ppt on BASICS OF ARTHROSCOPY by Dr.vishwanath B.B, PG in orthopaedics in JJM MEDICAL COLLEGE, Davangere

1. GOOD MORNING

2. J.J.M. MEDICAL COLLEGE
DAVANGERE
MODERATORS:
DR. RAMESH R.
PROFESSOR AND UNIT CHIEF
DR. MALLIKARJUN REDDY
PROFESSOR
SEMINAR ON
BASICS OF ARTHROSCOPY

3. CHANGE :the golden rule of life
So the same here
rom invasive to less
invasive……

4. MEANING OF ARTHROSCOPY
 This word arthroscopy came
from GREEK ,
 "arthro" (joint)
And
 "skopein" (to look).
 The term literally means "TO
LOOK WITHIN THE JOINT
Simply as if you see a room
through a key – hole instead
of opening doors. ….

5.  Basic instruments and Equipments
 Care and sterilization of instruments
 Irrigation system
 Tourniquet
 Leg holders
 Anesthesia
 Advantages and Disadvantages
 Indications and contraindications
 Basic Arthroscopic techniques
 Complications
 Knee arthroscopy
 Shoulder arthroscopy
 Ankle arthroscopy
 Hip arthroscopy

6. BASIC INSTRUMENTATION KIT
Arthroscope : 30 degree
70 degree
Fibreoptic cables
light sources
Accessory instruments
Television cameras
Probe
Scissors
Basket forceps
Grasping forceps
Knife blades
Motorized shaving systems
electrosurgical lasers & radio
surgical instruments

7. ARTHROSCOPY : EQUIPMENTS
ASSEMBLY
Arthroscope
camera
Fibreoptic cable
light source
T. V. monitor
POWER
irrigation fluid bags
y connector

8. MONITOR
 It is the device that
projects the image
created by the
arthroscope and the
camera head.

9. CAMERA HEADS
 The camera head is the “brains” of the arthroscopic
equipment.
 This is a device that attaches to the arthroscope
itself and is responsible for producing the image on
the screen.
 Inside the camera head there are small computer
chips that capture the actual image into a digital
image.
 Cameras are sterilized usingethylene oxide gas or
hydrogen peroxide gas

10. Camera head
arthroscope

11. LIGHT SOURCE WITH FIBRE OPTIC
CABLES
 All endoscopes utilize a light source to illuminate
the inside of the joint during the procedure.
 The light source consists of a box that houses the
bulb (usually xenon or LED) that connects to the
arthroscope via a sterile fiberoptic light cable.
 The light cables should always be gas sterilized
and carefully coiled loosely to avoid breaking

12. Camera head
Light source
arthroscope

13. INSTRUMENTS AND EQUIPMENT

14. ARTHROSCOPE
 An arthroscope is an optical instrument. Three
basic optical systems have been used in rigid
arthroscopes:
(1) the classic thin lens system,
(2) the rod-lens system, and
(3) the graded index (GRIN) lens system.

16.  Certain features determine the optical
characteristics of an arthroscope. Most important
are the diameter, angle of inclination, and field of
view.
 The angle of inclination, which is the angle between
the axis of the arthroscope and a line perpendicular
to the surface of the lens, varies from 0 to 120
degrees.
Angle of
inclination

17. The 25- and 30-degree arthroscopes are most commonly
used. The 70- and 90-degree arthroscopes are useful in
seeing around corners, such as the posterior compartments
of the knee

18.  Field of view refers to the viewing angle
encompassed by the lens and varies according to
the type of arthroscope.
 The 1.9-mm scope has a 65-degree field of view;
the 2.7-mm scope, a 90-degree field of view; and
the 4.0-mm scope, a 115-degree field of view.
 Wider viewing angles make orientation by the
observer much easier.

19. 0 °
Straight view not
recommended
30 °
Increase the field of vision
(90 )
Viewing angle

20. 70 °
For viewing special regions

23. ACCESSORY INSTRUMENTS
 The basic instrument kit consists of the following:
arthroscopes (30- and 70-degree); probe; scissors;
basket forceps; grasping forceps; arthroscopic
knives; motorized meniscus cutter and shaver;
electrosurgical, laser, and radiofrequency
instruments; and miscellaneous equipment.
 These instruments are used in performing most
routine arthroscopic surgical procedures.
 Additional instruments are available and are
occasionally used in special circumstances.

24. PROBE
The probe has become known over the
years as “the extension of the
arthroscopist’s finger.

25.  The probe is essential for palpating intraarticular
structures and in planning the approach to a
surgical procedure.
 The probe can be used to feel the consistency of a
structure, such as the articular cartilage; to
determine the depth of chondromalacic areas; to
identify and palpate loose structures within the joint,
such as tears of the menisci; to maneuver loose
bodies into more accessible grasping positions; to
palpate the anterior cruciate ligament and
determine the tension in the ligamentous and
synovial structures within the joint; to retract
structures within the joint for exposure; to elevate a
meniscus so that its undersurface can be viewed;
and to probe the fossae and recesses

26. Most probes are right angled with a tip
size of 3 to 4 mm, and this known size of
the hook can be used to measure the size
of intraarticular lesions.

27. SCISSORS
 Arthroscopic scissors are 3 to 4 mm in diameter
and are available in both small and large sizes. The
jaws of the scissors may be straight or hooked .
The hooked scissors are preferred because the
configuration of the jaws tends to hook the tissue
and pull it between the cutting edges of the
scissors.

28. BASKET FORCEPS
 The standard basket forceps has an
open base that permits each punch or
bite of tissue to drop free within the
joint.
 It is useful in trimming the peripheral
rim of the meniscus, or it can be used
instead of scissors to cut across
meniscal or other tissue.
 Configuration- straight or hooked
 Available in angles of 30, 45 and 90
degree.
 15 degree up biting and down biting
curves are available.
Biting end
Open base

29. GRASPING FORCEPS
 Grasping forceps are
useful to retrieve material
from the joint, such as
loose bodies or synovium,
or to place meniscal flaps
and other tissues under
tension while cutting with a
second instrument.
 The jaws of the grasping
forceps may be of single-
or double-action design
and may have regular
serrated interdigitating
teeth.
Single action
Double action

30. KNIFE BLADES
 A variety of disposable blade
designs are available: hooked
or retrograde blades; regular
down-cutting blades, both
straight and curved; and
Smillie-type end-cutting
blades.
 These blades should be
inserted through cannula
sheaths or encased within a
retractable sheath mechanism
so that the cutting portion of
the blade is exposed only
when it enters the field of
arthroscopic vision.

32. MOTORIZED SHAVING SYSTEMS
 Consists of an outer, hollow sheath and an inner,
hollow rotating cannula with corresponding
windows .
 The window of the inner sheath functions as a two-
edged, cylindrical blade that spins within the outer
hollow tube.
 Suction through the cylinder brings the fragments of
soft tissue into the window, and as the blade
rotates, the fragments are amputated, sucked to the
outside, and collected in a suction trap.

33. Uses :
 Designed for meniscal cutting or trimming, for
synovial resection, and for shaving of articular
cartilage.

34. ELECTROSURGICAL, LASER, AND
RADIOFREQUENCY INSTRUMENTS
 Electrocautery has been used as an arthroscopic tool for
cutting and hemostasis most often after arthroscopic
synovectomy and subacromial decompression.
 It also has been used for both cutting and hemostasis in
lateral retinacular release for malalignment of the patella.
 Reported complications of radiofrequency meniscal ablation
include articular cartilage damage, osteonecrosis, and tissue
damage caused by the irrigant.

35. IMPLANTS
 Suture anchors
 Meniscal repair devices
 Devices for tendon and ligament fixation and articular
cartilage repair.
Suture anchors

37. MISCELLANEOUS EQUIPMENT
Sheath
Blunt trocar
Sharp Trocar

38. CARE AND STERILIZATION OF
INSTRUMENTS
 Arthroscopy equipment that is heat stable may be
autoclaved for sterility.
 Heat- or moisture-sensitive equipment may be
sterilized with a low-temperature hydrogen peroxide
gas plasma.

39. IRRIGATION SYSTEMS

40.  Irrigation and distention of the joint are essential to all
arthroscopic procedures. Joint distention is maintained
by lactated Ringer solution during arthroscopy.
 It is physiological and results in minimal synovial and
articular surface changes.
 Usually, two 5-L plastic bags of lactated Ringer solution,
interconnected with a Y-connector.
 The bag usually is placed 3 to 4 feet above the level of
the joint, thus producing approximately 66 to 88 mm Hg
of pressure.
 Addition of epinephrine (1 mg per liter of saline)
significantly increases visibility.

41. DISTENTION PRESSURE
 For knee 60-80 mmHg
 For shoulder 30 mmHg less than systolic blood
pressure.
 For elbow and ankle 40-60 mmHg

42. TOURNIQUET
 During arthroscopic procedures of the knee, ankle,
elbow, and other distal joints, a tourniquet is almost
always applied and is inflated as needed.
Advantages :
1) Increased visibility
Disadvantages :
1) Blanching of the synovium, which makes
differentiation and diagnosis of various synovial
disorders difficult, and
2) The possibility of ischemic damage to muscle and
nervous tissue with prolonged tourniquet time of more
than 90 to 120 minutes.

43. Contraindications :
Thrombophlebitis and significant peripheral
vascular disease

44. LEG HOLDERS
The biggest advantage of a leg holder is
that it permits application of stress primarily
to open the posteromedial compartment for
better viewing, manipulation of the
meniscus, and posterior horn meniscal
surgery, especially in tight knees.

45.  The lateral aspect of the distal thigh can be levered
against this post for opening of the posteromedial
compartment.
 The post does not confine or prevent the knee from
being positioned in an almost unlimited number of
positions, including flexion and the figure-four position; it
therefore has advantages over many of the expensive
commercial leg-holding devices.
 If a patellofemoral joint or a lateral compartment
problem is anticipated, a valgus stress post may be
chosen to make viewing of these compartments easier.
For endoscopic repair of the anterior cruciate ligament,
a lateral post should be used or the end of the table
should be flexed to allow full unobstructed knee flexion.

46. ANESTHESIA
 Diagnostic arthroscopy can be performed with the
patient under local, regional, or general anesthesia.
 Local anesthesia can be used for many
arthroscopic procedures around the knee and ankle
in a cooperative patient with intravenous sedation .
 Chondrotoxicity is known to occur with lidocaine
and epinephrine.
 Combined spinal and epidural is best for knee and
ankle.

47. ADVANTAGES
 Reduced postoperative morbidity
 Smaller incisions
 Less intense inflammatory response
 Improved visualization
 Absence of secondary effects
 Reduced hospital stay
 Reduced complication rate
 Improved follow-up evaluation
 Possibility of performing surgical procedures that
are difficult or impossible to perform through open
arthrotomy

48. DISADVANTAGES
 Working through small portals with delicate and
fragile instruments.
 Maneuvering the instruments within the tight
confines of the intraarticular space may produce
significant scuffing and scoring of the articular
surfaces.
 Requires experienced surgeon
 Time consuming
 Requires special instruments
 Expensive

49. CONTRAINDICATIONS
 When the risk of joint sepsis from a local skin
condition is present or when a remote infection may
be seeded in the operative site
RELATIVE CONTRAINDICATIONS
 Partial or complete ankylosis around the joint
 Major collateral ligamentous and capsular
disruptions of the joint

50. TRIANGULATION TECHNIQUE

51.  Triangulation involves the use of one or more
instruments inserted through separate portals and
brought into the optical field of the arthroscope, the
tip of the instrument and the arthroscope forming
the apex of a triangle.
 Separation of the instruments from the arthroscope
improves depth perception and, perhaps the most
significant advantage, permits independent
movement of the arthroscope and the surgical
instrument, which is essential for operative
arthroscopy.

52. COMPLICATIONS
Damage to
Intraarticular
structures
Damage to Menisci
and Fat pad
Damage to
Cruciate ligaments
Damage to
Extraarticular
structures
Blood vessels
Compartment
syndrome
Nerves
Ligaments and
tendons

53. DAMAGE TO INTRAARTICULAR
STRUCTURES
 Most common complication of knee arthroscopy
 Damage to the articular cartilage surfaces by the tip of
the arthroscope or the operating instrument is the most
common complication.
 It leads to progressive chondromalacic changes and
degenerative arthritis.
 Prevention :
 The joint should be opened with leverage or traction first
and the arthroscope allowed to slide into the space
created.
 Use of a leg holder or a leverage post during knee
surgery, as well as traction or distraction devices during
shoulder, hip, and ankle procedures, is helpful.

54. DAMAGE TO MENISCI AND FAT PAD
 The anterior horn of either meniscus of the knee
can be damaged by incision or penetration if the
anterior portals are located too inferiorly.
 Repeated penetration of the fat pad causes
swelling of the pad and obstruction of view and may
also result in hemorrhage, hypertrophy, or fibrosis
of that structure.

55. DAMAGE TO CRUCIATE LIGAMENTS
 Occurs during meniscal excision when an
intercondylar attachment is cut.
 When motorized instruments are débriding the
intercondylar notch.

56. DAMAGE TO EXTRAARTICULAR
STRUCTURES

57. BLOOD VESSELS
CAUSES
 Direct penetration or laceration
 From pressure caused by excessive fluid
extravasation.
 Popliteal artery is at risk during meniscectomy
when intercondylar attachments are cut, especially
when arthroscopic knives are used.
 Both the popliteal artery and vein have been
damaged during meniscal repairs as the sutures
are placed posteriorly.
 Extensive arthroscopic synovectomies have been
associated with injury to the genicular arteries.

58. ANKLE
 Anterior tibial artery is at risk during anterior
approaches for ankle arthroscopy, especially with
the anterocentral approach.
ELBOW
 Brachial artery may be damaged during
establishment of either the anteromedial or
anterolateral portal.
 Fluid extravasation also may compress this vessel
in the antecubital fossa.

59. SHOULDER
 The axillary artery may be injured by an
arthroscopic instrument plunging through the
axillary pouch.
 More often, axillary vessel occlusion is caused by
fluid extravasation or excessive arm traction

60. COMPARTMENT SYNDROMES
CAUSE
 From fluid extravasations
PREVENTION
 By using gravity inflow or lower pump pressures
and ensuring adequate outflow, most of these
complications can be avoided.

61. NERVES
CAUSES
 Direct trauma from a scalpel or sharp trocar
 By traction from overdistraction
 By mechanical compression or compression from
fluid extravasation
 By prolonged ischemia from excessive tourniquet
use
 By a poorly defined mechanism of injury to the
anatomical nervous system that results in reflex
sympathetic dystrophy

62. PREVENTION
 By marking portals appropriately
 Making sure the scalpel penetrates the skin only
 Using a hemostat to spread down to the joint
capsule in proximity to a nerve
 Routinely using blunt trocars.
 Maintaining proper joint distention and distraction
 Padding nerve and bony prominences, and
 Proper patient positioning

63.  Saphenous nerve or sartorial branches of the
femoral nerve are injured in knee arthroscopy.
 Axillary nerve in shoulder arthroscopy.
 Traction neurapraxia of the brachial plexus may
occur when strong traction and distraction of the
shoulder have been used.
 Neurovascular injury is the major risk of elbow
arthroscopy:
 Anterior portals place the radial and posterior
interosseous nerves at risk on the lateral side and the
median nerve at risk on the medial side
 Posteromedial portals place the ulnar nerve at risk.

64. LIGAMENTS AND TENDONS
 The medial collateral ligament may be injured by
accessory medial portals around the knee, or it may
be torn by severe valgus stress in an attempt to
open up the medial compartment.

65. OTHER COMPLICATIONS
HEMARTHROSIS
 The superior lateral geniculate vessels usually are
cut in lateral retinacular releases, and the inferior
lateral geniculate vessels may be lacerated just
anterior to the popliteal hiatus during lateral
meniscectomy and synovectomy.

66. THROMBOPHLEBITIS
 Incidence varies
 No specific risk factors are found for DVT
 Probable risk factors include
Age > 50 years
Tourniquet time > 60 minutes
PREVENTION :
 By using LMW heparin 12 hours prior to surgery and
continuing 48 hours postoperatively

67. INFECTION
RISK FACTORS
 The use of intraarticular corticosteroids
 Prolonged tourniquet time
 Patient age of more than 50 years
 Failure to prepare the surgical site again before
conversion to arthrotomy
 Procedure complexity
 And history of previous procedures and noted that
several reported outbreaks of infection after
arthroscopy were related to breaks in infection
control or to contaminated instruments.

68. ANTIBIOTIC PROPHYLAXIS
 1 g cefazolin intravenously within 1 hour of the skin
incision.
 Patients older than age 80 years are given 2 g.

69. TOURNIQUET PARESIS
 Temporary paresis in the extremity occurs if
tourniquet is used more than 90-120 minutes.
 Carefully monitoring the tourniquet pressure and
testing the accuracy of the tourniquet gauges
minimize these problems.

70. SYNOVIAL HERNIATION AND FISTULAS
 Small globules of fat and synovial tissue may
herniate through any of the arthroscopic portals.
Usually, the larger the portal, the greater the
chance of this complication.
 No specific treatment is required.
 If it persists then excision is required.
 Fistulas more commonly are associated with
posteromedial knee and ankle portals.
 To improve closure, these portals should be
sutured.
 Patient should receive antibiotics, and the knee
should be immobilized for 7 to 10 days.

71. INSTRUMENT BREAKAGE
 0.03% incidence
 If an instrument breaks, the surgeon should
immediately close the outflow cannula but the
inflow should be left open to keep the joint
distended.
 If the broken instrument is in the visual field, total
attention to keeping it in view and removing it is
essential.
 If the broken piece is located, a suction apparatus
or a magnet may be introduced through an
accessory portal to stabilize and remove the small
broken fragment.

72. KNEE
In general, knee arthroscopy is performed for diagnosing and treating a variety of
knee problems. The common indications are:
 1. Meniscal tears
 2. ACL tears
 3. PCL tears
 4. Removal of loose bodies
 5. Synovectomy (removal of diseased synovial tissue) in cases of:
a. Rheumatoid arthritis
b. Infections (pyogenic arthritis, tuberculous arthritis)
c. Pigmented villonodular synovitis
d. Synovial chondromatosis (multiple loose bodies)
 6. Joint debridement & washout for osteoarthritis
 7. Articular cartilage injuries and defects requiring:
a. Abrasion arthroplasty
b. Mosaicplasty
c. Autologous cartilage implantation (ACI)
 8. Lateral retinacular release for patellar maltracking
 9. Patellar clunk syndrome following total knee replacement
 10. Evaluating knee joint prior to doing Unicompartmental knee replacement (UKR)
or High tibial osteotomy (HTO)
 11. Arthroscopic assisted fixation of tibial plateau fractures

73. PATIENT POSITIONING

74. STANDARD PORTALS

76.  Anteromedial
 Anterolateral
 Posteromedial
 Superolateral

77. ANTEROLATERAL
 Almost all structures clearly visualised except
 PCL
 Anterior portion of lateral meniscus
 Periphery of posterior horn of medial meniscus
 1cm above lateral joint line
 1cm lateral to patellar tendon
 1cm below patella

78.  The trochar and sleeve are inserted at 70° of knee
flexion.
 Firm, gradual pressure applied until there is a
reduction in resistance, indicating that the trochar
has passed through the joint capsule.
 knee is extended to around 20° of flexion and the
trochar advanced, passing through the
patellofemoral joint.
 Its intra-articular position can be confirmed by
sweeping the arthroscope gently from side to side –
it can be felt to be beneath the patella.
 If it is outside the knee joint, it will not sweep from
side to side.
 position of the arthroscope should be confirmed
before removing the trochar, introducing the camera
and turning on the saline inflow

80. PRECAUTIONS
 Portal too near the joint line-
 the ant. horn of the lateral meniscus can be lacerated
 difficulty in maneuvering the scope.
 Too superior to the joint line-
 prevents viewing of the posterior horns of the menisci
and other posterior structures.
 Immediately adjacent to the edge of the patellar
tendon
 can penetrate the fat pad, difficulty in viewing and in
maneuvering the scope within the joint.

81. ANTEROMEDIAL
 This portal is located similarly to the
anterolateral portal: 1 cm above the
medial joint line, 1 cm inferior to the tip of
the patella, and 1 cm medial to the edge
of the patellar tendon.
 For additional visualisation of lateral
compartment and to probe lateral and
medial compartment structures.
 Needle inserted such that it exits just
above medial meniscus

82. POSTEROMEDIAL
 1cm above PM joint line in line with lateral
border of medial femoral condyle
 ‘soft spot’ between the tendon of
semimembranosus, the medial head of
gastrocnemius and the medial collateral
ligament.
 Before distention of the joint, this small
triangle can be palpated easily with the
knee flexed to 90 degrees.
 The knee must be maximally distended
with irrigating solution so that the
posteromedial compartment balloons out
like a bubble when the knee is flexed to 90
degrees (saphaneous nerve)

83.  For repair or removal of displaced posterior horn
meniscal tears and for removal of posterior loose
bodies that cannot be displaced into the medial
compartment and removed through an anterior
portal.
 For total synovectomy.

84. SUPEROLATERAL
 Most useful for viewing the dynamics of
the patellofemoral articulation.
 Lateral to the quadriceps tendon and
about 2.5 cm superior to the SL corner
of the patella.
 Evaluation of patella tracking, patellar
congruity, and lateral overhang of the
patella and for suprapatellar
synovectomy.

85. OPTIONAL PORTALS
 Posterolateral Portal
 Proximal Midpatellar Medial and Lateral Portals
 Accessory Far Medial and Lateral Portals
 Central Transpatellar Tendon (Gillquist) Portal

86. ARTHROSCOPIC EXAMINATION OF THE
KNEE
 A methodical sequence of examination should be
developed, progressing from one compartment to
another and systematically carrying out this sequence in
every knee.
 The knee should be divided routinely into the following
compartments for arthroscopic examination
 1. Suprapatellar pouch and patellofemoral joint
 2. Medial gutter
 3. Medial compartment
 4. Intercondylar notch
 5. Posteromedial compartment
 6. Lateral compartment
 7. Lateral gutter and posterolateral compartment

89. SHOULDER
Indications for shoulder arthroscopy
 1. Shoulder instability (recurrent dislocation of shoulder)
 2. Impingement syndrome (pain on lifting the arm)
 3. Rotator cuff tears
 4. Calcific tendonitis tendinitis (calcium deposition in the
rotator cuff)
 5. SLAP tears
 6. Tears of long head of biceps tendon
 7. Frozen shoulder (periarthritis)
 8. Removal of loose bodies
 9. Synovectomy for:
a. Inflammatory conditions like RA
b. Infections (like TB)
c. Synovial chondromatosis

90. PATIENT POSITIONING

91. Lateral decubitus position

92. PORTALS

93. Before making arthroscopic portals, a
thorough understanding of the local
anatomy is necessary to prevent damage
to neurovascular structures

94. POSTERIOR PORTAL
 Primary entry portal for
shoulder arthroscopy.
 It allows examination of
most of the joint and
assists in the placement of
subsequent portals .
 This portal is located 1.5 to
3.0 cm inferior and 1.0 cm
medial to the posterolateral
tip of the acromion.
 Between the infraspinatus
and teres minor muscles.

95. POSTEROINFERIOR 7-O’CLOCK
PORTAL

96. ANTERIOR PORTAL
 Observation of the
posterior capsule and the
rotator cuff and for an
anterior view of the
glenohumeral ligaments
and the subscapularis
tendon.
 Anterior portal is made
slightly lateral to a point
halfway between the
anterolateral tip of the
acromion and the coracoid
process.

97. ANTEROINFERIOR 5-O’CLOCK PORTAL
 Along the leading edge of
the inferior glenohumeral
ligament at the 5-o’clock
position along the glenoid
rim.
 The portal travels through
the subscapularis and
lateral to the conjoined
tendon.
 Allows appropriate access
to the leading edge of the
inferior glenohumeral
ligament.

98. SUPERIOR PORTAL
 This portal penetrates the
trapezius muscle and
passes through the
supraspinatus muscle
belly.
 The suprascapular nerve
and artery lie
approximately 3 cm
medial to the superior
portal at its closest point
 Useful for passage of
suture retrieval devices
for rotator cuff repair.

99. LATERAL PORTAL
 The lateral portal is
the primary operative
portal for the
subacromial space. It
is located 3 cm lateral
to the lateral border
of the acromion and
passes through the
deltoid muscle.

100. PORTAL OF WILMINGTON
 Providing access to the
glenoid and superior
labrum.
 The location is 1 cm
anterior and 1 cm lateral to
the posterior acromial
angle.

101. DIAGNOSTIC ARTHROSCOPY
Superior part of shoulder joint with biceps
tendon inserting into superior labrum.
Humeral head is superior right, and glenoid
is inferior.

102. Superior glenohumeral ligament and
subscapularis tendon on right with middle
glenohumeral ligament inferiorly

103. Normal sublabral hole

104. Buford complex showing insertion of
middle glenohumeral ligament directly into
biceps anchor

105. Middle cord variant of glenohumeral
ligament crossing subscapularis tendon.

106. Inferior pouch. Glenohumeral ligaments
and labrum are seen

107. Capsular attachment to humeral head
observed through inferior pouch.

108. Rotator cuff evaluated for fraying, partial
tears, or calcification. Supraspinatus
tendon is seen superiorly with biceps
tendon in center of picture.

109. Posterior articular surface, posterior
labrum, posterior pouch, and posterior
capsule observed with arthroscope
inserted anteriorly.

110. Posterior band of inferior glenohumeral
ligament

111. Anterior band of inferior glenohumeral
ligament observed from anterior portal.
Humeral insertion of ligament is superior.

112. Capsulolabral attachment to glenoid
observed through anterior portal

113. View of subacromial space with cuff below
and acromion above

114. DIAGNOSTIC SHOULDER ARTHROSCOPY VIDEO

115. ANKLE
Indications for diagnostic ankle arthroscopy include the following:
 Unexplained pain, swelling, stiffness, instability
 Locking and popping
Indications for therapeutic ankle arthroscopy include the following:
 Articular injury
 Soft-tissue injury
 Posttraumatic soft-tissue impingement
 Bony impingement
 Arthrofibrosis
 Instability
 Arthroscopic-assisted fracture fixation
 Synovitis
 Loose bodies
 Intra-articular bands
 Tendinitis
 Osteophytes
 Osteochondral defects
 Arthrodesis
 Septic arthritis

116. PATIENT POSITIONING

117. PORTALS

118. HIP
One of the most common indications for hip
arthroscopy is
 Management of femoroacetabular impingement
(FAI) and associated labral tears.
 Loose bodies
 Chondral pathology
 Degenerative joint disease
 Avascular necrosis (AVN)
 Synovial disease
 Instability
 Internal and external snapping hip
 Joint sepsis

119. PORTALS
Anterior portal
Anterolateral portal
Lateral portal
1 cm superior
and anterior to
the anterior
edge of the
greater
trochanter.
1 cm posterior and
superior to the greater
trochanter.
intersection of a line drawn from the
tip of the greater trochanter and a
line extending inferiorly from the
anterior superior iliac spine.