ARTHROSCOPY •Endoscopic method •Imaging and treatment •In general or spinal anestesia • knee • shoulder • ankle • elbow • wrist • hip • small joints Arthroscopy •Camera •Arthroscop – rigid tube with a lens 30º or 70 º •Xenon light with optic cabel •ASC pump •Instruments •Shaver •Vaper •Printer, VIDEO, DVD S6R00004 Arthroscopy Menisci Chondropathy- shaving, debridement, abrasion arthroplasty, microfractures Plasty of ligaments Suture of rotator cuff Instability of shoulder Repair of transchondral lesions Support in treatment of intraarticular fractures Biopsy Advantages •Perfect visualisation •Less postoperative pain •Fast physioterapy •Small incision S6R00001 The knee joint- complicated structure Articulating bones: Femur, tibia and patella rozkydal_koleno_back rozkydal_koleno_front rozkydal_koleno_iso Stability of the knee Koleno medial Medial side Stability of the knee KOleno lateral Lateral side Stability of the knee Cruciate ligaments Koleno ACL Koleno PCL Stability of the knee joint Menisci Koleno menisky Stability of the knee KOleno zepředu Muscles The knee joint •Traumatology • •Chondropathy • •Degenerative findings S6R00002 Traumatology –Haemarthrosis –Meniscus lesion –Rupture of ligaments –Dislocations of the patella –Transchondral fractures History •History • •Mechanism of injury • Examination •Clinical examination •Aspiration •Blood patches •X- ray •MRI •Ultrasonography Clinical examination •Swelling, haematoma •Effusion •ROM •Tenderness •Stress test for stability •Maneuvers •Patela examination S2400072 Lachman test Anterior drawer sign Posterior drawer sign Anterior drawer sign, pivot shift test S2400094 S2400094 Valgus stress test Varus stress test Meniscus •Mechanism of injury •Tests: Mc Murray • Steinmann I • Steinmann II • Appley • Turner • Payer • Childress- squat test • Meniscus •Fibrocartilago •High elasticity •Paracapsular zone • - vessels Red zone red- white zone white zone Functions •Bumper •Stabilisator •More congruency •Distribution of synovial fluid •LM – more mobile •MM – prone for injury Koleno menisky Ruptures of menisci S2400065 •Longitudinal, horizontal, radial •„bucket handle type“ -Typical blockage •Degenerative lesions •Discoid meniscus Ruptury menisků S2400065 •longitudinální, horizontální, radiální •„ucho od koše“ -typické bloky kolena •degenerativní léze Ruptures of menisci •Longitudinal, horizontal, radial •„bucket handle type“ -Typical blockage •Degenerative lesions •Discoid meniscus Meniscus treatment •Menisectomy •partial •subtotal •complete Partial meniscectomy S6R00004 Parciální menisektomie S2400098 S6R00004 Subtotal menisectomy Subtotální menisektomie outside-in inside-out all-inside Suture of meniscus- meniscopexis S6R00002 l lLimitována kapacita hojení menisku lNejlepší výsledky v red zóně lTrhliny v rozsahu 0-2mm od pouzdra – nejlepší potenciál k zhojení - sutura v avaskulární zóně – poop. 75% pac. asympt. / follow-up 51m / lVertikální horizontální rpt. - ↑ potenciál k zhojení lTraumatická vs. degenerativní ruptura Techniky sutury Outside – in Inside – out All – inside Vertikální longitudinální ruptura lResekce vede k 3x ↑ kontaktnímu tlaku lZlatý standard – inside-out lDop. vertikální matracový steh, odstup 3-5mm - biomechanicky výhodnější než horizontální steh lA: Inside-out B: All-inside C: All inside knot tying tech. l Horizontální ruptura lNevede k ↑ tlaku lResekce 1 lišty => redukce kontaktní plochy o 59 % => ↑ tlaku lSutura horizonzální rpt. snižuje kontaktní tlak k minimálním hladinám lMenší potenciál k zhojení lSnaha o zachování obou lišt menisku lHealing rate 78,6 % lExcelentní výsledky zhojení u mladých pac. lAll – inside – kompresní cirkumferentní steh po obvodu léze Radiální ruptura l lRpt. 60 % centrální zóny nemá vliv na ↑ tlaku - parc. menisektomie lRpt 90 % siginifikantně ↑ tlak - sutura l lA: Inside-out -horizontální matracový steh lB: All-inside knot tying lC: Transtibiální technika ASK sutura menisku S6R00002 PDS vlákno Ligaments- ACL, PCL Koleno ACL Koleno PCL Rupture of ligaments •Sprain •partial rupture • total rupture •Mechanism of injury •Tests of stability S2400073 „Unhappy trias“ Rupture of ACL •Tests of stability •Lachman test •Anterior drawer sign •Pivot-shift test Lachman test Rupture of PCL •In dashboard injury •Posterior drawer sign Rupture of ACL •Frequent injury ACL zdravý Acute rupture of ACL • –Debridement –Physiotherapy –Limited activity –Orthesis balance defiancetiger6_99 Physiotherapy Orthesis Indication for reconstruction •1/3 of cases Þ BTB graft •Bone-Tendon-Bone S2400101 BTB graft •Bone-Tendon-Bone Press fit technique Hamstrings (m. semitendinosus + m. gracilis) Hamstr schema Hamstr Fixation by screws Technique ACL IS výsl S2400100 ACL plasty- press fit technique Femoral canal • Tibial canal • Tightening of the graft Graft in situ Aftertreatment •6 weeks orthesis • •Weight bearing after 6 weeks • •Sports activity after 9 months – ER 1 Chondropathy Outerbridge. H.K. ER 2 Chondropathy I. II. III. IV. Chondropathy I. st. S6R00001 Soft cartilage Chondropathy II. st. S6R00002 Fissures in the cartilage Chondropathy III. st. •Fibrilation- „ crab meet“ Chondropathy IV. st. S6R00002 Defects to subchondral bone Defects of cartilage •Patella Medial condyle Shaving and drilling - - abraze subch Drilling - Hangody, L., 1992 Defects up to 2 - 4 cm2 Osteochondral autograft transfer- OAT Mosaicplasty ER 12a Osteochondral autograft transfer- OAT ER 12b ER 13 ER OAT 1 OAT ER OAT 1 4 years after surgery Patella •Chondropathy •Subluxation •Dislocation • • Chondropathy of the patella S2400114 Clinical symptoms Chondropathy of the patella •Lateral hyperpression • •Lateral release S2400113 Lateral release •Incision of lateral retinaculum Traumatic dislocation of the patella •Always laterally •Conservative treatment •Operative treatment S2400115 Types of patella Recurrent dislocation of the patella •posttraumatic •congenital •habitual • ASK – lateral release + medial capsuloraphy Open surgery Transchondral fracture S6R00002 Removal of destroyed cartilage Osteochondral fractures S6R00006 Fixation by pins Arthroscopy of the shoulder Subacromial decompression Suture of rotator cuff Chronic instability SLAP lesion labrum ASAD – artroscopic subacromial decompression •Removal of bursa •Acromioplasty - shaver Burr acromioplasty RotCuf Rupture of rotator cuff •Suture: -arthroscopically - Suture anchor inserted Completed rotator cuff repair Rupture of rotator cuff •Suture: -from small incison ASC- stabilisation •Fixation of the labrum to the bone – stitches and arrows B 1 ASC- stabilisation •Fixation of the labrum • to the bone – stitches, arrows S6R00001 •SLAP lesion • •Rupture of insertion of the •tendon of long head of biceps