arthroscopic supracentesis

Arthroscopy equipment includes straight needle endoscope, cannula needle, cold light source, optical fiber, surgical instruments and camera system. Arthroscopic diameter and field of view are different. The diameters are 1.7mm, 2.3mm, 2.7mm. The field of view 30° lens is most commonly used. Based on the anatomical features of the temporomandibular joint, arthroscopy is mainly used for superior cavity puncture examination and treatment. The superior cavity puncture can be used for the lower lateral and intra-aural approach. The former has a wide field of view and is widely used in clinical practice. The lower cavity is small, the operation is difficult, and the arthroscopy is rarely performed in the clinic. This section mainly introduces the arthroscopic examination of the superior lateral approach. Temporomandibular joint structure. Curing disease: Indication 1. The temporomandibular joint has unbearable pain or a ringing patient. 2. Patients with limited temporomandibular joint function. 3. The temporomandibular joint imaging examination has positive signs to be confirmed. 4. Need to be an intra-articular biopsy patient. 5. Suspected patients with traumatic and rheumatoid arthritis of the lower jaw. 6. Patients with a history of arthroscopic or open temporomandibular joint surgery need to evaluate the condition of the joint. Contraindications 1. Patients with bleeding disorders throughout the body. 2. Infections in the ear area of the joints and skin damage. Preoperative preparation 1. Shave the skin on the hairline 10cm in the ear, pay attention to clean the ear and the external auditory canal. 2. Prepare special surgical equipment for scrubbing and disinfection. Arthroscopy and optical fiber can be fumigated in 40% formalin glass jar for 12h. Metal equipment is sterilized by high pressure steam. The camera can be disinfected. It is connected to the arthroscope to achieve isolation and reduce camera wear. Surgical procedure Mark the puncture point Arthroscopy requires the insertion of an articular trocar and a lavage needle, so two body surface puncture points are to be marked. The first puncture point is located at the midpoint of the trailing edge of the tragus to the outer iliac line, 1 cm before the tragus, and the second puncture point is located about 0.5 cm before the first puncture point, and is marked with methylene blue. In addition, methylene blue can be used to mark the joint socket, joint nodules and condyle boundary. Then, the patient is opened with a large opening, and the original joint socket has a depression, and the most concave portion at the top of the depression is the first puncture point, and the tip of the depression is the second puncture point. 2. Irrigation needle puncture Use the 7th to 9th needle as the lavage needle, pierce the skin from the first puncture point, and bend the needle forward 30° forward. After the bone surface, firstly inject 1.5ml of anesthetic into the joint cavity, such as pulling out the clear liquid. If the syringe piston is not pressurized, the piston retreat phenomenon can be observed, indicating that the puncture is successful. Then connect the silicone tube and 20ml syringe, in order to push the saline or lactated Ringer's solution to expand the joint cavity and rinse, or inject the flushing liquid into the continuous infusion bottle. The height of the infusion bottle is about 70cm above the joint to maintain the joint cavity. Certain pressure. 3. Casing puncture A 2 mm skin incision was made with a pointed blade at the second puncture site, thereby making an endoscopic trocar puncture. The trocar with a sharp inner core needle is inserted through the puncture point incision, and the needle tip is inclined forward and upward by about 15°, and points to the posterior aspect of the joint nodule, and slowly penetrates into the superior joint cavity. At the same time, the assistant slowly injects physiological saline into the joint cavity by the lavage needle to expand it. When the trocar penetrates the joint capsule, there is a sense of breakthrough. At this time, the inner core needle is taken out, and if liquid flows out from the trocar, the irrigation channel has been established. Then insert the blunt inner core needle and push it a little into the joint cavity to remove the blunt inner core needle and insert it into the arthroscope for examination. If you need to perform surgery in the joint, make a 2mm skin incision at the third puncture point 3cm in front of the tragus. Use a trocar with a sharp inner core needle, install a triangle, and then perform an upper joint puncture. In the surgical cannula, when the end of the surgical cannula is observed by the arthroscope, the inner core needle can be taken out and various endoscopic surgical instruments can be inserted for surgery. 4. Arthroscopy observation Arthroscopic anatomy divides the superior joint cavity into the upper posterior synovial crypt, the superior anterior synovial crypt and the intermediate lumen. The synovial fossa, the posterior disc area and the synovial membrane covering the bottom of the crypt can be observed in the superior posterior synovial crypt; the joint nodule, the anterior disc and the disc front can be observed in the anterior synovial crypt The synovial membrane; the intermediate cavity is located in the center of the superior cavity joint region, the upper part is the posterior aspect of the joint nodule, and the lower part is the articular disc. The aortic plate body has no blood vessels and is milky white, rich in blood vessels, and there is a clear boundary between the pink synovial membrane. The front part of the disc is flat. The posterior part of the disc is called the disc nodule, and the two sides are the inner and outer grooves. Arthroscopy should include lateral, longitudinal and dynamic observation. Lateral observation is to slide along the surface of the disc surface in the anteroposterior direction. The surface of the disc and the joint socket and the synovial membrane before and after the disc are observed. The longitudinal observation is the sliding observation inside and outside. Dynamic observation refers to the observation of the movement of the articular disc, the posterior disc area and the synovial membrane in open, closed and lateral activities. On the basis of familiarity with the normal anatomy of the joint cavity, it is important to pay attention to the abnormal pathological conditions, such as whether the articular disc is displaced, deformed or perforated, whether the synovial membrane is swollen, proliferated or degenerated, and there is no fiber between the articular disc and the joint socket. Adhesives, floating objects in the joint cavity, etc. 5. Dial out the puncture needle After the arthroscopy is completed, the joint cavity is rinsed with normal saline. The trocar is pulled out first, and the fluid in the joint cavity is aspirated as much as possible by the irrigation needle, and 12.5 mg of strong prednisone and strong pine is injected into the acetic acid. Out the irrigation needle. The puncture incision was sutured with a 5-0 silk thread, and the joint was partially compressed with a dressing. complication 1. Cheek swelling Due to the leakage of perfusate into the surrounding soft tissue during surgery, it usually disappears after 2 days. 2. Bleeding According to the anatomical measurement, the distance from the posterior point of the tragus to the superficial temporal artery is 8 to 15 mm, and the 80% arthroscopic puncture point is located 8 to 17 mm before the apex of the tragus. Therefore, the puncture has the risk of damaging the superficial blood vessels, and the superficial temporal artery wall It is thick and elastic, and the chance of injury is very small. The wall of the superficial vein is thin, and the trocar can be damaged when it is puncture. When puncture is clinically performed, pay attention to the needle insertion point and avoid touching the superficial blood vessels by touching the finger. If the bleeding or hematoma occurs in the stab wound, immediately put the gauze on the hand for a while, and if necessary, percutaneous suture can stop the bleeding. In addition, the small blood vessels in the joint capsule are damaged by bleeding, and they can disappear by irrigating and pressing. 3. Facial nerve branch injury After arthroscopic surgery, there may be symptoms of disappearance of the frontal pattern or closed eyes, which are mostly temporary and can be self-healing in a short period of time. The cause may be related to the injury during puncturing of the trocar, the swelling of the cannula during surgery, and the swelling of the lavage fluid to the tissue surrounding the joint.