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).
1. Aglietti P, Buzzi, R, Bassi, PB, et al. (1994) Arthroscopic drilling in juvenile osteochondritis dissecans of the medial femoral condyle. Arthroscopy. 10, 286-291.
2. Bertrand SG, Lewis, DD, Madison JB, de Haan JH, Stubbs WP, Stallings JT. (1997) Arthroscopic examination and treatment of osteochondritis dissecans of the femoral condyle of six dogs. 33, 451-455.
3. Boeck, DEH, Casteleyn, PP, Opdecam, P. 1982) The reliability of arthroscopy. Acta. Orthop. Scan. (48, 524-528.
4. Dandy, JD, Flanagan, PJ, Steenmeyer, V. (1982) Arthroscopy and the management of the ruptured anterior cruciate ligament. Clin. Orthop. 167, 43-49.
5. Foland, JW, McIlwraith, CW, Trotter, GW. (1992) Arthroscopic surgery for osteochondritis dissecans of the femoropatellar joint of the horse. Equine Vet. J. 24, 419-423.
6. Gaugham EM. (1996) Arthroscopy in food animal practice. Vet. Clin. North Am. Food Anim. Pract. 12, 233-247.
7. Gestel Van, MA. (1985) Diagnostic accuracy of stifle arthroscopy in the dog. J. Am. Anim. Hosp. Assoc. 21, 757-763.
8. Gillguist, J. (1980) Operative arthroscopy. Endoscopy. 12, 281-287.
9. Gillguist, J, Oretorp, N. (1982) Arhroscopic partial menisectomy. Clin, Orthop. 167, 29-33.
10. Glinz. W, Segantani, P, Kagi, P. (1980) Arthroscopy in acute trauma of the knee joint. Endoscopy. 12, 269-274.
11. Huang, TL, Rieger, RW, Barmada, R, et al. (1979) Correlation of arthroscopy with other diagnostic modalities. Orthop. Clin. North Am. 10, 523-534.
12. Ireland, J, Trickey, EL, Stoker, DJ. (1980) Arthroscopy and arthrograhy of the knee. J. Bone Joint Surg. (Br). 62-B, 3-6.
13. Jackson, RW, Abe, I. (1972) The role of arthroscopy in the management of disorders of the knee. J. Bone Joint Surg. (Br). 54-B, 310-322.
14. Johnson, LL. (1980) Arthroscopy of the shoulder. Orthop. Clin. North. Am. 11, 197-204.
15. Kivumbi, CW, Bennett, D. (1981) Arthroscopy of the canine stifle joint. Vet. Rec. 109, 241-249.
16. Korn, MW, Spitzer, RM, Robinson, KE. (1979) Correlations of arthropraphy with arthroscopy. Orthop. Clin. North. Am. 10, 535-543.
17. Leslie, IJ, Bentley, G. (1977) Arthroscopy in diagnosis of chondromalacia patellae. Ann. Rheum. Dis. 36, 287.
18. Lilleby, H. (1984) Shoulder arthroscopy. Acta Orthop. Scan. 55, 561-566.
19. Lund, F, Nilsson, BE. (1980) Arthroscopy of the patello-femoral joint. Acta Orthop. Scan. 51, 297-302.
20. Mann, M. (1980) Arthroscopy of the knee joint in the diagnosis and follow-up observation of osteochondritis dissecans. Endoscopy. 12, 275-280.
21. Matava, MJ, Brown, CD. (1997) Osteochondritis dissecans of the patella: arthroscopic fixation with bioabsorbable pins. 13, 124-128.
22. Miller, CW, Presnell, KR. (1985) Examination of the canine stifle: Arthroscopy versus arthrotomy. J. Am. Anim. Hosp. Assoc. 21, 623-629.
23. Mital, MA, Karlin, LI. (1980) Diagnostic arthroscopy in sports injuries. Orthop. Clin. North Am. 11, 771-785.
24. Northmore-Ball, MD, Dandy, DJ. (1982) Long-term results of arthroscopic partial menisectomy. Clin. Orthop. 167, 34-42.
25. Patel, D, Fahmy, N, Sakayan, A. (1982) Isokinetic and functional evaluation of the knee following arthroscopic surgery. Clin, Orthop. 167, 84-91.
26. Person, MW. (1987) Prosthetic replacement of the cranial cruciate ligament under arthroscopic guidance. A pilot project. Vet. Surg. 16, 37-43.
27. Person, MW. (1986) Arthroscopy of the canine shoulder joint. Comp. Cont. Ed. 8, 537-546.
28. Person, MW. (1985) A procedure for arthroscopic examination of the canine stifle joint. J. Am. Anim. Hosp. Assoc. 21, 179-186.
29. Siemering, GH, Eilert, RE. (1986) Arthroscopic study of cranial cruciate ligament and medial meniscal lesions in the dog. Vet. Surg. 15, 265-269.
30. Siemering, GH. (1978) Arthroscopy of dogs. J. Am. Vet. Med. Assoc. 172, 575-577.
31. Vatistas, NJ, Wright, IM, Dyson SJ. (1995) Comparison of arthroscopy and arthrotomy for the treatment of osteochondritic lesions in the femoropatellar joint of horses. Vet. Rec. 137, 629-632.
32. van Bree, HJ, Ryssen B. (1998) Diagnostic and surgical arthroscopy in osteochondrosis lesions. J.Anim. Hosp. Assoc. 28, 161-189.
33. Victoroff BN, Marcus, RE, Deutsch, A. (1996) Arthroscopic bone peg fixation in the treatment of osteochondritis dissecans in the knee. Arthroscopy, 12, 506-509.
34. Wiley, AM, Older, WJ. (1980) Shoulder arthroscopy. Am. J. Sports Med. 8, 31-38.