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Arthroscopy's Advances
Technological innovations and state-of-the-art tools have dramatically improved joint surgery.
Patrick Connor
Publish Date: July 25, 2014   |  Tags:   Surgical Video and Imaging
arthroscopic technology SEE YOUR WAY CLEAR Arthroscopic technology allows minimally invasive views and interventions where open surgery was once the only option.

The combination of technology, technique and skill that drives arthroscopy lets surgeons examine, clean up and reconstruct joint anatomy through minimally invasive incisions and ready patients for outpatient discharges and rapid rehabilitation. Here are some of the ways arthroscopy’s advances over the past decade or two have made the process more efficient, more effective and safer.

Visual evolution
The most commonly performed arthroscopic procedures, by a long margin, are meniscectomies in the knees and shoulder repairs of all types, such as rotator cuff and labrum tears. Knees and shoulders are large joints, so those areas are amenable to arthroscopy, but the reason why they see the most frequent treatment is simple epidemiology: They’re the joints that are injured most often. But arthroscopy enables a view into any joint — knee, shoulder, hip, ankle, elbow or wrist — and the view has only improved over time.

The original innovation of arthroscopy in the mid-1960s was its pencil-thin probe, which, when coupled with a light source and magnifying lens, offered orthopedic surgeons a look inside the joint without opening it up. Since then, the arthroscope has evolved into even more sophisticated equipment. Fiber optics have replaced bulbs for providing light, while high-definition miniaturized cameras and video monitors have changed the view of surgery and, in turn, improved surgeons’ abilities to maneuver in and around joints. The advent and widespread adoption of exquisitely good HD scopes and monitors allow unparalleled opportunities to diagnose and treat.

Surgeons can also capture the images they see, recording still photos and videos digitally with the press of a button at the base of the scope. Physicians use that ability toward a range of different purposes. For my part, I’m most often using captured images to document the injury that existed and to demonstrate what was accomplished by the conclusion of the case. This is a useful reference not only for the patient’s chart, but also for the physical therapist who’s managing the patient’s rehabilitation. It’s important for them to see the pathology they’re working with, but cartilage, ligaments and tendons aren’t highly visible through radiographic images.

shoulder repair surgery SHOULDER THE LOAD Patrick M. Connor, MD, performs a shoulder repair surgery at OrthoCarolina in Charlotte, N.C.

Tools and action
It cannot be overstated how revolutionary arthroscopic tools have been to joint surgery. The development of arthroscopic instruments that, like the scope, gain access to the joint through small incisions allows for a rapid transition from diagnosis of the condition to treatment and repair. Arthroscopic shavers debride torn and damaged tissue and arthroscopic burs mill down the bone spurs causing irritation. Tools that integrate suction ability can capture and remove the trimmed tissue and bone dust instantly.

One of the biggest arthroscopic instrument advances over the past 15 years or so has been electrosurgical wands to ablate or cauterize tissue. Cautery devices are helpful for stopping bleeding in all types of cases, but these wands work while submerged in irrigation fluid at a minimally invasive surgical site. Previous arthroscopic electrocautery options were more primitive, limited in their power settings and more risky in terms of the potential for thermal injury to adjacent tissue.

The latest tools make it possible for surgeons to perform surgeries they thought they’d never do through a scope. Morbidity is decreased and outcomes may also be improved. Consider, for example, the traditional method of repairing a torn rotator cuff. We’d have to make a sizable skin incision, detach the deltoid muscle, reach the depth of the injury, chisel down the bone spur, manually sew up the tear, then repair the deltoid we’d detached before closing the incision. Arthroscopically we can perform the same repair just as well or better without causing such tissue trauma in the process. The same goes for replacing torn anterior cruciate ligaments with grafts, or other joint procedures that used to require extensive exposure.

arthroscopic images and video KNEE DEEP Surgeons have the ability to capture arthroscopic images and video at their fingertips.

Fixation and fluid flow
The bone-and-tissue repairs of joint surgery demand a mechanism by which tissue can be fixed to bone. High-strength suture is often the solution, but tying a reliable, stable knot through the straw’s-width of an arthroscopic access port can prove challenging.

In recent years, we’ve seen the introduction of a wide variety of knot-tying devices and insertable, pre-tied implant systems for rotator cuff and meniscus repairs. One particularly advanced technology lets surgeons tighten up noose-like sutures that have already been tied. Such innovations stand to make surgery more efficient and help surgeons to deliver more reproducible results.

Joints are essentially collapsed spaces. Fluid irrigation is necessary to keep the joint space open in order to insert scopes to visualize anatomy and instruments to treat injuries. A continual, consistent flow of saline solution ensures that the fluid remains clean enough to see through and the pressure remains high enough to keep the joint open.

Traditionally, this inflow has been the work of gravity. A bag of saline is hung on an IV pole and tubing feeds the fluid into the joint, with the pressure controlled through strategic raising and lowering of the bag. The circulating nurse must keep a close eye on the fluid level and replace emptying bags in time to prevent disruption of the flow. Setting up multiple bags to dispense fluid simultaneously but staggered can help to avoid disruption. Arthroscopic shavers and suction devices can help to remove outflowing fluid waste and forestall extensive post-procedure mopping and cleanup.

A number of specialized arthroscopy pump systems are commercially available, which not only offer more precise control over fluid inflow and capture of outflow, but also ensure balanced pressure in the joint for a more stable operative site. This is particularly important in shoulder surgeries. While the knee is encapsulated and does not experience as much swelling as a result of fluid flow, the shoulder’s anatomy is different, and the risk of painful swelling and complications increases over time.

surgical innovation OVERALL OUTCOME The ultimate measure of surgical innovation is its impact on patient care.

Assessing the advances
A lot of technological tweaks have been introduced into arthroscopic surgery, which promise previously unattainable techniques or efficiency. Some are helpful developments, while others are flashes in the pan. Does efficiency equate to better outcomes? Not always. One of the things we surgeons and administrators struggle with is determining which are true advances for the field.

The key to adopting new technology — in other words, approving the purchase of new equipment — is assessing the available options as a team. The expensive scope system may be great for the surgeon, but a burden on the facility’s budget. The inexpensive one might be more manageable on the bottom line, but it may affect the quality of surgical visualization. And which one’s components will the sterile processing department be able to turn around in time to keep up with the daily OR schedule? Taking a team approach can get views from all angles.

Above all, though, find out what you can about the technology through the available research and scientific data. Are its best outcomes reproducible? All surgical devices ultimately are judged by the roles they play in facilitating successful patient outcomes.

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