ridge of the femoral condyle.
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15.14 View of a normal right shoulder showing normal synovial membrane surrounding a small part of the biceps tendon: normal blood vessels run in the synovial membrane and the synovial villi are small.
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15.15 Pathological changes of the synovial membrane. (a) Stifle: tumoural changes. (b) Stifle: infection. (c) Shoulder: acute, light inflammation. (d) Elbow: moderate chronic inflammation. (e–f) Shoulder: acute, severe inflammation. (g) Elbow: severe chronic inflammation. (h) Shoulder: villi surrounding ‘joint mouse’. (i) Stifle: chronic inflammation and discoloration. (j) Stifle: synovial villi at the inner border of the meniscus.
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15.16 Normal tendons and ligaments. (a) Elbow: medial collateral ligament. (b) Elbow: annular ligament, attachment at the lateral coronoid process. (c) Elbow: crossing of the medial collateral ligament and distal part of the biceps tendon. (d) Carpus: intra-articular ligaments. (e) Shoulder: biceps tendon. (f) Shoulder: medial glenohumeral ligament. (g) Stifle: cruciate ligaments. (h) Stifle: origin of the long digital extensor tendon.
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15.17 Images of flexor enthesopathy in a left elbow. (a) Medial compartment of the elbow showing an affected enthesis of the flexor muscle (arrowhead); visible normal structures are: part of the medial epicondyle (white arrow) and the anconeal process (black arrow). (b) Fibrillation and partial rupture of the enthesis.
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15.18 Subchondral bone in different joints. (a) Displaced fragment of the medial coronoid process: yellow subchondral bone covered by white cartilage. (b) Soft bone visible during motorized shaving of a coronoid fragment. (c) OCD of the shoulder: subchondral bone is visible underneath the cartilage flap. (d) OCD of the elbow: large bleeding defect of the medial humeral condyle. (e) Defect of talus after removal of large fragment (white arrow) with concurrent erosion of the distal tibia (black arrow). (f) Complete cartilage erosion of the medial compartment of the elbow joint. A fragment is visible in the middle of the image, between the medial condyle (white arrow) and the remaining part of the medial coronoid process (black arrow). (g) Severe kissing lesions of the medial condyle (arrowed). (h) Superficial cartilage lesions of the medial condyle (arrowed).
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15.19 Menisci of dogs. (a) Normal meniscus. (b) Luxated bucket handle tear of the medial meniscus with cranial displacement. A small grasper is approaching it. (c) Synovial villi covering the axial border of the medial meniscus. (d) Fibrillation of the axial border of the lateral meniscus.

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