Shoulder Arthroscopy

Arthroscopy of the shoulder is typically performed through craniolateral and caudolateral portals initially. Once you have become comfortable with this arthroscopic technique for the shoulder, then the hanging limb arthroscopic technique will be important to master so that the medial compartment can be directly accessed, lateral compartment pathology can be more fully visualised, additional arthroscopically guided techniques can be performed and concurrent shoulder and elbow arthroscopy can be performed more easily and efficiently. For the lateral approach, the patient is positioned in lateral recumbency with the affected limb up, the joint is distended with isotonic saline, a camera portal is established in the craniolateral or caudolateral portal and a 2.7 mm long 30-degree foreoblique arthroscope with camera is inserted. Fluid flow is maintained through the camera cannula. The joint should be explored and assessed using a standard compartmental approach as follows:

 Cranial compartment - biceps tendon, bicipital groove, synovium, supraglenoid tubercle

 Medial compartment - synovium, subscapularis tendon, medial glenohumeral ligament, medial 'labrum'

 Caudal compartment - caudal glenoid, caudal 'labrum', synovium

 Lateral compartment - lateral glenohumeral ligament, synovium, lateral 'labrum'

 Articular cartilage of glenoid cavity and humeral head

The advanced techniques we will cover for the shoulder include medial compartment stabilisation using the TightRope device, lateral compartment stabilisation using suture anchors and supraglenoid tubercle avulsion repair.

Elbow Arthroscopy

Arthroscopy of the elbow is typically performed through craniomedial (instrument) and caudomedial (camera) portals. Although other portals have been described and may be helpful for very specific applications, the standard medial portals allow access to the entire joint in most cases. The patient is placed in dorsal recumbency so that the medial aspects of each elbow can be accessed without repositioning. A 1.4-, 1.9-, or 2.7-mm short 30-degree foreoblique arthroscope can be used based on equipment availability and patient size. For the elbow, we will discuss various arthroscopic techniques for assessment and management of fragmented medial coronoid process.

Combined Shoulder and Elbow Arthroscopy

For adult dogs with forelimb lameness that cannot be definitively localised to a single joint, we now commonly perform arthroscopy of both shoulders and both elbows as a comprehensive approach to diagnosis and understanding of forelimb lameness in dogs. Complete shoulder arthroscopy is performed first in all dogs with the dog in dorsal recumbency and the limbs in the hanging position. If treatment of shoulder pathology is deemed necessary, this is completed prior to elbow arthroscopy. The limbs are then taken out of the hanging position and complete arthroscopic assessment of both elbows is performed using caudomedial and craniomedial arthroscope and instrument portals. Importantly, each dog is carefully rolled toward the side of the elbow undergoing arthroscopy for each joint to avoid undue stresses on the shoulder joints, particularly abduction, which may have detrimental effects on periarticular tissues and/or surgical treatments performed on the shoulders. Each joint is fully examined arthroscopically and each major articular structure assessed, imaged and recorded in the medical record.

Hip Arthroscopy

Hip arthroscopy is performed through craniolateral and caudolateral portals. The patient is placed in lateral recumbency with the affected limb up. We routinely use a 2.7mm 30-degree foreoblique arthroscope for the hip. The arthroscope can be placed in either portal, with the remaining portal used for instruments if necessary. Distal traction on the limb aids in entering the joint and for subsequent manipulations. We routinely perform hip arthroscopy on all double pelvic osteotomy (DPO) candidates, and have recently started using a 1.1-mm flexible scope to assess the articular surfaces and intra-articular structures for degree and extent of pathology. Pre-triple pelvic osteotomy (TPO)/DPO arthroscopy appears to provide vital information regarding patient selection, and perhaps prognosis, that other means of preoperative assessment may not address. Using the 1.1-mm scope, we are able to assess these joints under sedation in an outpatient setting that saves clients time and money. We have also used hip arthroscopy as a means of exploration for diagnosis and biopsy, as well as treatment of acetabular and avulsion fractures in select cases.

Stifle Arthroscopy

Arthroscopy of the stifle is typically performed through craniolateral and caudolateral portals using a 2.7-mm short 30-degree foreoblique arthroscope. The affected limb is prepared for aseptic surgery using a hanging limb technique. The dog is placed in dorsal recumbency with the hindlimbs extending past the edge of the patient table. In this manner, the surgeon can position the limb such that the paw is in contact with his or her torso, allowing flexion and extension of the stifle to be achieved while the hands are left free to manipulate the arthroscope and instruments. The portals are placed medial and lateral to the patellar ligament at a point slightly proximal to the midpoint of the patella-to-tibial tuberosity distance. This allows maximum initial visualisation while minimising the amount of fat pad that must be removed to access the relevant structures. Some arthroscopists employ the use of an egress cannula placed in the proximal aspect of the joint. However, I do not find this necessary or additive in my experience. The craniolateral camera portal is established by inserting the obturator and cannula directed from the craniolateral skin incision across the joint to the medial compartment. The camera can then be inserted and initial visualisation and orientation can be established. Complete exploration of the joint can be performed by moving the arthroscope and changing the direction of view with the 30-degree foreoblique scope. We typically explore the stifle joint in the following order:

 Medial articular compartment (medial femoral and tibial condyles, cranial horn of medial meniscus)

 Medial joint pouch (medial trochlear ridge and joint capsule)

 Intercondylar notch (cruciate ligament, notch) - often requires debridement of fat pad and proliferative synovium

 Lateral articular compartment (lateral femoral and tibial condyles, cranial horn of lateral meniscus)

 Lateral joint pouch (lateral trochlear ridge, joint capsule, long digital extensor tendon of origin)

 Proximal compartment (patella, trochlear groove)

The techniques we will cover for stifle arthroscopy include meniscal release, partial meniscectomy, meniscal repair and patellar luxation repairs.

Hock Arthroscopy

Arthroscopy of the hock can be performed through dorsolateral, dorsomedial, plantaromedial and plantarolateral portals. Currently, we have performed arthroscopy on the hock for osteochondrosis (OC)/osteochondritis dissecans (OCD) flap removal, debridement and curettage; exploration for diagnostics including synovial biopsy; chip fracture removal; and arthroscopic-assisted talar fracture repair. The hock is a very difficult joint in which to manipulate instruments, especially with respect to the typical OC lesions encountered, and care must be taken to avoid damaging intra-articular structures, as well as the equipment. Most often, the patient is placed in sternal recumbency with the hindlimbs hanging off the end of the table, as the plantarolateral and plantaromedial portals are most commonly used (medial talar OC lesions, talar fractures, exploratory with biopsy). The dog is placed in dorsal recumbency using a hanging limb preparation technique when the dorsal portals are to be used (lateral talar OC lesions). Rarely, the dog is placed in lateral recumbency using a hanging limb preparation technique with the affected limb up if both dorsal and plantar portals are needed (complete exploratory). We use a 1.9- or 2.7-mm short 30-degree foreoblique arthroscope, depending on the size of the patient. A mini-shaver with a 2.0-mm shaver blade is extremely useful in the hock. Small curettes and graspers are also very useful for manipulation in this joint.