LOOKING AHEAD 4K video is still out of reach for most, but several other tools and techniques can help surgeons achieve the visual acuity they seek.

Innovative technology keeps providing better and better views in arthroscopic surgery, but there's merit to some old-fashioned techniques, as well, when you're trying to make sure your view is as clear and crisp as it can possibly be. Here are several areas to consider when you're about to repair a troublesome shoulder, elbow, hip, knee or ankle — and you want to make sure what you get is what you see.

• 4K HD. Perched atop the food chain of arthroscopic visualization is 4K ultra-high-definition with its rich spectrum of colors, vivid depth perception and lifelike clarity.

When high-def cameras and monitors came along, we wondered how we ever got along without them. And many of us assumed that was about as good as it could get. But as the 4K pioneers and purveyors will tell you, the incremental leap from HD to 4K may be even more impactful. Some 4K systems even let you optimize your view depending on the kind of work you're doing — laparoscopic, arthroscopic or endoscopic. But the reality is that for many — if not most — 4K is out of reach, at least for the time being. As prices come down and facilities transition, it may become the new standard, but for now, most of us are still working in simple high-def mode. Fortunately, however, there are other tools and techniques we can use to achieve the visual acuity we seek.

• Through the fog. The technology that helps military personnel see their way through clouds, smoke and other harsh air and land conditions has been co-opted by at least one manufacturer to help surgeons see their way through the fog, smoke and debris of arthroscopy.

A sophisticated algorithm can brighten images in dark and posterior compartments of joints, desaturate colors and use edge enhancement to increase the detail and contrast of specific structures.

Is it cost-effective? The manufacturer says so. I can't say for certain, but if it shortens the length of surgery by allowing you to spend less time dealing with smoke, blood, cloudy water and other debris, it seems likely. We all know how expensive every minute of OR time is.

ON TARGET Optimal portal placement and the right angled scope help put arthroscopic knee repair in the right perspective.

• LEDs. When it comes to light sources, Xenon has long been a staple, but LEDs seem to be the new trend. They do seem to provide a little brighter illumination, along with a more compact interface and a longer lifespan, with some companies now promising up to 50,000 hours.

• Portal placement. Of course no matter how good your lighting is, or how sophisticated your instruments are, if your portal isn't in precisely the right place, you're going to have a heck of a time seeing what you want to see. A technique I learned years ago and still use is to use a spinal needle to make sure I have the exact placement I need.

If I'm doing a routine knee arthroscopy, or ACL or meniscus repair, and I want to make sure the angle of my portal allows me to get to the location I need, I make a little needle stick in the skin and advance the spinal needle all the way across the joint until I can actually touch the structure I want to repair. Let's say I want to be able to hit the back of the medial compartment. If my portal is too high on the medial side, I'm going to run into the femoral condyle. If it's too low, I'm going to run into the tibial plateau. But the spinal needle makes it easy to get just the right elevation. I can make several needle sticks, if necessary. And once I've localized the proper location, I can remove the needle and advance an 11 blade to make the portal incision right where the mark is. It's a technique that eliminates guesswork.

• Fluid pressure. As every orthopedic surgeon knows, maintaining optimal fluid pressure is an extremely important component of visualization. But it can be challenging to strike the right balance between controlling bleeding and pumping too much fluid into the joint. You don't want to over-pressurize and have the area around the joint blow up like a water balloon.

Here's where I stumbled upon an old-fashioned technique that for me works better than fluid pumps. And Isaac Newton would have loved it.

That's right, gravity. I'd tried a couple of pumps, but they didn't always seem accurate to me, and occasionally my joints were getting over-pressurized. Then I happened to observe a surgeon who was doing a posterolateral corner reconstruction, and I noticed he wasn't using a pump. When I asked about it, he said he'd given it up 5 years earlier, because he'd had the same complaint I'd had. Get your hospital to buy an irrigation tower, he said, and you'll never go back. That was 7 years ago, and he was right: I haven't gone back.

Some surgeons will say it's absurd — that they would never give up their pumps, and that I must be stuck in a different century. But for me, simple gravity works better. The tower is like a giant rolling IV pole with a pulley system, so the circulating nurse doesn't have to lift multiple 10-pound bags of fluid way up over her head several times throughout a procedure. You just hook up the fluid bag, plug it into the hoses, raise it up with the pulleys and use the height of the bag to regulate the flow, lowering it when you want to decrease the flow. You can have 2 bags going at once, or you can clamp one and just keep the other one going. My tower has places for 4 bags, so they can be changed out without having to stop, and we can always stay ahead.

If you have a shiny new pump that works for you, I won't argue with you. But the simple old-fashioned way turned out to be a eureka moment for me, and it's also a money-saver.

• 70-degree scope. The vast majority of orthopedic surgeons rely heavily on 30-degree arthroscopes for shoulders, knees and ankles, but it's important to have a 70-degree scope in your arsenal, too — and to know when to use it.

For example, in elbow arthroscopy, the 70 is very helpful when you want to see the coronoid fassa and look for loose bodies in the anterior compartment. In the gutters especially, it's nice to have. Or, if you're working in the posterior knee compartment — and you want to be able to see the posteromedial and posterolateral recesses, that's very easy to do. Just put the 70-degree scope right through the middle on either side of one of the cruciate ligaments, depending on which compartment you want to see, and it will let you see around the corner much better. The same goes for ankle reconstruction. If you're looking for Talar Dome osteochondral lesions, it's nice to have the 70-degree scope.

I actually look forward to the day when we'll have flexible scopes in orthopedics, like those that are available to gastroenterologists. Not only would we improve visualization, but also we'd be less likely to ding some of the internal structures that rigid scopes can bump up against.

• Fluid waste. If you're using coblation to dissect and remove tissue, you'll create less debris, but coblation wands can also produce bubbles, and if you don't have a good evacuation system, you're not going to evacuate those bubbles as well. So another thing to consider is a fluid waste management system with a large canister. You'll be able to maintain visualization better by regulating the suction, and of course you'll make life easier for the OR team, because they'll have to empty just one container of used arthroscopic fluid at the end of the case. OSM