ARTHROSCOPE IN SHOULDER ARTHROPLASTY

Leong Tze Lun

2010548426 leong31@hku.hk

Abstract: Traditional open surgery to correct soft tissue injuries in the present has been replaced with a more technological advanced arthroscope. This paper summarises the historical development of optics and science in driving the advent of the arthroscope and addresses the technology that made it possible. It also introduces the common joint arthroplasty surgeries particularly for the shoulder joint performed by orthopedic surgeons worldwide and states the reasons for its importance in the eld of orthopedics. The paper then ends with the discussion of the future of arthroscope and joint arthroplasty in the eld of medicine.

I. HISTORY OF ARTHROSCOPE Arthroscope is a device commonly used nowadays by orthopedic surgeons in hospitals around the world to perform surgeries termed arthroplasty (also known as keyhole surgery). Arthroscope is actually a part of the family of endoscopes and its history of being introduced to the eld of medicine very much begins with the invention of endoscopes. Endoscope is an instrument that allows us to peek into the human body. Historical records show that the rst prototype was invented by the Romans and subsequently improved upon in the 19th and 20th century. Early 19th century saw the rst attempt made by Philip Bozzini to peek into the human body specically the urinary tract and bladder using what he named the Lichtleiter [Fig 1] (German for light guiding instrument). In 1853, almost half a century after Bozzini, the worlds rst device named as an endoscope [Fig 2] was designed and developed from Antoine Jean Desormeaux of France. Subsequent improvements in technology and the eld of science led to the introduction of rigid gastroscopes to look into the human stomach and nally the rst exible gastroscope by Dr. Rudolph Schindler [Fig 3]. [5, 6]

Fig 1: Lichtleiter by Philip Bozzini in 1805. An interesting fact was that the invention of this sophisticated light guiding instrument coincided with the invention of the rst light bulb by Sir Humphry Davy in 1800. The understanding of the principles of light and electricity at that time might have instigated the use of electric powered light bulbs to see the inner human body. [6]

Optical Lens

Solution container

Fig 2: One can clearly see the improved design and more sophisticated features of the Desormeauxs Endoscope compared to Bozzinis Lichtleister. The addition of optical lens probably shows the development of humans understanding of optics (invention of telescopes, microscopes and binoculars) to give further insight about human biology. [6]

Fig 3: The exible gastroscope has come a long way from more than a century ago. This tube is 75 centimeters in length and 11 millimeters in diameter. About 1/3 of the entire length of the tube toward the tip could bend to a certain degree. The tip of the gastroscope contains a light bulb that transmits light to the internal structure and this light is then reected and captured by numerous lenses along the tube to produce an image for the observer. [6]

Besides the optical and electrical revolution that pave the way for sophisticated endoscopes, the advancement of materials science and our ability to understand the nature of chemistry allowed us to fabricate more efcient and biocompatible materials suitable to meet the needs of the medical eld. It allowed us to materialise the concept of ber optics and ushered in an era of high throughput of information and high resolution image reconstruction. It may seem that arthroscopes are not distinct from endoscopes but they actually are. Although, the history of arthroscope stems from the development of endoscopes but so do many other medical equipments that share the same roots such as laparoscope used in abdominal surgery and bronchoscope used in throat surgery. This is because the concurrent development of arthroscope together with the other scopes masked the unique development path that arthroscopes took. However one cannot doubt that arthroscope ushered in an era of optical surgery that is minimally invasive. Pioneers in the eld of arthroscope include Kenji Takagi The Father of Arthroscopy and Masaki Watanabe The Father of Modern Arthroscopy [5] who both created prototypes and whose designs are still resembled in modern day arthroscopes. [Fig 4]

a
Figure 4: (a) Takagi No.1 Arthroscope (b) Watanabe No. 21 Arthroscope [5]

Arthroscope is unique and distinct in its own way as its development in the late 20th century distinguished it from the other scopes. This is because the site of arthroplastic surgery such as the knee and shoulder joint is vastly different from the abdomen, stomach or the intestines. It has different requirements too as surgical tools used in joint surgeries are different and hence arthroscope must be developed to best complement the precision tools needed by surgeons. The term keyhole surgery is aptly used today due to arthroplastys surgical nature that only requires three small incision holes by surgeons and is considered minimally invasive by the medical community. The understanding of the history of arthroscope is hence important to fully grasp the repercussions and impact it has had on orthopedics and medicine and to pave the way for future developments.

Figure 5: The historic paper by Dr. Burman in 1931 that instigated further explorations into the clinical use of arthroscopes in joint surgeries. [5]

II. THE PHYSICS BEHIND AN ARTHROSCOPE The ability of arthroscope to produce high resolution and real time video that enables surgeons to perform the keyhole surgery is due to the use of ber optics in the cables of the arthroscope. Fiber optics are glass drawn to very ne diameters in the order of micrometers. It consists of a dielectric core usually doped silica of high refractive index surrounded by a cladding of lower refractive index [Fig 6]. [1, 3]

Figure 6: (a) The composition of a ber optic tract (b) The distribution of the refractive index of the core and the cladding relative to that of air, nair 1 [1]

The important physics involved in the successful working of a ber optic is the theory of total internal reection based on the concept of refractive index in optics. [1, 3] There exists a unique property of light rst discovered by John Tyndall in 1854 who managed to guide light through a series of total internal reection. The phenomenon of total internal reection allows ber optics to transmit light through a large distance even through bents. The special property of the doped silica which constitute the core that has a high refractive index compared to cladding ensures that total internal reection can occur. The physics of total internal reection stems from the property of light refraction. When incident light is rst shone into the core, the light will be refracted further from the normal in the cladding. As the angle of incidence increases, the angle of refracted light in the cladding increases until it the angle of incidence reaches a critical angle. Hence, any angle of incidence more than the critical angle will be totally reected [Fig 7]. Hence all the light rays will be transmitted from one end to the other. [1, 3]

Figure 7: (a) Angle of incidence < critical angle (b) Angle of incidence = critical angle (c) Angle of incidence > critical angle constitutes total internal reection (d) Illustration of total internal reection through a bent optic bre. [3, 1]

The specic ber optics bundle used in the arthroscope is known as the coherent bundle. [1] Incoherent bundle is not used because as opposed to coherent bundle, bers are not aligned properly and hence cannot form a clear image. An illustration of coherent bundle is found in Figure 8. A coherent bundle is enclosed in a sheath of bers that carry light from outside to illuminate the interior of the shoulder of knee joints and the reected light is transmitted back through the bundle to a video processing unit to produce a real time video for the surgeon. [Fig 9]

Figure 8: A coherent bundle transmitting the same image as that which is received. [1]

Figure 9: A clearer illustration of the coherent bundle coupled together with other channels in the arthroscope. [2]

III. SHOULDER ARTHROPLASTY Since the advent of the modern day like arthroscope by Kenji Takagi in the 1930s [5] and the subsequent explorations on its medical use, joint arthroplasty has been one of the most performed orthopedic surgery in the world. It has gained popularity among surgeons due to its benets to patients post-surgery compared to that of a traditional open joint surgery. One of the very common shoulder injuries suffered by both the young and old is anterior and posterior shoulder instability. The reason for such a common occurrence is due to the relative fragile glenoid socket in our shoulder compared to other joints in the body [Fig 10]. The shoulder joint being a ball and socket joint allows a great degree of control over its exibility and movement (almost 360 motion). Hence, the relative probability of suffering from joint instability is high and the most common cause of instability is dislocation of the joint either due to over exertion of the shoulder joint, sudden trauma to the shoulder or sports such as basketball and baseball. [Fig 11] Therefore, in this section I will briey introduce a common procedure using the arthroscope to correct for such anterior and posterior instability.

Figure 10: Shoulder Anatomy that shows the glenoid socket. Imagine the fragility of the joint given that the joint ligament is thin while at the same time allows such high degree of movements (swinging and occasionally bearing heavy loads) [9]

Figure 11: Dislocation of the humerus away from the socket causing the ligament to tear [10]

Fig 12: (a) Traditional open shoulder injury where a big incision is needed. (b) Arthroscopy assisted shoulder joint surgery

Below are the step by step brief analysis of the procedure for an anterior reconstruction. Posterior reconstruction will follow the same procedure and only differs in the location. a. Three small openings are incised for the procedure. One opening for the arthroscope, one to access the anterior and the other for the access of the posterior. The posterior and inferior labrum is debrided using a shaver to clear debris [Fig13].

Arthroscope

Posterior channel

Anterior channel

Shaver

Figure 13 [4]

b. Sutures are inserted into the posterior channel for plication of the posterior region. This is done to ensure that the posterior region is stable before anterior reconstruction is performed [Fig 14].

Figure 14 [4]

c. Once the plication of posterior region is completed, a Liberator elevator is used to detach the anterior capsule to ensure complete mobilization of the anterior tissue [Fig 15].

Figure 15 [4]

d. The anterior glenoid region is further debrided and burred to remove soft tissues and expose a small amount of cancellous bone. The cancellous bone will later be the site of attachment of screws used as suture anchors [Fig 16].

Figure 16 [4]

e. First pilot hole is drilled to hold the rst suture anchor and two more holes are drilled at the 4:30 and 3:30-oclock position [Fig 17]

Figure 17 [4]

f. A Mini-Revo (Linvatec Inc.) [4] screw is inserted into the rst pilot hole and sutures are attached to it and aligned in the direction of the anterior shoulder ligaments [Fig 18].

Figure 18 [4]

g. Numerous steps to perform a stable stitch is then done [Fig 19].

Figure 19 [4]

h. Repeat the suturing steps for the other locations in the anterior and posterior regions. Once completed, stability of the shoulder join is restored. Recovery period normally in 3 to 5 months. [Fig 20].

Figure 20 [4]

IV. ADVANTAGES AND DISADVANTAGES OF JOINT ARTHROPLASTY The introduction of arthroplasty in orthopedics has been a major force in driving medical cost down in many health care systems in the world. As the population of the world reached 7 billion early this year based on the United Nations Global Population Statistics, more and more people rely on the ability of public health care systems to meet the demands of adequate healthcare provision. Hence, any medical technologies that are proven to be safe and can improve cost efciency is a blessing to any health care system that strives to improve the populations quality of life. The reduction in cost, postoperative complications and the improvement in quality of life is achieved due to the reduced risk of performing joint arthroplastic surgeries as compared to the traditional open surgery employed. The elimination of unnecessary open surgeries reduced the need to use strong general anesthesia and the risk of developing postoperative infections. It is widely known that general anesthesia produces undesirable side effects in patients such as abnormal brain structure development, paralysis of upper airway tract and many more. The reduced risk of contracting infections mentioned above also indirectly reduced the need to dispense wide range antibiotics which reduces the risk of patient contracting antibiotic resistance. Joint arthroplasty also has aesthetic values besides the medical benets. Small holes needed for the surgery allows minimal scar formation while providing the same efcacy if not better than traditional open surgery. Aesthetic values are important for a subset of the population such as those in the modeling profession. Although joint arthroplasty seems awless but it do has its own unique complications, risks and inadequacy. Although traditional open surgery confers more risk to the patient but it is still widely used in some of the joint surgeries such as joint replacement surgeries and fracture surgeries. The arthroscope is limited only to surgeries that repair soft tissues but not hard tissues and as such proves to be inadequate in certain orthopedic applications. Furthermore, there have been complications reported by patients who underwent joint arthroplasty surgeries. Examples include blood clot due to introduction of arthroscope in contact with biological tissues, nerve damage as difculties arise in maneuvering the arthroscope via a video monitor, unwanted side effects due to administration of general anesthesia [7, 8] and minor infections. It is inherently difcult to avoid such complications as joint repair and reconstruction ultimately requires incision at the shoulder for probing purposes. V. THE FUTURE OF ARTHROSCOPE IN ARTHROPLASTY

I do believe that arthroscope is here to stay as one of the vital medical equipments needed for joint arthroplasty surgeries. Despite its inadequacy and certain risks involved, it remains to be one of the most effective techniques at present to treat many knee and shoulder joint complications. Due to the relatively fragile nature of the glenoid socket of the shoulder joint and the knee joint, we often suffer from soft tissue injuries as oppose to hard tissue injury such as the fracture of bones. Presently, many athletes and the general population have beneted from joint arthroplasty enabled by the development of arthroscopes. Common injuries such as Anterior Cruciate Ligament injury, Rotator Cuff Injury and Shoulder Instability can now be solved easily via an arthroscope improving the quality of life of many including myself. I have a past experience of having the problem of left shoulder instability and had it corrected via shoulder joint arthroplasty. Therefore, I see great potential in the arthroscope being improved on in the future to provide high denition real time video feed and possibly extended to include fracture xation capabilities with the advent of more sophisticated and precise surgical tools.

REFERENCES
[1] Ghatak AK, Thyagarajan K, Introduction to Fiber Optics, (Cambridge University Press, 1998) , Chap. 3. [2] Boppart SA, Deutsch TF, Rattner DW, Optical Imaging in Minimally Invasive Surgery, Surg. Endosc (1999) 13: 718-722. [3] Khare RP, Fiber Optics and Optoelectronics, (Oxford University Press, 2004), Chap. 2. [4] Snyder Stephen J, Shoulder Arthroscopy Second Edition, (Lippincott Williams & Wilkins, 2002) Chap. 9. [5] Passler HH, Yang Y, The Past and Future of Arthroscopy, [6] Olympus Corporation, History of Endoscope, http://www.olympus-global.com/en/corc/history/story/endo/origin/ (2012) [7] Loepke AW, Soriano SG, An assessment of the effects of general anesthetics on developing brain structure and neurocognitive function, Anesth Analg (2008) 106(6): 1681-707 [8] Taight AR, Knight PR, The effects of general anesthesia on upper respiratory tract infections in children, Anesthesiology (1987) 67(6): 930-5

[9] Virtual Medical Center, Anatomy of the Shoulder, http://www.virtualmedicalcentre.com/anatomy/anatomy-of-the-shoulder-glenohumeraljointscapulo-thoracic-joint/61 (2012) [10] McFarland EG, Petersen SA, Sports Medicine & Shoulder Surgery, Department of Orthopaedic Surgery, Johns Hopkins Medicine, http:// www.hopkinsortho.org/orthopedicsurgery/shoulderinstability.html (2012)