What is Arthroscopy?

Arthroscopy is an endoscope applied to the internal examination of the articular cavity. It can directly observe the synovium, cartilage, meniscus, and ligaments. Especially, arthroscopic techniques can be used to diagnose various arthritis. Provides pathological evidence. It plays an irreplaceable role in the diagnosis, treatment and scientific research of various synovitis. It not only provides intuitive information for joint disease, but also can remove and repair the diseased tissue in the joint under non-open surgical conditions. It has the advantages of less pain, fast recovery, reduced postoperative complications and surgical costs.

Arthroscopy

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Arthroscopy is applied

Arthroscopy has evolved from the huge lens system that first required direct vision through the eyepieces to reflect the image on the monitor through a television camera system to make the image clearer and avoid adverse effects to the operator (such as retinal burns). In recent years, the development of optical fibers has also created conditions for the miniaturization of arthroscopes, from arthroscopes with a diameter of 4.5mm to 0.5 to 1.8mm, and even similar to a needle-shaped arthroscope with a No. 16 syringe, which makes the inspection more convenient. Convenient and more simplified auxiliary conditions (such as rehabilitation room, staffing, equipment, etc.), sometimes the examination can be performed in the outpatient clinic, the cost is also lower, and the inspection joints can be as small as the temporomandibular and interphalangeal joints. Although images of small arthroscopes may not be as clear as ordinary arthroscopes, they are sufficient to provide reliable information for clinical analysis.

The application of arthroscopy in China started relatively late. After the first national arthroscopy course held in Shenyang in 1982, the technology was widely developed throughout the country. At present, ordinary arthroscopy is still used, mainly for knee joint examination and open-sight surgery, such as

Although arthroscopy can provide intuitive diagnostic information, it is a traumatic operation after all. Therefore, after a detailed medical history, comprehensive physical examination, and necessary auxiliary examinations (including joint fluid analysis), it is not clear when the diagnosis can be made. application.

2.1 Indication

Diagnosis of unknown inflammatory and non-inflammatory arthropathy (especially RA, OA or

3.1 General steps

The miniaturization of arthroscopy has simplified its operation to outpatient and local anesthesia, but we still use ordinary knee arthroscopy.

Diagnosis and treatment of common rheumatic diseases

In the diagnosis of synovial lesions of the knee joint, the epicondylar synovium is generally the object. The normal epicondylar synovial membrane is smooth and flat, and small parallel arteries and veins can be clearly seen. The color of the synovial membrane is light red, with a small number of synovial villi, which are thin, thin, and translucent. In the early stages of different rheumatic diseases, synovial changes are hyperemia, edema, villous hyperplasia, and even bleeding. It is not easy to identify during arthroscopy, but it has its own characteristics after developing to a certain stage.

4.1 Rheumatoid arthritis

Early rheumatoid synovitis is difficult to diagnose with arthroscopy. Like general synovitis, only non-conductive lesions of the synovium are shown, but other joint tissues, such as the articular cartilage surface and meniscus, have not changed significantly. When entering the exudation period, there are turbid slender villous hyperplasia, redness, edema, and exudation of filamentous, membranous, or irregular lumps, which are called "cellulose". Grayish yellow. When the course of the disease progressed, the villi showed a membrane-like polyp-like or massive hyperplasia, and the deposition of "cellulose necrosis" was visible in the joint cavity. In the chronic phase, the synovial membrane has fibrous tissue repairing villi, and the old and the new are mixed. The more characteristic manifestations are: the inner and outer condyles near the synovial marginal cartilage, and even the normal cartilage parts of the inner and outer menisci, especially in the anterior and posterior horns, with obvious vascular crest extension, forming an uneven cartilage erosion surface. Continue to develop, articular cartilage surface and meniscus gradually fibrosis, after the tibiofemoral joint and patellofemoral joint fibrous tissue proliferation and adhesion, the joint cavity is closed, then arthroscopy can not enter. Typical pathological changes of the synovium: formation of lymphoid follicles; fibrinoid degeneration; formation of inflammatory granulomas. These three types can overlap and cross. Synovial membranes can also have IgG, lgM, complement, and rheumatoid factor (RF) deposition.

In the past, the judgment of the degree of RA knee injury mainly relied on the X-ray joint phase. This can only be an indirect estimation of the changes of cartilage in the joint cavity, but it is difficult to judge the pathological changes of the synovium. Fujikawa and others in Japan performed knee arthroplasty, which made it possible to observe synovial hyperplasia, articular cartilage, and meniscus, but the test still has a lot of limitations. Arthroscopy can directly observe the pathological changes of the synovium, but there are still difficulties in classifying the lesions. Salisbury et al. Performed 51 RA knee arthroscopy, and judged the degree of destruction of articular cartilage by synovial hyperplasia, vascular wing formation and meniscus degradation, which were divided into four stages. Pingkou Homozygous and others also tried to classify the synovial morphology as seen by the naked eye under arthroscope. We refer to their criteria to classify RA arthroscopic morphology into the following three areas:

1. Synovial hyperplasia level 0: no synovial hyperplasia; level I: mild hyperplasia, thickening and hyperemia of synovium or mild villous hyperplasia can be observed; level II: moderate hyperplasia, coarser villous hyperplasia can be observed , Easy to bleed; Grade III: hyperplasia, villous hyperplasia to arthroscopic vision is not clear, along the cartilage edge or cartilage surface with blood vessel formation.

2. Deposition of cellulose necrosis Grade 0: No deposition of cellulose necrosis; Grade I: Mild, that is, a small amount of cellulose necrosis deposited in the joint cavity; Grade II: Moderate, that is, moderate or scattered cellulose necrosis in the joint cavity Deposition; Grade III: Severe, that is, large or diffuse cellulose necrotic deposits in the joint cavity.

3 Cartilage destruction level 0: no cartilage destruction; level I: slight fibrosis and roughness of the cartilage surface can be observed; level II: obvious fibrosis, roughness, cracking and yellowing of the cartilage surface or erosion, ulceration and Fracture; Class III: Bone is exposed and replaced by granulation tissue.

4.2 Osteoarthritis

Under arthroscopy, pale villi are slender, mostly tree-like or feathery, and congestion and infiltration of inflammatory cells are not obvious. There is no deposition of cellulose-like necrosis and blood vessels. The articular cartilage has obvious changes, the cartilage surface is dark, sometimes there is a ulcerated surface, the cartilage is detached or exfoliated, and even part of the bone is exposed. This phenomenon is most obvious in the femoral medial malleolus and medial tibial plateau, and the lateral tibiofemoral joint usually occurs slowly . Different levels of osteophytes can be seen at the upper and lower ends of the sacrum, the proximal synovial transition site of the femoral condyle, and the inner and outer femoral condyles. The meniscus also degenerates, wears or ruptures.

4.3 Crystal arthritis

(Gout, pseudogout, etc.) The possibility of crystalline arthritis should be considered in elderly patients with late-onset arthritis. White shiny crystals of urate or pyrophosphate can be seen under arthroscopy, which are located in the synovium, cartilage and Joint wall. The presence of corresponding crystals can be found in synovial fluid and pathological sections of the synovium. In the acute phase, the villi can also show congestion and swelling.

1. Under gout arthroscopy, white, shiny, punctate urate deposits were found on the synovium and cartilage, and monosodium urate crystals (MSU) were seen in the synovial pathology section, showing needle-like shapes.

2. False gout is calcium pyrophosphate deposited on the synovium and cartilage. Pathological sections can be found with dihydrate calcium pyrophosphate crystals (CPPD), which are spindle-shaped, rectangular, or diamond-shaped.

3 Hydroxyapatite arthritis showed calcium deposits to the naked eye, and synovial section electron microscopy showed hydroxyapatite crystals.

4.4 Tuberculous arthritis

There is no obvious change in early tuberculous synovitis. Later, the synovium may be red and swollen, uneven, villi may be thick and turbid, and some visible swelling and red granulation tissue will cover the synovial surface. At last, the synovial membrane will be severely fibrotic and necrotic and shed. Filled in the joint cavity, a large number of regular soft free bodies were found to be a characteristic change. Synovial pathology showed more granulation tissue formation, scattered in LanghanS cells, and the synovial surface was more caseous. Necrotic.

4.5 Infectious arthritis

Synovial adhesions, necrosis, and discoloration of cartilage are visible to the naked eye in infectious arthritis. Pathological examination can reveal pathogenic bacteria and a large number of polymorphonuclear leukocytes infiltration.

4.6 Pigmented Villonodular Synovitis

The change of the membrane along the membrane is not obvious in the early stage, because the synovium and villi of the lesion contain heparin, so after the development of the lesion, the synovium and villus in the joint cavity are different from the general synovium with yellowish brown, and the villi are significantly hyperplastic. Mostly stick-shaped.

4.7 Unexplained chronic synovitis and its differential diagnosis

Chronic synovitis is not uncommon clinically, although its nature has not been confirmed by pathological biopsy, it is only chronic inflammation. The joint environment examination was synovial hyperemia and redness, some had obvious villous hyperplasia, and some did not. Villous forms were different, slender, stick-shaped and so on. Differential diagnosis of various types of chronic synovitis is difficult, especially in the early stages. Therefore, it is necessary to pay attention to the clinical history, symptoms, signs, X-rays and laboratory tests, and to make a comprehensive analysis based on arthroscopic findings. The final diagnosis must be made. Rely on the results of pathological examination. According to the analysis of a total of 78 cases (99 knees) of various types of chronic synovitis by Professor Dong Tianxiang of Beijing Construction Workers Hospital, rheumatoid synovitis is the most common, with 48 cases (62 knees) and tuberculous synovitis. Six cases (6 knees), 6 cases (6 knees) of pigmented villous nodular synovitis, and 18 cases (25 knees) of chronic synovitis of unknown cause, all of which were confirmed by pathological examination and laboratory tests. Statistics show that rheumatoid synovitis is the largest, accounting for about 2/3 of all cases, and some of the unknown causes of chronic synovitis have not been confirmed by pathology as RA, but clinical symptoms and laboratory analysis still have rheumatoid synovitis. Possible. From the analysis of arthroscopy, each type of chronic synovitis has its own characteristics. The author believes that if there is irregular white cellulose in the joint cavity or femoral condyle cartilage near the synovial edge and meniscus with obvious blood vessels Introduction can help the diagnosis of rheumatoid arthritis.

4.8 Arthroscopic treatment of common rheumatic diseases

There are many types of surgery under the microscope, and only the surgery under the microscope-synovectomy is introduced.

Rheumatoid synovitis is first treated with medical drugs. If the effect is not good, the knee joint is still swollen, effusion, pain and recurrent, and after half a year of treatment failure, it is the indication for this surgery. However, there are a few cases that are completely ineffective through medical treatment, and even those whose symptoms and signs are significantly aggravated. Although the course of disease is less than half a year, this surgery can also be considered. Especially after drug treatment, most joint symptoms improved, but the swelling and pain of a single knee joint did not alleviate, which is a clear indication for performing synovial surgery. After synovectomy, drug therapy should generally be continued.

The surgical method is to first puncture the epidural needle on the inside of the supracondyle, and then inject physiological saline through the infusion set to fill and expand the joint cavity. Make a puncture in the rolled anterolateral side and insert an arthroscope for a comprehensive intra-knee examination. Subsequently, a puncture was made at the anterior medial surface of the subcondyle, and biopsy forceps (or nucleus pulposus) were inserted, and multiple synovial tissues with significant hypertrophic villi, hyperemia and edema were excised for pathological examination. A cutter was then inserted into the medial anterior medial area of the iliac crest, and the iliac superior capsule and femoral condyle surface were "blindly removed" first. End of the synovium, and then need to use arthroscope to observe whether the synovium is completely removed, and supplemental cutting. Then make a puncture in the superior and lateral iliac crests, insert an arthroscope, and insert cutters alternately in the anterolateral and anterolateral inferior condyles, sequentially cut the medial and lateral wall synovial membranes and the subcondylar fat pad synovial membranes, and check the superior condyles again Whether the synovial membrane is completely cut. Finally, the mirrors and cutters are alternately inserted into the inferior anterolateral and inferior anteromedial sides of the inferior zygomatic joint, namely the medial and lateral tibiofemoral joints and intercondylar fossa. The arthroscope was extended into the tibiofemoral joint, and the posterior joint cavity synovium was cut as much as possible. Finally, check whether the inner and outer crypts, including the inner and outer meniscus edge synovium, have been completely cut, and the operation is complete. The cut synovial film fragments have been sucked into the external bottle through the suction tube of the cutter. Then repeatedly flush the joint cavity with a large amount of physiological saline until the discharge is clear. After draining the liquid, suture the puncture skin with a needle, wrap the wound and the entire knee joint with a large cotton pad, and press tightly with an elastic bandage. It should not be too loose or too tight. If it is too loose, there may be blood accumulation in the joint cavity Too tight will affect blood circulation in the lower limbs.