Arthroscopy or the Direct Visualization of Joints: An Experimental Cadaver Study

Michael S. Burman (Fig 1) was born in New York City. After his preliminary education, he obtained his medical degree from the University of Michigan in 1926. He did an internship at the Mt. Sinai Hospital in Cleveland. He spent 2 years in Steindler’s orthopaedic program at the University of Iowa and practiced at the Hospital for Joint Diseases in New York City. He was awarded the Henry W. Frauenthal Traveling Scholarship, which was a turning point in his career, because it allowed him to travel abroad and continue his pioneering observations on arthroscopy. He served on the staff of the Hospital for Joint Diseases for the remainder of his professional career.Fig 1.: Dr. Michael Samuel Burman (Reprinted from Parisien JS (ed): Arthroscopic Surgery. New York, McGraw Hill xiii, 1988.)Burman began his work in the anatomic laboratory of New York University Medical School. Using his traveling scholarship, he then went to Dresden, Germany to work at the Institute of Pathology of the Krankenhaus der Friedrichstadt. There he had access to fresh cadavers on which to perfect his arthroscopic studies. These studies formed the basis for the classic article. On returning to New York, Burman did arthroscopy on his patients and demonstrated his techniques at surgical meetings. One of his foreign visitors was the Japanese surgeon Watanabe. There is no question that Burman’s role in the early development of arthroscopy was very significant. The classic article reports on arthroscopic studies on cadavers. Burman describes his findings in various major and minor joints. Because of the length of the article, only the section devoted to arthroscopy of the shoulder is presented. THE JOURNAL OF BONE AND JOINT SURGERY ARTHROSCOPY OR THE DIRECT VISUALIZATION OF JOINTS An Experimental Cadaver Study By Michael S. Burman, M.D., New York, N.Y. Scholar of the Henry W. Frauenthal Travel Scholarship, Hospital for Joint Diseases Introduction The idea first occurred to us in the latter part of the year 1929 that it might be possible to see the interior of joints directly through a proper instrument introduced into the joint. In February 1930, we consulted with Mr. Reinhold Wappler concerning the construction of an instrument for this purpose. An instrument was devised according to our particular requirements. At that time, Mr. Wappler told us that he had not heard of any instrument for such a purpose, nor had he ever made any similar instrument. We first began work in March 1930 in the Anatomy Laboratory of the New York University Medical School, through the kindness and interest of Dr. Harold Senior, Professor of Anatomy. Material being so limited then, we were asked by Dr. Senior to delay further work until autumn of the same year, at which time a greater abundance of material was sure to be available. In September 1930, however, we sailed to Europe, and it was not until February 1931 that we again resumed work in the Pathologic Institute of the Krankenhaus der Friedrichstadt-Dresden, through the great courtesy of Dr. Georg Schmorl. The following is a complete report of the work done both in New York and in Dresden. It was not until we had completed our work that we were informed that Bircher had preceded us. Priority should be awarded to him, since his work was done in 1922. A brief survey of the high lights of his work, which was incidental to his study of meniscal injuries, is necessary. He used the Jacobacus laparoscope in a joint filled with oxygen or nitrogen gas. On the basis of a few cadaver experiments, he believed that only the knee joint was suitable for examination. He reported twenty clinical cases which were examined through his instrument, with the findings subsequently confirmed by operation. He saw changes in the meniscus (such as hemorrhage and tears), osteochondritis of the femur, and synovial tuberculosis, etc. In a foot-note, he says that he examined fifteen other cases, in addition to the twenty described. His work does not seem to have received any support. In 1925, in a speech in Holland, Bircher again affirmed the value of this endoscopy of the knee joint, especially in the diagnosis of meniscal lesions*. We have also received word from Dr. Leo Mayor that Dr. H. Finkelstein and he have also been working on this same problem, during a period of time coincident, in general, with our work. The term “arthroscopy” is self-evident, and everyone to whom the idea is mentioned coins the term spontaneously. It is thus natural to designate the instrument as the “arthroscope”. Bircher called the process variously “endoscopy of the knee joint”, “arthro-endoscopy”, and “arthroscopy”. GENERAL PRINCIPLES OF ARTHROSCOPY When it occurred to us that a potential space—such as a joint cavity—might be filled so that an actual space resulted, then the first principle of arthroscopy had been determined. Distention, by a non-irritant fluid–such as distilled water, boric acid solution, physiological salt solution—or by a non-irritant gas—such as air, oxygen, or even carbon dioxid—creates an actual joint space, into which the visualizing apparatus may be inserted. Theoretically and practically, fat is the greatest obstacle to good vision and, therefore, the distending agent must be strong enough to push the fat away from the things to be seen. To separate joint surfaces, so that a greater space results, traction is necessary. This traction also separates fat pads in contact with structures to be visualized. Manual traction is best and varies in direction and force with the joint to be examined. Reyher noted that, with the use of average man power, plus a force of one hundred pounds, the condyles of the knee joint could be separated only three and five-tenths millimeters; a force of forty pounds separates them one millimeter. We do not know of any other exact experimental observations on this subject, but, in the course of this work, we have noticed, empirically, that in cadavera the amount of joint separation by traction depends directly on the musculature and ligamentous apparatus of the joint, and possibly on air pressure. The more emaciated and weak-muscled the cadaver, the greater is the separation. Individual joints vary. This applies particularly to the shoulder joint, where, in some cases, we were able to separate the joint surfaces even up to one-half inch. This is more likely to take place in the shoulder joint with a relaxed capsule and a flabby musculature, the tendon of the long head of the biceps humeri apparently offering no resistance. We have not been able to separate the apposing surfaces of the hip joint, and a separation does not seem likely after studying the anatomical structure of the joint. In the knee, traction does give a slight advantage to visualization; but, in the average adult, we doubt if the apposing surfaces can be separated more than a few millimeters. The strong attachments of the crucial and lateral ligaments effectually prevent good separation of the joint surfaces. In the child, however, a good separation can be effected sometimes. In the wrist, traction does increase joint space, sometimes even as much as one-eight to one-quarter of an inch, depending on the relaxed state of the wrist. An arthritic wrist usually does not allow much or any separation by pull. We have not been able to accomplish any separation in the ankle; and in the elbow, when it is strongly flexed, the effect of traction is almost negligible. Position of the joint noticeably determines better or poorer visualization. Correct position, combined with the factors of distention and traction, plus the use of a proper technique, render good visualization of a joint easy. The proper position for the various joints will be discussed respectively under the joints considered. It is to be emphasized that traction is used in the line of position of the limb. At times, one may use pressure to bring certain structures into better view,–as pressure behind the head of the tibia to bring out the superior surface of the tibia, pressure before or behind the head of the humerus, etc. At times, it is also advisable to use motion, either of rotation, or of flexion and extension, to orient us or bring out certain structures better. In moving the joint, while the arthroscope is within it, all motions must be made slowly and gently, in order to avoid injury to joint structures and to the instrument. Puncture of the joint should be done carefully, so that the large trocar does not tear away cartilage or bone, nor injure soft tissues. Cartilage may be quite easily grooved, especially in the narrower joints, if one is not careful. We have had this happen a few times, and, since cartilage shows so little regenerative power, such an unfortunate accident possibly might be the beginning of an arthritis or the formation of a loose, cartilaginous body in the joint. However, if cartilage is removed, most of it is generally carried away in the deep groove of the trocar, in which the electric lamp lodges. There it appears as whitish or grayish, flaky strips. We stress this damage to the cartilage, since it is not an unlikely accident. Rough handling of the trocar within the joint may cause hemarthrosis of the joint, with a possible tendency to the formation of secondary adhesions. ARTHROSCOPY OF THE INDIVIDUAL JOINTS We have examined more than ninety joints, –about forty knee joints, about twenty hip joints, about twenty-five shoulder joints, four wrist joints, and two or three ankle and elbow joints. In every case, we have compared our findings as seen through the arthroscope, with those seen when the joint has been opened. The joint was also examined through a capsular puncture in many cases, after the skin and subcutaneous tissues had been cut down to the capsule. We thus double-checked our findings as seen through the arthroscope by the usual skin puncture. The joints of children are generally seen in their entirety in one field of vision; those of adults in several. The joint to be examined was distended with water, which was introduced under moderate force by a syringe. When the needle is in fat, it is difficult to distend the joint. If the capsule has been punctured through and through, the joint may not fill well, since the fluid passes out into the soft tissues. One should be careful that air is not introduced, when distending the joint with water, since air bubbles obstruct and distort vision. Air bubbles are spherical, blackish in color, and with a polished surface, reflecting high lights. The bubble moves with the motion of the joint, can be pushed up and down, and can be punctured by the trocar. An air bubble may be large enough to cover the entire field of vision. The danger of air embolism, though very slight, is to be considered. A bloody fluid appears as uniform red and is easily recognized. 1. SHOULDER JOINT The structures that can be seen in visualizing the shoulder joint are: the head of the humerus up to the anatomical neck at the site of capsular insertion, the entire glenoid fossa with its ring or labrum of encircling fibrocartilage, the origin and course of the long head of the biceps tendon, as it passes through the joint above the head of the humerus. The joint space is a definite space of some considerable dimensions, into which fat and synovial villi project in varying amounts. We have used both the anterior and the posterior puncture of the shoulder, of the type described in the text-books. Both punctures are easy, though the anterior one may possibly injure the cephalic vein. In using the posterior puncture, we have not seen the biceps tendon, since this is in the upper anterior part of the joint. The posterior puncture is as effective otherwise. When the puncture is made, the limb is held in about seventy to eighty degrees of abduction and in some external rotation, traction being made strongly downwards in the line of position of the limb. It may be necessary to steady the neck by counter-resistance. The joint is then filled enough so that water spurts back through the trocar; the telescope is then inserted. With the anterior puncture, we once noticed the filling of the bicipital groove on the arm, when the joint was distended; the needle may have been in the biceps tendon or in its encircling vagina mucosa intertubercularis, that extension of the synovia which surrounds the biceps tendon in the joint. The anterior part of the joint is seen at its widest when the arm is strongly rotated externally and abducted to about one hundred degrees; the posterior part of the joint, when the arm is internally rotated and less abducted. It is not always necessary to approach the limits of rotation. As one first looks in, one may see nothing but a yellowness, indicating that one is in fat. The trocar is moved gently up or down until an actual view of the joint space is seen. One can always be sure that one is in the joint proper when water spurts back through the trocar. The joint space is usually grayish black in tone, with a reddish tint or glow of the lamp. Fat, either in strands or in compact pads, may be seen to encroach on the joint space, and even partially obscure cartilaginous surfaces. One usually sees dimly the inferior part of the capsule in the depths, through an anterior puncture. The head of the humerus, when the needle is turned towards it, is seen in the field of vision as a section of a sphere (the needle being at nine or twelve o’clock); and when the cartilage is normal, the surface is a gleaming white, with sometimes a bluish tint beneath the white. Rotation verifies the fact that we see the head, and increase or decrease of traction may separate or approximate the head in relation to the glenoid fossa. The posterior and inferior surface of the head is seen best by a posterior puncture, and, with rotation, especially internal rotation, most of the head can be seen. In arthritis, the cartilaginous surface is not as shiny as normal, less white, even grayish, with the gleam lost, and zones of erosion may be seen. In one case, grooves made in the cartilage by the trocar were well seen. The glenoid fossa is usually seen in its entirety, though it may be sometimes covered partially by fat. Its relative smallness, as compared with the head of the humerus, is well observed. The needle should face at three o’clock (right shoulder) or at nine o’clock (left shoulder), with the lamp opposite the center of the glenoid fossa. The entire fossa, including its outlying labrum, can then be inspected. The cartilaginous covering of the glenoid fossa does not appear as gleaming white as that over the head of the humerus. The origin of the biceps tendon is easily determined, and the tendon can be traced over the head of the humerus until it leaves the joint. It is not possible in every case to see the tendon, since the upper part of the joint is often covered with fat and synovia which conceal it from view. The tendon appears as a band about one-quarter to three-eighths of an inch wide, glistening yellowish white (yellowish because of the light of the lamp), passing through a grayish joint space. The color contrast is strong. As the arm is bent at the elbow or extended, one notices the movements of the biceps tendon. When the arm is under traction so that the biceps tendon is stretched taut, with the arm in moderate abduction and external rotation, flexion of the elbow relaxes the tendon so that it curls on itself. Extension of the elbow tightens it. When pathological changes, especially those of an arthritic nature, are present in the joint, it may be difficult to see the biceps tendon, since it is easily covered by hypertrophic and hyperaemic fat. It should be traced from the glenoid fossa. In general, it may be said that the shoulder joint is the easiest and most consistent of all joints to visualize. SUMMARY A new procedure for the examination of the larger joints has been described. Certain effects of dyes on cartilage have also been noted. We believe arthroscopy to be a key procedure in the study of joint physiology and pathology. The method as yet is still in its infancy and only the connected work of many men can establish its full value.