Table Of ContentSpringer-Verlag
Berlin Heidelberg GmbH
MMIICCHHAAEELL J. STROBEL
Manual of
AARRTT HROSCOPIC
SSUU RGERY
WWiitthh 22335522 Separate Color lllustrations
~ Springer
ISBN 978-3-540-85737-2
Michael J. Strobel, Priv.-Doz. Dr. med.
Orthopădische Gemeinschaftspraxis Library of Congress Cataloging-in-Publication Data
Hebbelstr. 14a Strobel, Michael. [Arthroskopische Chirurgie. English]
D-94315 Straubing, Germany Manual of arthroscopic surgery 1 Michael Strobel. p.; cm.
Includes bibliographical references and index.
ISBN 978-3-540-85737-2 ISBN 978-3-540-87410-2 (eBook)
Revised, updated, and enlarged translation DOI 10.1007/978-3-540-87410-2
of the German edition.
1. Joints-Endoscopic surgery-Handbooks, manuals, etc.
Ti tie of the German edition: 2. Arthroscopy - Handbooks, manuals, etc. 3· Knees - Endo
scopic surgery - Handbooks, manuals, etc. l. Title.
Strobel: Arthroskopische Chirurgie
©Springer-Verlag Berlin Heidelberg 1998 [DNLM: 1. Joint Diseases-surgery. 2. Arthroscopy-methods.
3. Joint Diseases-diagnosis. 4· Joints-surgery. WE 312 S919a
2001a] RD561 .S75813 2001 617.4'72059-dc21 oo-069836
ISBN 978-3-540-85737-2
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Originally published by Springer-Verlag Berlin
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Manual of Arthroscopic Surgery
---------------------------------------
Acknowledgments
A book of this magnitude cannot reflect the work of a and level of detail that I would not have thought possi
single individual. Rather, it is the result of years of col ble. He has succeeded in combining exceptional esthetic
laboration among my surgical colleagues in Straubing, value with an extremely high information content.
the illustrator, Springer Verlag, and the author. This book would not have been possible without the
I am grateful to the surgical staff at our clinic, espe commitment of Springer-Verlag and its staff. I particu
cially Andrea Kienberger, Evi Schwarz, Agnes Albert, larly acknowledge the efforts of my friend Dr. Udo
and Petra Baumann, for their valuable assistance and for Schiller, who regrettably is no longer with Springer-Ver
putting so much time and effort into the digital docu lag. He helped to plan the book and laid the groundwork
mentation of interesting intraoperative findings. I thank for reproducing the illustrations in digitized form. I
Markus "Willi" Wild for his help in organizing the digi thank Gabriele Schroder for her support and for the
tal documentation and the many image files, and I thank many encouraging conversations involved in the some
Petra Broschinsky for her help with patient records. I times difficult task of transforming my wishes into real
also thank Karl-Heinz Semmelmann for scanning the ity. I thank Mrs. Linde Prodehl for handling the copy
many radiographs into the computer and setting up the editing, which was not always easy given the extensive
digital data files. subheadings in the manuscript.
Prof. Dr. Jorg Grunert (Erlangen) provided a wealth I am particularly indebted to Bernd Wieland of Sprin
of technical advice and proofread the chapters on wrist ger-Verlag, with whom I forged a friendship during the
arthroscopy and endoscopic carpal tunnel release. I am many months of the production process. Mr. Wieland
also grateful to Prof. Andre Gachter (St. Gallen, Switzer took care of the proof arrangements and page layouts,
land), Dr. Andreas Weiler (Berlin), Scott Rodeo (New processed the many digital image files, and handled
York), Prof. Peter Habermeyer (Heidelberg), and Dr. Kai technical problems and updates in a calm, efficient, and
Uwe Jensen (Hamburg) for their many technical sugges supportive manner. It is largely the result of his personal
tions and for providing illustrations. commitment that the book has achieved its present form
I thank my partner Dr. Hanns M. Fett (Straubing) for and qualitative perfection.
proofreading the manuscript and for supplying many In closing, I express thanks to my family and personal
helpful suggestions, illustrations, and additional materi friends for their support and ask them to forgive me for
als for the chapter on shoulder arthroscopy. I thank Dr. neglecting them during the planning and production
Heinz-Jurgen Eichhorn for his support and technical phases of this book.
input. Without all these friends and colleagues, it would not
I extend special thanks to Petra Flechtner, who did have been possible to create this book in its present
most of the typing and almost all the revisions, and to form.
Uli Schultes and Carola Urlinger.
I thank Thomas Heller (Tubingen) for the brilliant
computer-rendered graphics, which reflect a precision Michael J. Strobel
Manual of Arthroscopic Surgery
---------------------------------------
Preface to the English Edition
After the German book "Arthroskopische Chirurgie" range of normal findings and normal variations, but
proved to be such a success, both friends and visiting also for intraoperative use in performing specific surgi
physicians as well as Springer-Verlag asked me to pre cal procedures with care.
pare an English edition. Compared to the numerous, I would like to extend my thanks to Gabriele M.
well-known textbooks of arthroscopic surgery in the SchrOder (Springer-Verlag, Heidelberg), who actively
English-language literature, particularly in the US, this supported me in the conception and planning of the
volume deliberately does not intend to present purely English edition of the book. Special thanks also go to
scientific treatises on the individual disease entities and Bernd Wieland (Springer-Verlag, Heidelberg), who-as
surgical techniques. On the contrary, the goal of this for the German edition - not only designed the layout
book is to present and describe in detail those arthro but also has produced the book cover and the illus
scopic techniques which have proven to be clinically trations to my utmost satisfaction. I thank my friend
effective in hundreds and thousands of patients on a Andreas Weiler (Berlin) for the numerous histological
daily basis, and thus it does not aspire to meeting the figures and the corrections. Thanks also go to Dr. U. Hor
demand of being "complete." In particular, the therapy ras (Giessen), who provided several histological and
and surgical techniques have been standardized and the electron microscopic illustrations. Mr. Terry C. Telger
operative steps are presented in a "how to do" format (Fort Worth, Texas) in his reliable way provided a perfect
which is easy to follow. Particular importance has been translation of the book into English. For this, I owe him
attached to problems and pitfalls, which can affect the a genuine debt of gratitude. Thanks are extended once
operative procedure considerably and in the worst-case again to Petra Flechtner (Straubing), who spent a tre
scenario even cause the surgical treatment to fail. mendous amount of time in typing and correcting the
With respect to the German edition, the chapters on manuscript of this book, too. I would also like to thank
lesions of the meniscus and on the anterior and poste my wife Patricia for the proof reading and at the same
rior cruciate ligaments have been completely revised apologize to her for the "months of neglect" for the time
and expanded. The other chapters have been reworked it took to put this English edition together.
and updated. Furthermore, many of the illustrations
have been replaced and modified so that the visual pre I do hope that the readers will find pleasure in this book
sentation of arthroscopic findings and operative steps is and also that it helps them in their daily clinical work
even better. Hence, there are over 340 more illustrations and furthers their enjoyment of the field of arthroscopy.
than in the German edition. A superb visual presenta
tion is essential, particularly in arthropscopic surgery,
not only to be able to recognize and diagnose patholog Michael J. Strobel
ical conditions and to distinguish them from the large September 2001
Manual of Arthroscopic Surgery
---------------------------------------
Preface to the German Edition
Arthroscopic surgical procedures are no longer limited ings are useful for describing operative procedures, they
to the knee but are commonly performed on a variety of often convey only a vague impression of the actual prac
joints. While numerous books have been published on tice of arthroscopic surgery. For this reason, I have cho
arthroscopic surgery, many deal with only a single joint sen to illustrate the various types of joint pathology and
or address various joints and surgical techniques in a their treatment in series of arthroscopic views that give
somewhat haphazard fashion. As a result, many col a detailed, step-by-step visual account of the procedures.
leagues have approached me with the suggestion that I This approach requires exceptionally high-quality im
author a practice-oriented textbook on arthroscopic ages in which even fine details can be appreciated. My
surgery. initial plan was to use video prints as illustrations. But
This book is intended to cover the full spectrum of improvements in digital image technology caused me to
arthroscopic surgical procedures and endoscopically reconsider, and almost all the arthroscopic views pre
assisted intraarticular operations in an up-do-date, sented in this book consist of digitized video images.
practice-oriented "how to" format that takes into ac This accounts for their exceptionally fine quality.
count current arthroscopic trends. The information is It is hoped that this surgical textbook will motivate
presented in a consistent, easy-to-use format that per the reader to delve more deeply into arthroscopic tech
mits rapid referencing of specific topics of interest. The niques, their indications, and the differentiated manage
coverage of specific disorders is clear, practice-appli ment of arthroscopically treatable disorders in various
cable, and detailed, with particular emphasis placed on joints. May the book serve as a reference tool and per
arthroscopic findings, therapeutic management, and the haps even a manual for arthroscopic practitioners, en
surgical techniques that have proven most successful in abling them to plan and conduct arthroscopic surgical
the day-to-day practice of arthroscopic surgery at our procedures more efficiently and successfully for the ben
institution. efit of their patients.
A problem in all arthroscopic textbooks is how best
to convey diagnostic findings and the various steps Straubing, May, 1998
involved in surgical procedures. While schematic draw- Michael J. Strobel
Manual of Arthroscopic Surgery
-------------------------------------------
Contents
PART I: Knee Joint
1.13.4 Lateral Instrument Portals . 65
1.13.5 Posterior Instrument Portals 65
CHAPTER 1: Knee Joint- General Part 3 1.13.6 Switching Portals . 70
1.13.7 Problems ... 72
1.1 Historical Development ....... . 4 1.14 Examination Sequence . . . 73
1.2 Instrumentation (Arthroscopy System) 5 1.15 Complications. . . . . . . . 73
1.2.1 Arthroscope. 5 1.15.1 Instrument Breakage. 73
1.2.2 Sheath . . ... 9 1.15.2 Nerve Injuries. . . . 75
1.2.3 Light Source. II 1.15.3 Vascular Injuries . 76
1.2.4 Light Cable .. 12 1.15.4 Bony Injuries . . . 76
1.3 Video System . . . . . . 13 1.15.5 Ligament Injuries. 76
1.3.1 Video Camera 13 l.l5.6 Cartilage Damage 77
... ..
1.3.2 Monitor . . .. IS l.l5.7 Infection 80
1.3.3 Digital Video . 16 Ll5.8 Thrombosis . . . . 80
1.3.4. Picture-in-a-Picture 17 l.l5.9 Compartment Syndrome 80
1.4 Probe . . . . . . . . . . . . . 17 1.15.10 Effusion ....... 80
1.4.1 Triangulation . . . . 17 1.15.11 Synovial Fistula .... . 80
1.4.2 Rendezvous Principle 17 1.15.12 Skin Complications .. 81
1.5 Mirrors . . . . . . . . . . . . . 17 l.l5.13 Lost Tissue Fragments . 81
1.6 Surgical Instruments . . . . . . . 22 1.15.14 Reflex Sympathetic Dystrophy 81
1.6.1 Mechanical Instruments . . 23 1.15.15 Arthroscopy of the Wrong Knee. 82
1.6.2 Motorized Instruments (Shavers). . 27 1.15.16 Rare Complications ... 82
1.6.3 Electrosurgical Instruments. . 32 1.16 Documentation . . . . . . . . . . . 83
1.6.4 Lasers . . . . . . . . . 40 1.16.1 Written Documentation . 83
1.6.5 Special Instruments . 43 1.16.2 Image Documentation . . 84
1.7 Anesthesia . . . . . . . . . . . 48 1.16.3 Recommended Documentation System 87
l.7 . I General Anesthesia. . 48 1.17 Outpatient Arthroscopy .. 87
1.7.2 Regional Anesthesia . . 48 1.17.1 Indications . . . . 87
1.7.3 Local Anesthesia . . . . 48 l.l7.2 Contraindications 87
1.8 Positioning . . . . . . . . . . . . 49 l.l7.3 Setting ....... 87
1.8.1 Straight-Leg Position. . 49 1.17.4 Organization . . . 88
1.8.2 Flexed-Knee Position . 49 1.17.5 Patient Selection . 88
1.9 Tourniquet . . . . . . . . . . . 50 1.17.6 Patient Reception. 89
..
1.9.1 Tourniquet Placement . 50 1.17.7 Premedication 89
1.9.2 Arthroscopy without Tourniquet Inflation. 50 1.17.8 Patient Preparations . . 89
1.9.3 Arthroscopy with Tourniquet Inflation. 51 1.17.9 Anesthesia ...... . 90
1.9.4 Arthroscopy in an Exsanguinated Field . 51 1.17.10 Surgical Procedure . . . 90
1.10 Draping. . . . . . . . . . 51 1.17.11 Postoperative Management . 91
1.11 Distention Medium. . . . 52 1.17.12 Documentation . 92
l.ll.l Gas Distention . 52 1.17.13 Quality Control. 92
1.11.2 Fluid Distention 53 1.18 Indications . . . . . . . . 93
1.11.3 Irrigation System. 54 1.18.1 Hemarthrosis . . 93
1.12 Setup and Preparations for Arthroscopy. 56 1.18.2 Second-Look Arthroscopy. 94
1.12.1 Arthroscopy Cart. . . . . . . . 56 l.l8.3 Established Indications 95
1.12.2 Connecting the Basic Equipment. 57 1.19 Contraindications. . . . . . . . . . . 95
1.13 Portal Placement. . . . . . . 57
1.13.1 Arthroscope Portal. . . . . . . . . 58
1.13.2 Instrument Portal . . . . . . . . . 61
1.13.3 Medial Instrument Portals. . . . . . . . . . 64
X
. . . . . . . . . 97 2.13 Anterior Cruciate Ligament . . . . . . . . . . . .... 367
2.13.1 Acute ACL Rupture . . . . . . . . . . . 369
2.1 Menisci . .............. . 99 2.13.2 Chronic ACL Rupture,ACL Deficiency. 376
2.1.1 General Therapeutic Principles .. 101 2.13.3 Partial ACL Tear and Scarring . . . . 515
2.1.2 Longitudinal Tears .. 116 2.13.4 BonyAvulsionoftheACL........ 518
2.1.3 Bucket-Handle Tears. 132 2.13.5 Personal Experience, Current Trend
2.1.4 Flap Tears ..... 151 and Outlook . . . . . . . . . . . . . ... 522
2.1.5 Radial Tears . . . . . 159 2.14 Revision Surgery of the Anterior Cruciate Ligament . 525
2.1.6 Horizontal Tears . . . 164 2.14.1 Limitation of Motion ..... . 525
2.1.7 Degenerative Lesions 166 2.14.2 Deficiency and Rerupture. 529
2.1.8 Ramp Lesions. . . 171 2.14.3 Locking ...... . 555
2.1.9 Meniscal Cysts . . . . 178 2.14.4 Pain . . . . . . . . . 556
2.1.1 0 Discoid Meniscus . . 182 2.14.5 Recurrent Swelling. 558
2.1.11 Crystalline Deposits . . . . . . . . . . 193 2.14.6 ACL Graft Removal 560
2.1.12 Hypermobile Meniscus . . . . . . . . 193 2.14.7 Guidlines for Revision ACL Reconstruction. 568
2.1.13 Removal of Meniscal Repair Devices . 196 2.15 Posterior Cruciate Ligament . . . 571
2.1.14 Postoperative Management . . . . . . 199 2.15.1 Acute PCL Rupture. . . . 574
2.1.15 Future Directions in Meniscal Surgery. 199 2.15.2 Chronic PCL Deficiency. . 588
2.2 Cartilage. . . . . . . . . . . . . . . . . . . 201 2.15.3 Posterolateral Instability . 633
2.2.1 Degenerative Cartilage Lesions . . 202 2.15.4 Bony Avulsion of the PCL . . 638
2.2.2 Traumatic Cartilage Lesions . . . 212 2.15.5 Combined PCL and ACL Injuries. . 638
2.3 Synovium . . . . . . . . . . . . . . . . . . 235 2.16 Revision Surgery of the Posterior Cruciate Ligament . 643
2.3.1 Reactive (Secondary) Synovitis. 235 2.16.1 PCL Rupture andACL Reconstruction. . 645
2.3.2 Primary Synovitis . . . . . . . . 242 2.16.2 PCL Rupture and MCL Repair . . . 646
2.3.3 Traumatic Synovial Lesions . . . 249 2.16.3 PCL Rupture and Immobilization
2.3.4 Posttraumatic Synovial Changes . 251 in Flexion . . . . . . . . . . . . . . . 64 7
2.4 Synovial Plicae . . . . . . . . . . 253 2.16.4 Incorrect Tunnel Placement . . . 648
2.4.1 Medial Patellar Plica. . . . . . . . . 253 2.16.5 Deficient Operative Stabilization . . 651
2.4.2 Infra patellar Plica . . . . . . . . . . 259 2.16.6 Revision Problems. . 652
2.4.3 Suprapatellar Plica, Suprapatellar Septum .. 263 2.17 Fractures. . . . . . . . . . . . . . 659
2.5 Femoropatellar Joint . . . . . . . . . . . . . . . 267 2.17 .1 Patellar Fracture . . . . 659
2.5.1 Femoropatellar Pain Syndrome (FPPS) . 267 2.17 .2 Upper Tibial Fracture . 661
2.5.2 Excessive Lateral Pressure Syndrome 2.18 Infection . ........... . 663
(ELPS) . . . . . . . . . . . . . . 270
2.5.3 Patellar Dislocation . . . . . . 275
2.5.4 Cartilage Lesions,
Patellofemoral Osteoarthritis . 284
2.5.5 Osteochondritis Dissecans . 285
2.6 Osteophytes . . . . . . . . . . .... 289 673
2.6.1 Osteophytes in the Anterior
Intercondylar Area. . .... 289 3.1 Historical Development . . . . ..... 673
2.6.2 Osteophytes on the Femoral Condyle 291 3.2 Instrumentation (Arthroscopy System). 673
2.6.3 Osteophytes on the Medial 3.3 Video System 674
or Lateral Tibial Plateau . . . . . . 293 3.4 Probe. . . . . . .... 674
2.6.4 Osteophyte on the Patellar Apex . 294 3.5 Distraction. . . . . . . 674
2.7 Osteochondral Lesions . . . . . . . .... 297 3.6 Operating Instruments 674
2.7.1 Osteochondritis Dissecans (OCD) . . 297 3.7 Anesthesia. 675
2.7.2 Osteochondral Fractures . 310 3.8 Positioning 675
2.8 Baker Cyst . . . . . . . . . .. . 315 3.9 Tourniquet. 676
2.9 Loose Bodies . ......... . . 319 3.10 Draping .. 676
2.9.1 Free Loose Bodies .. . . 319 3.11 Distention Medium . 676
2.9.2 Multiple Loose Bodies. . 326 3.12 Setup and Preparations for Arthroscopy . . 676
2.9.3 Fixed Loose Bodies .. . 329 3.13 Portal Placement ..... . 676
2.10 Osteoarthritis . . . . . . . . .. . 331 3.13.1 Gross Anatomy . 676
2.11 Tumors and lntraarticular Ganglia . . 335 3.13.2 Anterior Portals . . 677
2.12 Limited Motion and Scarring ..... 341 3.13.3 Posterior Portals . 679
2.12.1 Cyclops Syndrome . . . . . . 341 3.13.4 Transmalleolar Portals . . 680
2.12.2 Infrapatellar Contracture Syndrome. 346 3.13.5 Transtalar Portals . . .. . 680
2.12.3 Mechanical Restriction Caused 3.13.6 Placement of the Arthroscope Portal . . 680
by Fixation Material . . . . . . . 349 3.13.7 Placement of the Anteromedial Portal 682
2.12.4 Notch Stenosis ......... . 354 3.13.8 Placement of the Posterolateral Portal . 684
2.12.5 Local Adhesions, Arthrofibrosis 358 3.13.9 Switching the Arthroscope
and Instrument Portals . . . . . . . . . . 686
