Surgical Approaches to the Joints: Arthrotomy and Arthroscopy

By Dr. Zubair Khalid, DVM, MS, PhD · 2026-08-11

Key Takeaways

• Arthrotomy offers direct visualization and is indicated for complex fracture repair, total joint replacement, and procedures requiring extensive intra-articular manipulation or implant placement, though it involves greater soft tissue trauma and potentially increased postoperative pain.
• Arthroscopy provides magnified, panoramic visualization through minimal portal-based access, excelling in diagnosis, targeted biopsy, and treatment of focal lesions like osteochondrosis, with generally less soft tissue trauma and faster recovery.
• The choice between arthrotomy and arthroscopy is procedure-dependent, with arthroscopy being the treatment of choice for osteochondrosis lesions in the shoulder, elbow, and stifle due to its diagnostic advantages and ability to debride lesions within the same procedure.
• Arthrotomy remains essential for procedures requiring open reduction and internal fixation of articular fractures or extensive intra-articular reconstruction, such as proximal tibial intraarticular ostectomy for cranial cruciate ligament injury.
• Specialized instrumentation, including an arthroscope, camera, light source, fluid pump, and hand instruments, along with a substantial learning curve, are required for arthroscopic surgery, contrasting with the standard surgical instruments used for arthrotomy.
• Complications specific to arthrotomy include surgical site infection and capsular dehiscence, while arthroscopy carries risks of fluid extravasation, iatrogenic cartilage damage, and instrument breakage, necessitating meticulous technique and appropriate fluid management.

Open arthrotomy and arthroscopic surgery represent the two principal routes by which a surgeon gains access to the synovial joint in dogs and cats. This article compares these approaches across the shoulder, elbow, stifle, and tarsocrural joints, with emphasis on indications, instrumentation, surgical decision-making, and complications. It serves the practicing veterinarian who must choose between techniques for diagnostic exploration, biopsy, lavage, fracture management, or soft tissue procedures within a joint. The clinical question addressed is direct: when does open exposure remain necessary, and when does arthroscopy offer equivalent or superior outcome with less morbidity?

The evolution of joint surgery in small animals has followed a trajectory already travelled in human and equine surgery. Early skepticism about arthroscopy, often expressed as a claim that arthrotomy was equally valuable and easier to perform, has given way to enthusiasm as the diagnostic and therapeutic advantages of the endoscopic approach have been demonstrated in the dog van Bree and Van Ryssen, institutional publication on diagnostic and surgical arthroscopy in osteochondrosis lesions. That transition has not been uniform across all joints or all procedures. Arthrotomy retains a clear role in complex fracture reconstruction, total joint replacement, and procedures requiring implant placement or extensive intra-articular manipulation. Arthroscopy excels in diagnosis, targeted biopsy, and treatment of focal lesions such as osteochondrosis, where it has been advocated as the treatment of choice van Bree and Van Ryssen, institutional publication on diagnostic and surgical arthroscopy in osteochondrosis lesions.

At a Glance

Principles of Joint Access

The synovial joint presents unique surgical challenges. Dense fibrous capsule, articular cartilage with limited healing capacity, and the need to preserve proprioceptive and vasomotor function all constrain the surgeon's approach. The fundamental principle governing either technique is atraumatic exposure: the articular surface must not be damaged by instruments, the capsule must be closed securely, and the collateral and intracapsular ligaments must be preserved unless their division is an explicit part of the planned procedure.

Arthrotomy achieves exposure through a skin incision, division of the deep fascia, and incision of the joint capsule along a line that avoids critical structures. The approach may be extended proximally or distally to allow luxation or subluxation of the joint, as in the medial parapatellar approach to the stifle with lateral patellar luxation. This exposure is generous and permits the use of standard instruments, but it carries inherent costs: greater soft tissue dissection, increased postoperative pain, and a capsular incision that must heal before full weight-bearing is comfortable.

Arthroscopy replaces the large incision with small portals through which a rigid endoscope and instruments are passed. The joint is distended with fluid to create a working space, and the optical system provides magnification and illumination far superior to direct vision. The surgeon can examine the entire articular surface, including regions inaccessible through a standard arthrotomy, and can probe cartilage to assess its integrity. The principal limitation is technical: the procedure requires specialised equipment, a fluid management system, and a surgeon trained in the interpretation of the endoscopic image.

Comparative Indications

The choice between arthrotomy and arthroscopy is procedure-dependent instead of joint-dependent. For osteochondrosis lesions of the shoulder, elbow, and stifle, arthroscopy permits accurate staging of the lesion, assessment of the surrounding cartilage, and debridement within the same procedure van Bree and Van Ryssen, institutional publication on diagnostic and surgical arthroscopy in osteochondrosis lesions. The elbow joint, in particular, has proven difficult to assess fully through open approaches, and arthroscopy has substantially improved diagnostic accuracy for fragmented medial coronoid process and other developmental lesions.

Arthrotomy remains the standard for procedures that require implantation of hardware or extensive intra-articular reconstruction. Proximal tibial intraarticular ostectomy for cranial cruciate ligament injury, for example, is performed through a lateral stifle arthrotomy that allows removal of ligament remnants, meniscal surgery, and direct visualization of the osteotomy site Jerram, Walker, and Warman, institutional publication on proximal tibial intraarticular ostectomy. Similarly, fracture repair involving the articular surface generally demands open reduction to achieve anatomic reconstruction and stable fixation.

Meniscal surgery illustrates the overlap between techniques. Arthroscopically guided partial meniscectomy is feasible and has been compared directly with minimally invasive medial arthrotomy in dogs with cranial cruciate ligament rupture and medial meniscal injury Ertelt and Fehr, institutional publication on cranial cruciate ligament repair with and without meniscal lesions. Both approaches allow resection of the damaged meniscal portion, and the choice depends on surgeon experience, available equipment, and the concurrent procedure planned for stifle stabilization.

Instrumentation and Technical Requirements

Arthrotomy requires no equipment beyond standard surgical instruments. The essential items are a scalpel, periosteal elevators, retractors, and appropriate suture material for capsular closure. The approach must be planned with reference to regional anatomy, and the surgeon must be prepared to extend the incision if exposure proves inadequate.

Arthroscopy demands a more substantial investment. The core components are a rigid arthroscope, typically 1.9 to 2.7 mm in diameter for small animal use, a light source and cable, a camera and monitor, and a fluid delivery system capable of maintaining joint distension at controlled pressure. Hand instruments include probes, grasping forceps, biopsy punches, and motorised shavers. The surgeon must also have a means of managing fluid outflow to prevent excessive extravasation into periarticular tissues.

The learning curve for arthroscopy is real and should not be underestimated. The surgeon must learn to orient the image, to move the scope and instruments in a coordinated fashion within a confined space, and to interpret the appearance of normal and abnormal tissue under magnification. The elbow joint is particularly demanding because of its complex anatomy and the small working space available.

Complications and Failure Modes

Both techniques carry specific risks. Arthrotomy exposes the joint to prolonged open time, increases the risk of surgical site infection, and may be complicated by capsular dehiscence or delayed healing. The larger incision also contributes to postoperative pain and may delay return to function.

Arthroscopy introduces risks related to fluid management and instrument manipulation. Fluid extravasation into periarticular tissues can obscure the surgical field and, in severe cases, compress neurovascular structures. Instrument breakage within the joint is a recognized complication, and iatrogenic cartilage damage can occur if the surgeon is not meticulous in technique. The procedure also requires more time than a simple arthrotomy, particularly during the learning phase, which may be relevant in patients with concurrent systemic disease.

Complication rates for specific procedures have been reported. In one series of dogs undergoing proximal tibial intraarticular ostectomy through lateral arthrotomy, complications occurred in 20% of dogs, with the most common being injury to the long digital extensor tendon and plate failure Jerram, Walker, and Warman, institutional publication on proximal tibial intraarticular ostectomy. These figures provide a benchmark against which arthroscopic outcomes can be compared, although direct comparative data remain limited for most procedures.

Preoperative Assessment and Case Selection

The decision between arthrotomy and arthroscopy begins with a structured assessment of the patient, the joint, and the suspected pathology. Signalment, body weight, and conformation influence joint access. Large-breed dogs with substantial periarticular muscle mass present greater difficulty for arthroscopic portal placement than small-breed dogs, while feline joints tolerate arthroscopic fluid distension less predictably due to their smaller joint volumes and thinner capsules.

Diagnostic imaging precedes surgical planning. Radiographs identify effusion, osteophytes, subchondral bone changes, and fractures. CT provides superior delineation of intra-articular fragments, particularly in the elbow and tarsus. MRI, where available, adds soft tissue detail but rarely changes the decision between open and arthroscopic approaches. Arthrocentesis with fluid analysis and culture should be performed when sepsis is suspected, since the presence of infection alters both the urgency of intervention and the choice of approach.

Patient status modifies the decision. Arthroscopy requires specialized equipment, a fluid pump or gravity inflow system, and a surgeon familiar with the technique. When these resources are unavailable, arthrotomy remains a reliable alternative. The American College of Veterinary Surgeons small animal resources note that surgical decision-making should account for institutional capability and surgeon experience alongside patient factors.

Arthrotomy Technique by Joint

Shoulder Arthrotomy

Cranial approach to the shoulder uses a skin incision from the acromion to the proximal humerus, with division of the acromial head of the deltoideus and tenotomy of the infraspinatus tendon when greater exposure is needed. The joint capsule is incised cranially, lateral to the biceps tendon. Caudal lesions require a separate caudolateral approach with retraction of the teres minor.

Elbow Arthrotomy

Medial arthrotomy addresses fragmented medial coronoid process and medial compartment disease. The approach divides the flexor carpi radialis and pronator teres origins, with care to preserve the median nerve and artery. Lateral arthrotomy exposes the lateral coronoid and radial head but provides poor access to the medial compartment. Combined approaches are occasionally necessary for complex fractures.

Stifle Arthrotomy

Parapatellar arthrotomy with lateral or medial displacement of the patella remains the standard open approach. The incision extends from the quadriceps tendon proximally to the tibial tuberosity distally. The joint is inspected systematically: patella, trochlear ridges, femoral condyles, menisci, and cruciate ligaments. The proximal tibial intraarticular ostectomy series used lateral arthrotomy for cranial cruciate ligament injury, reporting a 20% complication rate with the most common complications being long digital extensor tendon injury and plate failure, which illustrates the morbidity associated with open exposure.

Tarsal Arthrotomy

Dorsal arthrotomy exposes the distal tibia and talar trochlea. Medial and lateral approaches address malleolar fractures and OCD lesions of the medial or lateral trochlear ridges. The bovine tarsus presents additional considerations, where arthrotomy is commonly performed for joint lavage and injury treatment, and ultrasound-guided nerve blocks have been shown to improve the accuracy of regional anesthesia compared with landmark-based techniques, which is relevant when planning open tarsal surgery in cattle.

Arthroscopic Technique by Joint

Shoulder Arthroscopy

The patient is positioned in lateral recumbency with the affected limb uppermost. A caudolateral portal is established first for the arthroscope, with a craniolateral portal for instrumentation. Biceps tendon, subscapularis tendon, and the caudal joint pouch are examined systematically. OCD lesions of the humeral head are debrided with a motorized shaver through the instrument portal.

Elbow Arthroscopy

Elbow arthroscopy requires precise portal placement due to the complex anatomy. The arthroscope is introduced through a medial portal proximal to the medial epicondyle, with the joint distended by fluid. A second medial portal allows instrumentation. The anconeal process, medial coronoid, and radial head are visualized. The institutional review of diagnostic and surgical arthroscopy in osteochondrosis lesions states that in the elbow, arthroscopy has evident diagnostic advantages and allows treatment within the same procedure, making it the preferred approach for osteochondrosis lesions in this joint.

Stifle Arthroscopy

Stifle arthroscopy uses a lateral or medial portal with the joint in flexion. The cruciate ligaments, menisci, and articular cartilage are examined. Partial meniscectomy can be performed arthroscopically. A comparative study of minimally invasive cranial cruciate ligament repair found that dogs undergoing arthroscopically guided partial meniscectomy had a 65% rate of no lameness at six months, compared with 87% in dogs treated by minimally invasive medial arthrotomy, though the clinical significance of this difference is uncertain given the small sample and lack of randomization.

Comparison of Approaches

Decision Framework

The choice of approach follows a hierarchy of considerations. First, the procedure must be feasible through the chosen approach. Fracture fixation requiring plate application, joint replacement, and extensive synovectomy mandate arthrotomy. Second, the pathology must be addressable arthroscopically. Osteochondrosis lesions in the shoulder, elbow, and stifle are well suited to arthroscopic treatment, and the published experience in dogs supports arthroscopy as the treatment of choice for these lesions. Third, the surgeon must have the skill and equipment to complete the procedure arthroscopically without excessive operative time or risk.

Patient size and joint volume matter. Arthroscopy in cats and small dogs is technically demanding due to limited working space. Arthrotomy may be the more practical choice in these patients for all but the simplest procedures. Conversely, large-breed dogs with deep joints benefit most from arthroscopic magnification and illumination.

The presence of sepsis shifts the balance toward arthrotomy in most cases. Open drainage, lavage, and debridement are more complete, and the risk of fluid extravasation through an infected capsule is avoided. Arthroscopy can be used for diagnostic lavage and biopsy in suspected septic arthritis, but definitive open management is often preferred.

Meniscal injury in the stifle presents a nuanced decision. Arthroscopic partial meniscectomy preserves the meniscal rim and minimizes morbidity, but the comparative study of minimally invasive techniques reported better lameness outcomes with minimally invasive medial arthrotomy, suggesting that open meniscal surgery with careful tissue handling may be at least equivalent. The surgeon should choose the approach that allows complete meniscal inspection, since missed meniscal tears are a common cause of persistent lameness after cruciate surgery.

Documentation and Monitoring

Operative records should include the approach used, portals or incisions created, findings in a standardized joint examination sequence, procedures performed, and any complications. Arthroscopic images should be archived for each joint compartment. Postoperative monitoring focuses on incisional healing, lameness progression, and range of motion. Seroma formation is more common after arthrotomy, while delayed swelling after arthroscopy suggests fluid extravasation or iatrogenic cartilage injury.

Serial lameness evaluation at two, six, and twelve weeks postoperatively detects early complications. Persistent lameness beyond this period warrants repeat imaging and consideration of missed pathology. The MSD Veterinary Manual provides general guidance on postoperative orthopedic assessment and rehabilitation that applies to both approaches.

Recognized Complications and Early Detection

Hemorrhage, iatrogenic cartilage damage, and incomplete lesion access dominate the complication profile for both approaches. Open arthrotomy permits direct visualization of bleeding vessels, but the larger exposure increases soft tissue trauma and postoperative swelling. Arthroscopy reduces iatrogenic trauma yet introduces fluid extravasation, pump-related tissue edema, and the risk of instrument breakage within the joint.

Early detection relies on structured postoperative assessment. Serial lameness scoring, joint circumference measurement, and range of motion evaluation should be performed at 24 hours, 7 days, and 14 days. Persistent swelling beyond 72 hours suggests excessive haemarthrosis or synovial fluid leakage. Reduced range of motion out of proportion to expected surgical discomfort warrants re-evaluation under sedation. Radiographic assessment is indicated when implant failure or fracture propagation is suspected, particularly after tibial plateau procedures where plate failure has been documented as a recognized complication proximal tibial intraarticular ostectomy outcome data.

Septic arthritis presents with acute worsening lameness, marked joint effusion, and pyrexia. Arthrocentesis with cytology and aerobic culture should be performed before empirical antimicrobial therapy. Delayed diagnosis converts a manageable infection into irreversible cartilage loss.

Common Errors and Corrective Action

Less experienced surgeons frequently misjudge portal placement in arthroscopy. A portal placed too close to the instrument portal prevents adequate triangulation and causes instrument conflict. The corrective action is to mark bony landmarks before distension and to place portals with the joint in a neutral or slightly flexed position, then confirm intra-articular position by visualizing the probe against the synovium before advancing instruments.

In arthrotomy, the most common error is inadequate exposure through an excessively small incision. Surgeons then struggle with retraction, traumatise the articular surface with instruments, and perform incomplete meniscal or osteochondral work. The corrective action is to extend the incision early instead of persist with poor visualization. A second error is failure to protect articular cartilage during retraction, moistened gauze sponges or specialised retractors should be placed between the retractor blade and the joint surface.

Fluid management errors during arthroscopy include using excessive pump pressure, which forces fluid into periarticular tissues and obscures the surgical field. Pressure should be set to the minimum required for distension and reduced during instrument exchange. Inflow should be stopped during meniscal resection to prevent fragment displacement.

Troubleshooting Table

Limitations of Current Evidence

Comparative outcome data between arthrotomy and arthroscopy in small animals remain limited. One study evaluating minimally invasive meniscal surgery reported a higher percentage of dogs free from lameness at six months after minimally invasive medial arthrotomy compared with arthroscopically guided partial meniscectomy, but the study was not randomised and used a single stabilization technique cranial cruciate ligament repair with meniscal lesions. This finding contradicts the broader clinical impression that arthroscopy offers superior visualization and faster recovery, and it highlights the need for prospective randomised trials.

Expert opinion still differs on whether arthroscopy should replace arthrotomy for all osteochondrosis lesions. Early institutional publications argued that arthroscopy should replace classical surgical methods for shoulder, elbow, and stifle osteochondrosis diagnostic and surgical arthroscopy in osteochondrosis lesions. However, some surgeons maintain that arthrotomy remains appropriate for simple, well-defined lesions in large-breed dogs where the additional equipment cost and surgical time of arthroscopy are not justified. The evidence base does not resolve this disagreement.

Referral and Escalation Criteria

Referral to a specialist surgeon is warranted when the practitioner lacks the equipment, caseload, or experience to perform the chosen approach safely. Specific triggers include revision arthrotomy after failed prior surgery, intra-articular fractures requiring precise reduction, and cases where arthroscopic skills are insufficient to complete the planned procedure and conversion to arthrotomy is not straightforward.

Laboratory involvement is indicated for suspected septic arthritis, where culture and susceptibility testing guide antimicrobial selection, and for synovial fluid analysis when immune-mediated arthropathy is in the differential diagnosis. Histopathology of synovial biopsies should be considered when neoplasia or chronic inflammatory conditions are suspected.

Regulatory reporting obligations vary by jurisdiction. Complications involving implant failure that could indicate a product defect should be reported to the manufacturer and, where applicable, to the relevant national pharmacovigilance or medical device authority. Professional indemnity insurers should be notified of any complication that may lead to a claim. The American Veterinary Medical Association practice resources provide guidance on professional conduct and client communication standards, while WOAH terrestrial animal health standards address reportable disease considerations that may apply if postoperative infection involves a notifiable pathogen.

Frequently Asked Questions

How Do I Choose Between Arthrotomy and Arthroscopy When Cost and Equipment Are Limiting Factors?

Arthroscopy requires a substantial capital investment in scope, camera, light source, fluid pump, and hand instruments, plus ongoing maintenance and sterilization costs. When these resources are unavailable, arthrotomy remains a reliable alternative for most joint conditions. The evidence comparing outcomes is mixed. One study of stifle surgery found that dogs treated by minimally invasive medial arthrotomy had a higher percentage of sound dogs at six months than those treated by arthroscopically guided partial meniscectomy, although the groups differed in meniscal injury severity outcomes of minimally invasive stifle surgery in dogs. For practices beginning joint surgery, mastering a standard arthrotomy for each joint provides a safe foundation. Arthroscopy can be introduced gradually, starting with diagnostic evaluation of the elbow and shoulder, where its advantages over open approaches are most clearly documented diagnostic and surgical arthroscopy in osteochondrosis lesions.

What Should I Do When the Ideal Equipment Is Unavailable Mid-Procedure?

Convert to arthrotomy without hesitation. The key is recognizing the limitation early, before prolonged fluid extravasation obscures tissue planes. If the scope image degrades from hemorrhage or debris and cannot be cleared within a few minutes of lavage and pressure adjustment, open conversion is the safer path. Similarly, if a meniscal probe or grasping forceps fails and no functional replacement exists, proceed with arthrotomy. The arthroscopic portals can be incorporated into the arthrotomy incision or closed separately. Document the reason for conversion in the surgical record. Conversion is not a complication, it is sound surgical judgment. The surgeon who has rehearsed the corresponding arthrotomy for each joint will find the transition straightforward.

How Does the Approach Differ in Cats Compared With Dogs?

Feline joints are smaller, so arthroscopic portals and instrument sizes must be scaled down. A 1.9 mm or 2.3 mm scope with a 2.5 mm cannula is typically the largest that fits comfortably in the feline elbow or shoulder. Fluid flow rates must be reduced to avoid overdistension and capsular rupture. Arthrotomy incisions are correspondingly shorter, and retraction must be gentler because feline periarticular tissues tear more easily. The stifle is the most commonly explored joint in cats, and a medial parapatellar arthrotomy provides adequate exposure for cruciate assessment and meniscal inspection. Postoperative analgesia requirements differ, and cats require more careful monitoring for signs of pain, which they mask effectively. The MSD Veterinary Manual provides species-specific guidance on perioperative care and analgesic protocols.

What Records Should I Keep for Joint Surgery Cases?

The surgical record must document the approach used, the joint surfaces inspected, the findings in each compartment, and the specific procedures performed. For arthroscopy, record portal locations, fluid volumes, and any intraoperative complications such as instrument breakage or excessive hemorrhage. For arthrotomy, note the capsular closure pattern and suture material. Include a diagram when possible, particularly for meniscal lesions or cartilage defects. Photographs and video clips from arthroscopy are valuable for client communication and for comparison at recheck examinations. Record the reason for choosing the approach, especially when converting from one technique to another. The American College of Veterinary Surgeons resources offer guidance on standard surgical documentation and postoperative care expectations that can be adapted to your practice system.

How Should I Explain the Choice of Approach to a Client?

Explain that both approaches access the same joint and aim to achieve the same surgical goals, but they differ in how the joint is visualized and instrumented. Arthroscopy uses a small camera and requires only small stab incisions, which may reduce soft tissue trauma. Arthrotomy opens the joint directly and provides a wider field of view. The choice depends on the specific condition, the equipment available, and the surgeon's experience. For osteochondrosis lesions in the shoulder, elbow, and stifle, arthroscopy is considered the preferred treatment where the technique is available arthroscopy for osteochondrosis lesions in the dog. For other conditions, such as complex fractures or prosthetic ligament replacement, arthrotomy may be necessary. Be honest about expected outcomes, recovery times, and the possibility of conversion from one approach to the other.

When Should I Refer a Joint Surgery Case instead of Proceed in General Practice?

Refer when the required expertise or equipment is unavailable and the condition falls outside your comfort zone. Specific triggers include complex elbow pathology, where diagnostic arthroscopy has documented advantages over open exploration, and revision procedures after failed prior surgery. Refer also when imaging suggests pathology that may require advanced techniques, such as osteochondritis dissecans of the shoulder in a large-breed dog, where arthroscopic treatment is the established standard arthroscopic treatment of osteochondrosis lesions. If you cannot achieve adequate visualization or stable fixation, referral is appropriate. The American Veterinary Medical Association practice resources provide guidance on referral communication and continuity of care. Early referral is preferable to a compromised intraoperative decision.

Related Clinical & Scientific Guides

• Perioperative Antibiotic Prophylaxis: Timing and Selection
• Surgical Approaches to the Femur and Stifle
• Fracture Healing Assessment: Radiographic and Clinical Evaluation

References and Further Reading

• Diagnostic and surgical arthroscopy in osteochondrosis lesions.. 1998.
• Cranial cruciate ligament repair in dogs with and without meniscal lesions treated by different minimally invasive methods.. 2009.
• Proximal tibial intraarticular ostectomy for treatment of canine cranial cruciate ligament injury.. 2005.
• Replication of chronic abnormal cartilage loading by medial meniscus destabilization for modeling osteoarthritis in the rabbit knee in vivo.. 2013.
• Mouse femoral intramedullary injection model: technique and microCT scan validation.. 2008.
• Local Anesthesia of the Bovine Tarsus: A Cadaver Study Comparing Anatomical Landmark-Based and Ultrasound-Guided Nerve Blocks.. 2025.
• American College of Veterinary Surgeons Animal Health Resources. American College of Veterinary Surgeons.
• MSD Veterinary Manual, Professional Edition. MSD Veterinary Manual.
• American Veterinary Medical Association Practice Resources. American Veterinary Medical Association.

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This article is educational professional reference material for veterinary audiences. It is not a substitute for veterinary diagnosis, individual clinical judgment, current product labeling, or applicable regulatory requirements.