Table Of ContentHans-Rudolf Henche
Arthroscopy
of the Knee Joint
With a Foreword by Erwin Morscher
Translated by P. A. Casey
With 163 Figures, most in Colour
Diagrams by F. Freuler
Springer-Verlag Berlin Heidelberg GmbH
HANS-RUDOLF HENCHE, Dr. med., Kreiskrankenhaus Rheinfelden,
7888 Rheinfelden
Translator: Dr. P.A. CASY, Oberwohlenstr. 45,
CH-3033 Wohlen/Bern
Translation of the German edition:
Die Arthroskopie des Kniegelenks
ISBN 978-3-662-02318-1 ISBN 978-3-662-02316-7 (e Book)
DOl 10.1007/978-3-662-02316-7
Library of Congress Cataloging in Publication Data. Henche, Hans-Rudolf, 1940 - Arthroscopy
of the knee joint. Translation of Die Arthroskopie des Kniegelenks. Bibliography: p. . In
cludes index. I. Knee-Examinatipn. 2. Arthroscopy. 3. Knee-Diseases-Diagnosis. I. Title.
RD56l.H4513 617'.582'0754 79-19528
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©by Springer-Verlag Berlin-Heidelberg 1980
Originally published by Springer-Verlag Berlin Heidelberg New York in 1980
The use of registered names, trademarks, etc. in this publication does not imply, even in
the absence of a specific statement, that such names are exempt from the relevant protective
laws and regulations and therefore free for general use.
Reproduction of figures: Gustav Dreher GmbH, Stuttgart
2124/3130-54210
Dedicated to
ERWIN MORSCHER
in gratitude
v
Foreword
In 1921 the Swiss surgeon BIRCHER published the first report on ar
throscopy of the knee joint. The initial trials with the method revealed
problems, mainly technical in origin, which caused it to be abandoned
and forgotten until recently. Modern technical improvements, for
which Japanese orthopaedic surgeons, above all WATANABE, were
mainly responsible, have now led to a revival of interest in this method
of investigation. The quality and versatility of the instruments currently
available and the experience of the endoscopists who use them are
such that arthroscopy of the knee joint is becoming an indispensable
diagnostic aid. Arthroscopy is superior to arthrotomy in every respect;
it is not only simpler but can be carried out on an ambulatory basis
under local anaesthesia. In addition, it provides more information than
arthrotomy, and the arthroscopic findings can be simply documented
photographically. The complication rate is extremely low; cumulated
statistics recently obtained from six clinics revealed no case of infection
following nearly 4,000 arthroscopies. The main indication for arthros
copy is the "painful, diagnostically obscure knee joint" in the widest
sense. The procedure is also useful for further investigation of knee
joint lesions which have already been diagnosed, as it allows their
type and extent to be diagnosed more precisely, and the indication
for surgery in a given case can be assessed more clearly. Unnecessary
surgery can often be a voided in this manner. Arthroscopic biopsy
is simple, and a variety of operations (e.g. cartilage transplantation)
can be followed up endoscopically.
Since 1971, arthroscopy ofthe knee joint has been carried out systema
tically at the Orthopaedic Clinic of the University of Basel by Dr.
H.R. HENCHE, and the associated technique has gradually been im
proved. In particular, Dr. HENCHE has succeeded in perfecting endoscopy
of the gas-filled joint and has developed it into a standard procedure.
Dr. HENCHE has summarized his experience of over 500 arthroscopies
in this manual, which provides an introduction to, and a practical
description of the technique for the surgeon who has to deal with
the diseased or injured knee joint.
Finally, it must be emphasized that the development of arthroscopy
is continuing, and there is no doubt that the ability to perform endo
scopic surgery will be included among the benefits which future techni
cal advances will bring.
Basel Prof. E. MORSCHER
VII
Preface
The possibility of using a thin optical device to look into the knee
joint and directly diagnose the causes of otherwise cryptogenic joint
problems has fascinated surgeons since the beginning of this century.
EUGEN BIRCHER and KENJI TAKAGI took up this challenge indepen
dently at the beginning of the twentieth century. They earned no
laurels from their contemporaries, as they were unable to document
their findings and thus provide evidence with which to reassure the
doubters.
Diseases of the cartilage of the knee joint are difficult to diagnose
and assess clinically, and this explains the early interest in arthroscopy
at an orthopaedic clinic such as that in Basel. My teacher, Prof.
ERWIN MORSCHER, had been convinced by ROBERT W. JACKSON in
Toronto that it was possible to inspect the inside of the knee joint
by arthroscopy. On becoming Director of the Orthopedic Clinic in
Basel in 1971 he asked me to study and develop the technique of
knee joint arthroscopy, a commission which I regarded at that time
as a very unpleasant duty. In 1971 we began to carry out arthroscopy
on patients whose diagnosis was clear and on those in whom arthrot
omy was to be carried out immediately following the arthroscopy.
The results of our first arthroscopies were frequently scanty. We fol
lowed the techniques described by WATANABE in his arthroscopy atlas,
but nevertheless we seldom succeeded in precisely identifying an area
of cartilage.
With the aid of all the members of the surgical team the technique
described was developed in the years 1971-1972. I am particularly
grateful to Professor HUGIN, who assisted me in the solution of techni
cal problems.
In recent years investigation of joints by arthroscopy has gained accep
tance in many clinics. The questions ahd requests of colleagues who
wished to start using the method gave me the idea of summarizing
my experience in tlie form of a book. This monograph is also intended
t'o encourage those who, like me, have been disappointed by the dissat
isfying initial results of this apparently·simple method. For this reason
an ample proportion of this "recipe book" is devoted to the complica
tions and sources of error.
Dr. FRANZ FREULER contributed greatly to this book by furnishing
the diagrams which accompany the photographs. I am very grateful
to him for his collaboration. In preparing the photographic documen
tation I received considerable help from Mrs. THIERSTEIN; the high
quality of the documentation could not have been achieved without
her skill and cooperation. Finally, I should like to thank Miss R.
WAGNER and her secretarial colleagues.
VIII
This book is being published at a time when arthroscopy is leaving
the experimental phase and becoming a routine clinical method. There
is no doubt that it will gain enormously in popularity in the coming
years. If this book succeeds in fuelling the latter process it will have
achieved its purpose.
Rheinfelden H.R. HENCHE
IX
Contents
1. Historical Perspective . . . .
2. Instruments and Equipment. . 3
a) Calibre of the Arthroscope . 3
b) Quality of the Optical System. 3
c) Instrument Connectors . . . 3
d) Expandability of the System . 3
3. Examination of the Liquid- or Gas-Filled Joint 13
a) Examination of the Liquid-Filled Joint 13
b) Filling of the Knee Joint with Gas . . . . 13
c) Alternate Filling of the Knee Joint with Liquid and Gas 13
4. Documentation of the Arthroscopic Findings . 18
5. Indications for Arthroscopy. . 20
6. The Arthroscopy Appointment . 21
7. Anaesthesia for Arthroscopy 22
a) General Anaesthesia. . 22
b) Arthroscopy Under Local Anaesthesia . . 22
8. Preparation and Positioning of the Patient for Arthroscopy 23
9. Nurse's Preparations for Arthroscopy . . . . . . . . 25
10. Preparation of the Non-sterile Accessory Equipment . . 26
11. Approaches to the Knee Joint . . 2 7
12. Arthroscopy . . . . . . . . . 29
13. Preliminary Notes on the Anatomy of the Knee Joint . 34
14. Systematic Inspection of the Knee Joint Using the Lateral
Approach. . . . . . . . . . . . . . . . 37
a) Initial Situation. . . . . . . . . . . . 37
b) Inspection of the Femoropatellar Joint. . 40
c) Inspection of the Suprapatellar Recess. . 42
d) Inspection of the Intercondylar Region . 42
e) Inspection of tlie Posterior Horn of the Medial Meniscus 44
f) Inspection of the Lateral Part of the Knee Joint . . . . 46
15. Systematic Description of the Pathological Changes in the
Knee Joint as Seen Through the Arthroscope 50
a) Synovial Capsule . . . . . . . . . . . . ·. . . . . 50
XI
b) Pathological Changes in the Menisci. 50
c) Pathology of the Articular Cartilage. 51
d) Patellar Chondropathy. . . . . . . 51
e) Osteochondritis Dissecans . . . . . 63
f) Pathology of the Anterior Cruciate Ligament as Seen
Through the Arthroscope . . . . . . . . . . . . . . 63
16. Assessment of Internal Derangement of the Knee Joint for
Compensation Purposes . . . . . . 69
17. Arthroscopic Operations . . . . . . . . . . .. 71
a) Biopsy of the Synovial Membrane. . . . . . 71
b) Electrocoagulation of Connective Tissue Strands in the
Suprapatellar Recess . . . . . . . . . . . . . . . . . 72
c) Removal of Loose Bodies in the Knee Joint; Resection
of Torn Meniscus Flaps 74
References . . 81
Subject Index . 85
XII
