The Arthroscopy Book

Prévia do material em texto

In 1984, Casscells stated "Diagnostic arthroscopy and, perhaps
even more important, arthroscopic surgery constitute what is
probably the outstanding achievement in orthopedic surgery
in the past decade" (Casscells 1984). While the author of this
statement would probably admit to being biased, it is a
fair reflection on the success and acceptance of the role of
arthroscopy in human orthopedics. Although generally
considered a modern surgical procedure, the technique took
considerable time to develop. The first endoscopic examin-
ation of a knee joint was performed in 1918 by Professor Takagi
at the University of Tokyo (Takagi 1933). Later the technique
was pioneered in the United States by Burman and colleagues
(Burman 1930, Burmanet aI1934). The first practical arthro-
scope was developed by Watanabe (a pupil of Takagi) in 1960
(Watanabe 1960), and he also developed some basic principles
for arthroscopy of the knee. In 1965, his techniques were
brought to North American by Robert Jackson of Toronto
(Jackson 1987).
In the early 1970s, the arthroscope began to achieve real
clinical use (Casscells 1971, Jackson & Dandy 1972), and the
first course in arthroscopy of the human knee in the United
States was given in 1973. The procedure of diagnostic
arthroscopy initially met with considerable skepticism within
circles of human orthopedic specialists until its value was
demonstrated in the total evaluation of the knee (Dandy &
Jackson 1975, Watanabe et a11978, Casscells 1980). There-
after, arthroscopy became firmly established as a diagnostic
tool in human orthopedic practice, and these early days have
been the subject of reviews by Casscells (1987) and Jackson
(1987); the interested reader is referred to these sources for
more information.
In the middle of the 1970s, arthroscopy moved into the
second phase of its development, with the realization of the
potential to perform surgery under arthroscopic visualization
(O'Connor 1974, 1977, Dandy 1981, Jackson 1983). The
development of appropriate techniques and suitable instru-
mentation followed (Johnson 1977, O'Connor 1977, Dandy
1981). It also became apparent that the therapeutic advan-
tages of arthroscopy included not only the surgical procedures
per se (which can be grouped under the heading of surgical
arthroscopy or arthroscopic surgery) but also the benefits
from joint lavage and lysis of adhesions (Jackson 1974,
O'Connor 1974). The advantages were low morbidity, early
postoperative movement and reduced hospitalization times.
Impressive advances then occurred in both technology
and technique. The first arthroscopic surgery was meniscectomy
in humans, followed by procedures such as patellofemoral
malalignment, abrasion arthroplasty, shaving for chondro-
malacia, and synovectomy. The advantages of arthroscopic
meniscectomy have been well documented and arthrotomy is
now a rarity (Pettrone 1982, McGinty 1987). The manage-
ment of conditions involving the meniscus is also a good
example of how new concepts have evolved from the increased
diagnostic accuracy afforded by arthroscopy and the potential
to re-examine a knee with minimal morbidity Gackson 1986).
The most important of these new concepts was probably the
preservation of meniscal tissue, which led to the technique of
partial meniscectomy and then to initial arthroscopic repair
(Keene et al 1987). The development of more complex
procedures followed and cruciate repairs are now performed
arthroscopically (Shrock & Jackson 1996). The use of
arthroscopy in man now encompasses the shoulder, elbow,
wrist, digital, ankle, hip, and temporomandibular joints
G ohnson 1986). It is the most common orthopedic procedure
performed today; current estimates cite approximately 9000
orthopedic surgeons performing arthroscopy in the United
States alone (McGinty 1987).
Arthroscopy in the horse has gone through a similar
evolution. In 1949, the human pioneer Watanabe reported
arthroscopy of the equine hock. Large animal arthroscopy
was first presented in the German literature in 1973
(Knezevic pers com 1984) and appeared in the English
language in 1975 and 1977 (Smith 1975, Knezevic& Wruhs
1977). Diagnostic arthroscopy of the equine carpus was first
reported in 1974 (Hall & Keeran 1975), but was described
more extensively by McIlwraith & Fessler in 1978. Reports of
its use in other joints followed and diagnostic arthroscopy of
the equine stifle joint was reported in 1982 (Nickels & Sande
1982).
As in human orthopedics, use of the arthroscope in horses
extended into surgical practice as technology and techniques
of triangulation developed. Some surgical manipulations
under arthroscopic visualization in the horse were mentioned
by Knezevic & Wruhs in 1977, but arthrotomy remained the
accepted means of completing surgery. The first description of
equine arthroscopic surgery involved the carpus (Ommert
1981, Valdez et al1983) and further descriptions involved
the carpal, fetlock, tarsocrural, and femoropatellar joints
198J). Uescriptions of diagnostic and surgical arthroscopic
procedures in the carpal, fetlock. tarsocrural and femoro-
patellar joints were detailed in textbook form in 1984
(McIlwraith 1984b). At that time, the first author used
arthroscopic surgery as the routine method of joint surgery
for virtually all conditions, with the exception of subchondral
cystic lesions of the medial condyle of the femur. some carpal
slab fractures. and fractures of the proximal sesamoid bones.
Arthroscopic techniques were subsequently developed and
described in the second edition of the book in 1990
(McIlwraith 1990a). The use of arthroscopic surgery in the
treatment of third carpal slab fractures was reported by
Richardson in 1986; its use in the treatment of subchondral
cystic lesions in the medial condyle of the femur was docu-
mented originally by Lewis in 1987. Techniques for diagnostic
and surgical arthroscopy of the shoulder were described in
1987 (Bertone & McIlwraith 1987. Bertone et al 1987.
Nixon 1987). At the time of the second edition, arthroscopy
had also been performed in the distal interphalangeal.
proximal interphalangeal, and elbow joints. Arthroscopes
had also been used in the sinuses and tendon sheaths
(McIlwraith 1990a).
By 1990, arthroscopy in the horse had gone from being a
diagnostic technique used by a few veterinarians to the
accepted way of performing joint surgery. Prospective and
retrospective data substantiated the value of the technique in
the treatment of carpal chip fractures (McIlwraith et al19 8 7).
fragmentation of the dorsal margin of the proximal phalanx
(Yovich & McIlwraith 1986). carpal slab fractures (Richardson
1986), osteochondritis dissecans of the femoropatellar joint
(Martin & McIlwraith 1985a, McIlwraith & Martin 1985),
osteochondritis dissecans of the shoulder (Bertone et alI987).
and subchondral cystic lesions of the femur (Lewis 1987).
During this period. the use of diagnostic arthroscopy led to
the recognition of previously undescribed articular lesions,
many of which are now also treated using arthroscopic
techniques.
Since 1990. there has been further sophistication of
techniques: new ones have been developed and treatment
principles have been changed based on new pathobiologic
knowledge and further prospective and retrospective studies
defining the success of various procedures. Many of these
recent advances have been recorded in a recent publication
(McIlwraith 2002a). For example. there has been further
documentation of success rates following arthroscopic
removal of fragments from the dorsoproximal margin of the
proximal phalanx (Kawcak & McIlwraith 1994, Colon et al
2000). Advances in understanding the pathogenesis of
osteochondral disease and fragmentation in the carpus and
fetlock have also been reported (Kawcak et al 2000. 2001).
which naturally led to progress in diagnosis and treatment.
Parameters for thesurgical treatment of joint injury have
been carefully defined (McIlwraith & Bramlage 1996).
Arthroscopic treatment of fractures in the previously con-
sidered inaccessible palmar aspect of the carpus has been
described (Wilke et al 2001) together with arthroscopy of
the palmar aspect of the distal interphalangeal joint
also led to understanding of the contribution of soft tissue
lesions to joint disease. In the carpus, tearing of the medial
palmar intercarpal ligament was first reported by Mcllwraith
in 1992 and its implications discussed by Phillips & Wright
(1994) and Whitton et al (1997a,b,c).
In the fetlock joints, success rates following arthroscopic
removal of osteochondral fragments of the palmar/plantar
aspect of the proximal phalanx have now been documented
(Foerner et al 1987, Fortier et al 1995), and results for
arthroscopic treatment of osteochondritis dissecans of the
distal dorsal aspect of the third metacarpal/metatarsal bones
have been reported (Mcllwraith & Vorhees 1990). Results of
arthroscopic surgery to treat apical (Southwood & Mcllwraith
unpublished data), abaxial (Southwood et al 1998a), and
basilar (Southwood & Mcllwraith 2000) fragments of the
sesamoid bones are also available in the literature.
Since the last edition, the results of arthroscopic surgery
for the treatment of osteochondritis dissecans in the tarso-
crural joint have been documented (Mcllwraith et al1991)
and the arthroscopic approach and intra-articular anatomy
of the plantar pouch of the joint have also been described
(Zamos et aI1994).
Considerable advances have been made in arthroscopic
surgery of the stille joints. The results of arthroscopic surgery
for the treatment of osteochondritis dissecans of the femoro-
patellar joint have been reported by Foland et al (1992). The
syndrome of fragmentation of the distal apex of the patella
was recognized and its treatment reported (Mcllwraith
1992). The use of arthroscopic surgery for treating certain
patellar fractures was discussed in the previous edition
and has since been reported in the literature (Marble &
Sullins 2000).
In the femorotibial joints, the use of arthroscopic surgery
to treat subchondral cystic lesions of the medial condyle of
the femur (Howard et al19 9 5) and proximal tibia (Textor et al
2001) have been reported. Cartilage lesions of the medial
femoral condyle have also been described (Schneider et al
1997). Arthroscopy has allowed great advances in the recog-
nition and treatment of meniscal tears and cruciate injuries
(Walmsley 1995, 2002; Walmsleyet al2003). It has also been
used to remove fragments from the intercondylar eminence of
the tibia (Mueller et al1994) and allow internal fixation of
another case of intercondylar eminence fracture (Walmsley
1997). Techniques have also been developed for diagnostic and
surgical arthroscopy of the caudal pouches of the femorotibial
joints (Stick et al 1992, Hance et al 1993, Trumble et al
1994). In addition, a single cranial arthroscopic approach to
all three joint compartments has been developed by Boening
(1995) and further reported by Peroni & Stick (2002).
Diagnostic and surgical arthroscopy of the coxofemoral
joint has been described (Nixon 1994, Honnas et al1993),
lesions identified and surgical treatments performed. The use
of the arthroscope is also no longer confined to the limbs, and
the anatomy of the temporomandibular joint has been
described recently (Weller et aI2002).
The use of arthroscopy in assisting repair with internal
fixation of articular fractures has become routine. This
previously possible. With the availability of such an a
traumatic technique. numerous lesions and "new" con-
ditions that are not detected radiographically can be
recognized.
2. All types of surgical manipulations can be performed
through stab incisions under arthroscopic visualization.
The use of this form of surgery is less traumatic, less
painful, and provides immense cosmetic and functional
advantages. Surgical intervention is now possible in
situations where it would not have been attempted
previously. The decreased convalescence time with earlier
return to work and improved performance is a significant
advance in the management of equine joint problems. The
need for palliative therapies is decreased, as is the number
of permanently compromised joints.
The initial optimism and advantages of arthroscopy in
equine orthopedic practice suggested in the first two editions
of this book have been substantiated. It is now accepted that
equine arthroscopic surgery has revolutionized equine ortho-
pedics. Problems have and will continue to be encountered,
but we know now that many are avoidable. Although the
technique appears uncomplicated and attractive to the
inexperienced surgeon, some natural dexterity, good three-
dimensional anatomical knowledge, and considerable practice
are required for the technique to be performed optimally.
Experience and good case selection are of paramount
importance and reiterating a passage from the first edition of
this book remains as pertinent today:
In 19 75. arthroscopy was underused and needless arthrotomies
were performed. The pendulum is now swinging rapidly in the
other direction. The current tendency in arthroscopy is toward
overuse. Some surgeons seems to be unable to distinguish
between patients who are good candidates for arthroscopy and
those who are not. and the trend is toward arthroscopy in patients
in whom little likelihood exists of finding any treatable disorder.
(Casscells 1984).
Three years later, another author stated that
of those 9,000 North American surgeons and the other surgeons
of the world performing arthroscopy, many are ill-prepared and
are therefore, not treating their patients fairly, Overuse and abuse
by a few is hurting the many surgeons who are contributing to
orthopedic surgery by lowering patient's morbidity, decreasing
the cost of health care, shortening the necessary time of patients
returning to gainful employment, and adding to the development
of a skill that has made a profound change in the surgical care of
the musculoskeletal system. (McGinty 1987).
Arthroscopy remains the most sensitive and specific diagnostic
modality for intrasynovial evaluation in the horse. This
is somewhat in contrast to human orthopedics, where
arthroscopy predominately is used for surgical interference
and much of its diagnostic function has or is being replaced
by magnetic resonance imaging (MRI). Arthroscopy has
continued to be of great benefit in the horse, with increased
recognition of soft tissue lesions in joints, tendons, sheaths,
and bursa. However, as stated above, while there are many
benefits gained from arthroscopy, it is technically demanding
and the need for training remains.
includes fractures of the metacarpal/metatarsal condyles and
carpal slab fractures (Richardson 2002, Bassage & Richardson
1998, Zekas et aI1999), Techniques have been described for
evaluation and treatment of so-called small joints, such as the
distal and proximal interphalangeal joints (Boening 2002,
Boening et a11990, Vail & McIlwraith 1992, Schneider et al
1994), In addition, joints in which lameness is less commonly
encountered. such as the elbow can also be examined
and treated arthroscopically (Nixon 1990),
Arthroscopic techniques for cartilage repair have been
developed and recently reviewed (McIlwraith & Nixon 1996,
Nixon 2002b), In general, we have tried to develop techniques
that enhance both the quantity and hyaline characteristics of
cartilage repair tissue while using the well-documented
advantages of arthroscopic surgery. Techniques include
cartilage debridement, cartilage reattachment. chondroplasty
and subchondral microfracture (micropicking) (McIlwraith &
Nixon 1996, Frisbie et al1999, Nixon 2002b).
The use of the arthroscope for evaluation and treatment of
tendon sheath problemshas been another area of major
advancement. The arthroscope has been used to assess and
treat tenosynovitis of the digital flexor tendon sheath, and
techniques for endoscopically assisted annular ligament
release have been described (Nixon 1990b. 2002a. Nixon et al
1993. Fortier et aI1999). Intrathecal longitudinal tears of
the digital flexor tendons have also been described by Wright
& McMahon (1999) and by Wilderjans et al (2003). The
arthroscope has also been increasingly useful for carpal sheath
conditions (McIlwraith 2002a. Nixon et a12003, Textor et al
2003); arthroscopic approaches have been described by
Cauvin et al (1997) and Southwood et al (1998b). Removal
of radial osteochondromas using arthroscopic visualization
is a significantly improved technique to open approaches
(Squire et al 1992) and has produced excellent results
(Southwood et al1999, Nixon et al2003, McIlwraith 2002b).
The use of tenoscopic division of the carpal retinaculum to
open the carpal canal has been recently described (Textor et al
2003) and superior check ligament desmotomy is now done
arthroscopically (Southwood et al 1997, Kretz 2001. Tech-
niques for tenoscopy of the tarsal sheath have been described
by Cauvin et al (1999) and methods of treatment reported by
Nixon (2002a).
Synovial bursae have also been examined with the
arthroscope. Techniques have been described for arthroscopy
for the intertubercular bursa (Adams & Turner 1999), the
calcaneal bursa (Ingle-Fehr & Baxter 1998). and the navicular
bursa (Wright et aI1999). To date, reports in the literature
have been dominated by cases of contamination and infection.
but lesions which explain previously undiagnosed lameness
referable to these sites have now been identified and treated
endoscopically.
Specific advantages of arthroscopy as a diagnostic
and surgical tool are mentioned throughout this book.
General advantages of the technique previously recognized
include:
1. An individual joint can be examined accurately through a
small (stab) incision and with greater accuracy than was
l'\eTerence~ t!oruer Lf\. NIXon Aj. Uucharme NG. et al. Tenoscopic examinatioI
and proximal annular ligament desmotomy for treatment 0
equine 'complex' digital sheath tenosynovitis. Vet Surg 1999; 28
429-435.
Frisbie DD. Trotter GW, Powers BE, et al. Arthroscopic subchondra
bone plate rnicrofracture technique augments healing of larg(
chondral defects in the radial carpal bone and medial femora
condyle of horses. Vet Surg 1999; 28: 242-255.
Hall ME. Keeran RJ. Use of the arthroscope in the horse. Vet Me(
Small Anim Clin 1975; 70: 705-706.
Hance R. Schneider RK. Embertson RM, et al. Lesions of the cauda
aspect of the femoral condyles in foals: 20 cases (1980-1990)
JAmVetMedAssoc 1993; 202: 637-646.
Honnas CM. Zamos DT. Ford TS. Arthroscopy of the coxofemora
joint of foals. Vet Surg 1993; 22: 115-121.
Howard RD. Mcllwraith CWo Trotter. GW: Arthroscopic surgery fol
subchondral cystic lesions of the medial femoral condyle iI1
horses: 41 cases (1988-1991) J Am Vet Med Assoc 1995; 206
846-850.
Ingle-Fehr IE. Baxter GM. Endoscopy of the calcaneal bursa in horse.
VetSurg 1998; 27: 561-567.
Jackson RW: The role of arthroscopy in the management of the
arthritic knee. cun Orthop 1974; 101: 28-35.
Jackson RW: Current concepts review. Arthroscopic surgery. J Bone
Joint Surg (Am) 1983; 65: 414-420.
Jackson RW: The scope of arthroscopy. Clin Orthop 1986; 208:
69-71.
Jackson RW. Memories of the early days of arthroscopy:
1965-1975. The formative years. Arthroscopy 1987; 3: 1-3.
--
l\.oams MN. rurner lA. hndoscopy of the intertubercular bursa in
horses.JAmVetMedAssoc 1999; 214; 221-225.
Bassage LH II. Richardson DW. Longitudinal fractures of the
condyles of the third metacarpal and metatarsal bones in
racehorses; 224 cases (1986-1995). J Am Vet Med Assoc 1998;
212: 1757-1764.
Bertone AL. Mcllwraith CW: Arthroscopic surgical approaches and
intra-articular anatomy of the equine shoulder joint. Vet Surg
1987; 16: 312-317.
Bertone AL. McIlwraith CWo Powers BE. Trotter GW. Stashak TS.
Arthroscopic surgery for the treatment of osteochondrosis in the
equine shoulder joint. Vet Surg 1987; 16: 303-311.
Boening KJ. Die arthroscopie des kniegelenkes bein pferd uber einen
zentralen zugang ou teill: Methodik Pferdehilkund 1995; 11:
247.
Boening KJ. Arthroscopic surgery of the distal and proximal
interphalangeal joints. Clin Equine Pract 2002; 1: 218-225.
Boening KJ. Saldern FC. Leendertse I. Rahlenbeck F. Diagnostic and
surgical arthroscopy of equine coffin joints. Proc Am Assoc
Equine Pract 1990; 36: 331-317.
Brommer H. Rijkenhuizen AM. van den Belt HAM. et al. Arthroscopic
removal of an osteochondral fragment at the palmaroproximal
aspect of the distal interphalangeal joint. Equine Vet Educ 2001;
13: 294-297.
Burman MS. Arthroscopy or the direct visualization of joints. An
experimental cadaver study. J Bone Joint Surg. 1930; 13: 669-695.
Burman MS. Finkelstein H. Meyer L. Arthroscopy of the knee joints.
J Bone Joint Surg 1934; 16: 255-268.
Casscells SW: Arthroscopy of the knee joint: a review of 150 cases.
J Bone Joint Surg (Am.) 1971; 53: 287.1971.
Casscells SW. The place of arthroscopy in the diagnosis and
treatment of internal derangement of the knee: an analysis of
1.000 cases. Clin Orthop 1980; 151: 135-142.
Casscells SW. Arthroscopy: diagnostic and surgical practice.
Philadelphia: Lea and Febiger; 1984.
Casscells SW: The early days of arthroscopy in the United States.
Arthroscopy 1987; 3: 71-73.
Cauvin ERJ. Munroe GA. Boyd JS. Endoscopic exannnation of the
carpal flexor tendon sheath in horses. Equine Vet J 1997; 29:
459-466.
Cauvin ER. Tappres 'IJ. Monroe GA. et al. Endoscopic examination of
the tarsal sheath of the lateral digital flexor tendon in horses.
Equine VetJ 1999; 31: 219-227.
Colon JL. Bramlage LR. Hance SR. Embertson RM. Qualitative and
quantative documentation of the racing performance of 461
thoroughbred racehorses after arthroscopic removal of dorso-
proximal first phalanx osteochondral fractures (1986-1995).
Equine Vet J 2000; 32: 475-481.
Dandy DJ. Arthroscopic surgery of the knee. Edinburgh: Churchill
Livingstone; 1981.
Dandy DJ. Jackson RW. The impact of arthroscopy on the
management of disorders of the knee. J Bone Joint Surg (Br)
1975; 57: 346-348.
Foerner JJ. Barclay WP. Phillips TN. et al. Osteochondral fragments of
the palmar/plantar aspect of the fetlock joint. Proc Am Assoc
Equine Pract 1987; 33: 739-744.
Foland JW. McIlwraith CWo Trotter GW. Arthroscopic surgery for
osteochondritis dissecans of the femoropatellar joint of the horse.
Equine Vet J 1992; 24: 419-423.
Fortier LA. Foerner ll. Nixon AJ. Arthroscopic removal of axial
osteochondral fragments of the plantar/palmar proximal aspect
of the proximal phalanx in horses: 119 cases (1988-1992). J Am
Vet Med Assoc 1995; 206: 71-74.
Johnson LL. Lompl"nenslve arLnroscoplC examination of the knee.
StLouis: Mosby; 1977.
Johnson 11. Arthroscopic surgery: principles and practice. St. Louis:
Mosby; 1986.
Kawcak CE, Mcllwraith CW: Proximodorsal first phalanx osteo-
chondral chip fragments in 320 horses. Equine Vet J 1994; 26:
392-396.
Kawcak CE, Mcllwraith CW, Norrdin RW, et al Clinical effects of
exercise on subchondral bone of carpal and metacarpophalangeal
joints in horses. AmJ Vet Res 2000; 61: 1252-1258.
Kawcak CE, McIlwraith CW, Norrdin RW, et al. The role of
subchondral bone in joint disease: a review. Equine Vet J 2001;
33: 120-126.
Keene CCR, Paterson RS, Teague DC. Advances in arthroscopic
surgery. Clin Orthop 1987; 224: 64-70.
Knezevic RF, Wruhs O. Arthroscopy in the horse, ox, pig, and dog.
Vet Med. Rev 1977; 1: 54-63.
Kretz MR. Clinical evaluation of 49 tenoscopically assisted superior
check ligament desmotomies in2 7 horses. Proc Am Assoc Equine
Pract 2001; 47: 484-487.
LewisRB. Treatment of subchondral bone cysts of the medial
condyle of the femur using arthroscopic surgery. Proc Am Assoc
Equine Pract 1987; 33: 887-893.
Marble GP, Sullins KE. Arthroscopic removal of patellar fracture
fragments in horses: 5 cases (1989-1998). J Am Vet Med Assoc
2000; 216: 1799-1801.
Martin GS, Mcllwraith CW: Arthroscopic anatomy of the equine
femoropatellar joint and approaches for treatment of osteo-
chondritisdissecans. VetSurg 1985; 14: 99-104.
Martin GS, Mcllwraith CWo Arthroscopic anatomy of the intercarpal
and radiocarpal joints of the horse. Equine Vet J 1985; 17:
373-376.
McGinty JB. Arthroscopy: a technique or a subspecialty? Arthroscopy
1987; 3: 292-296.
Caudal radial exostosis as a cause
'1977,
Equine Vet Sci 1981; 5:
177-182.
Peroni]F, Stick JA. Evaluation of a cranial arthroscopic approach to
the stifle joint for the treatment of femorotibial joint disease in
horses: 23 cases (1998-1999). J Am Vet Med Assoc 2002: 220:
1046-1052.
Pettrone FA. Meniscectomy: arthrotomy versus arthroscopy. Am J
Sports Med 1982: 10: 355-359.
Phillips TJ, Wright 1M. Observations on the anatomy and pathology
of the palmar intercarpal ligaments in the middle carpal joints of
Thoroughbred racehorses. Equine Vet J 1994; 26: 486-491.
Richardson DW. Technique for arthroscopic repair of third carpal
bone slab fractures in horses. J Am Vet Med Assoc 1986; 188:
288-291.
Richardson DW. Arthroscopically assisted repair of articular
fractures. Clin Equine Pract 2002; 1: 211-217.
Schneider RK, Ragle CA, Carter BG, et al. Arthroscopic removal of
osteochondral fragments from the proximal interphalagealjoint
of the pelvic limbs in three horses. J Am Vet Med Assoc 1994;
207: 79-82.
Schneider RK, Jenson p, Moore RM. Evaluation of cartilage lesions
on the medial femoral condyle as a cause of lameness in horses:
11 cases (1988-1994). J Am Vet Med Assoc 1997; 210:
1649-1652.
Selway Sf. Arthroscopic surgery: the carpal and fetlock joint. Proc
Am Assoc Equine Pract 1983; 29: 95-109.
Shrock KB, Jackson DW. Arthroscopic management of the anterior
cruciate ligament -deficient knee. In: McGinty JB (ed), Operative
Arthroscopy, 2nd ed Philadelphia: Lippincott Raven; 1996:
511-530.
Smith M. Arthroscopy in large animals. Proceedings of the 11th
Conference of the European Society of Veterinary Surgery, 1975.
Southwood 11, Mcllwraith CWo Arthroscopic removal of fracture
fragments involving a portion of the base of the sesamoid bone in
horses. J Am Vet Med Assoc 2000; 217:2 36-240.
Southwood 11, Stashak TS, Fehr IE, et al. Lateral approach for
arthroscopic removal of solitary osteochondromas from the
distal radial metaphysis in three horses. J Am Vet Med Assoc
1997; 210: 1166-1168.
Southwood 11, Trotter GW, Mcllwraith CWo Arthroscopic removal of
abaxial fracture fragments of the proximal sesamoid bone in
horses: 47 cases (1989-1997).J Am Vet Med Assoc 1998a; 213:
1016-1021.
Southwood 11, Stashak TS, Kainer RA. Tenoscopic anatomy of equine
carpal flexor synovial sheath. Vet Surg 1998b; 27: 15D-157.
Southwood 11, Stashak TS, Kainer RA, et al. Desmotomy of the
accessory ligament of the superficial digital flexor tendon in the
horse with the use of a tenoscopic approach to the carpal sheath.
VetSurg 1999; 28: 99-105.
Squire KR, Adams SB, Widmer WR, et al. Arthroscopic removal of a
palmar radial osteochondroma causing carpal canal syndrome in
a horse. J Am Vet Med Assoc 1992; 201: 1216-1218.
Stick JA, Borg LA, Nickels FA, et al. Arthroscopic removal of osteo-
chondral fragment from the caudal pouch of the lateral femoro-
tibial joint in a colt. J Am Vet Assoc 1992; 200: 1695-1697.
Takagi, K. Practical experience using Takagi's arthroscope. Nippon
Seikeigeka Cakkai Zasshi, 1933; 8: 132.
Textor JA, Nixon AJ, Lumsden J, et al. Subchondral cystic lesions
of the proximal extremity of the tibia in horses: 12 cases
(1983-2000). J Am Vet Med Assoc 2001; 218: 408-413.
McIlwraith CWo The use of arthroscopy. synovial fluid analysis and
synovial membrane biopsy in the diagnosis of equine joint
disease. In: Equine Medicine and Surgery. 3rd edn. American
Veterinary Publications. Santa Barbara, 1982.
McIlwraith CWo Arthroscopic surgery-atWetic and developmental
lesions. Proc Am Assoc Equine Pract 1983: 29: 103-110.
McIlwraith CWo Arthroscopy in Retrospect. Proc Am Assoc Equine
Pract 1984a: 30: 57-66.
Mcllwraith CW Diagnostic and Surgical Arthroscopy in the Horse.
Lenexa: Veterinary Medicine Publishing Company. 1984b.
McIlwraith CWo Experiences in diagnostic and surgical arthroscopy
in the horse. Equine VetJ 1984c: 16: 11-19.
McIlwraith CWo Diagnostic and surgical arthroscopy in the horse
(2nd edn) Philadelphia: FA. Lea & Fibiger; 1990a.
McIlwraith CWo Osteochondral fragmentation of the distal aspect of
the patella in horses. Equine Vet J 1990b; 22: 157-163.
McIlwraith CW: Tearing of the medial palmar intercarpal ligament
in the equine mid-carpaljoint. Equine Vet J 1992; 24: 367-371.
McIlwraith CW (ed). Arthroscopy -An Update. Clinical Techniques
in Equine Practice. Vol. 1. No.4. W.B. Saunders December:
2002a; 199-281.
McIlwraith CWo Osteochondromas and physeal remnant spikes in
the carpal canal. Proc. 12th Ann Vet Symp 2002b: 168-169.
McIlwraith CWo Bramlage LR. Surgical treatment of joint injury. In:
McIlwraith. CWo Trotter GW (eds). Joint disease in the horse.
Philadelphia: WB Saunders. 1996: 292-317.
Mcllwraith CWo Fessler J. Arthroscopy in the diagnosis of equine
joint disease. J Am V~t Med Assoc 1978; 172: 263-268.
McIlwraith CWo Foerner }P. Davis DM. Osteochondritis dissecans of
the tarsocrural joint: results of treatment with arthroscopic
surgery. EqVetJ.1991; 23: 155-162.
McIlwraith CWo Martin GS. Arthroscopy and arthroscopic surgery in
the horse. Comp Cont Educ 1984: 6: S46-S53.
McIlwraith CWo Martin GS. Arthroscopic surgery for the treatment
of osteochondritis dissecans in the equine femoropatellar joint.
VetSurg 1985; 14: 105-116.
McIlwraith CWo Nixon AJ. Joint resurfacing: attempts at repairing
articular cartilage defects. In: joint disease in the horse.
McIlwraith cw: Trotter GW (eds). Philadelphia: WB Saunders;
1996: 317-334.
McIlwraith CWo Vorhees SM. Management of osteochondritis
dissecans of the dorsal aspect of the distal metacarpus and
metatarsus. Proceedings 36th Annual Meeting Am Assoc Equine
Pract 1990; 36: 547-550.
McIlwraith cw: Yovich Jv; Martin GS. Arthroscopic surgery for the
treatment of osteochondral chip fractures in the equine carpus.
J Am Vet Med Assoc 1987; 191: 531-540.
Mueller FOE. Allen D. Watson E. et al. Arthroscopic removal of a
fragment from an intercondylar eminence fracture of the tibia in
2-year-old horse. J Am Vet Med Assoc 1994; 204: 1793-1795.
Nickels FA. Sande. B. Radiographic and arthroscopic findings in the
equine stifle. J Am Vet Med Assoc 1982; 181: 918-922.
Nixon AJ. Diagnostic and surgical arthroscopy of the equine
shoulder joint. Vet Surg 1987; 16: 44-52.
Nixon AJ. Arthroscopic approaches and intra-articular anatomy of
the equine elbow. Vet Surg 1990a; 19: 93-101.
Nixon AJ. Endoscopy of the digital flexor tendon sheath in horses.
VetSurg 1990b; 19: 266-271.
Nixon AJ. Diagnostic and operative arthroscopy of the coxofemoral
joint in horses. Vet Surg 1994; 23: 377-385.
Nixon AJ. Arthroscopic surgery of the carpal and digital tendon
sheaths. Clin Tech in Equine Pract 2002a; 1(4): 245-256.
Nixon AJ. Arthroscopic techniques for cartilage repair. Clin Tech
Equine Pract 2002b; 1(4): 257-269.
Nixon AJ. Sams AE. Duchame NG. Endoscopically assisted annular
ligment release in horses. Vet Surg 1993; 22: 501-507.
dorsomedial intercarpal ligaments of the mid-carpal joint. Vet
Surg 1997a; 26: 359-366.
Whitton RC. Rose RJ. The intercarpal ligaments of the equine mid-
carpal joint. Part II: the role of the palmar intercarpal ligaments
in the restraintof dorsal displacement of the proximal row of
carpal bones. Vet Surg 1997b; 26: 367-373.
Whitton RC. Kannegieter NJ. Rose RJ. The intercarpal ligaments of
the equine mid-carpal joint. Part III: clinical observations in 32
racing horses with mid-carpal joint disease. Vet Surg 1997c; 26:
374-381.
Wilderjans H. Boussaw B, Madder K. Simon O. Tenosynovitis of the
--~ "-"" -
l'extor JA. Nixon AJ. Fortier LA. Tenoscopic release of the equine
carpal canal. Vet Surg 2003; 32: 278-284.
Trumble TN. Stick AJ. Arnoczky SF. et al. Consideration of anatomic
and radiographic features of the caudal pouches of the
femorotibial joints of horses for the purpose of arthroscopy. Am J
Vet Res 1994; 55: 1682-1689.
Vacek JR. Welch RD. Honnas CM. Arthroscopic approach and intra-
articular anatomy of the palmaroproximal and plantaroproximal
aspect of distal interphalangeal joints. Vet Surg 1992; 4:
257-260.
Vail TB. Mcllwraith CWo Arthroscopic removal of an osteochondral
fragment from the middle phalanx of a horse. Vet Surg 1992; 4:
269-272.
Valdez H. Richmond J. Wain L. Fackelman G. Operative arthroscopy
in the horse. Equine Pract 1983; 5: 39-42.
Walmsley JP. Vertical tears in the cranial horn of the meniscus and
its cranial ligament in the equine femorotibial joint: 7 cases and
their treatment by arthroscopic surgery. Equine Vet J 1995; 27:
20-25.
Walmsley Jp. Fracture of the intercondylar eminence of the tibia
treated by arthroscopic internal fixation. Equine Vet J 1997; 29:
148-150.
Walmsley JP. Arthroscopic surgery of the femorotibial joint. Clin
Tech Equine Pract 2002; 1: 226-233.
cases. Equine Vet J 2003; 35: 402-406.
Watanabe M. Takeda S. The 21
Tokyo: Igaku Shoin. 1978.
Weller RR, Maieler 1}. Bowen
Whitton RC. McCarthy Rose RJ. The intercarpal ligaments of equine
mid-carpal joint. Part 1: the anatomy of the palmar and
~
with 300 or 700 lens angles; and a 1.9 mm diameter arthro-
scope with 300 lens angle. Generally. surgeons should choose
the largest diameter arthroscope that can safely be inserted
and maneuvered without causing damage. Small diameter
arthroscopes with appropriate operating instrumentation
have been developed for use in human carpal. metatarso-
phalangeal. and temporomandibular joints (Poehling 1988).
However. these are fragile. allow less illumination. and provide
a much smaller field of view (900 for 2.7-mm scope and 750
for 1.9-mm scope). Small diameter arthroscopes usually also
have a shorter working length (50-60 mm) because the
excessive flexibility of a longer instrument increases the risk
of breakage (Poehling 1988). More recently. a complete range
of sizes has also become available in video arthroscopes.
which are coupled directly to the video camera. This obviates
the need for a coupler and eliminates the potential for fogging
between the arthroscope eyepiece and camera Gackson &
Ovadia 1985). Flexible arthroscopes have also had a period of
limited use. but generally failed to provide true flexibility and
optical clarity (Takahashi & Yamamoto 1997). Combined
approaches. using a rigid arthroscope for most of the procedure
and a flexible arthroscope to access difficult areas of the hip.
ankle. or knee in people. have added to the more thorough
evaluation of these joints (Takahashi & Yamamoto 1997).
A 4 mm diameter arthroscope with a 25 or 300 lens angle
fulfills most needs of the equine surgeon (Fig. 2.1). A 4 mm
700 arthroscope can occasionally provide improved visualiz-
ation of specific areas of some joints such as the tarsocrural.
shoulder. and palmar/plantar aspect of the metacarpo/
of instrumentation is available for human
arthroscopic surgery, but much of it is unsuitable and
unnecessary for equine arthroscopy. Many of the operating
instruments are expensive and fragile; for equine use a
limited amount of equipment is generally essential or
appropriate. The descriptions and recommendations in this
text are based on the authors' experiences and personal
choices and numerous substitutions can be made. Obviously,
the potential for variation is extreme, and it is necessary to
continue to evaluate new instrumentation as it becomes
available or as new arthroscopic procedures are developed.
This chapter represents the authors' current views on
instrumentation.
The available arthroscopes vary in outer diameter, working
length, and in lens angle, which may be straight (0°) or
angled from 5° to 110°. Many manufacturers market 4 mm
diameter arthroscopes with 0°, 30°, or 70° lens angles and
working lengths of 160-175 mm. The field of view is often
115° or more, leading to their classification as "wide field of
view" arthroscopes. Most manufacturers produce small
arthroscopes, usually 2.7 mm diameter arthroscopes with
30° or 70° lens angles; a short 2.7 mm diameter arthroscope
Nephew -Dyonics8 (Fig. 2.3), the 300 Hopkins rod lens
telescope made by Karl Storzb, and the 300 direct view and
video arthroscopes made by Strykerc. Comparable-sized
arthroscopes are also available from Linvatecd, Richard WoW,
Zimmerl, Olympus8, Arthrexh, and other companies. The
advantages of the 25-300 angled lens are: (1) it provides an
increased field of vision; (2) rotating the arthroscope
increases the visual field without moving the arthroscope;
and (3) the end of the arthroscope can be placed at some
distance from the lesions, allowing easier access to the area
with instruments and minimizing the risk of damaging the
arthroscope.
All arthroscopes are used within a protective stainless steel
sleeve or cannula (Fig. 2.4). For a 4-mm arthroscope the
sleeve has a 5 mm or 6 mm diameter, and is connected to the
arthroscope through a self-locking system that varies between
manufacturers. The sleeve has one or two stopcocks for ingress
and/or egress fluid systems. The second stopcock is useful if
the surgeon uses gas and fluid distention interchangeably
during arthroscopy; otherwise, a sleeve with one stopcock
offers greater freedom of movement. A rotating stopcock is
critical to allow the ingress fluid line to be positioned away
from the limb and/or instruments as required. The space
between the sleeve and arthroscope allows flow of ingress
tarsophalangeal joints. Figure 2.2 illustrates the different
fields of view of a 250 arthroscope and a 700 arthroscope in
the same position in a tarsocrural joint. Popular choices in an
arthroscope for routine equine arthroscopy include the 300
videoarthroscope and direct view arthroscopes from Smith &
..Smlth&Nephew-Dyonlcs.150MlnutemanRoad. Andover. MA01810.
Tel: (978) 749-1000. www.smith-nephew.com
.~arIStonVeterlnaryEndoscopy.175 CremonaDrive. Goleta. CA 93117.
Tel: (800) 955-7832. www.ksvea.com
.'Stryker. 5900 Optical Court. San Jose. CA 95138. Tel: (800) 624-4422.
www.strykerendo.com
.dLlnvatec-Conmed Co. 11311 Concept Blvd.. Largo. FL 33773.
Tel: (800) 237-0169. www.linvatec.com
.'RIchard Wolf. 353 Corporate Woods Parkway. Vernon Hills. IL 60061.
Tel: (847) 913-1113. www.richardwolfusa.com
.rZlmmer. PO Box 708. 1800 West Center St.. Warsaw. IN 46581.
Tel: (800) 613-6131. www.zimmer.com
.SOlympus America Inc.. 2 Corporate Center Drive. Melville. NY 11747.
Tel: (800) 848-9024. www.olympusamerica.com
.hArthrex. 2885 South Horseshoe Drive. Naples. FL 34104.
Tel: (800) 933-7001. www.arthrex.com
~
sleeves have a wider diameter (5.8-6.0 mm
These so-called high-flow sheaths are very
for insertion of the sleeve in
In joints with a thick fibrous capsule
used to penetrate the
sharp trocars for insertion and blunt
in the sleeve are now largely redundant.
the arthroscope is provided by a fiberoptic
from a light source. The cable should be a
use of extremely light-sensitive video
by Richard Wolf Medical Instru-
with these light sources using video printers;
careful control of the white balance of the
A light source with a flash unit is largely
-
capture. Thesources may be high-intensity
illumination, xenon arc lamps (100-500 W), or
vapor lamps (McGinty 1984). The xenon light
-the replacement
Dyonics 300XL xenon 300 W source, a Baxter-Edwards!
Reliant 300 W xenon source, and a Stryker X-6000 500 W
xenon source (Fig. 2.7). The bulbs last from 350 to 500 hours,
which represents a recurring cost for busy practices.
Light sources that automatically adjust the light intensity
are useful to minimize the need for manual adjustment of
cold light fountain with 175 or 300-W lamp
-,--,- 2.7), .'Baxter-Edwards, Baxter Healthcare Corp, One Baxter Parkway, Deemeld.
IL 60015. Tel: (847) 948-2000. www.baxter.com
light intensity. Most have a feedback electrical signal from the
camera control to light source for intensity adjustment. The
Dyonics AutoBrite IITM Illuminator, the Stryker X-6000TM
light source, the Baxter-Edwards ReliantTM xenon light
source, and the Karl Storz light source all employ useful
intensity feedback control. Most have the option to use this in
an automatic mode or to switch to manual to override the iris
control. Additionally, many video camera control systems
now also compensate for variation in light intensity, which
reduces the need for light source intensity changes.
Video cameras
Diagnostic and surgical arthroscopy can be performed by
direct visualization through the arthroscope; however, this is
now rarely practical and is no longer recommended. The risks
of contaminating the surgical field and instruments are
obvious. In addition, depth perception and ability to perform
fine movements are severely compromised with the monocular
vision of a small image. Projection of images through a video
screen corrects these deficiencies and allows simultaneous
observation of the procedure by several participants Gackson
& Ovadia 1985). Additionally, video documentation through
still image capture, video recorders, and digital video capture
systems (described later) provide sound surgical training,
client satisfaction, and legal sense. Lightweight video cameras
are attached directly to the eyepiece of the arthroscope
(Fig. 2.8), eliminating the need for the eye to go to the arthro-
scope. This also provides a more comfortable operating
position since the surgeon can stand up straight, and the
hands can be placed at any level. It is also possible for an
assistant to hold the camera, which allows the surgeon use of
both hands to manipulate instruments for fine control or
access to difficult sites.
Solid-state video cameras are now conveniently small and
light and can be attached directly to videoarthroscopes,
eliminating the coupler and any chance of fogging (Fig. 2.9).
The united arthroscope and camera can be cold soaked,
and/or gas sterilized. The solid-state cameras currently
available produce an image from either one or three chips, or
more accurately, closed coupled device (CCD) chips (Whelan
&Jackson 1992, Johnson 2002). These chips produce excellent
image quality. Most modern cameras use digital enhancement
of the image, including motion correction algorithms, but
still output as an analog signal Gohnson 2002). Fully digital
cameras such as the Stryker 988TM video camera can write
directly to a CD without capture devices, and provide a dense
950 lines per inch image that requires an upgraded monitor
to derive the most benefit from its circuitry. Durable and high
image-quality video cameras used by the authors are
available from Karl Storz (Telecom SL camera), Smith &
Nephew -Dyonics (ED-3 and D3 three-chip cameras; HD900
single-chip camera), Stryker Endoscopy (888 and 988 three-
chip cameras), and Arthrex. Several manufacturers produce
autoclavable cameras: for example, the Smith & Nephew -
Dyonics 337 three-chip camera, which can be sterilized using
the flash autoclave cycle. in addition to more routine methods.
These cameras are well sealed. making them durable. but
have previously been available only as single-chip devices.
reducing the image quality. The authors' preferred method of
sterilization is with ethylene oxide gas (see Sterilization of
Equipment). This requires a minimal exposure/ventilation
time of 12 hours and. therefore. is usually suitable only for
the first surgery each day: Cameras for subsequent surgeries
sleeve. In countries where ethylene oxide is not
moisture between the arthroscope and camera
largely eliminated with cameras which have large,
vents is employed. the problem can be
and also by using warm irrigating fluid. Anti-
irrigation system
polyionic fluid is used for joint distention and
~ during surgical arthroscopic procedures. The
an intravenous set connected to
used in human small joint surgery are also frequently
inadequate (Oretorp & Elmersson 1986). The hand pump
allows the surgeon to broadly control the degree of distention
as well as the irrigation flow rate. A relationship between
fluid pressure and fluid extravasation into the soft tissues has
been recognized in man (Morgan 1987); extravasation
occurs at approximately 50 mmHg (Noyes et al 1987).
Control of fluid pressure is therefore desirable.
The most popular system for fluid delivery is now a
motorized pump. Such pumps can provide both high flow
rates and high intra-articular pressures. rThe simplest and
favored pump for two of the authors (C.WM. and I.M.W) is
an infusion pumpk, such as the one illustrated in Fig. 2.11.
Such pumps are relatively inexpensive (Table 2.1) and provide
high flow rates on demand, which is particularly useful for
distention of large synovial spaces (see also Chapter 3), but
automatic control of the pressure is lacking (Bergstrom &
Gillquist 1986, Dolk & Augustini 1989). If an outflow portal
is not open, excessive intra-articular pressures may cause
joint capsule rupture (Morgan 1987). Extravasation of fluid
is also a complication whenever excessive pressures are
generated, and compartment syndrome has occurred using
mechanical pressure delivery systems in man.
The ideal pressure and flow automated pump should be
capable of delivering necessary flow rates on demand, keep
pressure at adequate yet safe levels, and include safety
features such as intra-articular pressure-sensitive shutdowns
and alarms (Ogilvie-Harris & Weisleder 1995). Many new
pumps meet these criteria, including pumps made by Arthrex,
Stryker Endoscopy, Smith & Nephew -Dyonics, Karl Storz,
to apply pressure (Fig. 2.10). This method is satis-
is economical and provides distention superior to
feed developed by suspending the fluids above the
Inc., Baxter Health Care Corp, One Baxter
gravity flow through sleeves
and Linvatec (see Table 2.1; Figs 2.12-2.14). Most provide
pressures from 0 to 150 mmHg and fluid flows as high as
2 L/min. All but the 3M! and Linvatec pumps sense joint
pressures through the single delivery fluid line. These features
facilitate visualization when large joints or motorized
equipment result in a demand for high fluid flows. From a
reliability perspective, the roller pump design of the Arthrex,
Stryker, and Karl Storz pumps provide advantages over th(
centrifugal and piston pump design of other manufacturers
The significant cost of these sophisticated fluid deliver)
systems can be reduced by tubing lines that do not requirt
complete replacement of the entire pump assembly durin{
multiple case schedules. An example is the Arthrex pumI
assembly (see Fig. 2.12) which replaces only the sterile line t<
the patient between cases, providing new fluid delivery foJ
less than one-third the cost of a complete roller pump an<
patient line set-up. Pressure and flow automated pumps arl
more expensive (see Table 2.1) and involve a more comple;
set-up procedure during preparation for surgery. Howevel
equipment prices are often reduced or rolled into a minimun
purchase of tubing, so the actual equipment cost can b
passed on to each case. Set-up and calibration aresimpler 0]
some pumps than others (see Table 2.1). A nitrogen drivel
flutter valve pump with no electrical parts (Davolm) is a cos1
effective intermediate-style pump that bridges betweel
gravity feed and pressure-driven pumps (Fig. 2.15). Thi
system has been used by one author (A.J.N.) for many year
and is economical, simple to set up, pressure sensing, and ca
deliver high flow rates (Smith & Trauner 1999). The di:
advantages are the relatively slow recognition of pressUl
drops in the joint and the noise of the flutter valve pum
assembly.
The use of a balanced electrolyte solution, such as lactat(
Ringer's or Hartmann's solutions, rather than saline for joil
distention has been recommended based on studies that sho
.'3M Orthopedics Pro
1000. Tel: (888) 364.
:ts Division, 3M Cent.
77. www.mmm.com
rIossett Crossroad, PO.275. 
www.davol.com
MN
31No
us
120 NoN/A Fair
N/A
1.0 No 69 Good
reservoir gas tank, including the Karl Storz and Richard WoU
units (Fig. 2.16). Others, such as those from Unvatec, Stryker,
and Directed Energy, use a direct step-down valve system
from a commercial tank (Fig. 2.17). Arguments have been
advanced for the use of gas insufflation of the joint rather
than fluid distention during arthroscopy (Eriksson & Sebik
1982); the gaseous medium (carbon dioxide, helium, or nitrous
oxide) results in a sharper image with higher contrast. As
well as being useful for photographs, some evidence exists
that it may offer an increased degree of accuracy in assessing
cartilage damage in some situations (Eriksson & Sebik 1982).
In addition, it can prevent synovial villi from interfering with
the visual field. However, a pressure-regulating device and a
special system are necessary for gas insufflation. In addition,
gas escapes easily after removal of any appreciable mass
saline is not physiologic and inhibits normal synthesis of
proteoglycans by the chondrocytes of the articular cartilage
(Reagan et al1983). Any matrix depletion of the cartilage
during normal arthroscopic procedures would be minor and
certainly not permanent Gohnson et aI1983), but when the
cost of each fluid is similar, the use of the most physiologic
solution is logical. The results of another study evaluating
the acute effects of saline and lactated Ringer's solution on
cellular metabolism demonstrated an acute stress to both
chondrocytes and synoviocytes immediately after irrigation
with both fluids, although this was greater with saline. These
stress patterns (monitored by evaluating relative ATP
regeneration) are apparent after 24 hours, appear to
be returning toward normal by 48 hours, and are not
significantly different from control values 1 week later. Based
on these results, protection from full activity during this time
period was considered advisable (Straehley 1985).
Gas insufflation has been used routinely in equine arthro-
scopy by two of the authors G.B. and A.J.N.). Several types
of gas insufflators are available. Most have a small internal
portal. Gas emphysema, pneumo-
have been identified as
arthroscopy Gager 1980), and
better visualization when synovial
bone graft and fibrin-based
but many procedures start with liquid distention and only use
gas for short periods of defined activity, which limits emphysema.
Removal of small particles by suction obviously requires a fluid
medium, and fluid irrigation will also be necessary at the end of
any procedure for lavage and removal of debris.
At this stage, the authors consider the use of fluid irrigation
more convenient and experience with the use of fluid can
eliminate many of the problems associated with synovial villi
obstructing visualization. No additional equipment is necessary;
and although the images obtained have somewhat less contrast
compared with images from gas-filled joints, superficial dalhage
to the articular cartilage and other lesions are seen more
readily in the form of floating strands. Nonetheless, the addition
of gas may be a necessary and convenient step in the future if
bone grafting, laser surgery, or fibrin-based cell grafting become
an important feature of arthroscopic surgery.
Egress cannula
An egress cannula (Fig. 2.18) is a necessary item for most
arthroscopic procedures. It has an accompanying locking
trocar with either a sharp stylet or conical obturator. The
cannula is used to flush fluid through the joint in order to
clear blood and debris and optimize visibility. The outer end
has a luer attachment through which fluid can be aspirated
or to which a long, flexible egress tube can be attached to
transmit fluid to a bucket on the floor rather than having it
spillover the surgical site or equipment. The authors use a 2-
or 3-mmegress cannula (Fig. 2.18a) routinely at the beginning
of the arthroscopic procedure to flush the joint and to probe
and manipulate lesions. A larger diameter (4. 5-mm) cannula
(Fig. 2 .18c) can be used at the end of the procedure for
clearing debris. The 3-mm cannula usually is inserted without
the use of the stylet, because a portal has been made with a
blade. A conical obturator (Fig. 2.18d), however, is useful to
facilitate placement of the larger 4.5-mm cannula at the end
of the procedure.
are available from all arthroscopic instrument manufacturers.
Probes from different manufacturers vary in length and end
configuration. The probe end can be round, square or
rectangular and can vary from 3 to 6 mm in length. Longer
tips on the probe can hamper entry to the joint by tangling in
the capsule, while smaller probes are easy to insert but are
more prone to bending. A 3-mm rectangular end probe with
tapered shaft is convenient and durable (see Fig. 2.19). The
handle on probes can vary from a round smooth shaft. to a
rectangular shaft, which is easier to grasp, and to the
addition of a thumb bar for directed application of pressure.
Hand instruments for
arthroscopic surgery
As mentioned previously, a myriad of instruments are avail-
able from arthroscopic equipment manufacturers (Caspari
1987, Gross 1993, Ekman & Poehling 1994), most of which
are neither suitable nor necessary for equine arthroscopic
surgery. The instruments presented in this section are those
used by the authors to perform the procedures described in
this book. It is accepted that there are alternative, and
possibly better, ways to perform any given task and tech-
niques certainly will change. The current list is written with
the philosophy of keeping arthroscopy simple and practical
without compromising standards. A combination of
specialized arthroscopic instruments and instruments not
designed specifically for arthroscopic surgery is used.
Forceps
Currently. the authors use seven different forceps for
retrieving fragments and trimming lesions (Figs 2.20-2.24).
1. Routine use. The workhorse in most arthroscopy packs is
the Ferris-Smith intervertebral disc rongeur. For removal
of large fracture fragments and osteochondritis dissecans
flaps. a pair of Ferris-Smith cup rongeurs with a 7 -inch
shaft and a straight 4 x 10-rom bite (Scanlan Instruments)
is used. These forceps are better than other types for this
purpose. Variation exists with regard to the shape of the
jaws on different 4 x 10-rom Ferris-Smith rongeurs. A
narrow-nosed pair made by Sontec (Scanlan) is useful for
carpal and proximal phalangeal fragments. They pass
through the instrument portal easily and are appropriate
for small and medium-sized fragments (Fig. 2.20). Another
pair of Ferris-Smith rongeurs with a 6 x l2-rom cup is
used for larger fragments (Fig. 2.20). A set with the jaw
angled up and with a 4 x 10-rom cup are also useful in
some tight situations. Some surgeons use a pituitary
rongeur for longer fragments.
2. Small fragments. Also recommended is a pair of straight
ethmoid rongeurs with a 5-rom bite (Richard Wolf or
Scanlan Instruments). These instrumentshave a pointed
nose and are useful for procedures involving chip fractures
off the proximal aspects of the first phalanx (see Chapter 5).
Blunt Probe
This standard arthroscopic instrument (Fig. 2.19) is necessary
for diagnostic as well as surgical arthroscopy. Suitable probes
Fig. 2.19
(A) Variety of arthroscopic probes, from
large to small format, and with round.
rectangular and thumb plate handles.
(B) Probe ends vary in shape and size.
~
3. Long-handled forceps. A more verSatIle and longer
alternative to the Ferris-Smith rongeur is the Mcilwraith
arthroscopy rongeur (Fig. 2.21), made by Sontec
Instruments? Pituitary rongeurs are also used by other
arthroscopic surgeons for the same purpose.
4. Tight spaces. A small angled rongeur with slightlJl
pointed tip (Fig. 2.22), often referred to as a patella
rongeur (Sontec or Richard Wolf), is especially useful foI
retrieving small fragments from difficult places, including
.nSontec (formerly Scanlan) Instruments Inc., 7248 Tucson Wa~
Englewood, CO 80112. Tel: (800) 821-7496. www.Sonte.
Instruments.com
Elevators and osteotomes
The instruments primarily used for separating fragments
from parent bone include a small round-end curved periosteal
elevator or a straight narrow osteotome. Examples include
the small (6-mm) round-end SynthesO elevator, the 5-mm
Mcllwraith-Scanlan elevato~, and the 4-mm cottle osteotome
(Scanlan) (Fig. 2.25). An extra small (3-mm) curved Synthes
elevator is also occasionally useful (Fig. 2.25). A markedly
curved sharp-end periosteal elevator (Fig. 2.26) is useful for
removing apical sesamoid fragments (Foerner elevator;
Scanlan Instruments; see Chapter 5).
Cutting instruments
Numerous cutting instruments are available. Their use is
limited to certain situations. If sharp severance of structures
is required. special arthroscopic cutting instruments should
be used. The authors have used both reusable blades and
disposable blade systems (Fig. 2.27), made by Karl StOrzb,
the palmar surface of the metacarpal condyle or proximal
phalanx, the palmar recesses of the midcarpal joint, and
the underside of the patella. The use of sharp-edged
rongeur-type instruments is preferred in most situations
when pieces to be removed are still attached by soft tissue.
5. Loose bodies. Loose bodies can be retrieved with custom
equine loose body forceps, since most loose body forceps
available in catalogs of arthroscopic instruments are not
strong enough. For instance, Zimmer has taken the basic
Ferris-Smith design and changed the ends of the jaws for
specific purposes.
6. Cutting forceps. Basket forceps are used occasionally
(Fig. 2.23) for removal of cartilaginous flaps of osteo-
chondritis dissecans in the femoropatellar joint. A narrow,
modified basket forceps (see Cutting Instruments section)
is useful for severing soft tissue structures such as
villonodular pads.
7. Broken instrument retrieval. A fragment forceps with a
malleable shaft is also occasionally useful, but not
essential. These forceps are illustrated in Figure 2.24 and
are made by Scanlan Instruments (Sontec).
."Synthes (USA), PO Box 1766, 1690 Russell Road, Paoli, PA 19301. Tel:
(800) 523-0322. www.synthes-chur.ch
.nSontec (formerly Scanlan) Instruments Inc., 7248 Tucson Way,
Englewood. CO 80112. Tel: (800) 821-7496. www.Sontec Instruments.
com
.~arl Stol"l Veterinary Endoscopy. 175 Cremona Drive. Goleta, CA 93117.
Tel: (800) 955-7832. www.ksvea.com
.
Wolfe, BeaverP, Dyonics, Acufex-Smith & Nephe~, Concept-
Linvatec-Zimmer, and Bard-Parker. Sheathed blades are
also available and eliminate the risk of inadvertent
damage to other structures when introducing the blade
(Fig. 2.28).
.nSontec (formerly Scanlan) Instruments Inc.. 7248 Tucson Way.
Englewood. CO 80112. Tel: (800) 821-7496. www.Sontec Instruments.
com
."Richard Wolf. 353 Corporate Woods Parkway. Vernon Hills. IL 60061.
Tel: (847) 913-1113. www.richardwolfusa.com
."Beaver Surgical Products. Becton-Dickinson. BD Medical Systems. 1 Becton
Drive. Franklin Lakes. NJ 07417. Tel: (800) 237-2762. www.bd.com
.qAcufex Microsurgical Inc.. Smith & Nephew. 150 Minuteman Road.
Andover. MA 01810. Tel: (978) 749-1000. www.smith-nephew.com
Acquisition of the commonly marketed hook scissors is
not recommended for equine arthroscopy. The best scissor-
type cutting instrument available currently is the very
narrow basket forceps (Scanlan-Mcllwraith scissor action
rongeur) (Fig. 2.29).
The authors have found little indication for the retrograde
or hook knives. other than those available for arthroscopic
annular ligament transection (see Chapter 13). A menisco-
tome can be useful for breaking down fibrous capsule
attachments when freeing a chip as it makes a cleaner cut
than a periosteal elevator.
Curettes
Curettes are used for debridement of most osteochondral
defects, including those remaining following removal of
traumatic or developmental fragmentation, evacuation of
subchondral bone cysts, and debridement of foci of infection.
Closed spoon curettes are suitable for most purposes, but
open ring curettes may be preferable for the center of lesions
(Figure 2.30). Straight and angled spoon curettes, either 0 or
00 in size, are generally preferred for routine applications
(Fig. 2.30). A rasp is rarely necessary for smoothing debrided
bone regions in joints, but may be useful for smoothing larger
areas such as after radial osteochondroma removal. These
instruments are available in straight, offset convex and
concave designs from various manufacturers, including
Stainless Manufacturing Incr.
Self-sealing cannulas
.'Stainless Manufacturing In
CO 91773.
The use of self-sealing sleeves or cannulae is a logical answel
to the loss of fluid through instrument portals. Either devict
can be used by screw insertion into the tarsocrural, shoulder
or femoropatellar joints, but they are not useful in the carpu!
and fetlock because of the close proximity of joint capsule
and lesion. Disposable self-sealing 4.5-10-mm operating
cannulae are available through several manufacturers
(Arthrex, Dyonics, Richard Wolf, or Acufe~). They are useful
for repeatedly introducing small forceps, hand tools, and
shavers, but in the horse, removal of osteochondral fragments
is the most common procedure, and this can only rarely be
done through such cannulae. A 10-mm (I.D.) threaded self-
sealing disposable cannula with insertion obturator (Clear-
trac; Dyonics -Smith & Nephew) has been useful in shoulder
arthroscopy (Fig. 2.31), otherwise operating cannulae are
still rarely used in equine arthroscopic surgery.
Vacuum attachments
While motorized equipment should be used only with due
consideration to the synovial environment and tissues. these
instruments are extremely efficient and some surgical
procedures can only be done effectively with such equipment.
Synovial resection. whether performed locally to improve
visualization of lesions or therapeutically on a subtotal basis.
can only effectively be performed with motorized apparatus.
Similarly, some large areas of osseous debridement. such as
in shoulder or stifle osteochondrosis, become impossible to
complete reasonably without such equipment. The basic
concept of motorized instruments is a rotating blade within a
sheath to which suction can be applied. This pulls soft tissue
into the mouth of the blade and removes debris (Graf and
Clancy 1987). Most currently available systems are powered
electrically and consist of a control unit attached by an
electrical cord to a motorized handpiece. The latter may be
operated by buttons on the handpiece or via a foot pedal to
the control unit (Fig. 2.33).
Various instruments, including forceps and curettes, are
available with attachments so that suction can be applied as
they are used. The S.2-mm DyoVac (Fig. 2.32) suction punch
rongeur (Smith & Nephew -Dyonics)is used by one of the
authors (A.J.N.) for minor synovial resection, cartilage and
soft bone removal, or larger soft tissue pad or meniscus
trimming. As such, this versatile rongeur gets more use than
most instruments in routine arthroscopy. Further, it often
prevents having to set up motorized equipment. Use of
suction enables instant removal of debris as it forms during
debridement within the joint. However, with the high fluid
pressures used in equine arthroscopy, suction is often un-
necessary as free material is often spontaneously flushed out
through the suction channel. The use of suction during any
procedure requires an increased rate of ingress fluid delivery.
In general, the authors prefer to perform hand debridement
without suction, reserving it for use with motorized instru-
ments or to remove debris at the end of surgical procedures.
Motorized instrumentation
A large assortment of motorized arthroscopic instruments
are available from most of the equipment manufacturers.
h & Nephew. 15049-1000. 
www.sm
Cutting heads or blades for the motorized units can be
divided into three broad groups: (1) blades designed to
remove soft tissues such as synovium, plicae, and ligament
remnants; (2) blades to trim denser soft tissues such as
menisci; and (3) burrs for debriding bone. These blades are
mostly available in disposable forms, although renewed
interest in reusable blades has resulted from the economic
downturn in medical practice. However, even disposable
blades can be cleaned, sterilized and reused for a limited
number of procedures (not recommended by manufacturer).
In the authors' experience, this has been a safe practice.
Generally, "fatigue" damage to the blades occurs at the plastic
attachment to the handpiece or in the drive shaft of curved
synovial resectors.
The authors have experience with the Smith & Nephew -
Dyonics Arthroplasty SystemTM, the Richard Wolf Surgical
Arthro Power System, The Baxter-Edwards system, the
Stryker System, and the Karl Storz meniscotome. Dyonics
developed the original shaver, and the third- and fourth-
generation Dyonics systems (PS3500 and EP-1 shavers), are
still very popular. However, blade availability for these models
is becoming increasingly limited, and many surgeons are
upgrading to the Dyonics Power Mac system, or seeking a
different manufacturer. Current shavers have integrated
suction with hand control of suction intensity. Some
manufacturers such Smith & Nephew -Dyonics and Stryker
also have speed and rotation direction controls on the
handpiece. Rotation speeds up to 8000 rpm and bidirectional
capabilities are useful. The hand units of the Dyonics and
Stryker shavers are relatively heavy compared to Storz, Wolf,
and Baxter shavers, but the heavier units are generally more
powerful. All modern shaver motors can be autoclaved and
most can be flash-autoclaved or cold-sterilized as necessary.
Most shaver motors recognize the blade type that the user has
inserted and controls the motor speed range accordingly. Foot
control of shaver speed and direction, including oscillation
mode, is standard.
Each manufacturer provides a broad range of disposable
blades, which often come with 6-8 cutting tip designs and with
shaft diameter sizes of 5.5,4.5, or 3.5 mm. Some of these have
a curved shaft 2 cm from the tip to allow greater maneuver-
ability around joints. Additionally, a miniblade range of 2.0
and 2.9-mm cutters with a variety of tip ends also are
available. Three broad types of disposable blades (which can
be subjected to multiple uses) are available (Fig. 2.34):
1. smooth edged resectors, e.g. Dyonics Synovator and full
radius blades (in 3.5, 4.5, and 5.5 mm diameter sizes)
2. toothed edged resectors, e.g. Dyonics Orbit Incisor, Incisor
Plus, RazorCut, Turbotrimmer, and Turbowhisker blades
(in 3.5, 4.5, and 5.5 mm diameter sizes)
3. burrs, round or oval, e.g. Dyonics Abrader and Notch-
Blaster in round burrs, and Dyonics Acromionizer,
Acromioblaster, and StoneCutter in oval elongated burrs
(in 2.5, 3.5,4.0, and 5.5 mm sizes).
The smooth-edged resector blades are appropriate for
synovectomy. The toothed-edged resector (for trimming
denser soft tissue) can be used for articular cartilage debride-
ment, villonodular pad removal, and meniscus and soft bone
debridement, The round or oval burrs are occasionally used
in chronic degenerate joints, although other blades have
some value in similar situations.
Modern synovial resector units are much more useful than
previous types. Design changes including larger apertures,
higher speeds, narrower diameter drive shafts (easier debris
clearance), spiral flutes down the length of the drive shaft,
and application of suction, have all contributed to better soft
tissue resection and less clogging. The oscillating mode
capability of the motor (the unit switches automatically
between forward and reverse) facilitates cutting of fibrous
tissues and decreases clogging between the blade and
housing. The speed control is computerized, with a variable
speed capacity from 0 to 8000 rpm. High speeds are necessary
when using the burr, whereas slower speeds are used with the
soft tissue blades.
Stocking of all the blade types is unnecessary; most
surgeons develop a preference for 1 or 2 soft tissue blades, and
a burr. In the Dyonics range, the authors prefer the 5.5-mm
full radius blade (#7205307) for villonodular pads and
menisci, the 4.5-mm rotatable curved orbit incisor
(#7205320) or Incisor Plus (#7205687) for most other soft
tissue resection, and the 4.0-mm Acromionizer (oval burr;
#7205326) or 4.0-mm Abrader (round burr; #7205324) for
bone debridement (see Fig. 2.34). Recently, a range of dual-
use combination tips (Dyonics BoneCutter) have been intro-
duced, which resect both soft tissue and bone. These are
available in synovator and full-radius styles, and minimize
both inventory and the need to switch blades in surgery.
Use of suction on shavers generally improves cutting
performance. However, attention to the degree of filling of
the suction bottle is required to prevent the automatic suction
shut-off engaging, which can then allow fluid to flow back
from non-sterile tubing and couplers at the bottle through
the sterile patient line and out the shaver into the joint or
onto the sterile field. It has been recognized as a potential risk
in the use of shavers for some time (Bacarese-Hamilton et al
1991), and it is particularly likely to happen when the fluid
ingress runs out at that same moment, removing the positive
pressure forcing joint fluid into the suction line. Prevention
requires suction to be maintained on the tubing at all times,
or at the very least ensuring the joint is pressurized during
suction bottle exchange.
the subject of ongoing debate. investigation. and litigation
(Lee et al 2002). Given these issues. RF for chondroplasty
should be avoided until further studies define safe settings.
and the use of RF probes in cutting modes for capsule. check
ligament. or annular ligament transection should use the
minimal power settings that still achieve the desired effect.
and should absolutely avoid cartilage and underlying bone.
Lasers
Electrosurgical and
radiofrequency devices
Considerable interest and concurrent concern surrounds the
use of radiofrequency (electrosurgical) devices for cartilage
and synovial soft tissue procedures (Polousky et al 2000,
Medvecky et al2001, Lu et al2001, Lee et al2002; Sherk et al
2002). Radiofrequency (RF) devices utilize extremely high-
frequency alternating current (e.g. 330 kHz compared to the
60 Hz of regular alternating current), which passes to the
tissue at the applicator tip and then through the body to exit
at a wide grounding plate, essentially as for all electrosurgical
units. The cutting and vaporizing capability depends on the
power and waveform settings. High power settings andlow
voltage tends to cut, while low power settings at relatively
high voltage denatures and coagulates tissues (Sherk et al
2002). Used in the liquid environment of the joint, both of
these modes have found a place for excision of tissue (plica,
adhesions, villonodular masses), or denaturation of cartilage
(cartilage sculpting or chondroplasty). Radiofrequency
devices used in a cutting mode, at the lowest settings that will
still cut plica, ligament, menisci, or masses, seem to be safe if
the probe is directed away from cartilage and does not dwell
on bone (Polousky et al 2000, Lee et al 2002). Similarly,
thermal capsular shrinkage using low power settings has
many proponents and seems relatively low risk (Medvecky et
al 2001). However, RF devices used for thermal chondro-
plasty at recommended settings penetrate to the subchondral
bone and cause chondrocyte death (Lu et al 2000, 2001).
Despite the apparent smoothness of cartilage after RF
chondroplasty, the later necrosis can be devastating, and is
Lasers have been used in arthroscopic procedures for removal
of fibrillated cartilage. synovial proliferation and masses. and
for transection of plical and other adhesive syndromes
(Lubbers & Siebert 1997. Janecki et al 1998. Smith &
Trauner 1999). They have declined in popularity in recent
years due to the continued high cost of the units and concern
over thermal damage to the cartilage and underlying bone
(Atik&Tali 1999. Sclamberg & Vangsness 2002). Laser types
include COp Nd:YAG. Ho:YAG. and excimer wavelengths. The
use of CO2 lasers has diminished. while Ho:YAG and excimer
lasers have persisted (Roth & Nixon 1991. Smith & Trauner
1999. Doyle-Jones et al 2002). Laser capsule shrinkage for
shoulder and knee disorders and laser-assisted partial
meniscectomy remain the primary use in man (Lubbers &
Siebert 1997. Smith & Trauner 1999). Laser chondroplasty
has been controversial and. despite an excellent appearance
following laser sculpting. later cartilage necrosis and mounting
research evidence suggest the use of laser for cartilage debride-
ment is dangerous unless extreme care in power settings and
methods of application are employed Ganecki et al 1998.
Sclamberg & Vangsness 2002; Atik et al2003).
Laser-assisted arthrodesis of the distal tarsal joints
provides a minimally invasive method for cartilage debride-
ment and articular desensitization (Hague & Guccione
2000). Eventual distal intertarsal and tarsometatarsal joint
arthrodesis can develop; however. resolution of the symptoms
of bone spavin do not necessarily require radiographically
defined obliteration of these joints.
Still photography
Historically, still photographic images have been recorded on
35-mm film using a camera with a quick mount adaptor to
the arthroscope. However, this is time consuming, risks
contaminating the surgical field, and is extremely light
sensitive. A practical alternative is to use a digital camera
such as a Nikon Coolpix 4500 fitted with an endoscope
adaptor, e.g. Karl Storz rapid coupling adaptor (Fig. 2.35).
Images are viewed on a screen on the back of the camera,
stored on a memory card, and may be downloaded later to a
computer for image adjustment and archiving.
Video documentation
-
Capture of video clips as analog video on a ~-inch VCR i:
simple and cost-effective for case documentation. It does not
however, provide duplicate copies to provide the owner or
trainer with surgical documentation, nor does it provide easy
access to an individual case buried in the middle of a 120-min
video tape. Review of a video and subsequent image capture
for still printing is also very time consuming and does not
lend itself well to the flow of information to the client. How-
ever, video and s-video formatted VCRs have become very
cheap, and are better than no documentation. Further, simple
video digitizing programs, such as Windows MoviemakerTM
(Microsoft), iMovieTM (Apple), VideoStudio 6TM (ULead
Systems), or Pinnacle Studio Version 7TM (Pinnacle Systems
Inc), all provide a means to capture video from !-inch tapes as
digital video (e.g. MPEG format) or as digital still images (e.g.
JPEG format) that can then be stored electronically or printed
out for several cents an image on a color ink-jet printer.
Additionally, digital video clips can be edited, trimmed,
spliced, and assembled into an annotated presentation
using these programs. Other capture systems using Hi8
video capture have been described and for a complete review
of arthroscopic image documentation, the reader is
directed to a recent review which provides an in-depth
comparison of systems, cabling, connectors, and output
devices (Frisbie 2002).
capture the image (often by clicking a button on the video
camera), and store and arrange the images during the
surgery. A 3.5 x 5 or 6 x 8-inch print is produced when a
preset number of images have been accumulated to memory.
The print quality (300 dpi) from a high end, digitally
enhanced, 3-chip camera can be photographic quality
(Brown 1989). The authors have used the Sony Mavigraph
UP-5600MD, Mavigraph UP-5200MD and the Mavigraph
UP2900 color video printers. The UP-5600MD provides
excellent image quality at approximately $1 per page. These
units sell for $4,000-$6,000. More economical storage can
be provided from small devices such as the Sony MavicapTM
electronic capture and storage device. This stores images on
floppy disks, which can then be printed on an office computer
and inexpensive color ink-jet printer.
Complete digital capture and storage devices for arthro-
scopic use are manufactured by Karl Storz, Stryker, and
Dyonics. All three units are expensive, but store both digital
still images (TIFF format-with Storz AIDA and JPEG formats
with others) and digital video clips (MPEGI or 2), with the
touch of a button on the camera head. The Stryker SDC Pro
2TM and the Storz AIDA are the more sophisticated units in
the field of digital storage devices (Figs 2.37 and 2.38). The
units have touch screen patient input, and image editing for
still image output. Image printing can be done in the surgery
by attaching an inexpensive HP deskjet printer, while still and
video images are also saved on the system's hard drive. At the
completion of each case, the files are saved on CD or DVD. The
software in the unit provides versatile settings that allow
extensive customization of image capture and compression,
image editing, output styles, text addition, and internet
access. Retail prices range from $12,000 to $16,000. The
Smith & Nephew -Dyonics Vision 625 Digital Capture
Digital ima~e capture and
storage devices
Arthroscopic image printing and storage has undergone
significant improvement along with the electronic revolution
of the previous decade. The simplest technique for image
documentation is electronic capture and printing on a dye
sublimation printer (Brown 1989. Johnson 2002). Self-
contained units such as the Sony MavigraphS (Fig. 2.36).
.'Sony Electronics, 1 Sony Drive, Park Ridge, NJ 07656. Tel:
(201) 930-1000. www.sonystyle.com
materials may deteriorate from thermal shock; various
materials expand and contract at different rates in response
to the rapid temperature changes in a steam autoclave. Some
manufacturers sell autoclavable arthroscopes, which provide
a more durable arthroscope for steam sterilization. Gas
sterilization with ethylene oxide is effective and safe, but it is
not always available, is time consuming and does not allow
multiple procedures in a day using a single set of
instruments.
Consequently, the use of a 2% solution of activated
dialdehyde (Cidex@, Surgikos Inc:) was developed as an agent
for cold sterilization procedures. Cidex Plus@ has a 30-day
shelf life after reconstitution, compared to the 14-day span of
Cidex@, which provides cost savings for frequent users. The
safety and effectiveness of Cidex has been documented