Zeki OGURTAN1 Kadircan OZKAN2 Cengiz CEYLAN3
1. DVM, Ph D., Assistant Professor,
Department of Surgery, College of Veterinary Medicine, University of Selcuk,
Kampus, Konya, 42031.
2. DVM, Ph D., Professor, Department of Surgery, College of Veterinary Medicine,
University of Selcuk, Kampus, Konya, 42031.
3. DVM, Ph D., Research Assistant, Department of Surgery, College of Veterinary
Medicine, University of Selcuk, Kampus, Konya, 42031.
Arthroscopy is a valuable diagnostic tool for detecting intra-articular joint
derangements which can not be assessed by clinical and other routine roetgenographic
methods. With experience, the diagnostic accuracy of arthroscopy is comparable
to other modalities. Arthroscopic evaluations of stifle and shoulder joints
in mainly dogs among domestic animals have been reported and added significantly
to the diagnosis of pathologic conditions. Physical examination, roentgenographic,
arthroscopic and arthrographic studies are not competitive but complementary
to each other. Arthroscopy requires patience, time and experience to reach adequate
and accurate results.
Comparative veterinary studies using arthroscopy and arthrograhy for stifle
and shoulder joint avaluations in dogs and other domestic animals, have not
been reported.
Arthroscopy of the knee was first introduced by Siemering (30) who along with
Kivumbi first described the normal and abnormal anatomy of the joint in 1978.
Synolvial membrane hypertrophy, articular cartilage fibrillation, (15, 28) osteochondritis
dissecans (OCD) (5, 6, 20, 31) immune-mediated arthritis, (22) and osteophytes
(28) can be evaluated by arthroscopy. Arthroscopic biopsy (15, 28) can be performed
under arthroscopic guidance (28).
Operative orthroscopy for anterior cruciate ligament (ACL) replacement was first
introduced by Person in 1987. Reconstruction of the ACL under arthroscopic control
is reported in man and described in dogs (26). The mean time to complete the
surgical procedure in dogs is 60 minutes, which is shorter than that required
by conventional surgical procedure (26). This study was compatible with the
findings of replacement of ACL in man (4). Arthroscopy is used in long term
evaluation of various knee problems (29). One year follow-up studies after ACL
repair and meniscus surgery have been carried out by arthoscopy in dogs (29).
Long term arthroscopic follow-up studies, evaluating the functional use of the
knee have been done in man (24, 25). In two reports, evaluating 200 and 125
artroscopic procedures, reported an error rate of 12% and 6%, respectively (8,
9).
Laxity of the collateral ligament is often diagnosed in clinical examinations.
Arthroscopy is of value in determining the location of the collateral ligament
lesions whether the injury is in the meniscofemoral of meniscotibial part of
the ligament (23).
Operative procedures can be performed during arthroscopy (4, 8, 10, 13, 23-25)
to include excision of bucket handle lesions, (8-10) flaps, (8, 9) and horizontal
clevage tears (9). However, arthroscopic menisectomy is considered more difficult
in comparison with the traditional knee surgery (13).Arthroscopic drilling was
found to be effective to promote healing of OCD lesions in children (1). Arthroscopic
autogenous bone peg transfixion of femoral (33) and patellar (21) OCD lesions
have been reported in man.
Intra-articular cartilage injuries are also detectable through arthroscopic
examinations (10, 23). The importance of arthroscopy in the diagnosis of popliteal
tendon avulsion, (23) and chondromalacia patella (17) has also been reported.
The type of synovial villi that can be observed through arthroscopic examinations
are filamentous (feather-like), slender, polyp-like, stunded (rounded), clubbed,
fringe-like, twig-like, membranous (fon-like), cauliflower-like (moss-like)
and interlacement villi (15). In the normal joints; the slender, polyp-like,
stunded or dubbed types of synovial villi are in majority. On the other hand;
thick membranous, cauliflower-like, twig-like, or fringe-like villi are predominant
in the joints with synovitis (15).
Irrigation of joint is a necessity and carried out with physiologic saline solution
for visualization of internal structures (4, 7, 8, 13, 28). Joint distention
with isotonic saline (13, 15, 19) mixed with methylmethionine (19) faciliates
identification of joint structures. Aspiration of joint fluid.is of significant
value (4, 8, 13, 15, 19) to prevent obscuring intra-articular structures (15).
Removal of blood, maintenance of joint distension, and dispersion of heat from
tungsten light are benefits of using isotonic saline solution (13) for joint
irrigation. Iced fluids are considered helpful in decreasing the intra-articular
hemorrhage in surgical diagnosis and arthroscopy of the shoulder joint (27).
Carbon dioxide, air, and nitrous oxide have all been used for joint distention
and have the advantage of sperior joint distention and reducing the obscuring
effect caused by hemorrhage (27).
The 1.7 mm (15, 27, 30), 2.2 mm (7, 27), and 2.7 mm (22, 28, 29) arthroscopes
are generally used in examination of stifle and shoulder joints in dogs. A 700
foreoblique arthroscope in shoulder joint is recommended for better visualization
of the medial compartment and the bicipital tendon sheath in which loose bodies
are frequently located (27). Pericapsular infiltration of saline prevents the
arthroscopic instrument from being introduced into the joint cavity, and may
hamper evaluation of the intra-articular structures due to the collapse of the
joint space (15, 28). This problem can be overcome by proper insertion of the
needle through the joint space, and aspiration of synovial fluid. Joint fibrosis
and adhesions may hinder insertion of arthroscope (15).
Different sequences of examination of stifle joint have been reported. Because
of the extensive hyperemia of synovial membrane induced by arthroscopy, evaluation
of this structure is recommended at the beginning of the procedure (7). The
initial examination of the suprapateller pouch, followed by medial compartment
evaluation, then the intercondylar space, and the lateral compartment examination
was suggested by Siemering and Miller. Person recommends medial compartment
followed by the femoropatellar joint, medial and lateral trochlear ridge, and
suprapatellar pouch should be examined last (28). Kivumbi has recommended the
initial examination of the suprapatellar pouch, be followed by evaluation of
the femoropatellar pouch, the medial compartment, the intercondylar notch, and
then the lateral compartment. Difficulties have been reported in visualization
of the popliteal tendon, and the area between the intercondylar portion of the
caudal horn of the medial meniscus and the medial collateral ligament with the
technique described by Kivumbi (15).
The lateral and medial joint compartments, patellar femoral and suprapatellar
area can be efficiently observed by anterolateral approach (13). Anteromedial
approach is a necessity when the lateral compartment is to be evaluated (12,
13). Anteromedial approach is not used to observe the posterior horn of the
medial meniscus (13), but either the anteromedial or lateral approaches can
provide adequate visualization of the the posterior horn of the lateral meniscus
(13). Visualization of the posterior horn of the medial meniscus in arthrotomy
and arthroscopy is very difficult due to the obstruction caused by the medial
femoral condyle (11, 12). However, arthroscopic evaluation of the posterior
horn of the medial meniscus can be achieved through posterior puncture with
a small diameter arhroscope (11). Superior arthroscopic examination can be obtained
by combining both anterior and posterior approaches (11). The medial or lateral
suprapateller approaches for arthroscopy provide adequate visualization of the
patellofemoral compartment, with limited access to the menisci (13). The lateral
parapatellar approach provides access for all intra-articular structures.
The use of combined caudolateral and/or caudomedial approaches enable the arthroscopist
to visualize the popliteal area and the area between the medial collateral ligament
and the caudal horn of the medial meniscus (15).
In man and dog, arthroscopic examination of the knee and shoulder is generally
done under general anesthesia (3, 8-13, 16, 22, 23, 26-30, 34). Arthroscopic
evaluation of knee joint in man may also be performed, using an epidural (11,
13), spinal (11) or local anesthesia (9) when the procedure is limited to biopsy
of synovium, or diagnostic purposes (9, 11, 13). General anesthesia is recommended
for the patient comfort, to facilitate muscle relaxation, which will improve
manipulation of joint compartments, and prevent mechanical damage to the arthroscope,
and joint structures (10, 13, 15).
The efficacy of double-contrast arthrography in the diagnosis of medial and
lateral meniscus tears was 94 % and 88 %, respectively (16).
Whereas; arthroscopic confirmation was 98 % for the medial, and 100 % for the
lateral menisci which had also undergone double-contrast arthrography (16).
Similar accuracies have been achieved with arthroscopy (84 %), and with double-contrast
arthrograpy (86 %) in meniscal lesions (12), with a combined accuracy for arthrography
and arthroscopy of 98 % (12).
Arthroscopy may alter the clinical and arthrographic diagnoses and prevent unnecessary
surgery (11, 16). In one report, arthroscopy changed the incorrect arthrographic
and clinical diagnoses in 31 of 32 cases (11)
Arthroscopy is reported to be more accurate in the evaluation of medial and
lateral meniscus tears compared to arthrography (11, 16). However; the posterior
horn of the medial meniscus is reported to be difficult to demonstrate arthroscopically
(12). Double-contrast arthrography, however; is reported to be a highly accurate
diagnostic procedure in detecting the medial meniscus lesions and should be
preferred to arthroscopy (12, 16).
Hemarthrosis is a major concern during the arthroscopic investigation of joints
(4, 10, 23). Good visualization of joint structures can be obtained (4, 10)
by irrigation of the joint with saline, and removal of blood clots. In one report;
on acutely induced knee joints, 48 of 76 cases had developed massive hemarthrosis,
however; arthroscopy even under this type of condition is recommended (10).
Others have not suggested to carry out the arthroscopic procedures when hemarthrosis
is present (13).
Scarification of articular cartilage of humeral head, partial tear of the labrum
(18, 34), and pericapsular leakage are other reported complications of arthroscopy
(18). latrogenic infection, following knee arthroscopy in man has not been reported
(11, 13). Infections that were encountered with arthroscopy, were after surgical
intervention (11, 13). Local swelling due to the instrument insertion in the
course of arthroscopy occurred but resolved within hours (11). Thrombophlebitis,
broken bulbs and short circuits that result in quadriceps contraction, are reported
complications of arthroscopic intervention in man (13).
In companion animals, complications associated with arthroscopy are difficulties
in introducing the arthroscopic sleeve or trocar, inadvertent insertion of instruments,
intra-articular hemorrhage, subcutaneous fluid accumulation, pericapsular infiltration
of saline (15, 27, 30), obstruction of view by intra-articular structures (15,
30), instrument breakage, inadvertent lacerations of tendons, articular cartilage
scarification (27), and scope bending (7). Infection, following arthroscopy,
was not reported. Siemering stated that dogs, weighing less than 6 kg of body
weight, impede successful arthroscopic examinations of all internal joint structures
(30).
The dogs that were subjected to arthrotomy, required more time to return to
a normal gait pattern than those undergoing arthroscopy (11), which is in agreement
with the results obtained in man (24, 25). Bertrand reported that no lameness
was present 1 to 14 days with a mean of 3 days, following arthroscopy (2).While
significantly higher success rate was found in 3 year olds horses, it was significantly
lower in yearlings subjected to arthroscopy (5).
Histological and cytological examinations of synovial membrane and synovial
fluid revealed more extensive vascular damage and inflammatory reaction in the
arthrotomy group than those subjected to arthroscopy (22). It would be feasible
to conclude that reliable accuracy in complex joint problems makes arthroscopy
a popular technique. (9, 10, 13, 14, 16-20, 23, 32).
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