Therapeutic Arthroscopic Procedures

Knee Arthroscopy - Scope & Staples

• Scope:
  • Diagnostic: Visualize menisci, ligaments (ACL/PCL), cartilage, synovium.
  • Therapeutic: Multiple options.
    • Meniscal tears: Meniscectomy (partial/total), meniscal repair (all-inside, inside-out, outside-in techniques).
    • Ligament injuries: ACL/PCL reconstruction (BTB, hamstring grafts).
    • Cartilage lesions: Chondroplasty, microfracture, OATS.
    • Synovial pathology: Synovectomy (e.g., PVNS).
    • Loose body removal.
    • Patellofemoral: Lateral release, patellar debridement.
  • Fluid Management: Saline for distension & visualization.
• Key Fixation ("Staples"):
  • Meniscal Repair: Sutures, bioabsorbable anchors (all-suture, PEEK), darts.
  • ACL/PCL Reconstruction:
    • Fixation: Interference screws (metal/bio), suspensory devices (Endobutton), cross-pins.
    • Graft tensioning vital.
  • Cartilage Repair (OATS): Press-fit plugs, scaffold fixation.
• Portals & Risks:
  • Portals: Std. AL (anterolateral), AM (anteromedial); accessory as needed.
  • Risks: Infection, DVT, nerve injury, stiffness, instrument breakage.

  ⭐ The "terrible triad" (O'Donoghue's triad) involves injury to the ACL, MCL, and medial meniscus, often requiring arthroscopic intervention for ACL and meniscal components.

Shoulder Arthroscopy - Rotator & Repair

• Indications: Symptomatic rotator cuff tears (RCTs) failing >3-6 months conservative therapy; acute traumatic tears in active patients.
• RCT Overview:
  • Muscles (SITS): Supraspinatus (most common), Infraspinatus, Teres minor, Subscapularis.
  • Types: Partial (articular/bursal-sided), Full-thickness. Patterns: Crescent, U-shaped, L-shaped. Massive tears: >5 cm or involving ≥2 tendons.
• Repair Principles:
  • Debridement of tear margins, footprint preparation (bleeding bone bed for healing).
  • Anchors: Metal, bioabsorbable, PEEK, all-suture types.
  • Constructs: Single-Row (SR); Double-Row (DR) for ↑biomechanical strength & potentially ↓re-tear rates in larger tears; Suture-bridge techniques.
• Common Adjuncts: Subacromial decompression (SAD)/acromioplasty for impingement; biceps tenotomy/tenodesis if biceps pathology present.
• Post-operative: Sling immobilization (4-6 weeks), structured, phased physiotherapy crucial for outcomes.
• Complications: Stiffness (adhesive capsulitis), re-tear (most common), infection, anchor pull-out, deltoid dysfunction, nerve injury (axillary n.).

⭐ The "critical zone" (Codman's critical zone) of the supraspinatus tendon, a hypovascular region approximately 1 cm proximal to its insertion on the greater tuberosity, is the most common location for degenerative tears and subsequent failure of repair due to poor healing potential.

Other Joints & Complications - Wider View & Watchouts

• Elbow Arthroscopy:
  • Uses: Loose bodies, osteochondritis dissecans (OCD), synovitis, capsular release.
  • Nerve at risk: Posterior interosseous n. (PIN).
• Ankle Arthroscopy:
  • Uses: Talar OCD, impingement (anterior/posterior), synovitis.
  • Nerves at risk: Superficial peroneal n., sural n.
• Hip Arthroscopy:
  • Uses: Femoroacetabular impingement (FAI), labral tears, loose bodies. Traction needed.
  • Nerves at risk: Lateral femoral cutaneous n., sciatic n.
• Wrist Arthroscopy:
  • Uses: Triangular Fibrocartilage Complex (TFCC) tears, ganglion removal, diagnostic.
  • Common portals: 3-4, 4-5 (radiocarpal).

• General Arthroscopy Complications:
  • Intra-op: Instrument breakage, chondral injury, neurovascular damage, fluid extravasation (⚠️ compartment syndrome risk, esp. ankle/elbow).
  • Post-op: Infection (septic arthritis <1%), Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE), stiffness/arthrofibrosis, Complex Regional Pain Syndrome (CRPS), portal issues (neuroma, sinus).

⭐ Pudendal nerve neurapraxia can occur in hip arthroscopy due to perineal post traction.

High‑Yield Points - ⚡ Biggest Takeaways

• Partial meniscectomy is preferred over total for degenerative tears to prevent early osteoarthritis.
• ACL reconstruction commonly uses hamstring autografts (semitendinosus-gracilis).
• Rotator cuff repair is indicated for full-thickness tears to restore shoulder function.
• Bankart repair addresses recurrent anterior shoulder dislocation by fixing the anteroinferior labrum.
• SLAP lesion repair targets tears of the Superior Labrum Anterior to Posterior.
• Loose body removal prevents joint locking and further cartilage damage.
• Microfracture for cartilage defects stimulates fibrocartilage formation.