- Email: [email protected]
Arthroscopy
Injury (1990) 21,283-286 Printedin Great Brifain
283
Arthroscopy I. G. Stother Orthopaedic
Department,
Glasgow
Royal Infirmary, Glasgow,
Introduction Early work on arthroscopy was carried out in the first quarter of this century throughout the world; in Europe by Bircher (Bircher, 1921), in the United States by Kreuscher (Kreuscher, 19251, Burman (Burman and Mayer, 1936) and notably in Japan by Takagi (Takagi, 1939). The technique did not, however, gain its current widespread acceptance until the early 1960s.
The telescope One of the important factors in the rapid growth of the specialty during the 1960s was the development of a reliable arthroscope with a rigid optical system, irrigation channel and eyepiece as seen on most current instruments. The Watanabe 21 arthroscope (Watanabe and Takeda, 1960) had all these features, although it still used a tungsten filament bulb within the joint for illumination. Further developments which have allowed improved image quality include the development of ‘light cables’ which allow the use of powerful light sources fixed outside the joint and improved optical performance with the use of coated lenses. Development of the arthroscope itself is still continuing. The field of view has gradually increased, making orientation within the joint easier for the surgeon. Oblique viewing instruments have been developed allowing the surgeon to view behind and beyond fixed intra-articular structures. At the same time, smaller diameter telescopes have been developed. Instruments used for large joints are usually 4-5 mm in diameter. Small instruments, down to 1.7 mm diameter, are currently available for inspecting smaller joints such as the wrist. It is a tribute to the advances in telescope design that many of these very small diameter instruments transmit images which are of a quality and brightness which was only available with the 5 mm telescopes 20 years ago.
light sensitive and sterilizable by immersion in activated glutaraldehyde. They allow surgeons to teach and to use assistants. Video libraries such as the one belonging to The Arthroscopy Association of North America provide a large range of teaching tapes.
Hand instruments A large range of specialized surgical instruments is now available. Special knives, scissors, grasping forceps and punches are available in a range of sizes and curvatures. Specialized instruments exist for individual procedures, such as meniscus suture and ligament repair. Most arthroscopic surgeons have their favourite instruments. It is important that the operating theatre and sterile supply staff are trained in the care of these instruments. It is also important that budget holders realize that these instruments are small, subject to large loads and do not last indefinitely.
Power instruments Power instruments consisting essentially of rotating blades or burrs are finding increasing use. A few procedures can only easily be carried out with power instruments, e.g. synovectomy of the knee or elbow or acromioplasty of the shoulder. Other procedures such as surgical debridement of arthritic joints can be much more effectively and rapidly performed with these power instruments. Electrocautery is also used for arthroscopic surgery. It is essentially a cutting and coagulating tool and is especially useful for procedures where bleeding is a potential problem, for example around the shoulder when no tourniquet can be used. Lasers are now available for arthroscopy. Their routine role and special advantages remain to be defined.
The knee joint
Television and video Television cameras and video recording are now available routinely in major centres carrying out arthroscopic surgery. Early cameras were relatively bulky and heavy tube cameras. They were important in allowing arthroscopists to teach other surgeons and so make the expanding range of arthroscopic techniques more widely practised. Current cameras weigh very little and are very small, often measuring no more than 3 cm x 3 cm x 3 cm. They are also very 0 1990 Butterworth-Heinema 0020-1383/90/050283-4
UK
Ltd
Clinical diagnosis of internal derangements of the knee joint has never been demonstrated to be more than about 70 per cent accurate (Jackson and Abe, 1972; Noble and Erat, 1980). It is not surprising, therefore, that the knee was one of the first joints to be arthroscoped widely. Early workers who developed diagnostic techniques include Jackson in Toronto, Canada, and Dandy in Cambridge, England (Jackson and Dandy, 1976). Diagnostic arthroscopy of the knee joint has developed
284
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No. 5
so that at the present time the whole of the joint can be inspected and palpated. In the majority of cases an adequate diagnostic arthroscopy can be carried out using an anterolateral insertion of the telescope and an anteromedial insertion of the probe. The technique for inspecting the posterior compartment, based on these approaches, has been well described by Lysholm and Gillquist (1981). Multiple entry sites are possible and may be used in different cases (Whipple and Bassett, 1978). Recent advances in imaging techniques have achieved similar accuracy to diagnostic arthroscopy. Double contrast arthrography has been shown to diagnose accurately meniscus pathology (Ireland et al., 1980). One advantage of arthrography is that no operating theatre time is required, although injections of contrast medium and air is required. Magnetic resonance scans have the advantage of being completely non-invasive and will show not only the menisci but also the cruciate ligaments and the state of the articular cartilage. False-positive results have, however, been a problem in some series using this technique (Handelberg et al., 1990) and at the present time arthroscopy probably remains the diagnostic ‘gold standard. Operative arthroscopy of the knee joint was a logical development of the diagnostic method. The advantages of arthroscopic over open surgery for the patient include shorter hospitalization, more rapid rehabilitation and smaller scars (Chama and Tubbs, 1981; Ma&inlay and Stother, 1983). One of the main impacts of arthroscopy has been the development of conservative meniscus surgery. Preservation of a rim of meniscus has been known to give better results than total excision of the meniscus in the long term for many years (Tapper and Hoover, 1969). Partial meniscectomy in the form of excision of the displaced portion of a full bucket handle type of tear can, of course, be carried out at arthrotomy, but resection of posterior horn tags and short posterior bucket handle tears can only be carried out arthroscopically. Meniscus repair has been practised with increasing frequency. The precise indications are not yet defined, but it should certainly be considered in children and young adults. The factors leading to sound healing following repair have been discussed by Scott et al. (1986) and by Muckle (1990). Healing occurs most readily in short tears near the periphery of the meniscus. If there is any associated anterior cruiciate ligament damage this should be stabilized if the meniscus repair is to have a reasonable chance of success. The most technically difficult tears to suture are the posterior horn tears and there is some risk of damage to neurovascular structures if the posterior exposure is inadequate (Barber and Stone, 1985). The whole area of ligamentous instability of the knee joint is dealt with elsewhere in this volume by Nigel Tubbs. Suffice it to say that arthroscopic control of the repair of both acute and chronic ligamentous tears has been described. Perhaps the main advantage of such methods is that they minimize the scarring of the skin. Synovectomy for inflammatory arthritis remains unpredictable in its outcome, whether the procedure is carried out by open arthrotomy or by arthroscopy. The advantage of arthroscopic synovectomy is that it gives the patient a relatively rapid postoperative recovery and it can, therefore, be recommended more easily than a classical open synovectomy (Smiley and Wasilewski, 1990). The role of variousarthroscopic procedures in degenerative arthritis remains controversial. Jackson and McCarthy
(1971) reported good results from local ‘tidying’ of the joint and removal of meniscus and articular cartilage tags, together with extensive irrigation. The subject has recently been reviewed by Burkes (1990). Anterior knee pain remains a difficult area. Perhaps the most useful contribution of arthroscopy has been to make the diagnosis of ‘chondromalacia patellae’ apply to the specific changes described by Outerbridge (1961), which are visible on the articular surface of the patellofemoral joint at arthroscopy. The cause of these lesions remains obscure in many cases. Recurrent subluxation or dislocation of the patella remains largely a clinical and radiological diagnosis, although ridging of the articular surface on the back of the patella may help to confirm the diagnosis. Other lesions of the joint surfaces may present with instability or swelling, Osteochondral lesions should probably most easily be seen on plain radiographs. Chondral flaps, however, may have no radiological features and may only be discovered at arthroscopy.
The shoulder joint Arthroscopy of the shoulder (glenohumeral joint and subacromial bursa) has developed rapidly in recent years (Rockwood, 1988). The scale of the joint is such that essentially the same instruments are suitable for both knee and shoulder arthroscopy. Diagnostic arthroscopy allows inspection of all the intra-articular structures, notably the joint surfaces, the glenoid labrum, the biceps tendon, the rotator cuff (on both sides) and the coroco-acromial ligament. In cases of shoulder instability, tears of the labrum can be identified as well as detachment of the labrum from the margin of the glenoid (Blankart lesion). In addition, the size and state of the infraglenoid recess, which may contain loose bodies, can also be seen. The articular cartilage of the head of the humerus can be inspected for the Hill-Sachs type on the posterosuperior surface. Identification of these lesions may be useful, especially in cases where previous surgery has failed for recurrent anterior dislocation of the shoulder (McAuliffe et al., 1988). Impingement problems (rotator cuff syndromes) can also be investigated by diagnostic arthroscopy. The rotator cuff can be examined with a probe on each side and can be assessed for inflammation, fibrosis and thinning, as well as for complete tears. While shoulder arthroscopy allows accurate diagnosis of rotator cuff disorders, it is by no means the only investigation that can be used to assess the state of the rotator cuff. Ultrasound has been reported to be approximately 90 per cent accurate in identifying rotator cuff tears (Middleton et al., 1986). More recently, Bunker (1987) has been able to demonstrate not only complete tears but also partial thickness tears using ultrasound. Arthrography is also well established as a means of showing rotator cuff tears when they are complete. However, arthroscopy is probably of more value in assessing the cause of persisting symptoms after surgery for instability (Wiley, 1990) and is more likely to be of value in assessing persisting pain after rotator cuff repairs (Calvert et al., 1986). Operative arthroscopy of the shoulder is practised in relatively few centres. The success rate for surgery for instability is not yet as high with artl-uoscopic procedures as it is for conventional open stabilization. In contrast, arthro-
Stother:
Arthroscopy
scopic surgery for impingement syndromes appears to be relatively successful. Most rotator cuff disease, with the exception of acute major tears, will initially be treated conservatively (Cofield, 1985). However, persisting symptoms can be treated by local resections using power instruments. Local debridement and synovectomy are the smallest procedures. Resection of the coraco-acromial ligament and of the inferior surface of the acromion can also be carried out when there is evidence of local compression (Gartsman, 1990). However, where there is a distinct tear in the rotator cuff open repair appears to give the best results. On occasion a combined arthroscopic and open procedure may be useful (Levy et al., 1990).
The wrist joint Using short, small diameter telescopes (1.7-2.5 mm diameter) and similarly sized irrigation cannulae and instruments, it is possible to examine most areas of the wrist joint, including the radiocarpal joint, distal radioulnar joint and the midcarpal joint. The main indications for special investigations are pain and instability. In many such cases there is damage to the intercarpal ligaments and this may be demonstrated by stress radiographs showing, for example, scapholunate dissociation. Further investigations, such as arthrography, may show the radiopaque medium to flow from one compartment of the wrist to another through the areas of ligamentous damage. Diagnostic arthroscopy allows such damaged ligaments to be localized accurately. For example, in scapholunate dissociation a gap can clearly be seen between the scaphoid and lunate bones which are normally tightly bound together in the radiocarpal joint. Damage to the triangular cartilage (meniscus of the wrist) can also be seen when the radiocarpal joint is arthroscoped. Such damage, which is associated with pain and clicking, may take the form of flap or bucket handle tears. Operative arthroscopy can be useful for stabilizing carpal dissociations. For example, scapholunate dissociation can be demonstrated with an arthroscope in the radiocarpal joint. The position of reduction can be visualized and then this reduction can be maintained by the insertion of percutaneous wires to hold this position. This allows fibrosis and healing and the wires are removed some 6 weeks later. Lesions of the triangular cartilage are treated in much the same way as lesions of the meniscus in the knee joint using smaller instruments. The aim is to leave a stable portion of the triangular cartilage in situ. Arthroscopy of small joints, such as the wrist joint, demands small instruments and accurate placement of these instruments. Any surgeons contemplating starting arthroscopy of the wrist would be well advised to consult the excellent videos which are available from North America and, as with any other arthroscopic technique, to work with someone who is familiar with the details of the method before attempting to carry it out themselves.
Other joints Arthroscopy has been used both diagnostically and therapeutically in many other joints; two perhaps deserve a special mention. In the elbow joint, arthroscopy allows a good view of the joint and has been useful for removing loose bodies and also in performing synovectomy in rheumatoid arthritis. In the temporomandibular joint there is
285
an internal fibrocartilage and arthroscopy has been used to investigate pain and instability in this joint also. The
future
It is always difficult to anticipate future trends in orthopaedies. It seems likely that the use of the arthroscope, for purely diagnostic purposes, will decline as non-invasive imaging techniques become more widely available. As far as operative arthroscopy is concerned, it seems equally likely that the range of procedures carried out through the arthroscope is likely to increase. The attraction of arthroscopic surgery is that it allows adequate visualization of joints with the smallest amount of damage to the skin and surrounding soft tissues. This in turn minimizes the morbidity arising from the surgery; the economic and social consequences of this seem likely to ensure that arthroscopic procedures remain part of the orthopaedic surgical repertoire for many years to come.
References Barber F. A. and Stone R. G. (1985) Meniscal repair. J Bone Joint Surg. 67B, 39. Bircher E. (1921) Die Arthro Endoskopic. Z&r&~. Chir.48, 1460. Bunker T. D. (1987) A pilot study of the demonstration of rotator cuff defects using real time ultrasound. J. Bone joint Surg. 69B, 498. Burkes R. T. (1990) Arthroscopy and degenerative arthritis of the knee. A review of literature. Arfhroscopy6 (i), 43. Burman M. S. and Mayer L. (1936) Arthroscopic examination of the knee joint. Arch. Surg. 32, 846. Calvert P. T., Packer N. P., Stokes D. J. et aI. (1986) Arthrography of the shoulder after operative repair of the rotator cuff. 1. Bone Joint5.0-g.68B, 147. Chama G. S. and Tubbs N. (1981) Early results of arthroscopic surgery of the knee. In&ry 13,227. Cofield R. H. (1985) Rotator cuff disease of the shoulder (current concepts review). J. BoneJointSurg.67A, 974. Gartsman G. M. (1990) Arthroscopic acromioplasty for lesions of the rotator cuff. J &me joint Surg. 72A, 169. Handelberg F., ShahaIpur M. and Casteleyn P. P. (1990) Chondral lesions of the patella evaluated with computer tomography, magnetic resonance imaging and arthroscopy. Arfhroxopy 6 (i), 24. Ireland J, Trickey E. L. and Stoker D. J. (1990) Arthroscopy and arthrography of the knee. 1. Bone JointSurg.62B, 3. Jackson R. S. and Abe I. (1972) The role of arthroscopy in the management of disorders of the knee. J. Bone JointSurg. 54B, 310. Jackson R. W. and Dandy D. J. (1976) Arfhroscopyoffhe Km. New York: Grune and Stratton. Jackson R. W. and McCarthy D. D. (1971) Arthroscopy of the knee is osteoarthritis. In: Gordon D. A. ed. Proceedings of the FourthCanadianConferenceon RheuwmficDiseases.University of Toronto Press. Kreuscher P. (1925) Semilunar cartilage disease, a plea for early recognition by means of the arthroscope. IllinoisMed. J. 47,290. Levy H. J., Uribe J. W. and Delaney L. G. (1990) Arthroscopic assisted rotator cuff repair. Arthroscopy6(i), 55. Lysholm J. and Gillquist J. (1981) Arthroscopic examination of the posterior cruciate ligament. J. Bone JointSurg.63A, 363. McAuIiffe T. B., Pangayatselvant T, and Bayley I. (1988) Failed surgery for recurrent anterior dislocation of the shoulder J. Bone Joint Surg. 7OB, 798.
286
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.
Ma&inlay J. Y. and Stother I. G. (1983) Therapeutic arthroscopy of the knee. Scott. h/ied. 1. 28,239. Middleton W. D., Reinus W. R., Totty W. G. et al. (1986) Ultrasonic evaluation of the rotator cuff and biceps tendon. 1. Bone Joint Surg. 68A, 440. Muckle D. S. (1990) Meniscal resuture: an appraisal of failed cases. Proceedings of the British Orthopaedic Association. Spring 1990. Noble J. and Erat K. K. (1980)In defence of the meniscus. J Bone Joint Surg. 62B. Outerbridge R. E. (1961) The aetiology of chondromalacia patehae. J. Bone Joint Ssrg. 52B, 296. Rockwood C. A. (1988) Shoulder arthroscopy (editorial). J. Bone Joint Surg. ?OA, 639. Scott G. A., Jolly B. L. and Henning C. E. (1986) Combined posterior incision and arthroscopic intra-articular repair of the miniscus. 1. &me Joint Surg. 68A, 847. Smiley P. and Wasilewski S. A. (1990) Arthroscopic synovectomy. Arthroscopy 6(i), 18. Tagaki K. (1939) The arthroscope. J. Jpn. Orthop. Assoc. 14,359.
5
Tapper E. M. and Hoover N. W. (1969) Late resuhs after meniscectomy. J Bone Joint Surg. 5 IA, 5 17. Video Supplement to Arthroscopy. Arthroscopy Association of North America. 70W Hubbard Street, Suite 202, Chicago IL 60610. Watanabe M. and Takeda S. (1960) The number 21 arthroscope. 1. ]pn. Orthop. Assoc. 34,1041. Whipple T. L. and Bassett F. H. (1978) Arthroscopic examination of the knee. Polypuncture technique with percutaneous intraarticular manipulation. 1. Bone Joint Surg. 60.4, 444. Wiley A. M. (1990) Instability of the shoulder: use of the arthroscope for diagnosis and treatment. Proceedings of the British Orthopuedic Association. Spring 1990.
Requests for reprints shouti be addressed to: Mr I. G. Stoiiler FRCS, Orthopaedic Department, Glasgow Royal Infirmary, Glasgow G4 OSF, UK.
283
Arthroscopy I. G. Stother Orthopaedic
Department,
Glasgow
Royal Infirmary, Glasgow,
Introduction Early work on arthroscopy was carried out in the first quarter of this century throughout the world; in Europe by Bircher (Bircher, 1921), in the United States by Kreuscher (Kreuscher, 19251, Burman (Burman and Mayer, 1936) and notably in Japan by Takagi (Takagi, 1939). The technique did not, however, gain its current widespread acceptance until the early 1960s.
The telescope One of the important factors in the rapid growth of the specialty during the 1960s was the development of a reliable arthroscope with a rigid optical system, irrigation channel and eyepiece as seen on most current instruments. The Watanabe 21 arthroscope (Watanabe and Takeda, 1960) had all these features, although it still used a tungsten filament bulb within the joint for illumination. Further developments which have allowed improved image quality include the development of ‘light cables’ which allow the use of powerful light sources fixed outside the joint and improved optical performance with the use of coated lenses. Development of the arthroscope itself is still continuing. The field of view has gradually increased, making orientation within the joint easier for the surgeon. Oblique viewing instruments have been developed allowing the surgeon to view behind and beyond fixed intra-articular structures. At the same time, smaller diameter telescopes have been developed. Instruments used for large joints are usually 4-5 mm in diameter. Small instruments, down to 1.7 mm diameter, are currently available for inspecting smaller joints such as the wrist. It is a tribute to the advances in telescope design that many of these very small diameter instruments transmit images which are of a quality and brightness which was only available with the 5 mm telescopes 20 years ago.
light sensitive and sterilizable by immersion in activated glutaraldehyde. They allow surgeons to teach and to use assistants. Video libraries such as the one belonging to The Arthroscopy Association of North America provide a large range of teaching tapes.
Hand instruments A large range of specialized surgical instruments is now available. Special knives, scissors, grasping forceps and punches are available in a range of sizes and curvatures. Specialized instruments exist for individual procedures, such as meniscus suture and ligament repair. Most arthroscopic surgeons have their favourite instruments. It is important that the operating theatre and sterile supply staff are trained in the care of these instruments. It is also important that budget holders realize that these instruments are small, subject to large loads and do not last indefinitely.
Power instruments Power instruments consisting essentially of rotating blades or burrs are finding increasing use. A few procedures can only easily be carried out with power instruments, e.g. synovectomy of the knee or elbow or acromioplasty of the shoulder. Other procedures such as surgical debridement of arthritic joints can be much more effectively and rapidly performed with these power instruments. Electrocautery is also used for arthroscopic surgery. It is essentially a cutting and coagulating tool and is especially useful for procedures where bleeding is a potential problem, for example around the shoulder when no tourniquet can be used. Lasers are now available for arthroscopy. Their routine role and special advantages remain to be defined.
The knee joint
Television and video Television cameras and video recording are now available routinely in major centres carrying out arthroscopic surgery. Early cameras were relatively bulky and heavy tube cameras. They were important in allowing arthroscopists to teach other surgeons and so make the expanding range of arthroscopic techniques more widely practised. Current cameras weigh very little and are very small, often measuring no more than 3 cm x 3 cm x 3 cm. They are also very 0 1990 Butterworth-Heinema 0020-1383/90/050283-4
UK
Ltd
Clinical diagnosis of internal derangements of the knee joint has never been demonstrated to be more than about 70 per cent accurate (Jackson and Abe, 1972; Noble and Erat, 1980). It is not surprising, therefore, that the knee was one of the first joints to be arthroscoped widely. Early workers who developed diagnostic techniques include Jackson in Toronto, Canada, and Dandy in Cambridge, England (Jackson and Dandy, 1976). Diagnostic arthroscopy of the knee joint has developed
284
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No. 5
so that at the present time the whole of the joint can be inspected and palpated. In the majority of cases an adequate diagnostic arthroscopy can be carried out using an anterolateral insertion of the telescope and an anteromedial insertion of the probe. The technique for inspecting the posterior compartment, based on these approaches, has been well described by Lysholm and Gillquist (1981). Multiple entry sites are possible and may be used in different cases (Whipple and Bassett, 1978). Recent advances in imaging techniques have achieved similar accuracy to diagnostic arthroscopy. Double contrast arthrography has been shown to diagnose accurately meniscus pathology (Ireland et al., 1980). One advantage of arthrography is that no operating theatre time is required, although injections of contrast medium and air is required. Magnetic resonance scans have the advantage of being completely non-invasive and will show not only the menisci but also the cruciate ligaments and the state of the articular cartilage. False-positive results have, however, been a problem in some series using this technique (Handelberg et al., 1990) and at the present time arthroscopy probably remains the diagnostic ‘gold standard. Operative arthroscopy of the knee joint was a logical development of the diagnostic method. The advantages of arthroscopic over open surgery for the patient include shorter hospitalization, more rapid rehabilitation and smaller scars (Chama and Tubbs, 1981; Ma&inlay and Stother, 1983). One of the main impacts of arthroscopy has been the development of conservative meniscus surgery. Preservation of a rim of meniscus has been known to give better results than total excision of the meniscus in the long term for many years (Tapper and Hoover, 1969). Partial meniscectomy in the form of excision of the displaced portion of a full bucket handle type of tear can, of course, be carried out at arthrotomy, but resection of posterior horn tags and short posterior bucket handle tears can only be carried out arthroscopically. Meniscus repair has been practised with increasing frequency. The precise indications are not yet defined, but it should certainly be considered in children and young adults. The factors leading to sound healing following repair have been discussed by Scott et al. (1986) and by Muckle (1990). Healing occurs most readily in short tears near the periphery of the meniscus. If there is any associated anterior cruiciate ligament damage this should be stabilized if the meniscus repair is to have a reasonable chance of success. The most technically difficult tears to suture are the posterior horn tears and there is some risk of damage to neurovascular structures if the posterior exposure is inadequate (Barber and Stone, 1985). The whole area of ligamentous instability of the knee joint is dealt with elsewhere in this volume by Nigel Tubbs. Suffice it to say that arthroscopic control of the repair of both acute and chronic ligamentous tears has been described. Perhaps the main advantage of such methods is that they minimize the scarring of the skin. Synovectomy for inflammatory arthritis remains unpredictable in its outcome, whether the procedure is carried out by open arthrotomy or by arthroscopy. The advantage of arthroscopic synovectomy is that it gives the patient a relatively rapid postoperative recovery and it can, therefore, be recommended more easily than a classical open synovectomy (Smiley and Wasilewski, 1990). The role of variousarthroscopic procedures in degenerative arthritis remains controversial. Jackson and McCarthy
(1971) reported good results from local ‘tidying’ of the joint and removal of meniscus and articular cartilage tags, together with extensive irrigation. The subject has recently been reviewed by Burkes (1990). Anterior knee pain remains a difficult area. Perhaps the most useful contribution of arthroscopy has been to make the diagnosis of ‘chondromalacia patellae’ apply to the specific changes described by Outerbridge (1961), which are visible on the articular surface of the patellofemoral joint at arthroscopy. The cause of these lesions remains obscure in many cases. Recurrent subluxation or dislocation of the patella remains largely a clinical and radiological diagnosis, although ridging of the articular surface on the back of the patella may help to confirm the diagnosis. Other lesions of the joint surfaces may present with instability or swelling, Osteochondral lesions should probably most easily be seen on plain radiographs. Chondral flaps, however, may have no radiological features and may only be discovered at arthroscopy.
The shoulder joint Arthroscopy of the shoulder (glenohumeral joint and subacromial bursa) has developed rapidly in recent years (Rockwood, 1988). The scale of the joint is such that essentially the same instruments are suitable for both knee and shoulder arthroscopy. Diagnostic arthroscopy allows inspection of all the intra-articular structures, notably the joint surfaces, the glenoid labrum, the biceps tendon, the rotator cuff (on both sides) and the coroco-acromial ligament. In cases of shoulder instability, tears of the labrum can be identified as well as detachment of the labrum from the margin of the glenoid (Blankart lesion). In addition, the size and state of the infraglenoid recess, which may contain loose bodies, can also be seen. The articular cartilage of the head of the humerus can be inspected for the Hill-Sachs type on the posterosuperior surface. Identification of these lesions may be useful, especially in cases where previous surgery has failed for recurrent anterior dislocation of the shoulder (McAuliffe et al., 1988). Impingement problems (rotator cuff syndromes) can also be investigated by diagnostic arthroscopy. The rotator cuff can be examined with a probe on each side and can be assessed for inflammation, fibrosis and thinning, as well as for complete tears. While shoulder arthroscopy allows accurate diagnosis of rotator cuff disorders, it is by no means the only investigation that can be used to assess the state of the rotator cuff. Ultrasound has been reported to be approximately 90 per cent accurate in identifying rotator cuff tears (Middleton et al., 1986). More recently, Bunker (1987) has been able to demonstrate not only complete tears but also partial thickness tears using ultrasound. Arthrography is also well established as a means of showing rotator cuff tears when they are complete. However, arthroscopy is probably of more value in assessing the cause of persisting symptoms after surgery for instability (Wiley, 1990) and is more likely to be of value in assessing persisting pain after rotator cuff repairs (Calvert et al., 1986). Operative arthroscopy of the shoulder is practised in relatively few centres. The success rate for surgery for instability is not yet as high with artl-uoscopic procedures as it is for conventional open stabilization. In contrast, arthro-
Stother:
Arthroscopy
scopic surgery for impingement syndromes appears to be relatively successful. Most rotator cuff disease, with the exception of acute major tears, will initially be treated conservatively (Cofield, 1985). However, persisting symptoms can be treated by local resections using power instruments. Local debridement and synovectomy are the smallest procedures. Resection of the coraco-acromial ligament and of the inferior surface of the acromion can also be carried out when there is evidence of local compression (Gartsman, 1990). However, where there is a distinct tear in the rotator cuff open repair appears to give the best results. On occasion a combined arthroscopic and open procedure may be useful (Levy et al., 1990).
The wrist joint Using short, small diameter telescopes (1.7-2.5 mm diameter) and similarly sized irrigation cannulae and instruments, it is possible to examine most areas of the wrist joint, including the radiocarpal joint, distal radioulnar joint and the midcarpal joint. The main indications for special investigations are pain and instability. In many such cases there is damage to the intercarpal ligaments and this may be demonstrated by stress radiographs showing, for example, scapholunate dissociation. Further investigations, such as arthrography, may show the radiopaque medium to flow from one compartment of the wrist to another through the areas of ligamentous damage. Diagnostic arthroscopy allows such damaged ligaments to be localized accurately. For example, in scapholunate dissociation a gap can clearly be seen between the scaphoid and lunate bones which are normally tightly bound together in the radiocarpal joint. Damage to the triangular cartilage (meniscus of the wrist) can also be seen when the radiocarpal joint is arthroscoped. Such damage, which is associated with pain and clicking, may take the form of flap or bucket handle tears. Operative arthroscopy can be useful for stabilizing carpal dissociations. For example, scapholunate dissociation can be demonstrated with an arthroscope in the radiocarpal joint. The position of reduction can be visualized and then this reduction can be maintained by the insertion of percutaneous wires to hold this position. This allows fibrosis and healing and the wires are removed some 6 weeks later. Lesions of the triangular cartilage are treated in much the same way as lesions of the meniscus in the knee joint using smaller instruments. The aim is to leave a stable portion of the triangular cartilage in situ. Arthroscopy of small joints, such as the wrist joint, demands small instruments and accurate placement of these instruments. Any surgeons contemplating starting arthroscopy of the wrist would be well advised to consult the excellent videos which are available from North America and, as with any other arthroscopic technique, to work with someone who is familiar with the details of the method before attempting to carry it out themselves.
Other joints Arthroscopy has been used both diagnostically and therapeutically in many other joints; two perhaps deserve a special mention. In the elbow joint, arthroscopy allows a good view of the joint and has been useful for removing loose bodies and also in performing synovectomy in rheumatoid arthritis. In the temporomandibular joint there is
285
an internal fibrocartilage and arthroscopy has been used to investigate pain and instability in this joint also. The
future
It is always difficult to anticipate future trends in orthopaedies. It seems likely that the use of the arthroscope, for purely diagnostic purposes, will decline as non-invasive imaging techniques become more widely available. As far as operative arthroscopy is concerned, it seems equally likely that the range of procedures carried out through the arthroscope is likely to increase. The attraction of arthroscopic surgery is that it allows adequate visualization of joints with the smallest amount of damage to the skin and surrounding soft tissues. This in turn minimizes the morbidity arising from the surgery; the economic and social consequences of this seem likely to ensure that arthroscopic procedures remain part of the orthopaedic surgical repertoire for many years to come.
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Requests for reprints shouti be addressed to: Mr I. G. Stoiiler FRCS, Orthopaedic Department, Glasgow Royal Infirmary, Glasgow G4 OSF, UK.