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Understanding Arthroscopic Surgery
Just think about being able to peek directly into your injured joint through a little telescope and not only seeing what is wrong, but also being able to fix it! This is no futuristic dream: It’s what is being done today with arthroscopic surgery, one of the most common surgical procedures being performed in our nation. The arthroscope has revolutionized the field of orthopedic surgery, especially the care of sports and recreational injuries. Many of these injuries include the joints, or moving articulations, of the body such as the knee and shoulder. The arthroscope is a small surgical tool that allows direct visualization of the interior of the joint, and in many cases, the repair of damaged or injured areas through tiny incisions.
Arthroscopy has significantly enhanced the quality of orthopedic care available to patients. It allows for accurate diagnosis and treatment of a wide variety of conditions with less cost, discomfort and inconvenience to the patient. Recovery time is shorter and the need for incisions, and thus scars, is less.
The word arthroscopy comes from the Greek word arthro (joint) and scopos (to view). The current use of the arthroscope has evolved from pioneering efforts in Japan in the early 1900s. In the 1970s, technological developments allowed more widespread use of arthroscopy, although its main use at that time was in the knee, for diagnostic purposes only. Its roll has now expanded to widespread use in many joints including the knee, shoulder, elbow, wrist, ankle, and hip.
Arthroscopy is a safe, effective surgical procedure that is performed under anesthesia. The type of anesthesia usually involves general (patient asleep), spinal (legs asleep), or regional (area of arm or leg asleep). Local anesthesia can occasionally be employed. With all but general anesthesia, the patient is able to watch the procedure on a video monitor if he or she desires.
The surgeon places the arthroscope into the involved joint through tiny punctures. The arthroscope is a thin device smaller than a pencil but functions like a mini telescope. The typical arthroscope houses fiberoptic light bundles to carry light into the joint. The viewing end of the arthroscope allows several attachments. These include a hook-up to a high intensity light source, to illuminate the interior of the joint, and a small lens.
In the past, the surgeon would look directly into the lens but today a miniaturized camera is attached to the lens, transmitting a picture to a high-def television monitor. The surgeon operates in the joint while viewing the monitor. This skill requires specialized training, excellent hand-eye coordination and an almost videogame mentality.
The arthroscope’s lens system is designed so that the surgeon could peer around corners and into tiny crevices in the joint. As a result, more can be seen through the arthroscope than could be seen with the large incisions used in traditional “open” surgery.
Once the exact condition is diagnosed, the surgeon decides if it can be remedied via arthroscopic methods. Many surgical procedures can be performed through the arthroscope and these vary from joint to joint. The range of treatable conditions include painful or unstable joints with torn cartilage, joint surface damage (fracture or arthritis), torn ligaments, bone spurs and floating bone chips.
The arthroscope was first used in the knee, and even today, the knee remains the most common joint for the surgery. In addition to documenting the source of your knee problems, much can be done therapeutically for the knee via arthroscopy.
Each knee contains two C-shaped cartilage shock absorbers known as menisci. The menisci are frequently torn and can be arthroscopically repaired or removed, depending on the type and location of the tear. Only the torn portion is removed, leaving the remainder to continue to act as an important shock absorber. In some instances of complete meniscus removal, especially in younger patients, a completely new meniscus (usually taken from a cadaver) can be transplanted (meniscal allograft).
The joint surface covering or cushion (articular cartilage) can become damaged or injured (chondral fracture or chondral defect) or worn out, as commonly occurs with arthritis. Newer techniques and technology can be used to regenerate focal areas of joint cushion damage, hopefully preventing future arthritis. Also, although arthritis cannot be fixed with arthroscopy, in selected cases, sometimes arthritic knees can be improved if there are significant symptomatic meniscal tears present or other treatable abnormalities. Also, sometimes focal areas of arthritic wear can be dealt with in a way that encourages regrowth of some new joint surface. At this point in time, arthroscopy is not recommended if the main issue is significant arthritis.
A more recent advancement in knee arthroscopy involves the repair and/or replacement of certain internal ligaments within the knee. The anterior and posterior cruciate ligaments are important stabilizing ligaments that are commonly torn in athletes and active individuals.
Especially in the case of the anterior cruciate ligament (ACL), such a tear results in a “trick knee” that can buckle without warning, and easily be reinjured especially with sports. Although some individuals with this condition improve with rehabilitation alone, many have ongoing instability problems requiring surgical reconstruction of the ACL. This is especially true for active younger individuals who rarely can be managed successfully without ACL reconstruction. Arthroscopic techniques have improved the procedure greatly and allow the major portion to be done arthroscopically. Small incisions are still required to either harvest or insert the new ACL graft into the knee. This procedure has allowed a much quicker recovery, less pain and easier rehabilitation of this very common condition.
Arthroscopic techniques in the shoulder are similar to that in the knee in many ways. In the shoulder, the glenoid labrum, an important stabilizer (similar to the meniscus and the knee), is sometimes torn. It can be repaired or removed. Shoulder instability (recurrent subluxation or dislocation) can also be fixed arthroscopically.
The rotator cuff muscles, which are involved with shoulder strength and mobility, are prone to fraying, inflammation (tendinitis and tendinopathy) and also tears. When they are irritated and pinched, the ailment is known as impingement syndrome. The arthroscope can be used to repair rotator cuff tears and remove any impinging tissue.
In the elbow, ankle and hip, the most common arthroscopic procedure involves the removal of impinging bone spurs and loose bodies or bone chips. Also, problems with the joint surface can be evaluated and addressed, similar to what is done and the knee. Tendon issues such as tennis elbow (lateral epicondylitis) and golfer’s elbow (medial epicondylitis) can also be managed. The wrist contains a small triangular fibrocartilage that is often torn in a fall on the outstretched hand. This too can be repaired, or removed if necessary, through the scope.
The recovery timelines following arthroscopy depend on the problem found and the specific treatment rendered as well as the level of fitness and conditioning of the individual. Arthroscopic procedures are performed routinely as an outpatient with only minor discomfort in the postoperative period. Exercises are usually initiated within the first day or two, with gradual progression through rehabilitation, back to an active lifestyle. Certainly, more complicated procedure such as knee ligament reconstruction and rotator cuff repairs usually require a longer rehabilitation period for return to sports and activity.
The future should bring improved technology and thus greater application of this procedure. I expect much more in the area of regenerative orthopedics in which a variety of tissue such as ligaments, tendons and joint surfaces can be regenerated and regrown. This potentially could significantly improve, and even reverse, arthritis. Also, regenerative technologies using stem cells and growth factors should lead to accelerated recovery times for conditions like knee ACL reconstruction and shoulder rotator cuff repair. We are not there yet but current research in this area is quite promising.
Is arthroscopy for you? If you are experiencing joint pain or symptoms you should first be evaluated by your orthopedic surgeon. Many conditions will respond to a good exercise and rehabilitation program. Premier Orthopedics has many surgeons who specialize in arthroscopic surgery and can help with your diagnosis and individualized treatment plan. I believe that information is a critical part of medical care, so if you ultimately need arthroscopy, hopefully you now have the latest facts.
Nicholas A. DiNubile, MD