General Technique


2
General Technique


2.1 Anesthesia, Patient Support, and Pain Management


A surgical plane of general anesthesia is required for arthroscopy with the same considerations that would be employed for any orthopedic surgery. Beyond this basic criterion selection of preanesthetic medications, induction agents, maintenance anesthesia, and pain management are more patient driven than they are procedure driven. Anesthetic and support needs of the young dog undergoing shoulder arthroscopy for OCD are completely different than the needs of the geriatric dog undergoing multiportal elbow arthroscopy for debriding degenerative joint disease. Pain management needs also vary greatly depending on patient needs and on the specific arthroscopic procedure that is performed; however, pain medication needs are usually significantly less than those for an open arthrotomy or other open orthopedic procedure.


An example of a typical patient management protocol includes preanesthetic evaluation with CBC, blood chemistry profile, thoracic radiographs, EKG, and urinalysis. Preanesthetic, induction, and maintenance protocols that are appropriate for the patient are used based on those established for individual practices. Perioperative NSAIDs are given based on standards employed by the practice. Additional opiate pain medications are indicated for sensitive patients and for more extensive arthroscopic procedures such as multiportal elbow debridement or arthroscopic stifle debridement in conjunction with surgical management of cruciate ligament injuries. Intra‐articular local anesthetics are typically not used as they damage joint cartilage (Çevik and Gergin 2018; Jayaram et al. 2019; Lo and Sciore 2009) although single intra‐articular injections of some diluted local anesthetics have not been proven to be detrimental (Breu and Rosenmeier 2013; Dragoo et al. 2012; Kreuz et al. 2018). Personal experience has found that patients, although more comfortable the day of arthroscopy, have been more painful the day after surgery when local anesthetics were used. Another concern with intra‐articular placement of local anesthetics is systemic toxicity (Di Salvo and Bufalari 2015). Intra‐articular systemic pain medications may be beneficial in managing postarthroscopy pain (El Baz and Farahat 2019; Moeen and Ramadan 2017; Salman and Olgunkeleş 2019). Intra‐articular corticosteroids have been used occasionally in severely inflamed joints, but their use is controversial (Céleste et al. 2005; Doyle et al. 2005; Gogia et al. 1993; Murphy et al. 2000; Todhunter et al. 1996).


Supportive treatment typically includes intravenous crystalloid fluid therapy based on patient needs. Perioperative antibiotic administration is left to the discretion of the surgeon. Padded leg wraps are applied at the end of the procedure for distal joints including the elbow, carpus, stifle, and hock. The wraps are removed prior to release on the day following arthroscopy. Postoperative icing of joints undergoing extensive arthroscopy has been used when indicated.


2.2 Postoperative Care


Most patients are kept in the hospital until the day after arthroscopy was performed although many can be released on the day of surgery. Medications starting after the procedure include oral NSAIDs with Tramadol or other appropriate opiates. Patients are released with these medications for 7–14 days. Activity is restricted for a minimum of 2 weeks. In‐house activity is limited to walking with no running, jumping, roughhousing, going up or downstairs, jumping up or down off the furniture, or jumping in or out of the car. Outside activity is limited to leash walking sufficient for urination and defecation. A recheck examination is performed at two weeks after arthroscopy, and the activity level is adjusted based on the procedure that was performed and on patient progress. Additional pain medication is prescribed as indicated.


2.3 Patient Preparation, Positioning, and Operating Room Setup


Patients are most commonly prepared and draped in a manner similar to what would be employed for an open arthrotomy of the joint being examined. The limb or limbs are clipped, scrubbed, and draped for aseptic surgery as would be done for any open orthopedic procedure. Effective arthroscopy requires that the joint be freely movable and draping must allow a full range of flexion, extension, and rotation of the joint of interest. Endoscopes and accessory instrumentation are sterilized with cold sterilization, ethylene oxide, or by autoclaving. Many instruments that previously required cold or gas sterilization are now autoclavable greatly increasing efficiency of case management. It is very important that the specific instrument manufacturer’s recommendations for sterilization are followed.


The leg is positioned and stabilized by an assistant or it can be immobilized in a holding device. The authors experience has been using an assistant. Various immobilizing and distraction devices have been designed and tested (Böttcher et al. 2009; Devesa et al. 2014, 2015; Gemmill and Farrell 2009; Götzens et al. 2019; Kim et al. 2016, 2017, 2019; Park et al. 2018; Rovesti et al. 2015, 2018; Schulz et al. 2004; Winkels et al. 2016). Their use is at the surgeon’s preference. Basic principles of endoscopic operating room setup are followed (Freeman 1999). The patient and video monitor or monitors are arranged so that the telescope is pointed as close to directly toward the monitor as possible. This concept is essential to effective arthroscopy. Arthroscopy techniques are difficult enough to learn and master without the added disorientation of improper monitor placement. Portals are placed to achieve triangulation optimizing function for arthroscopic surgery with the telescope visual field and operative instruments positioned to converge on the intra‐articular operative site in the same visual plane as seen by the surgeon (Figure 2.1). The angle between the telescope and the operative instrument is kept between 30 and 60°. Too narrow an angle increases interference of the telescope with instrumentation or what is termed sword fighting. Working at an angle of more than 90° distorts translation of hand movements to movement on the video monitor.


Patient positioning and operating room setup are specific for each joint, for specific procedures within each joint, and for unilateral vs bilateral procedures. Having two monitors in the operating room greatly facilitates setup and performing arthroscopy especially when multiple joints are examined, or multiple procedures are done in a single joint.

Photo depicts triangulation in the stifle joint with the telescope (on the right) and the operative instrument (on the left) converging in the area of interest in the intercondylar notch for an operative procedure.

Figure 2.1 Triangulation in the stifle joint with the telescope (on the right) and the operative instrument (on the left) converging in the area of interest in the intercondylar notch for an operative procedure.


Source: Freeman (1999). © 1999, Elsevier.


2.3.1 Shoulder Joint


Bilateral shoulder arthroscopy is more commonly performed than unilateral procedures as most of the common shoulder abnormalities requiring arthroscopy occur bilaterally. When bilateral arthroscopy is being performed under the same anesthesia, the patient is positioned in dorsal recumbency with both legs suspended (Figure 2.2a) and clipping is done to allow sterile preparation to the midscapula (Figure 2.2b). Draping is done so that the patient can be rolled to each side providing access to both joints. Bilateral shoulder OCD and bilateral UCGOC procedures are performed with the patient placed in dorsal recumbency with a monitor placed at the caudal end of the patient (Figure 2.3). When the legs have been draped, the patient is rolled toward the side to be operated first and the surgeon stands ventral to the patient with an assistant standing on the same side caudal to the surgeon, between the surgeon and the monitor. After the first side has been completed, both surgeon and assistant move to the other side of the patient and the patient is rolled to expose the second shoulder. For bilateral bicipital tendon surgery and procedures involving medial joint structures, patient positioning and transfer from side to side is the same as for OCD and UCGOC surgery but the monitor is placed at the head of the patient and the assistant stands cranial to the surgeon, again between the surgeon and the monitor (Figure 2.4). Bilateral procedures involving manipulations in both the cranial and caudal joint compartments require two monitors: one placed at the head of the patient and one placed and the foot of the patient (Figure 2.5). Unilateral procedures in either the cranial or caudal areas of the joint are performed with the patient positioned in lateral recumbency with the joint to be examined on the upside and with the surgeon and assistant standing on the ventral side of the patient (Figure 2.6). Unilateral procedures performed with the patient in lateral recumbency can be performed with monitor position as for bilateral procedures or with the monitor on the dorsal side of the patient directly across from the surgeon. For the craniomedial telescope portal, the patient is prepared and draped in dorsal recumbency, but the legs are left attached to the suspension system. This is an uncommonly employed technique. An easier procedure is to use an Endocameleon Arthro or a 70° arthroscope to evaluate the lateral joint structures from the lateral portals.

Photo depicts a patient positioned in dorsal recumbency with the front legs hung in preparation for bilateral shoulder or elbow arthroscopy. (a) An AP view and (b) a lateral view.

Figure 2.2 A patient positioned in dorsal recumbency with the front legs hung in preparation for bilateral shoulder and/or elbow arthroscopy. (a) An AP view and (b) a lateral view.


Source: Timothy C. McCarthy. © John Wiley & Sons Inc.

Schematic illustration of an operating room setup for bilateral shoulder arthroscopy for OCD or UCGOC with the patient in dorsal recumbency. The surgeon and assistant stand on what will be the ventral side of the patient after it is rotated on the side away from the shoulder to be operated. The monitor is placed at the caudal end of the patient.

Figure 2.3 Operating room setup for bilateral shoulder arthroscopy for OCD or UCGOC with the patient in dorsal recumbency. The surgeon and assistant stand on what will be the ventral side of the patient after it is rotated on the side away from the shoulder to be operated. The monitor is placed at the caudal end of the patient. This arrangement is also used for bilateral elbow arthroscopy for UAP.


Source: Drawing by Cindy Cox.


2.3.2 Elbow Joint


Elbow arthroscopy is typically performed bilaterally at the same anesthesia, and dorsal recumbency is employed to allow access to both elbows using the same preparation as for the shoulder joint (Figure 2.2). The patient is prepared with both legs suspended, and draping is done so that the legs are freely movable and can be abducted for access to the medial aspect of both joints. Bilateral procedures for medial coronoid process pathology, for medial condylar ridge OCD lesions, and for general exploration of the elbow joints using the medial telescope portal and craniomedial operative portal are performed with the patient in dorsal recumbency with the monitor placed at the head of the patient (Figure 2.4). The patient is held in dorsal recumbency with positioning supports, sandbags, or a “V” trough, the leg to be operated is abducted, and the surgeon stands on the same side as the joint being operated. The assistant stands beside the surgeon on the patient’s cranial side between the surgeon and the monitor. A bolster is placed under the elbow joint to create a fulcrum for valgus stress with internal rotation to open the medial side of the joint. A one‐pound roll of cotton covered with a waterproof sterile drape is commonly used for the bolster (Figure 2.7a and b. When the first joint arthroscopy has been completed, both surgeon and assistant move to the other side of the patient and the other leg is abducted for the second procedure. Arthroscopy for bilateral ununited anconeal process removal is also performed with the patient in dorsal recumbency but with the monitor at the caudal end of the table, and the legs are abducted to provide access to the medial aspect of the joint for placement of a standard medial telescope portal, caudomedial operative portal, and a craniomedial operative portal (Figure 2.4). Ununited anconeal processes are commonly associated with medial coronoid process pathology, and this positioning with this portal selection allows evaluation of the medial coronoid process at the same time as anconeal process fragment removal. This positioning requires two monitors, one at each end of the patient (Figure 2.5). With only one monitor, there is the problem of working away from the monitor for coronoid process revision or fragment removal if required. If a second monitor is not available, alternatives are to perform a unilateral procedure with the patient in dorsal or lateral recumbency with the monitor placed across from the surgeon on the opposite side of the patient. Then to perform the second side, the monitor is moved when the surgeon and assistant change sides. An additional alternative is to use caudal portals for access to the anconeal process with the patient in dorsal recumbency and the monitor at the head of the table. Multiportal elbow arthroscopy for debridement of degenerative joint disease is typically performed as a unilateral procedure with the patient in dorsal recumbency so that the patient can be rolled from side to side for access to both medial and lateral aspects of the joint and with the monitor at the head of the patient.

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Nov 28, 2021 | Posted by in SMALL ANIMAL | Comments Off on General Technique
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