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3. Arthroscopy Sendi Lutut

ARTHROSCOPY SENDI LUTUT

Oleh Dr H Subagyo SpB - SpOT

 

B A B   I

P E N D A H U L U A N

 

Untuk lebih memahami bagaimana masalah yang terjadi pada lutut, maka sangatlah penting untuk terlebih dahulu memahami anatomi sendi lutut dan bagaimana bagian - bagian lutut tersebut saling bekerja sama untuk mempertahankan fungsi normal, seperti yang akan dibahas pada tulisan ini.

Sendi merupakan suatu engsel penghubung antara ruas tulang yang satu dengan ruas tulang lainnya, sehingga kedua tulang tersebut dapat digerakkan sesuai dengan jenis persendian yang diperantarainya.Sendi lutut ini termasuk dalam jenis sendi engsel , yaitu pergerakan dua condylus femoris diatas condylus tibiae. Jika terjadi gerakan yang melebihi kapasitas sendi maka akan dapat menimbulkan cedera yang antara lain terjadi robekan pada  meniscus sendi dan ligamentum di sekitar sendi.

Pada masa kini, arthroscopy sendi lutut adalah prosedur yang umum dilakukan oleh  dokter bedah tulang. Pada awalnya, arthroscopy lutut hanya digunakan untuk diagnosis saja.Setelah berkembangnya teknologi gambaran resonansi magnetik dan prosedur non - invasif lainnya, maka arthroscopy lutut sekarang digunakan untuk merawat berbagai patologi lutut.

 

 

Arthroscopy merupakan teknik yang “minimally invasive”, yang dipertimbangkan sebagai golden standard  untuk kelainan artikuler. Namun arthroscopy hanya mampu memeriksa permukaan tulang rawan secara visual dan tidak dapat memperlihatkan kerusakan yang mungkin terjadi pada jaringan yang di dalam, yang memungkinkan untuk menyembunyikan suatu kelainan yang ada.

Arthroscopy lutut dapat merawat berbagai patologi lutut, misalnya saja kelainan pada ACL ( Anterior Cruciata Ligament ) dan meniscus yang akan dibahas pada tulisan  ini. Anterior cruciata ligament (ACL) adalah komponen penting untuk menjaga stabilitas sendi lutut.Pada umumnya ACL dapat cedera pada keadaan ketika sedang lari  mendadak berhenti, jadi kaki terkunci dan tubuh terdorong ke depan, kemudian berputar arah / twist sehingga menyebabkan lutut terputar atau lompat dan mendarat dengan posisi lutut terputar.dimana terjadi perubahan gerak yang tiba – tiba.

 

Cedera meniscus adalah indikasi yang tersering untuk dilakukannya arthroscopy lutut.Cedera meniscus dapat terjadi akibat aktivitas atletik dan aktivitas sehari-hari dan dapat menyebabkan gangguan yang signifikan.

Akhir - akhir ini sering disinggung pengembangan stem sel dalam berbagai aspek terapi penyakit. Dalam laboratorium telah banyak dilakukan berbagai cara untuk memodifikasi sel ini sehingga dapat disimpan, diperbanyak, didiferensiasikan, bahkan dibuat agar menjadi suatu organ yang spesifik misalnya saja seperti terbentuknya kartilago. Hal ini sangat menarik, maka dari topik tersebut akan dibahas dalam tulisan ini.

 

B A B  I I

A N A T O M I   S E N D I   L U T U T

 

Anatomi Sendi Lutut tidak dibahas dalam makalah ini.

 

B A B  I I I

 A R T H R O S C O P Y    L U T U T

 

D E F I N I S I

 

Arthroscopy merupakan teknik yang “minimally invasive”. Arthroscopy berasal dari kata Arthro (sendi) dan Scopein (untuk melihat), sehingga arthroscopy dapat diartikan sebagai suatu pemeriksaan dalam dari suatu sendi dengan menggunakan sebuah instrumen cahaya spesial (arthroscope) yang dimasukkan ke dalam sendi melalui sebuah insisi yang kecil (biasanya kurang dari 1 cm) yang memperkenankan penglihatan secara langsung permukaan sendi. Tempat dimasukkannya instrumentasi tersebut dinamakan sebagai portal.

Hampir semua sendi dapat dilakukan arthroscopy.Namun, sendi-sendi yang paling sering dilakukan arthroscopy adalah pada sendi lutut, bahu dan pergelangan tangan.

 

 

Gambar dari sendi bahu dan sendi pergelangan tangan.

Sumber dari :http://2.bp.blogspot.com/_wGXDwOGWeQk/R9xBGhZJ1dI/AAAAAAAAAWc/x5ysl33o21c/s320/b.sepicon.gif.

 

Arthroscope merupakan instrumen yang sensitif, diameternya kurang dari 5 milimeter, memiliki sebuah sumber cahaya dengan serat fiber, dan terdapat kaca pembesar pada ujungnya.

Instrumen-instrumen kecil dengan kemampuan untuk memotong atau mencukur material isi sendi dapat dimasukkan melalui portal yang lain pada sendi. Jika diperlukan, sebuah kamera kecil dapat disambungkan pada arthroscope sehingga gambaran sendi dapat dilihat pada layar monitor untuk memudahkan pemeriksaan.

SEJARAH

Bedah arthroscopy telah berkembang sejak awal abad ke 20.Endoscopy dalam bedah ortopedi dilakukan pertama kali oleh Takagi pada tahun 1918 dengan menggunakan sistoscop untuk memeriksa sendi lutut.

Antara tahun 1921 dan 1926, Eugen Bircher menerbitkan beberapa karya tulis yang mendeskripsikan 60 prosedur arthroscopy lutut yang memperbaharui menisectomy terbuka.Ini adalah pertamakalinya arthroscopy telah digunakan dalam skala besar untuk tujuan klinis dan Bircher menggunakan Jacobaeus thoracolaparoscope.

Pada tahun 1950, Professor Harald H Hopkins mengembangkan sistem lensa berbentuk batang, yang dimana dipakai sampai masa kini pada arthroscop yang paling modern.Sepanjang 1970 sampai 1980, arthroscopy lutut meningkat popularitasnya sebagai metode untuk mengobati dan mendiagnosa gangguan - gangguan lutut.Pada tahun 1974, Onishi melakukan arthroscopy pada Temporo Madibular Joint untuk pertama kalinya.


 

Gambar dari  Eugen Bircher dan Harald H Hopkins.

Sumber dari :http://www.wirrizunft.ch/images/ueber_uns/Bircher-Eugen.jpg, dan http://i124.photobucket.com/albums/p7/NBBooks/HarryHopkins.jpg.

 

Pada masa kini, arthroscopy lutut adalah prosedur yang umum dilakukan oleh  dokter bedah tulang. Pada awalnya, arthroscopy lutut hanya digunakan untuk diagnosis saja.Setelah berkembangnya teknologi gambaran resonansi magnetik dan prosedur non-invasif lainnya, arthroscopy lutut sekarang digunakan untuk merawat berbagai patologi lutut.

 

Gambar dari sebuah arthroscopy.

Sumber dari :http://www.oralchelation.com/calcium/images/scoi-arthroscopy-main.jpg

 

 

ARTHROSCOPYVSMAGNETIC RESONANCE IMAGING (MRI)

 

Arthroscopy pada awalnya digunakan terutama sebagai alat diagnosis.Pada saat itu arthroscopy menyelamatkan banyak lutut dari arthrotomi yang tidak diperlukan.Pada masa kini, MRI telah tersedia untuk menyelamatkan lutut dari arthroscopy yang tidak diperlukan.Apabila telah ditemukan kelainan intracapsular, pembedahan arthroscopy dapat dilakukan setelah MRI.

 

Gambar dari arthrotomi.

Sumber dari :http://www.aaos.org/news/aaosnow/dec09/cover2-2.gif

 

MRI adalah alat penunjang yang tidak invasif, bebas dari morbiditas, lebih aman dan murah dibandingkan dengan arthroscopy.Sensitivitas dari MRI untuk memeriksa lesi meniscus dapat lebih dari 90%.Akan tetapi, arthroscopy diagnostik kadang disarankan terlalu awal. Pada suatu penelitian oleh Williamsmenunjukkan bahwa 51% pasien yang sedang menunggu untuk dilakukan arthroscopy karena adanya kecurigaan lesi meniscus, dibatalkan rencana arthroscopynya setelah diperiksa oleh MRI.

Apakah semua lutut harus diperiksakan MRI sebelum dilakukan arthroscopy?Permasalahan pada masa kini dan merupakan tantangan bagi para ahli adalah untuk mencegah MRI pada pasien-pasien yang secara pasti membutuhkan arthroscopyterapeutik dan mencegah arthroscopy yang invasif ketika terdapat lesi yang tidak dapat diterapi secara bedah.

MRI dapat mencegah pasien dari operasi yang tidak dibutuhkan, tetapi teknologi ini tidak boleh membuat bingung klinisi dalam memberikan penilaian yang profesional dan akurat.Ahli bedah yang kurang ahli dalam teknik arthroscopy disarankan untuk meminta pemeriksaan MRI terlebih dahulu pada kasus yang tidak pasti, tetapi bagi mereka yang percaya kemampuannya dalam manajemen gangguan lutut mungkin tidak membutuhkan keduanya. MRI sangat berguna, juga arthroscopy, akan tetapi, keduanya bukan merupakan suatu substitusi bagi penilaian klinis yang tepat.

Arthroscopy biasanya dipertimbangkan sebagai golden standard untuk kelainan artikuler.Akan tetapi, tingkat ketepatannya dalam evaluasi gangguan tulang rawan telah dipertanyakan.Telah diterima bahwa arthroscopy hanya mampu memeriksa permukaan tulang rawan secara visual dan tidak dapat memperlihatkan kerusakan yang mungkin terjadi pada jaringan yang di dalam, yang memungkinkan untuk menyembunyikan suatu kelainan yang ada.Walaupun MRI dapat memperlihatkan kelainan maupun kerusakan pada lapisan yang berada di dalam, golden standard arthroscopy dapat menutupi bukti-bukti ini sebagai sebuah temuan positif palsu. Sebuah teknologi yang sangat disukai dapat mengganggu hasil dari sebuah penelitian dan karena itu sebaiknya dipertimbangkan sebagai keterbatasan penelitian-penelitian mengenai sensitifitas dan spesifisitas  MRI.

 

Gambar dari MRI.

Sumber dari :http://www.sunrise-med.com/wordpress/wp-content/uploads/2010/02/DSC09854.jpg

 

Kuikka et all. melakukan penelitian mengenai perbandingan MRI dan arthroscopy sebagai golden standard. Penelitian tersebut menunjukkan bahwa MRI rutin dengan kekuatan 1,5 T merupakan tes yang spesifik dan relatif tepat dalam mendeteksi lesi tulang rawan traumatik. MRI memiliki sensitifitas dan spesifisitas yang baik pada pemeriksaan cedera ligamen dan meniscus. Pada penelitian terdahulu, akan tetapi, MRI tulang rawan memiliki hasil yang bervariasi ketika dibandingkan dengan arthroscopy, dengan sensitivitas berkisar dari 18% sampai 100%, spesifitas berkisar antara 50% sampai 100%, dan ketepatan berkisar antara 81,5% sampai 98%.

 

Gambar dari potongan koronal MRI-T2 lutut kanan satu hari setelah cedera.Sebuah jejas terlihat pada kondilus lateralis tibia (panah).Tulang rawan tampak normal dan utuh.

Sumber dari :http://www.orthspec.com/arthroscopic_surgery.htm

 

Gambar dari lutut yang sama 6 hari setelah cedera. Kelainan sedang (grade I) tampak pada tulang rawan pada kondilus lateralis tibia (garis).Robekan meniskus lateralis juga tampak.

Sumber dari :http://www.orthspec.com/arthroscopic_surgery.htm

MRI resolusi tinggi menggunakan “microscopy surface coil” memungkinkan penilaian setiap komponen triangular fibrocartilage complex (TFCC) dan memberikan tingkat ketepatan yang lebih tinggi terhadap cedera pada tempelan radial dan discus triangular fibrocartilage complex (TFC) dibandingkan dengan penelitian sebelumnya.MRI resolusi tinggi, akan tetapi, tidak dapat mendiagnosa distal radio ulnar ligaments (DRUL), proximal distal radio ulnar (PRUL), atau cedera ligamen ulnolunate secara akurat.

 

Gambar dari potongan aksial MRI-T2 dari lutut kanan 4 hari setelah cedera. Sebuah lesi tulang rawan tampak pada tulang subkondral pada facet medialis patela (panah), dinilai sebagai grade III.

Sumber dari :http://www.orthspec.com/arthroscopic_surgery.htm

 

 

 Gambar dari lutut yang sama 12 hari setelah cedera. Tulang subkondral pada facet medialis patela ditampilkan, dan lesi dinilai sebagai grade III pada arthroscopy.

Sumber dari :http://www.orthspec.com/arthroscopic_surgery.htm

MRI dapat digunakan tanpa biaya tambahan atau efek yang tidak menguntungkan dalam memastikan arthroscopy pada pasien dengan gejala lutut nonakut yang sangat dicurigai memiliki abnormalitas lutut intraartikuler.

Terdapat sedikit dokumentasi akan pita fibrosa intraartikuler pada literatur mengenai imaji, tetapi hal tersebut banyak dibahas pada literatur arthroscopy. Pita fibrosa intraartikuler merupakan penyebab yang tidak biasa pada nyeri lutut post-traumatik.

MRI bahu telah dinyatakan sebagai suatu pemeriksaan yang sensitif dan spesifik untuk mendeteksi robekan labral pada kekuatan 1,5 T atau kurang dibandingkan dengan arthroscopy.

MRI bahu pada kekuatan 3,0 T sangat sensitif dan spesifik dibandingkan dengan arthroscopy untuk mendeteksi robekan labral superior, anterior dan posterior.

MRI menyediakan taksiran yang berguna bagi pasien-pasien dengan kecurigaan adanya gangguan femoroacetabuler.

Teknik nonarthrografik resolusi tinggi dapat menyediakan informasi preoperatif terhadap keberadaan dan lokasi anatomis abnormalitas labral dan tulang rawan.

 

Gambar dari anatomi femoroacetabuler.

Sumber dari :http://www.colonialorthopaedics.com/HipArthroscopy_files/image004.jpg

 

DIAGNOSIS

Beberapa kondisi yang dapat didiagnosa atau diperbaiki oleh arthroscopy adalah adanya robekan tulang rawan, kontur sendi yang rusak, robekan ligamen, kerusakan pada patella, dan arthritis.

INDIKASI

Indikasi untuk arthroscopy lutut termasuk perawatan kelainan meniscal, lesi tulang rawan sendi spesifik, lesi osteochondral, corpus allienum, sinovitis tahap lanjut, robekan ligamen cruciata, dan beberapa fraktur tibia tertentu.Salah satu dari indikasi umum untuk arthroscopy lutut adalah tindakan debridement lutut arthritis.

 

Gambar dari ligament cruciata.

Sumber dari :http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/18003.jpg

 

Kontroversi aktual mengenai efektifitas arthroscopy untuk osteoarthritis lutut telah mucul ke permukaan.

Pada tahun 2002, sebuah artikel oleh Moseley dan kawan-kawan, hasil akhir dari pembilasan arthroscopy dan debridement lutut dengan arthritis tidak lebih baik dari plasebo.Tiga belas hari setelah dipublikasikan, Arthroscopy Association of North America (AANA) mengeluarkan sebuah pernyataan bahwa pasien-pasien dengan arthritis ringan dengan adanya gejala mekanikal dapat mendapatkan manfaat positif dari arthroscopy lutut.Keterbatasan dari penelitian yang dilakukan Moseley ini adalah populasi pasien yang tidak mencerminkan seluruh pasien yang mendapatkan terapi arthroscopy lutut. Karena itu para ahliorthopedic  tidak setuju dengan kesimpulan yang diambil dalam penelititan Moseley.

KONTRAINDIKASI

Kontraindikasi dari arthroscopy sangatlah sedikit.Kerusakan pada kapsul posterior lutut dapat menyebabkan ekstravasasi cairan ke jaringan sekitarnya. Hal ini akan menyebabkan pembengkakkan sehingga dapat terjadi sindrom kompartemen. Karena itulah kapsul posterior sebaiknya dibiarkan untuk menjadi parut dahulu atau diperbaiki secara primer sebelum dilakukan arthroskopi. Kontraindikasi lainnya adalah: ankilosis sendi, infeksi kulit setempat sekitar lokasi potensial tempat masuknya instrumentasi, yang dapat menyebabkan terjadinya sepsis sendi; dan infeksi yang jauh lokasinya namun masih dapat mengkontaminasi lokasi operasi.

 

KEUNTUNGAN

Pembedahan arthroscopy memiliki banyak keuntungan, yaitu: morbiditas pasca - operasi yang berkurang, diagnosis yang ditegakkan dengan lebih baik, tingkat komplikasi yang lebih rendah, dan insisi yang diperlukan lebih kecil.

Selain itu keuntungan lainnya adalah respons inflamasi berkurang yang berhubungan dengan berkurangnya nyeri pasca - operasi, biaya rumah sakit yang berkurang, dan visualisasi sendi yang lebih baik.

 

Gambar dari luka insisi arthroskopi lutut.

Sumber dari :http://kimogoree.typepad.com/messages_from_the_pale_bl/images/2007/10/26/arthroscopy_025_c.jpg

 

KERUGIAN

Berlawanan dengan keuntungannya, kerugian dari bedah arthroskopi lutut sangatlah sedikit.Arthroskopi membutuhkan ahli bedah untuk bekerja pada tempat yang terbatas dengan instrumen yang kecil.Kerusakan yang signifikan dapat terjadi pada tulang rawan sendi jika ahli bedah tidak terampil dan tidak hati-hati.Sebagai tambahan, bedah arthroscopy merupakan pembedahan yang sangat menyita waktu.

 

INSTRUMENTASI

Bedah arthroscopik membutuhkan peralatan yang spesial.Arthroscope adalah alat optik yang terdiri dari kabel serat optik yang dilindungi oleh lapisan logam dengan adanya lensa pada ujung distalnya. Arthroscop bervariasi dalam diameternya, mulai dari 1,7 mm sampai 7 mm, dengan diameter 4 mm menjadi alat yang paling sering digunakan pada arthroscopy lutut. Sudut inklanasi bervariasi dari 0o sampai 120o. Inklanasi 30o merupakan yang paling sering digunakan, dengan inklanasi 70o merupakan yang paling mudah digunakan untuk melihat daerah-daerah tepi, seperti lutut bagian posterior melalui intercondylar notch.

 

Gambar dari intercondylar notch.

Sumber dari :http://www.hughston.com/hha/b_11_3_2a.jpg

 

                                                  

Gambar dari arthroscope.

Sumber :http://goortho.net/images2/arthroscope.jpg

  

Gambar sudut inklanasi pada arthroscope.

Sumber : http://www.themedica.com/articles/gifs/Arthroscope.jpg/Arthroscope.jpg

 

Pada tahun 1976, McGinty dan Johnson memperkenalkan penggunaan kamera televisi untuk prosedur arthroscopik.Sebelum berkembangnya kamera televisi, ahli bedah harus mengintip melalui ujung proksimal arthroscop.Beberapa waktu ini, instrumen electrosurgical, laser, dan alat pelepas energi frekuensi radio telah digunakan pada beberapa kasus.

 

Gambar kamera televisi pada arthroscope.

Sumber :http://www.sportsmedicinedr.com/articles/shoulderarthroscopy/arthroscope.jpg

 

Gambar dari sumber cahaya arthroscope yang dapat disambungkan dengan layar monitor.

 

Gambar dari arthroscopy camera lense.


 Gambar dari arthroscope sheaths.

 

Gambar dari Janis arthroscopic sheaths lainnya.


 Gambar dari arthroscopic sheaths dengan snap in coupling mechanism.

 

Gambar dari arthroscope sheats dengan automatic lock – in coupling.

 

Gambar sebuah trokar dengan pengunci pada ujung proksimal

 

 

 

Gambar dari trokar dimasukkan kedalam kanula

Gambar dari trokar dan kanula yang siap untuk digunakan untuk membuat portal

Gambar dari probe arthroskopi.Probe arthroskopi konvensional (kiri) dan 5 set probe yang didesain spesial dengan sudut bervariasi (kanan).

 

 

Gambar dari bermacam – macam arthroscopy pump.

Gambar dari pump tubing.

 

Gambar dari fluid management di arthroscopy.


 

Gambar dari complete solution from the arthroscopy specialist.

 

Gambar dari arthroscopy instruments.

 

Gambar dari grasping forceps

 

Gambar dari punches

 

Gambar dari scissors.

 

Gambar dari biopsy forceps.

 

 

 

 

STERILISASI

Sebuah penelitian yag dilakukan oleh Johnson et al. mengenai cara sterilisasi yang baik menghasilkan bahwa autoklaf uap, yang direkomendasikan sebagai cara sterilisasi instrumen dengan lensa, dapan memperpendek masa pakai arthroscope dan ethylene oxide merupakan efektif dan aman namun membutuhkan waktu yang sangat lama (sekitar 12 jam) untuk mencapai suatu keadaan steril. Menurut mereka, glutaraldehyde dalam larutan 2% telah terbukti sebagai agen sterilisasi setelah 10 jam, agen desinfeksi dalam 15 menit.

 

 

 

Gambar dari ethylene oxide dan glutaraldehyde.

Sumber :http://www.2spi.com/catalog/supp/images/triton.jpg dan http://www.directdentalsupplies.com/admin/uploads/procided_2_medium.jpg

 

POSISI OPERASI

Posisi pasien merupakan hal penting dalam pembedahan arthroscopic lutut.Pasien diletakkan terlentang dan pemeriksaan lutut dilakukan di bawah anestesi spinal.Sebuah torniquet secara rutin dipasangkan pada paha tetapi tidak dikembangkan kecuali terjadi perdarahan yang mengganggu jalannya operasi.Sebuah pemegang kaki digunakan untuk memberikan posisi valgus untuk membuka aspek medial lutut.

Posisi lain yang biasanya digunakan adalah dengan memposisikan pasien terlentang dengan lutut berada pada ujung meja operasi, sehingga kaki akan dalam posisi tergantung untuk membentuk sudut 90o.

Gambar dari posisi kaki dalam keadaan tergantung dan posisi operator pada saat melakukan arthroskopi.

Sumber :http://catalog.nucleusinc.com/imagescooked/1636W.jpg

LOKASI PORTAL

Setelah pasien diposisikan dengan baik, jalur masuk instrumen yang tepat ditentukan. Arthroscopy standar biasanya hanya membutuhkan  2 jalur masuk (portal). Portal anterolateral digunakan untuk memasukkan arthroscope. Portal ini berada 1 cm superior garis sendi dan berdekatan pada atau dalam 1 cm lateral batas lateral tendon patelar. Portal anteromedial biasanya digunakan untuk memasukkan instrumentasi arthroscopic.Portal ini berada 1 cm di atas garis sendi dan berdekatan dan atau dalam 1 cm medial pada tepi medial tendon patelar.Portal tambahan yang sering digunakan adalah portal posteromedial.

Gillquist mempopulerkan penggunaan portal ini untuk melihat kompartemen posterior lutut dan untuk rekonstruksi ligamen cruciata posterior. Portal ini berada pada lutut dalam kondisi fleksi 90o dan meraba tempat yang tepat antara ujung posteromedial condylus femur dan tibia medialis. Beberapa ahli bedah menggunakan portal “outflow” yang berada superomedial atau superolateral dari patela.

 

Gambar dari contoh lokasi portal yang dapat digunakan.

PROSEDUR OPERASI

Sebelum operasi dimulai, daerah operasi sebaiknya dicukur dan dilakukan tindakan antiseptik untuk mengurangi kemungkinan terjadinya infeksi.Arthroscopy lutut dan pembedahan arthroscopik seringkali dilakukan dibawah teknik anestesi regional. Teknik anestesi regional perifer adalah teknik anestesi yang melibatkan anestesi lokal intraartikuler dikombinasi dengan blok kompartemen psoas dan nervus isciadica, dan blok femoral (3 in 1). Anestesia umum dan anestesi neuraxial mayor (spinal, epidural, dan kombinasi spinal epidural) juga biasanya digunakan untuk prosedur arthroscopi lutut.

Anestesi yang ideal untuk arthroscopy adalah anestesi yang secara teknik mudah untuk diberikan, memiliki awal kerja yang cepat dengan laju keberhasilan tinggi, pasien dapat pulang lebih cepat, memiliki sedikit atau tidak ada efek samping, murah, dan menyediakan kontrol postoperatif.Secara ideal, teknik yang dipilih sebaiknya dapat memberikan pilihan bagi pasien untuk melihat jalannya operasi melalui layar monitor. Kriteria yang telah disebutkan potensial terpenuhi oleh anestesi regional, akan tetapi, extremitas yang teranestesi secara total sedikit tidak diinginkan karena dapat memperpanjang masa rawat.

Goranson et al. meneliti mengenai penggunaan berbagai anestesi lokal untuk arthroskopi lutut maupun bedah arthroskopik. Penelitian dilakukan dengan menggunakan anestesi blok nervus femoralis dengan menggunakan bahan anestetik kerja cepat 2-chloroprocaine ditambah dengan anestesi intraartikuler menggunakan lidocaine. Hasil dari penelitian ini adalah teknik anestesi yang telah disebutkan di atas dapat menyediakan anestesi yang cukup dan kondisi operatif yang baik untuk arthroskopi lutut dengan rawat jalan, namun Goranson et al. menyarankan penggunaan hanya anestesi intrartikuler saja sebagai pilihan utama untuk arthroscopy karena mudah dan efektif.

 

Gambar Ketika kanula telah masuk kedalam ruangan intraartikuler, trokar dicabut, sehingga dapat terlihat cairan sinovium yang keluar.

 

Gambar saat melakukan insisi tambahan untuk membuat portal instrumen

 

Gambar dari peralatan arthroskopi telah siap di dalam portal


Gambar dari tindakan pembedahan arthroskopi sedang dilaksanakan

 

Gambar suasana pada saat arthroskopi

 

ARTHROSCOPY DIAGNOSTIK

Arthroscopy diagnostik sebaiknya dilakukan dalam urutan yang sama setiap kalinya. Lutut dapat dibagi menjadi beberapa kompartemen untuk pemeriksaan: kantung suprapatelar dan sendi patelofemoral; “gutter” medial; kompartemen medial; fisura intercondylaris; kompartemen posteromedial; kompartemen lateral, dan “gutter” lateral.

Dengan arthroscope pada kantung suprapatelar dan sendi patelofemoral, ahli bedah dapat melihat sinovium, patela, trochlear notch, plica sinovial, perlekatan, dan tendon quadriceps.Berikutnya, pada “gutter” medial diperiksakan terhadap corpus alienum dan sinovitis.Arthroscope kemudian dapat dibawa ke kompartemen medial dimana meniscus medialis, tulang rawan sendi tibia dan femur dapat diperiksa.Intercondylar notch kemudian dilihat untuk memeriksa keadaan ligamen cruciata anterior (ACL), ligament cruciata posterior (PCL), ligament mucosum, ligament meniscofemoral, dan ligament intermeniscal.Kompartemen posteromedial dapat dilihat melalui portal posteromedial atau dengan arthroscope 70o melalui intercondylar notch.Struktur-struktur kompartemen posteromedial adalah bagian posterior dari meniscus medialis, insersio tibial dari PCL, dan kapsul posteromedial. Meniscus lateral dan tendo popliteal dan bagian lateral dari tulang rawan sendi diperiksa pada kompartemen lateral. Akhirnya “gutter” lateral diperiksa apakah terdapat corpus alienum atau tidak.

Cedera meniscus adalah indikasi yang tersering untuk dilakukannya arthroscopy lutut.Cedera meniscus dapat terjadi akibat aktivitas atletik dan aktivitas sehari-hari dan dapat menyebabkan gangguan yang signifikan. Terdapat 5 pola robekan yang telah dideskripsikan: vertikal longitudinal, oblique, kompleks, radial, horizontal, dan bached handle. Indikasi untuk terapi arthroskopik pada cedera meniscus termasuk gejala-gejala yang mempengaruhi aktivitas sehari-hari, temuan fisik positif, kegagalan terapi non-bedah, dan ketidakberadaan penyebab nyeri lutut lainnya.

 

Gambar dari arthroskopi lutut dan orientasi anatomisnya

 

Gambardari iIlustrasi orientasi arhtroskop pada rekonstruksi robekan meniscus

 

ARTHROSCOPY THERAPEUTIK (ARTHROSCOPIC SURGERY)

Terapi terdiri dari perbaikan meniscus atau debridement.Hampir semua robekan meniscus membutuhkan debridement.Keberhasilan dari perbaikan meniscus bergantung sangat besar terhadap seleksi pasien.Pada umumnya kandidat untuk perbaikan meniscus sebaiknya berusia muda (biasanya lebih muda dari 30 tahun), dan dengan robekan pada 1/3 bagian perifer atau dalam 3-4 mm dari jembatan meniscocapsuler.

Robekan yang dapat diperbaiki adalah robekan yang tidak stabil, longitudinal, atau >1 cm panjangnya, dan tanpa terjadi degenerasi.Keberhasilan perbaikan meniscus berada diatas 90% ketika dilakukan bersamaan dengan rekonstruksi ACL.Penyebab keadaan ini belum diketahui, tetapi, perbaikan akses untuk memperbaiki meniskus dan hematom intrartikuler adalah mekanisme yang diusulkan. Terdapat beberapa teknik jahitan untuk permaikan meniskus, yaitu: “outside-in”, “inside-out”, dan “all-inside”, dan penggunaan alat sutur dan panah yang “biodegradable”.

Cedera tulang rawan sendi juga merupakan indikasi yang paling umum.Terapi untuk cedera penuh merupakan sesuatu yang menantang bagi ahli bedah ortopedi.Debridement arthroscopic (kondroplasti) untuk menghilangkan “loose flaps” dan kontur permukaan sendi dapat membantu meredakan nyeri, tetapi tidak dapat menyebabkan penyembuhan lebih lanjut.Teknik arthroplasti abrasi dan mikrofraktur merupakan tindakan untuk memaparkan tulang subkondral yang dapat digunakan untuk menstimulasi respons perbaikan.Hasil yang terjadi adalah terisinya sebagian jejas dengan fibrokartilago yang mengandung fibrokolagen tipe I bukan kolagen hialin tipe UU yang dihasilkan oleh kondrosit.

Pada tahun 1994, Brittberg, et al. memperkenalkan implantasi kondrosit otolog dalam usaha untuk meregenerasi tulang rawan sendi normal. Prosedur tersebut dilakukan dengan mengambil kondrosit artikuler, yang dikembangkan dalam kultur sel dan kemudian diimplantasi ke dalam jaringan yang rusak. Indikasi untuk implantasi kondrosit otolog adalah usia muda (umur dibawah 50 tahun), individu yang aktif dengan kerusakan tulang rawan femur terisolasi lebih dari 2 cm, yang tidak memiliki respons yang cukup terhadap prosedur arthroskopik sebelumnya. Untuk kelainan artikuler lainnya yang lebih kecil (5 mm2 – 2 cm2), sistem otograf tulang rawan dapat digunakan untuk mengganti tulang rawan sendi.Allograf tulang rawan dapat digunakan untuk mengisi lesi yang lebih besar (2 cm2 – 5 cm2).Kelebihan dari digunakannya allograf adalah kemampuannya untuk memperbaiki kontur anatomis sendi, tidak ada morbiditas lokasi donor, dan kemampuan untuk memperbaiki kelainan yang luas.

Teknik arthroscopic diterapkan untuk rekonstruksi ligamen lutut, khususnya ACL dan PCL. Keuntungan, yaitu: insisi yang lebih kecil, berkurangnya penempelan, rehabilitasi yang lebih baik, nyeri yang lebih sedikit, dan visualisasi yang lebih baik.

Rekonstruksi PCL dilakukan pada cedera PCL tingkat III, khususnya jika cedera PCL terjadi bersamaan dengan cedera ligamen lainnya.Bundel anterolateral merupakan komponen yang terkuat dari kompleks PCL dan karena itu selalu direkonstuksi.Beberapa teknik baru juga telah dapat merekonstruksi bundel posteromedial.

 

PERAWATAN MANDIRI

Pada pasien yang telah dilakukan arthroskopi pada lutut harus disarankan untuk menggunakan tongkat untuk mengurangi beban kerja sendi, memposisikan kaki lebih tinggi dalam beberapa hari pertama, fleksikan sendi secara perlahan dan reguler secepatnya, kompres dingin dapat membantu untuk mengurangi pembengkakkan dan ketidaknyamanan. Pasien dapat pula melakukan CPM (continous pasif movement ). Sarankan untuk tetap menjaga berat badan, hindari aktivitas berlebihan khususnya pada sendi lutut, tidak menyetir mobil dalam jangka waktu kurang lebih satu minggu.Pasien dapat kembali menjalankan aktivitas kembali seperti normal setelah tiga minggu, tetapi hal ini tidak dapat disamakan pada setiap individu.Pasien dapat kembali berolahraga dan beraktivitas fisik setelah dua atau tiga bulan.

 

Gambar dari CMP.

Sumber :http://goinglikesixty.com/wp-content/uploads/2009/10/cpm.jpg

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