Principles of arthrotomy & arthrocentesis

PRINCIPLES OF ARTHROTOMY & ARTHROCENTESIS

Bassey, A E M.B., B.S.

Dep’t of Orthopaedic & Trauma SurgeryUATH, Abuja

OUTLINE - ARTHROTOMY• INTRODUCTION

• DEFINITION• STATEMENT OF IMPORTANCE

• INDICATIONS• DIAGNOSTIC• THERAPEUTIC

• PRE-OPERATIVE CONSIDERATIONS• INTRA-OPERATIVE CONSIDERATIONS• POST-OPERATIVE CARE/REHABILITATION• COMPLICATIONS

• EARLY• LATE

• CURRENT TRENDS

INTRODUCTION

• This is an incision into a joint to expose its interior

• Although many of its roles have been usurped by minimally-invasive techniques, arthrotomy still remains a very useful tool in the management of joint diseases, moreso, in resource-constrained settings. Every orthopaedic surgeon of worth should therefore be well-grounded in its principles.

INDICATIONS

• DIAGNOSTIC• Assessment of joint trauma• Biopsy

• THERAPEUTIC• Incision & drainage• Debridement/removal of loose bodies• Ligament reconstruction• Fracture fixation• Disarticulation• Joint replacement• Tumour excision

PRE-OPERATIVE CONSIDERATIONS• Indication is first met• Consent – written, informed consent

INTRA-OPERATIVE CONSIDERATIONS• Anaesthesia – depends on site• Prophylactic antibiotics• Tourniquet (where feasible)• Approach

– Shoulder– Anterior (deltopectoral) approach– Posterior approach

– Elbow– Posterolateral approach– Posteromedial approach

– Wrist– Dorsal approach

– Hip– Anterior approach (children)– Lateral approach (adults)

– Knee– Medial parapatellar approach– Lateral parapatellar approach

– Ankle – Anteromedial approach– Anterolateral approach

TECHNIQUE – KNEE ARTHROTOMY• Anaesthesia – GA, SAB, epidural, femoral block• Position – supine with sandbag underneath

the hip• Tourniquet • Skin preparation• Incision – midline longitudinal incision

extending from 5cm above superior pole of patella to the tibial tuberosity

TECHNIQUE – KNEE ARTHROTOMY• Procedure –

• deepen incision thru subcut and deep fasciae• Develop medial flap to expose quadriceps tendon,

medial border patella and medial border ligamentum patellae• Incise medial aspect of knee joint capsule longitudinally

and adjacent to patella• Retract patella laterally for better view• Closure is done in layers

TECHNIQUE – SHOULDER ARTHROTOMY

• Anaesthesia – GA• Position – Supine• Skin preparation• Incision – Starts at coracoid process extending

inferolaterally along deltopectoral groove. 10 to 15cm long

TECHNIQUE - SHOULDER ARTHROTOMY

• Deepen incision thru subcut and deltopectoral fascia

• Retract p. major med, deltoid lat and cephalic vein medially or laterally

• Retract conjoint tendon medially with great care – MC nerve!

• Incise fascia lat to conjoint tendon to expose articular capsule

POST-OP CARE/REHABILITATION

• Wound care• Splintage and elevation of limb• Analgesia• Antibiotics?• Physical therapy

• Muscle strengthening• ROM exercises

COMPLICATIONS

• Early• Haemorrhage/haemarthrosis• Septic arthritis• Nerve damage

• Late • Stiffness• Chronic joint pain• Fibrous adhesions• Scars/contractures

CURRENT TRENDS

• Use of arthroscopy offers folllowing benefits– Decreased metabolic response to trauma– Decreased complication rate– Decreased hospital stay– Earlier return to work– Improved ability to perform some surgical

procedures e.g. partial meniscectomy

OUTLINE - ARTHROCENTESIS• INTRODUCTION

• DEFINITION • STATEMENT OF IMPORTANCE

• INDICATIONS• DIAGNOSTIC• THERAPEUTIC

• CONTRAINDICATIONS• PREPROCEDURAL CONSIDERATIONS• TECHNIQUE• POSTPROCEDURAL CARE• SYNOVIAL FLUID ANALYSIS

• MACROSCOPIC EXAMINATION• MICROSCOPIC EXAMINATION• CHEMISTRY• CYTOLOGY

• COMPLICATIONS• CONCLUSION

INTRODUCTION

• It is the sterile, surgical puncture of a joint with aspiration of fluid for diagnostic and/or therapeutic purposes

• It is an indispensable component of the management of joint diseases. In fact, the diagnosis of diseases such as septic arthritis and crystal arthropathy can only be made when arthrocentesis has been carried out

INDICATIONS

• Diagnostic• Septic arthritis• Tuberculous arthritis• Cyrstal arthropathy – gout, pseudogout

• Therapeutic • Septic arthritis (repeated aspiration)• Haemathrosis• Done prior to corticosteroid injection

CONTRAINDICATIONS• These are generally relative,– Overlying cellulitis– Bleeding diathesis

PREPROCEDURAL CONSIDERATIONS• It is an aseptic procedure• Consent – verbal consent would suffice• Equipment –

• Personal protective equipment – surgical gloves, face mask• Solution for skin prep – povidone-iodine, alcohol• Sterile gauze• 1% lidocaine (administered with 25 or 27 gauge needle.

Ethyl chloride spray is an alternative)• 5-, 10- or 20ml syringe depending on size of joint and

volume of effusion• Lighting

PREPROCEDURAL CONSIDERATIONS• Equipment (cont’d)– Needles• Large joints (shoulder, knee) – 21-18 gauge needle, 1.5in• Medium joints (wrist) – 21 gauge, 1in• Small joints (MCP) – 25 gauge, 1in

– Plaster– Sterile sample bottle (heparinized)

TECHNIQUE• Prior to skin prep identify landmarks and mark

needle insertion point• Anaesthesia – 1ml 1% lidocaine• Positioning – joint to be aspirated should rest

on a stable, immobile surface• Skin prep – ensure solution dries before start• Blind vs. image-guided aspiration

APPROACH• Considerations:

• These are designed such that the articular capsule bulges toward the inserted needle

• If on aspiration the tap is dry it may be that the needle isn’t in the joint space or the fluid is too viscous or the needle is blocked by debris. This is ameliorated by withdrawal and repositioning of the needle or changing it.

• Specific approaches• Shoulder

– Anterior: » Patient is seated» Arm adducted and externally rotated

APPROACH

• Shoulder– Anterior approach• Patient seated• Arm adducted and ext

rotated• Coracoid palpated &

needle inserted 1.5in laterally & inferiorly

– Posterior approach: Needle inserted inferior to acromion

APPROACH• Elbow– Elbow is at 90o

– Palpate olecranon, lateral epicondyle and radial head

– Insert needle laterally in triangle formed by the 3 structures above

APPROACH• Wrist– Wrist is kept neutral

& in line with forearm

– Palpate dimple overlying radio-carpal joint

– Insert needle perpendicular to limb

APPROACH• Hip– Anterior

• Patient supine• Palpate femoral artery

just below inguinal lig• Needle entry is 1in lateral

to art & inf to ing lig– Lateral

• Patient supine• Palpate greater troch• Needle insertion just ant

to tip of great troch, parallel to couch & inclined 45o cephalad

APPROACH• Knee– Parapatellar• Patient supine• Leg fully extended

(flexion of up to 15o is permissible)• Medial point of entry

is 2-3 o’clock• Lateral point of entry

is 9-10 o’clock• Insert needle

perpendicular to knee

APPROACH• Ankle – Patient supine– Ankle at 90o or slightly

plantarflexed– Medial to tibialis

anterior tendon is a palpable dimple which is the point of needle insertion

APPROACH• MCPJ– Finger is slightly

flexed – Needle inserted

dorsally, lat or med to extensor tendons

• MTPJ– Similar technique as

for MCPJ

POST PROCEDURAL CARE

• Apply gauze over puncture site

• Rest the drained joint for 48hrs

SYNOVIAL FLUID ANALYSIS• Macroscopic examination– Colour : straw-coloured, bloody, purulent– Turbidity: clear, turbid

• Microscopic examination– Microscopy: gram stain, AFB– Culture/sensitivity

• Chemistry– Crystal analysis: monosodium urate (gout), calcium

pyrophosphate dihydrate (pseudogout)– Glucose, protein, lactate dehydrogenase

• Cytology– malignancy

COMPLICATIONS

• Early– Haemarthrosis– Infection– Cartilage damage

• Late – Adhesion– Recurrence of effusion

CONCLUSION

• Arthrocentesis and arthrotomy are frequently performed procedures, often being carried out in tandem in the management of joint pathology.

• Despite the emergence of advanced technologies in current orthopaedic practice, the principles guiding the use of these techniques are still very valid today.

THANK YOU

REFERENCES• Apley’s System of Orthopaedics & Fractures, 9th Ed, pg

323• Chapman’s Orthopaedic Surgery, 3rd Ed, pp 3568-3569• Essential Orthopaedics & Trauma, Dandy D, Edwards

D, 5th Ed, pg 83• http://www.orthobullets.com/approaches/12028/kne

e-medial-parapatellar-approach• http://www.rileywilliamsmd.com/elbow/arthrotomy• http://www.wisegeek.com/what-are-the-different-rea

sons-to-perform-a-arthrotomy.htm• http://emedicine.medscape.com/article/2094114-ove

rview• http://www.anwresidency.com/simulation/guide/arth

ro.html• http://www.wheelessonline.com/ortho/aspiration_of

_the_hip_joint