Arthroscopy

Pietro Randelli David DejourC. Niek van DijkMatteo DentiRomain Seil Editors

Basic to Advanced

123

Arthroscopy

Pietro Randelli • David Dejour C. Niek van Dijk • Matteo Denti Romain Seil Editors

Arthroscopy

Basic to Advanced

ISBN 978-3-662-49374-8 ISBN 978-3-662-49376-2 (eBook) DOI 10.1007/978-3-662-49376-2

Library of Congress Control Number: 2016939390

© ESSKA 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature The registered company is Springer-Verlag GmbH Berlin Heidelberg

Editors Pietro Randelli San Donato Milanese Milano Italy

David Dejour Lyon France

C. Niek van Dijk Academic Medical Centre Orthopedic Surgery Univ of Amsterdam Amsterdam The Netherlands

ESSKA ASBLCentre Médical Fondation Norbert Metz 76, rue d’Eich1460 Luxembourg Luxembourg

Matteo Denti Istituto Clinico Humanitas RozzanoMilan Italy

Romain Seil Clinique d’Eich Centre Hospitalier Luxemburg Luxemburg Luxembourg

v

Dear colleagues and friends, Arthroscopy represents a powerful tool in the diagnosis and treatment of a

huge range of orthopedic diseases, becoming day by day more indispensable. The development of newly arthroscopic techniques allows a better treat-

ment of our patients with enormous benefi ts like pain reduction and faster recovery thus promoting a standard of care that needs to be reached worldwide.

In order to spread this knowledge as much as possible, the ESSKA board has decided to work for 4 years in the creation of this book. The aim of this collection of precious chapters has been to provide the “state of the art” about all available arthroscopic techniques divided per joint.

Some of the most important arthroscopists from different regions of the world have contributed to this book, and I would like to thank these leaders for their precious work.

I would like to quote as well all the editors of the book, for their sustain, and especially David Dejour and Niek Van Dijk, for their help to collect and review the papers of the knee and ankle sections, respectively.

All members of my team deserve to be thanked, especially Paolo Arrigoni and Davide Cucchi who worked very hard on this project.

From the production point of view, I would like to thank Mrs. Gabriele Schroeder and Mr. Claus-Dieter Bachem from Springer, for their support in the achievement of such a huge work.

I think that all the readers will be able to take advantage of this book in their daily practice and that this work will deserve to be quoted as a master-piece in the fi eld.

This book is dedicated to our families and friends who have made possible to all authors and editors to spend days and weeks to create this book without feeling guilty about the time we spend away from them.

Milano, Italy Pietro Randelli

Pref ace

vii

Part I General Content

1 History of Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Lars Goebel and Henning Madry

2 Surgery Set-Up, Instrumentations and Electronic Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Pietro Simone Randelli and Davide Cucchi

3 Standard Operative Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Petri Sillanpää, Paolo Arrigoni, and Davide Cucchi

4 Regional and General Anesthesia, Pain and Bleeding Control in Shoulder Arthroscopy and Upper Limb Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Paolo Grossi, Emilio Grilli, and Simone Repaci

5 Common Nerve Blocks of the Lower Limb . . . . . . . . . . . . . . . . . 59 Andrea Tognù , Daniele Genco , Luca Josca , Stefano Giarratana , and Paolo Grossi

Part II Knee David Dejour

6 Knee Arthroscopy: General Setup, Portal Options, and How to Manage a Complete Arthroscopic Investigation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Nicolas Pujol and Philippe Beaufi ls

7 Traumatic and Degenerative Meniscus Lesions: Diagnosis and Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Michael Hantes , Vasilios Raoulis , and Roland Becker

8 The Role of Meniscectomy in the Treatment of Traumatic Meniscus Tears: Technique Results Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Philippe Beaufi ls and Nicolas Pujol

Contents

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9 The Role of Arthroscopy in the Treatment of Degenerative Meniscus Tear . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Hélder Pereira , Ibrahim Fatih Cengiz , Joana Silva- Correia , Joaquim Miguel Oliveira , Rui Luís Reis , and João Espregueira-Mendes

10 Arthroscopic Meniscectomies for Congenital Meniscus Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Romain Seil , Tracey Gillman , Georges Assad , Klaus Dueck , and Dietrich Pape

11 Meniscal Repair: Indications, Techniques, and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Hélder Pereira , Ibrahim Fatih Cengiz , Joana Silva- Correia , Pedro L. Ripoll , Ricardo Varatojo , Joaquim Miguel Oliveira , Rui Luís Reis , and João Espregueira-Mendes

12 Meniscal Allograft Transplantation: Indications, Technique and Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Peter Verdonk , Nick Smith , Rene Verdonk , and Tim Spalding

13 Implantable Devices for Cartilage Repair in the Knee: Scaffolding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Stefano Zaffagnini , Alberto Grassi , Tommaso Roberti di Sarsina , Giulio Maria Marcheggiani Muccioli , Margherita Serra , and Maurilio Marcacci

14 Cartilage Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Peter Angele , Giuseppe M. Peretti , and Johannes Zellner

15 Cartilage Repair: Autograft Osteochondral Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Tim Spalding

16 Cartilage Repair: Arthroscopic Microfractures . . . . . . . . . . . . 189 Patrick Orth and Henning Madry

17 Cartilage Repair: Scaffolding . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Elizaveta Kon , Giuseppe Filardo , Luca Andriolo , Francesco Perdisa , Francesco Tentoni , and Maurilio Marcacci

18 ACL Tear: Complete and Partial, Associated to Medial and Lateral Damage . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Rainer Siebold and Georgios Karidakis

19 General Technical Consideration in Arthroscopic Anterior Cruciate Ligament Reconstruction . . . . . . . . . . . . . . . 217 A. Stoehr , A. Hochrein , and H. O. Mayr

Contents

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20 Arthroscopic Anterior Cruciate Ligament Reconstruction with Bone-Patellar Tendon-Bone . . . . . . . . . . . 223 Matteo Denti , Alessandro Quaglia , and Pietro Randelli

21 Arthroscopic Anterior Cruciate Ligament Reconstruction with Hamstring Tendons . . . . . . . . . . . . . . . . . . 229 Marco Valoroso , Guillaume Demey , Panagiotis G. Ntagiopoulos , and David Dejour

22 Anterior Cruciate Ligament Reconstruction with a Single- Bundle Autologous Quadriceps Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Jacques Menetrey , Etienne Cavaignac , and Philippe Tscholl

23 ACL Reconstruction, Single-Bundle Allograft . . . . . . . . . . . . . . 257 Jakob Van Oldenrijk , Peter A. J. De Leeuw , and Gino M. M. J. Kerkhoffs

24 ACL Reconstruction in Immature Athletes . . . . . . . . . . . . . . . . 269 Romain Seil , Julien Coquay , Alexander Hoffmann , and Franck Chotel

25 Revision Anterior Cruciate Ligament Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Etienne Cavaignac , Philippe Tscholl , Marco Valoroso , and Jacques Menetrey

26 PCL Tear: Complete, Partial, and Associated with Medial or Lateral Damage . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Chase S. Dean, Robert F. LaPrade, and Lars Engebretsen

27 Posterior Cruciate Ligament- Deficient Knee: Indications for Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Matteo Denti , Pietro Simone Randelli , Luca Mangini , and Davide Cucchi

28 Patellofemoral Instability: Classification, Indications for Surgery and Results . . . . . . . . . . . . . . . . . . . . . . 343 Paolo Ferrua , Panagiotis G. Ntagiopoulos , Roch Mader , and David Dejour

29 Synovitis of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 Massimo Berruto , Antonella Murgo , Paolo Ferrua , Francesco Uboldi , Daniele Tradati , Stefano Pasqualotto , and Bruno Michele Marelli

30 Arthroscopic Treatment of Knee Stiffness . . . . . . . . . . . . . . . . . 387 Massimo Berruto , Paolo Ferrua , Stefano Pasqualotto , Andrea Parente , Francesco Uboldi , Eva Usellini , and Bruno Marelli

31 Arthroscopic Fixation of Fractures Around the Knee . . . . . . . . 399 Pietro Randelli , Davide Cucchi , Filippo Randelli , Chiara Fossati , and Paolo Cabitza

Contents

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Part III Shoulder Pietro Randelli

32 Shoulder Arthroscopy: General Setup, Portal Options, and How to Manage a Complete Shoulder Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421 Radu Prejbeanu , Ion Bogdan Codorean , and Stefania Tanase

33 Arthroscopic Anatomy of the Shoulder . . . . . . . . . . . . . . . . . . . 431 Roman Brzóska , Wojciech Solecki , and Adrian Błasiak

34 Shoulder Instability: Traumatic and Atraumatic . . . . . . . . . . . 441 Maristella F. Saccomanno and Giuseppe Milano

35 Anterior Traumatic Instability Without Glenoid Bone Loss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457 Vivek M. Morey , Giuseppe Porcellini , Fabrizio Campi , Paolo Paladini , and Giovanni Merolla

36 Anterior Traumatic Instability with Glenoid Bone Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473 Ettore Taverna and Riccardo D’Ambrosi

37 Posterior Shoulder Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . 483 Ladislav Kovacic , Lennard Funk , and Pascal Gleyze

38 Humeral Avulsion of the Glenohumeral Ligament Lesion (aHAGL and pHAGL): Current Concepts in Treatment and Management . . . . . . . . . . 499 Philipp Proier , Stefan Buchmann , and Andreas Imhoff

39 Multidirectional, Microinstability, and Acquired Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511 Alessandro Castagna , Mario Borroni , and Giacomo Delle Rose

40 Shoulder Instability Associated to Humeral Head Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515 Grégoire Ciais and Philippe Hardy

41 Subacromial Impingement Syndrome . . . . . . . . . . . . . . . . . . . . 523 Giuseppe Sforza and Paolo Consigliere

42 Calcifying Tendonitis of the Rotator Cuff . . . . . . . . . . . . . . . . . 541 Olaf Lorbach and Romain Seil

43 Rotator Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551 Mark Tauber

44 Treatment of Partial Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . 563 Klaus Bak

Contents

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45 Subscapularis Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571 Maristella F. Saccomanno and Giuseppe Milano

46 Arthroscopic Repair of Full- Thickness Rotator Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581 Pietro Randelli , Paolo Capitani , Liborio Ingala Martini , and Vincenza Ragone

47 Biological Augments in Rotator Cuff Repair . . . . . . . . . . . . . . . 591 Christophe Charousset and Amine Zaoui

48 Massive Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597 António Cartucho

49 Long Head of the Biceps Pathology . . . . . . . . . . . . . . . . . . . . . . . 609 Boris Poberaj

50 AC Joint Pathology and Instability . . . . . . . . . . . . . . . . . . . . . . . 615 Natascha Kraus and Markus Scheibel

51 Glenohumeral Cartilage Damage and Arthritis . . . . . . . . . . . . 633 Bartek Kordasiewicz , Claudio Rosso , and Bruno Toussaint

52 Management of the Stiff Shoulder . . . . . . . . . . . . . . . . . . . . . . . . 663 Lennard Funk and Avanthi Mandaleson

Part IV Elbow Pietro Randelli and Paolo Arrigoni

53 Elbow Arthroscopy: General Setup, Portal Options and How to Manage a Complete Elbow Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675 E. Guerra , A. Ritali , A. Marinelli , G. Bettelli , M. Cavaciocchi , and R. Rotini

54 Anatomy at Risk, Portals, and Relevant Attentions to Reduce the Risk of Nerve Injury of the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683 Paolo Arrigoni , Riccardo D’Ambrosi , Enrico Guerra , and Pietro Randelli

55 Arthroscopic Treatment of Elbow Synovial Chondromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691 Joseph Pooley

56 Lateral Elbow Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703 Srinath Kamineni and Domingo Molina

57 Elbow Stiffness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 713 Bo Sanderhoff Olsen

58 Elbow Fractures Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725 André Thès and Philippe Hardy

Contents

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59 Osteochondritis Dissecans of the Capitellum . . . . . . . . . . . . . . . 733 Miguel Trigueiros

60 Arthroscopic Synovectomy for Rheumatoid Elbow . . . . . . . . . . 745 Mehmet Derviş Güner and Mehmet Demirtaş

61 Elbow Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753 John T. Heffernan , Michael O’Brien , and Felix H. Savoie III

62 Endoscopic Approach to Cubital Tunnel Syndrome . . . . . . . . . 763 Fabrizio Campi, Giovanni Merolla, Paolo Paladini, and Giuseppe Porcellini

63 Elbow Arthroscopy: Difficult Cases and Ulnar Nerve Preservation . . . . . . . . . . . . . . . . . . . . . . . . . . . 773 L. A. Pederzini , F. Di Palma , F. Nicoletta , and E. Tripoli

Part V HIP

64 General Aspects on Hip Arthroscopy . . . . . . . . . . . . . . . . . . . . . 787 Filippo Randelli , Fabrizio Pace, Daniela Maglione, Sara Favilla, Paolo Capitani, and Marco Brioschi

65 Hip Arthroscopy: Diagnostic Techniques . . . . . . . . . . . . . . . . . . 803 Ivan Dzaja , Harman Chaudhry , and Olufemi R. Ayeni

66 Arthroscopic Treatment of Femoroacetabular Cam Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815 Mohammad Masoud and Michael Dienst

67 Pincer Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835 Kotaro R. Shibata and Marc R. Safran

68 Hip Arthroscopy for the Treatment of Osteochondral Defects and Loose Bodies . . . . . . . . . . . . . . . . 847 Nicole A. Friel , Michaela Kopka , Volker Musahl , and Craig S. Mauro

69 Labral Lesions of the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 859 Sanjeev Bhatia , Karen Briggs , and Marc J. Philippon

70 Avascular Necrosis, Osteoarthritis and Synovitis . . . . . . . . . . . 867 Nicolas Bonin , Christophe Tissot , and Antoine Dangin

Part VI Wrist Paolo Arrigoni

71 General Aspects on Wrist Arthroscopy . . . . . . . . . . . . . . . . . . . 881 Loris Pegoli , Alessandro Pozzi , and Paolo Arrigoni

72 Arthroscopic Resection of Wrist Ganglia . . . . . . . . . . . . . . . . . . 891 C. Mathoulin , J. Garret , M. Gras , and V. Mesquida

73 Scapholunate Ligament Injuries . . . . . . . . . . . . . . . . . . . . . . . . . 903

Contents

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Jane C. Messina

74 Wrist Arthroscopy in Degenerative Conditions of the Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913 Michael Chu-Kay Mak and Pak-Cheong Ho

75 Wrist Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 931 John R. Fowler

76 Arthroscopic Arthrolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935 Riccardo Luchetti , Gregory Bain , Levi Morse , and Duncan McGuire

Part VII Ankle Niek Van Dijk

77 Anterior Ankle Arthroscopy: General Setup and Portal Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955 K. T. M. Opdam , R. Zwiers , and C. N. van Dijk

78 Anterior Ankle Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965 R. Zwiers , K. T. M. Opdam , and C. N. van Dijk

79 Soft Tissue Impingement of the Ankle . . . . . . . . . . . . . . . . . . . . 971 G. Cordier and S. Guillo

80 Anterior Bony Ankle Impingement . . . . . . . . . . . . . . . . . . . . . . . 979 Daniël Haverkamp

81 Osteochondral Defects of the Ankle . . . . . . . . . . . . . . . . . . . . . . 985 Gwendolyn Vuurberg and C. Niek van Dijk

82 Mosaicplasty for Treatment of Osteochondral Defects of the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 997 Tamás Gál , Ágnes Berta , and László Hangody

83 Scaffolding as Treatment for Osteochondral Defects in the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1003 Alberto Gobbi , Celeste Scotti , and Giuseppe M. Peretti

84 HemiCAP for Secondary Treatment for Osteochondral Talar Defects . . . . . . . . . . . . . . . . . . . . . . . . 1013 Mikel L. Reilingh , Christiaan J. A. van Bergen , Rogier M. Gerards , Inge C. M. van Eekeren , and C. Niek van Dijk

85 Retrograde Drilling for the Treatment of Osteochondral Lesions in the Ankle . . . . . . . . . . . . . . . . . . . 1023 Adam Lomax and James Calder

86 Osteoarthritis of the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033 Milan Handl

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87 Arthroscopic Ankle Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . 1043 Richard P. Walter and Ian G. Winson

88 Posterior Ankle Arthroscopy: General Setup and Portal Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1049 K. T. M. Opdam , R. Zwiers , and C. N. van Dijk

89 Posterior Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1055 Tahir Ögüt

90 Hindfoot Endoscopy for Posterior Ankle Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1067 P. P. d’Hooghe and C. N. van Dijk

91 Arthroscopy of Subtalar Joint . . . . . . . . . . . . . . . . . . . . . . . . . . 1079 Xavier Martin Oliva , Juan Manuel Rios , and Matteo Guelfi

92 Subtalar Arthroscopic Arthrodesis . . . . . . . . . . . . . . . . . . . . . . 1089 Peter A. J. de Leeuw and C. Niek van Dijk

93 Peroneal Tendoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1097 P. A. van Dijk , P. A. de Leeuw , and G. M. Kerkhoffs

94 Tendoscopy of the Achilles Tendon, Peroneal Tendon and Posterior Tibial Tendon . . . . . . . . . . . . . . . . . . . . . 1105 J. I. Wiegerinck and C. N. van Dijk

95 Achilles Tendon Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1115 Robert Śmigielski and Urszula Zdanowicz

96 Endoscopic Calcaneoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1125 R. Zwiers , J. I. Wiegerinck , and C. N. van Dijk

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1131

Contents

Part I

General Content

3© ESSKA 2016 P. Randelli et al. (eds.), Arthroscopy: Basic to Advanced, DOI 10.1007/978-3-662-49376-2_1

History of Arthroscopy

Lars Goebel and Henning Madry

The development of arthroscopic surgery can be regarded as one of the milestones in orthopedic surgery within the twentieth century, along with joint arthroplasty and the open reduction and internal fi xation of fractures [ 1 – 3 ].

The origin of arthroscopy comes from the Greek arthros for joint and scopein for to look. Physicians have long since attempted to look into body cavities. Its roots can be traced back to the time of the Roman Empire. In the ruins of Pompeii, evidence for the use of vaginal specu-lums and proctoscopes was made [ 4 , 5 ].

In modern times it was Philipp Bozzini (1773–1809), a German doctor from Mainz, who fi rst invented a primitive endoscope, his Lichtleiter , to inspect body cavities like the mouth, nasal cavity, rectum, or female bladder. When his invention was presented to the Rome Academy of Science (Italy) in 1806, the poten-tial of his invention was, however, not acknowl-edged at all [ 6 ] (Table 1.1 ).

Half a century later, Antoine Desormeaux (1815–1882), a French physician from Paris, developed in 1853 a gazogene cytoscope , which used a mixture of gasoline and turpentine to illu-minate and a system of mirrors to visualize the bladder. Today, his invention is regarded as the fi rst instrument for endoscopy [ 7 ].

In 1860 Julius Bruck (1840–1902), a German dentist from Breslau (now Wrocław, Poland), transluminated the bladder with a diaphanoscope from the rectum to remove bladder stones [ 8 ].

The German urologist Maximilian Nitze (1848–1906) from Berlin introduced a cysto-scope in 1876 which already used a heated plati-num loop for illumination [ 9 ]. One year later, his fi rst public demonstration took place at the Institut für Pathologie at the Stadtkrankenhaus Dresden - Friedrichstadt (Germany), the same place where 50 years later Michael Burman per-formed his arthroscopic cadaver studies [ 10 ] under the supervision of the German pathologist Christian Georg Schmorl (1861–1932).

After the invention of Thomas Edison’s light bulb, Maximilian Nitze and Josef Leiter (1830–1892), an Austrian surgical instrument maker from Vienna, designed the fi rst cystoscope with an incandescent light bulb for illumination in 1886 [ 11 ]. Maximilian Nitze was also the fi rst to take a photograph of the inside of a human blad-der 4 years later.

The Swedish physician Hans Christian Jacobaeus (1879–1937) from Stockholm invented, together with the Georg Wolf company

L. Goebel • H. Madry (*) Center of Experimental Orthopaedics, Saarland University Medical Center , Kirrberger Straße, Building 37 , 66421 Homburg/Saar , Germany

Department of Orthopaedic Surgery , Saarland University Medical Center , Kirrberger Straße, Building 37 , 66421 Homburg/Saar , Germany

Cartilage Net of the Greater Region, University of the Greater Region , 66421 Homburg/Saar , Germany e-mail: henning.madry@uks.eu

1

4

(Berlin, Germany), his laparo - thoracoscope in 1910. He used this technique for diagnostic pur-poses in undefi ned abdominal complaints and functional impairment and as well to treat pleural adhesions caused by tuberculosis [ 12 ].

In 1912 Severin Nordentoft (1866–1922, Fig. 1.1 ), a Danish surgeon and radiologist born

in Aarhus, presented his work on Endoscopy of Closed Cavities by the Means of My Trokart - Endoscope at the 41st Congress of the German Society of Surgeons in Berlin (Germany) [ 13 ]. He described a trocart - endoscope , which was similar to the Jacobaeus laparo - thoracoscope , consisting of a 5 mm diameter trocart, a fl uid

Table 1.1 Selected milestones of the history of arthroscopy within the past two centuries

Milestones in the history of arthroscopy

1806 Philipp Bozzini invents his Lichtleiter , the fi rst primitive endoscope 1853 Antoine Desormeaux develops a gazogene cytoscope to visualize the bladder 1860 Julius Bruck uses a diaphanoscope to transluminate the bladder from the rectum 1876 Maximilian Nitze introduces his cystoscope with a heated platinum loop for illumination 1886 Maximilian Nitze and Josef Leiter design the fi rst cystoscope with an incandescent light bulb 1890 Maximilian Nitze takes the fi rst photograph of the inside of a human bladder 1910 Hans Christian Jacobaeus invents his laparo - thoracoscope 1912 Severin Nordentoft, the fi rst arthroscopist , presents his results on endoscopy of the knee joint in Berlin 1918 Kenji Takagi uses a cystoscope to examine cadaver knees and later patients with tuberculous knees 1921 Eugen Bircher started to perform arthroendoscopies to diagnose meniscal pathologies 1925 Philip Kreuscher publishes his remarkable article on Semilunar Cartilage Disease 1931 Michael Burman performs cadaver studies and publishes his historical paper on Arthroscopy or the Direct

Visualisation of Joints , including the fi rst arthroscopic pictures ever published 1939 Ernst Vaubel publishes Die Arthroskopie , the fi rst book on arthroscopy 1954 Harold Hopkins introduces the principle of glass fi ber cold light 1955 Masaki Watanabe, the father of modern arthroscopy , develops the concept of triangulation and removes the

fi rst tumor arthroscopically 1957 Masaki Watanabe publishes his fi rst Atlas of Arthroscopy 1959 The Watanabe No. 21 arthroscope is produced in series 1960 Harold Hopkins develops rod lens systems for arthroscopes 1962 Masaki Watanabe performs the fi rst arthroscopic meniscectomy 1964 Robert Jackson is the fi rst foreign doctor to visit Watanabe acquiring his technique of arthroscopy 1967 The Watanabe No. 22 arthroscope is the fi rst arthroscope to use cold light 1968 Robert Jackson gives fi rst instructional course on arthroscopy at the American Academy of Orthopaedic

Surgeons 1972 John Joyce is the fi rst to organize private arthroscopy teachings 1973 Jan Gillquist promotes the central approach to the knee 1974 Richard O’Connor performs the fi rst partial meniscectomy in North America 1974 The International Arthroscopy Association (IAA) is founded 1975 Harold Eikelaar receives the fi rst PhD degree on arthroscopy 1976 Robert Jackson and David Dandy publish the fi rst textbook in English on arthroscopy of the knee 1976 Lanny Johnson develops the fi rst motorized shaver instrument 1982 The North American chapter of the IAA is converted to the Arthroscopy Association of North America

(AANA) 1984 The European Society of Sports Traumatology , Knee Surgery and Arthroscopy (ESSKA) is founded 1985 AANA’s journal Arthroscopy : The Journal of Arthroscopic and Related Research (Arthroscopy) is launched 1993 ESSKA’s journal Knee Surgery , Sports Traumatology , Arthroscopy (KSSTA) commences 1995 The IAA and the International Society of the Knee (ISK) assemble to the International Society of

Arthroscopy , Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) 2014 The Journal of Experimental Orthopaedics (JEO), ESSKA’s basic science journal, is introduced

L. Goebel and H. Madry

5

valve, and an optic tube. Of note, he reported about its application for endoscopy of the knee joint, besides suprapubic cystoscopy and lapa-roscopy [ 14 ]. It was thus Severin Nordentoft who fi rst coined the term arthroscopy for visual-ization of joint cavities, and, today, he is consid-ered as the fi rst arthroscopist . Nevertheless, in his presentation no evidence can be found that he ever applied his instrument to patients. At that time, only 90° optic lens systems were available. Moreover, the lens systems allowed only for a relatively poor overview of the joint because of sparse illumination as only about 10 % of the light of modern optics was transmitted. Severin Nordentoft already chose sterile saline as optical medium and advised the use of arthroscopy for the early diagnosis of meniscal lesions [ 14 ]. Interestingly, in the decades thereafter, other

arthroscopic pioneers never referred to him in their publications.

Kenji Takagi (1888–1963, Fig. 1.2 ), a Japanese orthopedic surgeon from Tokyo, applied in 1918 a cystoscope to look inside cadaver knees and later to examine knees affected by tuberculosis. His fi rst arthroscope, build in 1920, was 7.3 mm in diameter, thus relatively big and impracticable for a use within the knee. He continued sophisti-cating his cystoscope and developed a total of 12 different arthroscopes, with smaller diameter and different angels of view, that became the very prototypes for modern arthroscopes. Also, simple operations, such as biopsies, could be performed with operative instruments he invented. He also discussed distension of the knee with saline solu-tion to enlarge the joint cavity and to improve visualization [ 4 , 5 ].

The Swiss surgeon and politician Eugen Bircher (1882–1956, Fig. 1.3 ) started to perform arthroscopies in 1921 as an attempt to diagnose meniscus pathologies [ 15 ]. He was the fi rst to publish several papers on the topic of what he called arthroendoscopy and approximately per-formed 60 cases until 1926. Eugen Bircher used this procedure only in advance to arthrotomies.

Fig. 1.1 Severin Nordentoft (1866–1922), today acknowledged as the fi rst arthroscopist (Are reprinted with permission)

Fig. 1.2 Kenji Takagi (1888–1963) (Are reprinted with permission)

1 History of Arthroscopy

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Interestingly, Severin Nordentoft and Eugen Bircher never referred to each other despite both had presented their results at the annual con-gresses of surgery in Berlin. Eugen Bircher also used a 90° optic with a very limited fi eld of view, a little illumination, and a long dead end of the arthroscope. By 1930, Eugen Bircher quitted the use of his arthroendoscopy in favor of air arthrog-raphy, a radiographic technique expecting better visualization of joint contours.

Phillip Heinrich Kreuscher (1883–1943), a son of German immigrants, from Chicago (Illinois, USA) was the fi rst arthroscopist in Northern America. After initial studies about the collapsed lung treatment for pulmonary tubercu-losis, his academic focus shifted from 1917 onto athletic injuries and especially to the menisci, the semilunar cartilages of the knee. In 1925, his remarkable article on Semilunar Cartilage Disease : A Plea for the Early Recognition by Means of the Arthroscope and the Early Treatment of this Condition was published where he most likely used a Jacobaeus laparo -

thoracoscope [ 5 , 16 ]. In a letter to Michael Burman in 1931, he reported 25–30 cases where he applied his arthroscope, although later he did no longer perform arthroscopies. Perhaps like Eugen Bircher, not acknowledged in his time and possibly frustrated by the technical diffi culties, he instead focused on arthrography as well.

Michael Burman (1896–1974, Fig. 1.4 ) was a young American registrar for orthopedics [ 17 ]. He started to work with an arthroscope designed by Reinhold Wappler (1870–1932), a designer of electrosurgical instruments, in the anatomy labo-ratory of the New York University (New York, USA). In 1931 he succeeded to gain a travel schol-arship that allowed him to extend his research at the Institut für Pathologie at the Stadtkrankenhaus Dresden - Friedrichstadt [ 10 ]. Here, he applied dif-ferent dyes to visualize articular cartilage degen-eration and extended his cadaver studies. Also the fi rst hip arthroscopy is attributed to him, while Kenji Takagi in 1939 performed the fi rst hip arthroscopy in patients. Michael Burman pub-lished in 1931 his historical paper Arthroscopy or the Direct Visualisation of Joints [ 18 ]. The 20 col-ored aquarelles of arthroscopic fi ndings in differ-ent joints that were included are the fi rst

Fig. 1.3 Eugen Bircher (1882–1956) (Are reprinted with permission)

Fig. 1.4 Michael Burman (1896–1974) (Are reprinted with permission)

L. Goebel and H. Madry

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arthroscopic pictures ever published. The images were painted by Frieda Erfurt in Dresden, the institute’s medical artist. In the 1950s Burman col-lected arthroscopic images, but, unfortunately, he never found an editor who was willing to publish his Atlas of Arthroscopy [ 19 ].

Ernst Vaubel (1902–1989, Fig. 1.5 ) was a rheumatologist from Wiesbaden (Germany). Together with the Georg Wolf company , he improved with an oblique 45° optic the Jacobaeus laparo - thoracoscope that was then called Arthroskop nach Dr. E. Vaubel [ 20 ]. In 1939, the fi rst book ever published on arthroscopy, Die Arthroskopie , was published by Ernst Vaubel [ 21 ].

Unfortunately, the Second World War (1939–1945) delayed advancements in medical science, and for 16 years no paper on arthroscopy was published [ 4 , 22 ].

Masaki Watanabe (1911–1994, Fig. 1.6 ) was an orthopedic surgeon from Nagano, Japan, who

graduated from Tokyo Imperial University in 1937. He was a scholar of Kenji Takagi [ 23 ]. After World War II, he developed and sophisti-cated endoscopic instruments. His Watanabe No. 21 arthroscope (Fig. 1.7 ) was produced in series from 1959. Today, he is considered as the father of modern arthroscopy, and the Watanabe No. 21 arthroscope was the fi rst model widely accepted and used. Nevertheless, it had some disadvan-tages. For example, the incandescent light bulb sporadically broke within the knee joint, and the light carrier was susceptible for short circuit. Notably, Masaki Watanabe also developed the concept of triangulation in 1955, and it was also him who fi rst applied knee arthroscopy as thera-peutic tool to remove a giant cell tumor in 1955 from the recessus superior . In 1962, he per-formed an arthroscopic partial meniscectomy. Also he was the fi rst to obtain color photographs from the inside of a knee joint (Fig. 1.8 ). Yet, a color movie on arthroscopy presented at the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT) congress in 1957 in Barcelona (Spain) attracted only very few people.

Fig. 1.5 Ernst Vaubel (1902–1989) (Are reprinted with permission)

Fig. 1.6 Masaki Watanabe (1911–1994), the father of modern arthroscopy (Are reprinted with permission)

1 History of Arthroscopy

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His fi rst Atlas of Arthroscopy [ 24 ] was published in 1957 in English with illustrations by Fujihashi, followed by a second edition in 1969 containing illustrated color photographs.

Harold Horace Hopkins (1918–1994) was a British physicist born in Leicester, East Midlands. He developed both the principle of glass fi ber cold light in 1954 and the optical rod lens system in 1960 [ 25 , 26 ]. At fi rst glass fi bers were used for fl exible gastroscopes. The fi rst arthroscope to use cold light was the Watanabe No. 22

arthroscope built by Tsunekichi Fukuyo in 1967. Interestingly, Masaki Watanabe himself was not convinced and went on using his Watanabe No. 21 arthroscope with an offset tungsten bulb. While most American pioneers used this conven-tional arthroscope as well, European arthrosco-pists used cold light instruments starting from around 1969, produced by German manufactur-ers Karl Storz (Tuttlingen, Germany) and Richard Wolf (Knittlingen, Germany). The implementa-tion of rod lenses and cold light signifi cantly improved the visibility, and arthroscopies became safer and more reliable.

Robert W. Jackson from Toronto (Canada) went to Tokyo (Japan) on a traveling fellowship in 1964 to study tissue culture techniques [ 27 ]. After many inquiries he found Watanabe at Tokyo Teishin Hospital . Curiously, even in his own country, Masaki Watanabe’s work was unknown, and Robert Jackson was the fi rst foreign doctor visiting him. For months twice a week, he watched him and acquired the technique of arthroscopy, and, in return, taught Masaki Watanabe English. Before returning to the University of Toronto in 1965, he purchased a Watanabe No. 21 arthro-scope. In the fi rst year, he used it already on 25 cases, while frequently being criticized and ridi-culed by his colleagues. Despite this challenging environment, 70 cases were accomplished in 1966 and the numbers of case steadily grew there-after. Other surgeons from North America became aware of this technique. In 1968, Robert Jackson gave the fi rst instructional course on arthroscopy at the American Academy of Orthopaedic Surgeons (AAOS) [ 28 ]. From 1973 he invited Richard L. O’Connor to join him in these courses. In 1976, together with David Dandy, he pub-lished the fi rst textbook in English on arthroscopy of the knee.

Richard L. O’Connor (1933–1980) visited Masaki Watanabe in 1971 and 1972 and learned the technique from him. With Richard Wolf Medical Instruments Corporation (Vernon Hills, Illinois, USA), new instruments and arthroscopes were developed. He performed in 1974 the fi rst partial meniscectomy in North America. It was also him who introduced a rod lens-type opera-tion arthroscope [ 5 ].

Fig. 1.7 The Watanabe No. 21 was the fi rst arthroscope produced in series. It had an offset light bulb and an arthroscopic valve (Are reprinted with permission)

Fig. 1.8 Arthroscopic picture of a torn medial meniscus. The fi rst arthroscopic partial meniscectomy was per-formed by Masaki Watanabe in 1962 (Are reprinted with permission)

L. Goebel and H. Madry

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Lanny L. Johnson was one of the leading prac-titioners and innovators of arthroscopy in North America. He promoted the concept of multiple punctures to explore all regions of a joint and was a pioneer of arthroscopic shoulder surgery and rotator cuff repair, while other diarthrodial joints were also subjected to arthroscopy by him. Lanny Johnson developed many arthroscopic instru-ments, most notable the fi rst motorized shaver instrument in 1976 in cooperation with Dyonics (Andover, Massachusetts, USA). Johnson was also one of the fi rst arthroscopic surgeons video-taping his arthroscopies [ 5 ].

In 1972, John J. Joyce III (1914–1991) was the fi rst to organize a private arthroscopy teach-ing course at the University of Pennsylvania (Philadelphia, Pennsylvania, USA) [ 5 ].

Harold R. Eikelaar from the Netherlands was the fi rst recipient of a PhD degree on arthros-copy in 1975. Together with the Storz company , he developed the fi rst 30° forward oblique arthroscope.

Ejnar Eriksson was the fi rst professor for sports traumatology at the Karolinska Institute (Stockholm, Sweden) and hosted, as fi rst one, many arthroscopy courses in European countries.

Jan Gillquist, a Swedish orthopedic surgeon, in 1973 promoted the central approach through the patellar tendon to the knee.

Within the last decades, several arthroscopic associations were set up. The International Arthroscopy Association (IAA) was founded on April 26, 1974, when there were plans for a sec-ond private course on arthroscopy, after the fi rst one was held 1973 by John Joyce in Philadelphia. Masaki Watanabe was elected as its fi rst presi-dent, while the IAA’s purpose was set to foster by means of arthroscopy the development and dis-semination of knowledge in the fi elds of orthope-dics and medicine in order to improve the diagnosis and treatment of joint disorders . Initially, the IAA was constituted solely out of two chapters, North America and Japan. At fi rst, every 3 years IAA meetings were held corpo-rately with the SICOT, beginning 1975 in Copenhagen (Denmark), and from 1987 biennial meetings were held with the International Society of the Knee (ISK). In 1995 the ISK and IAA

joined to form the International Society of Arthroscopy , Knee Surgery and Orthopaedic Sports Medicine (ISAKOS, Fig. 1.9 ), with its fi rst meeting being held in Buenos Aires in 1997 [ 5 , 7 , 19 , 27 , 28 ].

The North American chapter of the IAA was converted into the Arthroscopy Association of North America (AANA, Fig. 1.10 ) in 1982 as it became apparent that a different kind of organi-zation was needed for Northern America to sat-isfy the educational needs of the increasing number of arthroscopists. Further being closely related to the IAA, meetings were now held annually. Its journal Arthroscopy : The Journal of Arthroscopic and Related Research (Arthroscopy) was launched in 1985.

In Europe, similar to the AANA, the European Society of Sports Traumatology , Knee Surgery and Arthroscopy (ESSKA, Fig. 1.11 ) was founded 1984 in West Berlin by Ejnar Eriksson from Sweden. Its clinical journal Knee Surgery , Sports Traumatology , Arthroscopy (KSSTA) was launched in 1993, with Eriksson serving as editor in chief. ESSKA inaugurated also its basic sci-ence Journal of Experimental Orthopaedics (JEO) in 2014.

Fig. 1.9 Logo of ISAKOS, the International Society of Arthroscopy , Knee Surgery and Orthopaedic Sports Medicine (Represents the offi cial logo of the above named society and was taken from the respective offi cial website)

1 History of Arthroscopy

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Similarly, the Asia Pacifi c Orthopaedic Society for Sports Medicine (APOSSM) was founded in 1995 together with ISAKOS. In 2012 APOSSM took its progression further to the development of its new society, the Asia - Pacifi c Knee , Arthroscopy and Sports Medicine Society

(APKASS, Fig. 1.12 ). Also, for South and Latin America, the Sociedad Latinoamericana de Artroscopia Rodilla y Traumatología Deportiva (SLARD, Fig. 1.13 ) was established.

Teaching the art of arthroscopy began at fi rst one-on-one with the instructor and the student looking through the same optic. It was later

Fig. 1.10 Logo of AANA, the Arthroscopy Association of North America (Represents the offi cial logo of the above named society and was taken from the respective offi cial website)

Fig. 1.11 Logo of ESSKA, the European Society of Sports Traumatology , Knee Surgery and Arthroscopy (Represents the offi cial logo of the above named society and was taken from the respective offi cial website)

Fig. 1.12 Logo of APKASS, the Asia - Pacifi c Knee , Arthroscopy and Sports Medicine Society (Represents the offi cial logo of the above named society and was taken from the respective offi cial website)

Fig. 1.13 Logo of SLARD, the Sociedad Latinoamericana de Artroscopia Rodilla y Traumatología Deportiva (Represents the offi cial logo of the above named society and was taken from the respective offi cial website)

L. Goebel and H. Madry

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facilitated by beam-splitting devices, allowing both to look at once into the joint [ 5 ]. Nevertheless it was still extremely susceptible for moving the arthroscope away. Later, fl exible fi ber optics were available, further facilitating teaching [ 26 ]. With the implementation of television monitors, slides, or videos, it was possible to better demon-strate pathological conditions, as well as techni-cal processes. Models out of rubber and plastic were developed for teaching, while today cadaver teaching centers represent the state of the art.

In the last decades, indications for arthroscopic therapies have been continuously expanded [ 29 ]. Almost every joint may be assessed and treated by arthroscopy. At the same time, techniques and indications are further sophisticated, e.g., for meniscal repair [ 30 , 31 ] or anterior cruciate liga-ment reconstruction [ 32 , 33 ]. Today, arthroscopy has to be regarded as the standard technique for many indications, compared with conventional methods. Its benefi ts include, but are not limited to, a reduced time of the healing process and a decreased number of complications while a diag-nosis and defi nitive operative treatment are facili-tated [ 3 ]. Future inventions may lead to three-dimensional arthroscopy, e.g., the invention of manual movable optics allowing the surgeon to turn the optic from 0 to 90°.

While in the early days, innovations by the pioneers of arthroscopy were often met with ignorance and skepticism, arthroscopic opera-tions now represent one of the key technological advancements of the past 100 years in orthopedic and trauma surgery.

References

1. Bong MR, Koval KJ, Egol KA. The history of intra-medullary nailing. Bull NYU Hosp Jt Dis. 2006;64(3–4):94–7.

2. Labusca L. Editorial: technology advancement and research progress in orthopedic surgery. Open Orthop J. 2013;7:118–9.

3. Carr AJ, Price AJ, Glyn-Jones S, Rees JL. Advances in arthroscopy-indications and therapeutic applica-tions. Nat Rev Rheumatol. 2015;11(2):77–85.

4. Pässler HH, Yang Y. The past and the future of arthroscopy. In: Doral MN, Tandogan RH, Verdonk R, editors. Sports injuries: prevention, diagnosis, treat-

ment and rehabilitation. Berlin: Springer; 2012. p. 5–13.

5. Jackson RW. A history of arthroscopy. Arthroscopy. 2010;26(1):91–103.

6. Reuter M. Philipp Bozzini (1773–1809): Der endos-kopische Idealist. Urologe A. 2006;45(9):1084–91.

7. Jackson RW. Quo venis quo vadis: the evolution of arthroscopy. Arthroscopy. 1999;15(6):680–5.

8. Zajaczkowski T, Zamann AP. Julius Bruck (1840–1902) and his infl uence on the endoscopy of today. World J Urol. 2004;22(4):293–303.

9. Herr HW. Max Nitze, the cystoscope and urology. J Urol. 2006;176(4 Pt 1):1313–6.

10. Kieser C, Michael S. Burman in Dresden. Arthroskopie. 2004;17:108–10.

11. Zykan M. Josef Leiter – Wiener Instrumentenmacher von Weltruf. Aktuelle Urol. 2011;42(4):223–4.

12. Hatzinger M, Kwon ST, Langbein S, Kamp S, Hacker A, Alken P. Hans Christian Jacobaeus: inventor of human laparoscopy and thoracoscopy. J Endourol. 2006;20(11):848–50.

13. Nordentoft S. Ueber Endoskopie geschlossener Cavitäten mittels meines Trokart-Endoskops. Zentralbl Chir. 1912;39:95–7.

14. Kieser C, Jackson RW. Severin Nordentoft: the fi rst arthroscopist. Arthroscopy. 2001;17(5):532–5.

15. Kieser C, Jackson RW. Eugen Bircher (1882–1956) the fi rst knee surgeon to use diagnostic arthroscopy. Arthroscopy. 2003;19(7):771–6.

16. Kreuscher PH. Semilunar cartilage disease: a plea for the early recognition by means of the arthroscope and the early treatment of this condition. Illinois Med J. 1931;47:290–2.

17. Parisien JS, Present DA. Dr. Michael S. Burman. Pioneer in the fi eld of arthroscopy. Bull Hosp Jt Dis Orthop Inst. 1985;45(2):119–26.

18. Burman MS. Arthroscopy or the direct visualization of joints: an experimental cadaver study. 1931. Clin Orthop Relat Res. 2001;390:5–9.

19. Watanabe M. Memories of the early days of arthros-copy. Arthroscopy. 1986;2(4):209–14.

20. Kieser C. Ernst Vaubel, der deutsche Pionier der Arthroskopie 1902–1989. Unfallchirurg. 2000; 103(1):93–7.

21. Vaubel E. Die Arthroskopie. Der Rheumatismus, Band 9. Dresden: Steinkopff; 1938.

22. Kieser C. Die Arthroskopie zwischen Weltgeschichte und Technik. Arthroskopie. 1999;12:111–6.

23. DeMaio M. Giants of orthopaedic surgery: Masaki Watanabe MD. Clin Orthop Relat Res. 2013;471(8):2443–8.

24. Watanabe M, Takeda S, Ikeuchi H. Atlas of arthros-copy. 1st ed. Tokyo: Igaku Shoin Ltd; 1957.

25. Ellis H. The Hopkins rod-lens system. J Perioper Pract. 2007;17(6):272–4.

26. Kieser C, Jackson RW. How cold light was introduced to arthroscopy. Arthroscopy. 2006;22(4):345–50.

27. Jackson RW. Memories of the early days of arthros-copy: 1965–1975. The formative years. Arthroscopy. 1987;3(1):1–3.

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28. Casscells SW. The early days of arthroscopy in the United States. Arthroscopy. 1987;3(2):71–3.

29. Katz JN, Gomoll AH. Advances in arthroscopic sur-gery: indications and outcomes. Curr Opin Rheumatol. 2007;19(2):106–10.

30. Seil R, VanGiffen N, Pape D. Thirty years of arthroscopic meniscal suture: what’s left to be done? Orthop Traumatol Surg Res. 2009;95(8 Suppl 1):S85–96.

31. Montgomery SR, Zhang A, Ngo SS, Wang JC, Hame SL. Cross-sectional analysis of trends in meniscec-

tomy and meniscus repair. Orthopedics. 2013; 36(8):e1007–13.

32. Araujo PH, van Eck CF, Macalena JA, Fu FH. Advances in the three-portal technique for anatomical single- or double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011; 19(8):1239–42.

33. Rodriguez-Merchan EC. Evidence-based ACL reconstruction. Arch Bone Jt Surg. 2015;3(1):9–12.

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Surgery Set-Up, Instrumentations and Electronic Equipment

Pietro Simone Randelli and Davide Cucchi

2.1 Surgical Environment

Arthroscopic surgery might be performed in operative theatre, in outpatient/ambulatory set-ting or in an offi ce; in any of these settings, basic requirements such as anaesthesia support, elec-tric power and suction for fl uid management must be present. Adequate sterilisation of arthroscopic equipment is also crucial [ 1 , 19 , 25 ].

2.2 Arthroscopy Tower

An arthroscopy tower is a vertical cart with various shelves on which electronic equipment for the arthroscopic procedure is placed (Fig. 2.1 ). Wheels allow moving the tower to the optimal position during surgery. Modern arthroscopy towers have a modular design to conform to any set-up needed. A monitor is

placed on the top of the arthroscopy tower. A smaller monitor may be placed on the opposite side of the main one or on another articulating arm to allow vision from other points of the room. The video camera unit and a light source unit are usually placed on the fi rst shelves under the monitor, together with possible external hard drives or documentation system units; a printer may be placed on the bottom shelf. A power box for motorised instruments and one for radiofrequency may be mounted on the arthroscopy tower or on separate carts. If used, the irrigation pump is usually placed also on the arthroscopy tower [ 1 , 18 , 19 ].

2.3 Light Source and Light Cable

A key feature of arthroscopy is to enable visuali-sation of internal structures with a minimal inci-sion. To obtain this, light must be brought inside the joint with an arthroscope. At the beginning of the arthroscopic and endoscopic era, light was produced by a candle and delivered through rigid instruments. Then, a light bulb was mounted on the tip of the arthroscope; in 1967, fi bre optics were introduced in arthroscopy by Masaki Watanabe (Fig. 2.2 ) [ 6 , 15 , 24 ].

Nowadays light is produced by a 100–300 W xenon lamp or by a LED and delivered to the arthroscope with fl exible fi bre optics. Light intensity and colour temperature are balanced by

P. S. Randelli (*) • D. Cucchi Dipartimento di Scienze Biomediche per la Salute , Università degli Studi di Milano , Via Mangiagalli 31 , Milan 20133 , Italy

IRCCS Policlinico San Donato , Via Morandi 30 , San Donato Milanese 20097 , Italy e-mail: pietro.randelli@unimi.it

2

14

internal feedback sensors and may be controlled on the camera head or on the arthroscopy tower. Filters and diffusion discs might be added to change light quality for special applications. Light loss must be minimal from light source to the joint; the quality of light delivered in the joint is affected by light source’s intensity and colour temperature, area of the transverse section of the light cable, light leaking in the connectors of the source-cable-arthroscope unit and possible dam-ages to single fi bres; a safety lock system pre-vents accidental separation of the light cable from the arthroscope. Adaptors may be used to fi t cables and arthroscopes from different genera-tions or manufacturers. The light concentration at

Fig. 2.1 An arthroscopy tower (Courtesy of Arthrex GmbH)

Fig. 2.2 Watanabe’s arthroscope No. 22, the fi rst direct- view scope with cold light illumination (Reprinted from: Copyright © 2006 Elsevier Inc., Kieser et al. [ 15 ], with permission from Elsevier)

P.S. Randelli and D. Cucchi

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the end of the light cable heats the focal point; therefore, this part must never be placed on the patient’s skin or on the drape as long as the light source is turned on, because of the risk of fi re or burns [ 1 , 18 , 19 ].

2.4 Arthroscopes and Cameras

Arthroscopes are telescopic devices which con-sist of a magnifying lens system sealed within a rigid tube; the distal (or objective) end contains the end of the fi bre optics bundle and the fi rst lens of the optical system. The proximal (or ocular) end is equipped with adapters to be attached to the video camera and the light cable. The image can be transmitted from the objective to the ocu-lar end through two basic optical systems: a rod- lens system, composed by long, cylindrical lenses separated by small spaces, and a single-image fi bre system, which is narrower in diameter and contains one image-transmitting fi bre bundle. Diameter and length of the arthroscope tube are

variable. Diameter and construction materials are important to prevent arthroscope bending, which alters light transmission and image quality.

Important optical characteristics of an arthro-scope are focal length, fi eld of view and resolu-tion. Focal length depends on arthroscope length and lens’s characteristics and infl uences depth of fi eld and magnifi cation. The fi eld of view depends on the arthroscope angle or “offset”; increasing the offset, the apparent and real fi eld of view will broaden and the image distortion will increase (Fig. 2.3 ). Most of the arthroscopes used today have a 30° offset, which allows the surgeon to visualize the articular environment with ease, but 0° and 70°-offset arthroscopes are also available. Resolution depends on light source and light transmission, lens integrity, imaging capturing device and monitor characteristics. The fi rst arthroscopes were designed for direct observa-tion (Fig. 2.4 ). Nowadays, arthroscopes are rou-tinely connected to a digital video camera, contained in a piece called “camera head”. A modern camera head contains usually a three-

Fig. 2.3 Image distortion and changes in apparent and real fi eld of view using arthroscopes with different offset (Reprinted and modifi ed from: Andrews and Timmerman [ 1 ], with permission from Elsevier)

2 Surgery Set-Up, Instrumentations and Electronic Equipment

16

chip CCD sensor; this means that a prism splits the image into the primary colours and projects it to three individual sensors. Multiple-sensor sys-tems enhance sharpness and improve colour bal-ance and resolution. An optical zooming system is built in the camera head and greater image magnifi cation can be digitally obtained by pixel enlargement [ 1 , 18 , 19 ].

2.5 Monitor, Image Capture Devices and Documentation System

The monitor usually sits on top of the arthros-copy tower and it is the device that shows the image created by the arthroscope and the camera head. Monitors have evolved from basic analogue projection boxes to fl at panel screens. Image cap-ture devices are commonly found on arthroscopy towers and can be either controlled from the tower or from the camera head. They ‘capture’ pictures or movies during arthroscopic procedure and save them onto CDs or external hard drives or in a documentation system. This allows to document the procedure digitally and to provide the surgeon and the patient with pictures or mov-ies of the arthroscopic procedure. Documentation systems might also be connected to hospital data-bases containing radiological and clinical data. Having actual pictures of the injury and the fi nal treatment outcome is important for referral sur-geons providing subsequent care and can help

patients understand their injuries and their prog-nosis for recovery. Numerous photo- and video- editing programmes are available from different providers; these are useful to add images to the clinical documentation or to prepare presenta-tions or publications.

2.6 Fluid Management

A clear view is essential to perform an arthroscopic procedure safely and effi ciently. Even if the arthroscope, light source and camera are functioning properly, debris and bleeding can block the arthroscopic view. A well-functioning irrigation system helps to widen the joint space and to clear all possible disturbances. Control of bleeding vessels, hypotensive anaesthesia and epinephrine in addition to irrigation fl uids are other ways to obtain a clear view.

Irrigation systems can be categorised into three types: gravity infusion, peristaltic volumet-ric pumps and centrifugal pumps; peristaltic pumps are divided in single and double rollers depending on absence or presence of an outfl ow pump. No consensus exists about optimal irriga-tion of joints during arthroscopic operations. Gravity infusion is safe, cheap and easy to pre-pare but does not allow to accurately control fl uid fl ow and permits to reach only low pressures. In pumps, a computerised console constantly mea-sures fl uid pressure and fl ow within the joint; the surgeon is enabled to optimise fl ow and pressure using pedals or from the arthroscopy tower. Modern systems automatically adjust for the pressure changes associated with the use of suc-tion devices and shavers [ 18 , 19 , 27 , 28 ].

In literature, different values are suggested for the optimal intra-articular pressure, depending on which joint is investigated and the surgeon’s pref-erences. Care has to be taken to avoid high pres-sure peaks, which can cause fl uid extravasation and soft tissue damage; abrupt movements of the joint may rapidly increase intra-articular pressure [ 1 , 7 , 8 , 26 ].

Fluid temperature affects core body tempera-ture, perioperative shivering and hypothermia. In endoscopic surgery, strong evidence recommends

Fig. 2.4 Eugen Bircher performing a knee arthroscopy (Reprinted from: Copyright © 2003 Elsevier Inc., Kieser et al. [ 30 ], with permission from Elsevier)

P.S. Randelli and D. Cucchi