Rigid endoscopy: arthroscopy

image of Rigid endoscopy: arthroscopy
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The use of arthroscopy in small animals for the treatment and diagnosis of joint disease has increased dramatically in the past 15–20 years due to advances in equipment and techniques. This chapter provides an introduction to small animal arthroscopy and discusses its indications, ancillary procedures, instrumentation and current applications.

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14.1 Dedicated arthroscopic suite for minimally invasive surgical techniques.
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14.2 Arthroscope tip, showing the arrangement of components.
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14.3 Arthroscopes of different sizes. Top to bottom: 1.9 mm, 2.4 mm and 2.7 mm.
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14.4 Field of view for a 2.7 mm arthroscope. The 2.4 mm arthroscope has a similar field of view.
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14.5 (a) A 2.7 mm arthroscope plus protective cover, cannula and obturators. (b) Sharp and blunt obturator tips.
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14.6 A basic instrument kit used in addition to bespoke arthroscopy instruments.
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14.7 (a) Instrument cannulae for elbow and shoulder arthroscopy, with switching stick (top). (b) Plastic cannula for use as an egress or instrument portal in the stifle or shoulder. (c) Rubber ‘passport’ cannulae with low-profile flanges that seat flush to the skin and minimize accidental pull-out when removing instruments.
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14.8 A 2 mm 90-degree probe.
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14.9 Grasping forceps. (a) Locking (left) and non-locking (right) handles; (b) locking forceps with grasping teeth for large fragment removal; (c) a variety of tips; (d) close-up of rat-toothed tip; (e) close-up of meniscal punch tips.
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14.10 A 2.0 mm hand burr for curettage of cartilage and bone.
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14.11 Arthroscopic knives. (a) Hook; (b) forward cutting.
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14.12 Examples of various styles of shaver heads for bone or soft tissue removal. (Courtesy of Arthrex GmbH)
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14.13 (a) Hand pressure infusion cuff. (b) Arthroscopy fluid pump.
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14.14 Dr Fritz aiming device for triangulation of instruments.
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14.15 (a) Four-quarter draping of the right elbow for arthroscopy. For routine elbow arthroscopy, a hanging limb is used for preparation only. The limb is then laid parallel to the table for the arthroscopic procedure. (b) Impermeable drape used to prevent strikethrough.
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14.16 Multiarm positional aid and stifle brace for multiarm attachment. (Courtesy of Veterinary Instrumentation, Sheffield)
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14.17 Shoulder joint. a = humeral head; b = subscapularis tendon; c = medial glenohumeral ligament; d = glenoid cavity.
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14.18 Model demonstrating the position of portals for shoulder arthroscopy. A = arthroscope portal; E = egress portal; I = instrument portal.
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14.19 Normal arthroscopic anatomy of the medial shoulder joint. a = glenoid; b = MGHL; c = subscapularis tendon; d = humeral head.
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14.20 Normal caudal humeral head.
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14.21 Normal caudomedial gutter.
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14.22 Cranial compartment of the shoulder joint. (a) Normal origin of biceps tendon and cranial joint capsule. (b) Normal variant of biceps tendon. (c) Bipartite biceps tendon.
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14.23 Lateral compartment of the shoulder joint. (a) Origin of lateral glenohumeral ligament. (b) Normal variant.
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14.24 Positioning of the patient for suspended limb shoulder arthroscopy. Note the position of the head to facilitate easy access to the craniomedial aspect of the shoulder. (Courtesy of C Deintt)
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14.25 Osteochondritis dissecans: lesion.
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14.26 Osteochondritis dissecans fragment being grasped. (Courtesy of B Van Ryssen)
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14.27 Incomplete ossification of the caudal glenoid.
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14.28 Subscapularis tear.
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14.29 Lateral glenohumeral ligament tear.
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14.30 Arthroscopic repair of a lateral glenohumeral ligament tear. (a) Placement of the suture anchor. (b) Advancement of the suture material into the joint, to ensure adequate visualization. (c, d) A lasso is used to extract the suture through the capsular tissue.
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14.31 Transverse ultrasound image of the biceps tendon, showing a hypoechoic ‘core’ lesion.
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14.32 Arthroscopic view of the biceps tendon, showing severe synovial hyperaemia.
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14.33 (a) Normal biceps tendon: with the shoulder in full flexion, the elbow cannot fully be extended. (b) Ruptured biceps tendon: the elbow can be fully extended.
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14.34 (a) Partial rupture of the biceps tendon. (b) Tenotomy using arthroscopic scissors. (Courtesy of B Van Ryssen)
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14.35 Model demonstrating the position of portals for medial elbow arthroscopy. A = arthroscope portal; E = egress portal; I = instrument portal.
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14.36 Normal arthroscopic anatomy of the elbow: (a) humerus and anconeal process; (b) caudal trochlear notch; (c) central trochlear notch; (d, e) cranial trochlear notch; (f) lateral coronoid process and radial head; (g) radial head and intercondylar fossa. A = anconeal process; CaTN = caudal trochlear notch; CeTN = central trochlear notch; CrTN = cranial trochlear notch; H = humerus; ICF = intercondylar fossa; LCP = lateral coronoid process; RH = radial head.
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14.38 Varying degrees of pathology, from cartilage fissure to complete displacement of the fragment, seen with fragmentation of the coronoid process. (a) Fissuring of the apical region of the medial coronoid process (MCP). (b) Non-displaced fragment of the MCP. (c) Probing of a non-displaced fragment to assess stability. (d) Non-displaced fragment of the MCP with adjacent Outerbridge Grade 3 lesions on the adjacent ulna and Grade 2 on the humerus. (e) Elevation of a fragment exposing the yellow necrotic subchondral bone.
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14.39 Synovitis associated with elbow pathology, in this case a displaced fragmented coronoid visible below the inflamed synovium. The yellow discoloration of the bone is caused by necrosis.
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14.40 Non-displaced osteochondritis dissecans lesion of the medial humeral head of the humerus.
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14.41 Mediolateral radiograph of a skeletally mature dog with ununited anconeal process (arrowhead) and secondary osteoarthritis. Osteophytes are denoted by the arrows.
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14.42 A non-displaced ununited anconeal process.
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14.43 Significant medial compartment osteoarthritis. Note the distinct demarcation between the medial and lateral compartments of the joint.
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14.44 Humeral intracondylar fissure. A circumferential cartilage defect (arrowed) can be seen clearly in the centre of the humeral condyle.
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14.45 Model demonstrating the position of portals for carpal arthroscopy. A1 and A2 represent alternative suggested arthroscope portal sites.
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14.46 Normal arthroscopic view of the antebrachial carpal joint. The radius is at the top, with the radiocarpal bone below.
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14.47 Cases of severe carpal synovitis can be investigated arthroscopically. (Courtesy of J Cook)
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14.48 Carpal chip fracture. (a) Fracture . (b) Fragment being removed using 2.7 mm grasping forceps. (c) The carpal defect in the subchondral bone following debridement with a power shaver. (Courtesy of J Cook)
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14.49 (a) Model demonstrating the position of portals for right hip arthroscopy. A = arthroscope portal; E = egress portal; I = instrument portal. (b) Clinical arthroscopy of the left hip (dorsal surface is uppermost; head is to the left).
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14.50 Normal arthroscopic anatomy of the right coxofemoral joint. (a) Normal cranial aspect of the femoral head and acetabulum on the abaxial side. (b) Normal caudal aspect of the femoral head and acetabulum on the abaxial side. (c) Normal joint capsule and caudal femoral head. (d) Normal Teres ligament insertion into the acetabular fossa. (e) Normal caudal femoral head and acetabulum on the axial side. (f) Normal joint capsule as it inserts caudally on the femoral neck. AcF = acetabular fossa; CaAR = caudal acetabular rim; CaFH = caudal femoral head; CaJC = Caudal joint capsule; CrAR = cranial acetabular rim; CrFH = cranial femoral head; FH = femoral head; FN = femoral neck; JC = joint capsule; TL = teres (round) ligament.
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14.51 Mildly displaced acetabular fracture with concomitant labral tear. (Courtesy of J Cook)
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14.52 Hyperplastic synovium. This may need to be removed in order to visualize the intra-articular structures.
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14.53 (a) Placement of a disposable plastic egress cannula into the proximolateral pouch of the stifle. (b) Femoropatellar joint space with the patella above. The egress cannula can just be seen on the left side of the image.
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14.54 (a) Stifle prepared and draped for arthroscopy. (b) Impermeable plastic drape used to prevent breakdown of asepsis.
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14.55 Model demonstrating the position of portals for stifle arthroscopy. A = arthroscope portal; E = egress portal; I = instrument portal.
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14.56 Origin of the long digital extensor tendon.
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14.57 Normal cruciate ligament. CaCL = caudal cruciate ligament; CrCL = cranial cruciate ligament.
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14.58 (a) Flounce of the normal medial meniscus (arrowed). (b) Normal medial meniscus (arrowed).
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14.59 Medial meniscal caudal horn fold. (a) The meniscus (M) appears normal until the joint is flexed. (b) After the stifle is flexed, the caudal horn (CH) is folded cranially. (c,d) Treatment with radiofrequency ablation.
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14.60 stifle osteochondritis dissecans (OCD) lesion of the medial trochlear ridge. FC = femoral condyle.
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14.61 Models demonstrating portals for tarsal arthroscopy. (a) Dorsal tarsal portals; (b) plantar tarsal portals. A1 and A2 represent alternative suggested arthroscope portal sites.
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14.62 (a) osteochondritis dissecans (OCD) lesion on the lateral trochlear ridge. (b) Synovitis secondary to an OCD lesion. The deep digital flexor tendon is to the left and the lateral trochlear ridge is to the right. (Courtesy of B Van Ryssen)
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14.63 Tarsal osteoarthritis with full-thickness cartilage loss and two visible wear lines.
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14.64 Septic arthritis in the hip of a dog presented for total hip replacement. (Courtesy of J Cook)
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