BR Arthroscopy Flashcards
Portals should be separated as widley as possible, consistent with the anatomy to avoid this?
Skin necrosis due to portals being placed too close together.
If an instrument fails or breaks within the joint what must be done immediately?
Outflow of saline should be shut down while inflow is left open to keep the joint distended for retreval of the broken piece.
What anatomical structures are considered when making an anterolateral portal?
Between the EDL and the superficial peroneal nerve.
When is the transmalleolar approach for lesions of the talus contraindicated?
In children with open physis
What anatomical structures should be considered when making an anteromedial portal?
Between the saphenous vein and the Tibialis anterior.
What is the most common size and angulation of an arthroscope used in an ankle?
2.7 mm and 30 degrees or 0 degrees of angulation
What is the minimum distance an accessory portal should be placed between the two working portals?
At least 1 cm apart to prevent skin necrosis.
How would one confirm that the loose body seen on x–ray is intra-articular instead of intra-capsular or extra articular?
perform an arthrogram in combo with CT or MRI
In anterior soft tissue inpingement of the ankle, pathology is generally limited to what?
The syndesmosis and the lateral gutter
When using a posterolateral approach one should avoid what anatomical structures?
Subcutaneous sural nerve or the short saphenous vein.
Also avoid inserting into the sTJ
Transmalleolar portals are more often required on which side of the joint and why?
On the medial side because lateral dome lesions are more anterior than on the medial side, and because the lateral malleolus is further posterior than the medial malleolus.
What are the three most common joint surveying techniques in ankle arthroscopy?
Pistoning
Scanning
Rotating
Prior to beginning arthroscopy which portal is made first?
Anteromedial to make use of transilumination over the anterolateral side.
What are the contraindications for manual distraction/gravity distraction?
Tight ankles, pathology not easily accessible, prolonged procedures.
What are the contraindications for the use of non-invasive distraction?
Impaired circulatory status Diabetes Generalized medical conditions Ankle edema Fragile skin
What are the contraindications to the use of skeletal distraction?
Local or generalized infections
Osteopenia
Open epiphysis
Lax ligaments
What are some of th indications for use of single heavy pin distraction?
Large bone structure in males
Long case/difficult pathology
Very tight ankles
Ankle arthrodesis
What are the recommended parameters of force and duration for non-invasive ankle distraction?
20-25 lbs of fore for about 30-45 minutes.
What specific type of synovitis occurs in three stages?
Chronic synovial chondromatosis
Which disease entity is characterized by synovitis with advanced papillary formation and hemosiderin cells present?
pigmented villonodular synovitis
Osteochondral lesions of the talar dome are commonly found where?
Commonly found on the anterolateral aspect or the posterior medial aspect of the dome.
What is the mechanism of injury for a medial talar OCD?
Plantarflexion and inversion
“PIMP”
What is the MOA of a lateral OCD lesion?
Dorsiflexion inversion with the tibia internally rotated on the talus.
What is used in drilling an OCD lesion of the talar dome?
.062 Kirschner wire
How should bone graft be placed in the articular cartilage of the talar dome?
The graft should be placed 1-2 mm below the level of the articular cartilage.
What is one method that has been proven helpful in viewing chondral lesions of the ankle joint?
Methylene blue dye injected into the joint and then washed out with irrigant saline.
What technique is used in arthroscopic ankle arthrodesis?
Arthroscopic transmalleolar cross screw fusion.
What are some of the advantages of arthroscopic approach to ankle fusion over the open method?
Less surgical morbidity and improved cosmesis.
What is a disadvantage of the arthroscopic approach to ankle fusion?
Severe varus/valgus malalignment is difficult to correct.
What is a contraindication to arthroscopic ankle fusion?
Varus/valgus greater than 15 degrees.
What type and size screw is used in arthroscopic ankle fusion to fuse the ankle?
Cannulated 6.5 mm cancellous screw system
What is considered abnormal values in the anterior drawer test?
Between 5-10 mm of anterior displacement of the talus from the distal tibia are considered abnormal, and over 10 mm of displacement is considered grossly abnormal.
In comparison with the unaffected extremity, the injured ankle should have an anterior drawer test result of 3 mm or more to be considered significant.
According to R.W. Jackson (1982), is more relief of symptoms achieved with diagnostic arthroscopy attributable to joint lavage or lyses of adhesions?
Joint lavage 21%
Lysis of adhesions 4%
Describe the Berdnt and Hardy Classification
Stage 1: Pitted lesion Stage 2: partial lesion non-displaced Stage 3: Full lesion non-dispalced Stage 4: Displaced lesion Describes OCD defects
Which side of the anterior half of the talar dome usually produces a shallow wafer shaped fracture?
Lateral
Which side of the posteror third of the talar dome is subject to deep, cup-shaped lesions?
Medial
What is the procedure for sterilization of an arthroscope?
First case - Ethylene oxide gas
Adittional cases: Activated glutaraldehyde solution for 20 minutes.
Arthroscopes cannot be autoclaved!
What is the probable diagnosis if only 10-12 mL of saline can be injected into the ankle joint capsule of a normal sized adult?
Capsular adhesions/fibrosis
Plantarfelxion of the foot increases the visualization for which arthroscopic approaches?
Anterior
Name some indications for ankle joint arthroscopy
Chronic ankle instability Persistent ankle joint pain Ankle fractures Ankle fusion Arthritis Adhesive capsulitis Synovitis Menoscoid bodies Chondromalacia Chondral and osteochondral defects Anterior impingement exostosis Pre-operative planning
The first person to perform an endoscopic intra-articular observation (1918) and also the first successful ankle arthroscopy?
Takagi
University of Tokyo
What instrument has a sharp point and is used to pierce the capsule?
Trocar
What instrument is blunt and is used to enter a joint?
Obturator used to prevent iatrogenic cartilaginous damage
Arthroscopes are available in what sizes?
1.7 mm to 8.0 mm
For chondromalacia, osteochondral defects, and osteoarthritis, burs are used to abrade articular defects to what level?
Viable bleeding bone.
What structure is the landmark for locating the proper site for an anteromedial portal approach for ankle arthroscopy?
Tibialis anterior tendon
Just go medial to it.
The anterocentral potal is always located lateral to what structure?
EHL
What is the purpose of the stopcock on the sidearm of the cannula?
The ingress or egress of fluids
What are the three types of light sources used in arthroscopy?
Xenon
Quartz halogen
Incandescent (Tungsten halogen)
Are the flutes in the sphere of an abrader more aggressive in cutting in a forward or reverse direction?
Forward
What two bones are the mechanical distraction system hooked into?
The lower tibia and the calcaneus
What radiographic view is used to evaluate an anterior drawer test?
Lateral
How many degrees of varus tilt are needed before an inversion stress test is considered abnormal?
More than 15 degrees comapred to the unaffected ankle.
What radiographic projection is used to evaluate an inversion stress test?
AP projection
What color is normal synovial fluid?
Normally clear, light, pale yellow
What color is infected synovial fluid?
Turbid
What color is synovial fluid with gout or rheumatoid arthritis?
Milky white
Abrasion arthroplasty resects necrotis islands of cartilage and/or subchondral bone to what depth?
Why?
1.0 mm (To the level of the tidemark) below the surface of subchondral bone.
Because this is the area that contains the vascularity that provides nutrition to support growth of new healthy hyaline cartilage
How far above the patient must bags used for gravity ingress system be placed?
2-3 meters
If visualization of the ankle joint is not adequate using the anterocentral portal, which anterior portal is the best alternative?
Why?
Anteromedial because of a lack of ligamentous structures and due to the fact that it has the least amount of pathology associated with it.
Therefore, it is less apt to have hypertrophic synovial tissue within it.
What type of portal allows for flushing and rinsing of a joint?
Egress portal
what is the term used to describe soft tissue pathology that involves the hypertrophy of normal anatomic structures secondary to the inflammatory process?
impingement syndrome.
Of ligaments, joint capsules, and synovial membranes, which does not have a rich supply of nerves?
Synovial membrane
How would acute synovitis appear differently from chronic synovitis arthroscopically?
Acute synovitis presents with long transparent hypertrophic villi and of uniform length, with an enlarged central vessel (injected) or a vessel that has ruptured (hemorrhagic hypertrophic synovitis)
Chronic hypertrophic synovitis is neither transparent nor hemorrhagic and presents with frayed opaque villi of different lengths secondary to the necrosis of the tips.
Fibers of what ligament make up the floor of the medial gutter?
Anterior tibtalar ligament of the deep deltoid
The medial bend is a part of the anatomy of what bone?
the tibia
What is the name of the depression in the talar surface that runs from anterior to posterior near the anterocentral portion of the ankle joint?
Sagittal groove
The anterior tibial lip is made of what substance?
Hyaline cartilage
The synovial recess is made of what substance?
Periosteum- covered subchondral bone
What is the name of the area between the tibial tubercle, the fibula and the lateral shoulder of the talus?
The lateral interval
What is the redundant joint capsule attached on top of the synovial recess of the tibia called?
capsular reflection
What is the name of the arthroscopic procedure in which one resects hypertrophic synovial tissue?
What cutting instrument is used?
Synovectomy
Shaver or punch or suction punch
What is the name of the arthroscopic procedure in which one debrides uneven or fibrillated cartilagenous tissue from the ankle joint?
Chondroplasty
Does a properly performed chondroplasty initiate cartilage repair? Why or why not?
No, because chondroplasty only smoothes out the fibrilated or uneven portions of cartilage. It does not revascularize the actual defect.
