Arthroscopic techniques have been used for nearly 90 years. Initially used in orthopaedic practice for meniscal examination and surgery, it can now be performed minimally invasively on any slightly larger joint. Minimally invasive surgery means less damage, preservation of more tissue structure and function, and shorter postoperative recovery time. The advent of arthroscopy has led to the use and improvement of minimally invasive techniques in joint surgery. With the improvement of the equipment, the advantages will be more obvious than traditional surgical methods.
The advantages of arthroscopy in arthrography: Arthrography includes X-ray arthrography, ultrasound, CT, MRI, and arthroscopy. Although volumetric and surface 3D reconstruction techniques can reproduce the internal three-dimensional structure of the examined area such as joints and spinal canal, they are still indirect means. The arthroscopic apparatus and supporting software can provide quantitative data on functional lesion properties, the extent of organic lesions, and peri-lesion reactive changes. In addition, arthroscopy allows for tissue biopsy.
The advantages of arthroscopy in the treatment of the locomotor system: Arthroscopy can operate in a very small area and channel with minimal interference with the structure and function of healthy tissues, examining hidden areas that cannot be observed under direct visualization, with high visualization and minimal trauma, minimizing adhesions to the joint slide and facilitating rapid functional recovery.
Currently, it can be used for the adjunctive treatment of almost all joint disorders except joint replacement.
Application of arthroscopy in clinical practice
I. Knee joint
The surface of the knee joint is covered with little soft tissue, making it easy to operate with the endoscopic system. Initially, arthroscopy was used to observe the joint structure, meniscus and cruciate ligament lesions, and to perform direct vision surgery after definite diagnosis. Nowadays, a variety of minimally invasive synovial, ligament, bone and cartilage procedures can be performed. The development of knee arthroscopy has led to the introduction and application of other arthroscopes.
(i) Meniscus: Arthroscopy is inferior to imaging and MRI in diagnosing damage to certain parts of the meniscus. MRI has a higher overall positive rate than arthroscopy for meniscal injuries, probably because the ligaments and synovial membranes around the joint limit the field of view and prevent direct detection of peripheral lesions. Compared with traditional meniscectomy, minimally invasive arthroscopic treatment can preserve more physiologically functional meniscus, remove as much diseased tissue as possible, better remove pathological factors affecting joint function recovery, and improve the quality of surgery. Traditional surgery increases the burden on the body, prolongs recovery time and delays functional exercise, and may aggravate local damage, resulting in postoperative joint adhesions and varying degrees of functional impairment.
( 2), cruciate ligament: The repair of the cruciate ligament, especially the anterior cruciate ligament, as soon as possible is of great significance for the recovery of joint function. The protective action of the limb at the early stage of injury is not conducive to special physical examination of the joint, especially in the presence of fracture, etc. Timely application of arthroscopy and treatment can reduce the patient’s pain, reduce secondary lesions and promote early recovery of function. Arthroscopic reconstruction of the intercondylar fossa and ligaments can be performed for both old and fresh ligaments with complete rupture, and the most commonly used methods include the reconstruction of the anterior and posterior cruciate ligaments by the bone-tendon-bone extrusion screw method and the reconstruction of the anterior and posterior cruciate ligaments by autologous/allogeneic tendons/artificial ligaments. The freely rotating lens helps us to clearly see the starting and ending points of the ligament, establish the bone channel, and complete the fixation of the compression screw. Since the reconstruction of posterior cruciate ligament is technically more difficult than that of anterior cruciate ligament. In addition to the limitations of the intercondylar fossa and the obstruction of the anterior cruciate ligament, reconstruction of the posterior cruciate ligament requires good visualization and often requires an additional posterior approach, which would result in a large area of soft tissue stripped from the posterior aspect of the knee and would not provide the desired visualization. In addition, for incomplete ligament rupture, the lens can be used to clearly identify the damaged area, and special tools such as planer can be used to smooth it out, and radiofrequency technology can be used to tighten the lax ligament. Radiofrequency technology applied on the basis of arthroscopy is also good for the repair of soft tissue injuries in joints.
( 3) Knee bone injury repair: Currently, it has been used to treat small intra-articular fractures and osteoarthrosis. For intra-articular fractures such as intercondylar ridge avulsion fractures and tibial plateau fractures, they can be fixed directly under the arthroscope or used to expand the surveillance area to show areas that are not easily observed under direct vision, avoiding enlarging the incision and increasing trauma. Treatment for osteoarthrosis, a degenerative disease, includes arthroplasty, debridement, molding, and osteotomy. As patients become more aggressive in their approach to care, more early lesions need to be treated, and arthroscopy can be used to get closer to the affected tissue. Inappropriate puncture of the knee during youth can precipitate the degenerative process, whereas degenerative joints should be more carefully protected, and the minimally invasive technique of arthroscopy is the logical choice.
(iv) Infectious and non-infectious arthritis: Arthroscopy can be used to treat septic arthritis. Chronic synovial diseases such as rheumatoid arthritis, gouty arthritis, synovial chondromatosis, tuberculosis, tumors, and pigmented villous nodular synovitis can be diagnosed and treated by arthroscopy.
Second, the hip joint
Hip surgery requires less soft tissue damage, as the femoral head is very intolerant to ischemia. Arthroscopy can be used to treat ischemic necrosis of the femoral head and synovial chondromatosis. Treatment of the former has the advantages of being less invasive, more accurate, more effective and easier. Microscopic removal of dead bone, medullary decompression, bone grafting, and bone grafting with vascularized tips can be performed with greater clarity and detail, and can examine tissue changes in various parts of the joint without damaging the round ligament. For osteoarthritis, rheumatoid arthritis, and ruptured glenoid labrum, we are able to perform subsurface resection, repair of degenerated cartilage, local excision of ruptured glenoid labrum, and intra-articular flushing under direct vision. In particular, after the diagnosis of synovial chondromatosis is made, removal of the free body is a difficult task, and it is impossible to extend the incision too much to remove it, so microscopic operation is a good solution. Since the hip joint is a typical pestle joint with tight junctions and well-developed surface soft tissues, arthroscopic manipulation requires a high level of skill. In the 1987 annual review of Arthroscopy, it was stated that hip arthroscopy should only be performed by highly experienced joint surgeons because of the complex and risky technique. Even so, complications are still much higher than in the knee, with a ratio of 1.6% hip to 0.775% knee complications, so it is important to learn well before performing this technique.
Shoulder joint
The following treatments have been performed: frozen shoulder release, rotator cuff injury repair, acromioplasty, and bursal resection. The advantages of adjunctive shoulder arthroscopy include direct observation and management of intra-articular lesions in the acromioclavicular and subacromial joints, clear diagnosis, guidance on surgical approach, and rapid postoperative recovery.
The advantages of adjuvant shoulder arthroscopy include direct observation and management of the acromioclavicular joint and subacromial joint lesions, clear diagnosis, guidance on surgical approach, and rapid postoperative recovery. For the treatment of anterior instability of the shoulder joint, most of the traditional open surgery can now be addressed arthroscopically, with early rehabilitation and fewer complications, and the ultimate outcome is almost identical to that of open surgery. In terms of diagnosis, arthroscopy is a reliable qualitative diagnostic tool for superior labral anterior-posterior tears (SLAP), better than MRI and CT.
Wrist and elbow joints
The elbow joint has a simple structure and thin soft tissue, which facilitates the use of arthroscopy. It includes free body removal, wear and tear shaping, osteotomy, and partial radial head resection with joint capsule release, which reduces the problems of long braking time and re-adhesion caused by open surgery. The wrist joint is composed of ulnar radius, carpal bone, ligament and cartilage, and the structure is relatively complex, with synovial membrane, ligament, cartilage, triangular cartilage and other structures, so it is difficult to carry out arthroscopic techniques. So far, the practical application in China is relatively small but still successful. What these two joints have in common is that the sliding devices such as adjacent vascular nerves or tendons are close to the puncture points where the joint can be accessed, which can easily cause collateral damage to these structures. Successful treatment of the wrist joint includes carpal tunnel release, synovial chondroma removal, triangular cartilage-related treatment, and in particular, microscopic internal fixation of navicular fractures with minimal trauma and blood supply disruption, which facilitates fracture healing. In the diagnosis of chronic painful diseases of the wrist joint. Arthroscopy is more useful than arthrography in identifying wrist disorders, and is most effective in identifying triangular cartilage tears.
V. Ankle joint
This joint, like the knee, is primarily a weight bearing joint and is the third most likely to be used for arthroscopy. Anteromedial and anterolateral approaches are often used, with posterior and anteromedial approaches being less common. As a weight-bearing joint, minimizing pain during walking is the main goal of the disease treatment. In practice, synovectomy and joint fusion have the same advantages of less injury, less pain, more uniform resection and fewer postoperative complications than traditional methods.
Sixth, finger ( toe ) joints
This type of joint is small, and the application of arthroscopic techniques is relatively small, and has not yet been reported in China. Overseas, there have been cases of cartilage surgery in metatarsophalangeal joints, thumbs, and other medium-sized interphalangeal joints using arthroscopy with a diameter of 2 mm or less.
Indications for arthroscopic surgery: Intra-articular synovial and cartilage lesions, such as connective tissue disease and degenerative disease. Intra-articular injuries. Free body of the joint. If the diagnosis is not clear by other means. Although arthroscopic surgery is characterized by less damage and faster recovery, the joint is still exposed to artificial damage, with a medical injury rate of about 0. 05%, on the basis of which arthroscopic arthropathy may occur, reminding us of the proper application of arthroscopic techniques. In addition to the indications and contraindications that must be mastered, it is important to learn the key techniques carefully. The operator’s own attitude, technique and proficiency are very important. Treatment attitude is the key, the doctor should analyze the pathological state objectively based on the microscopic findings and treat carefully to prevent subjective judgments.