Knee
Arthroscopy
What is arthroscopy?
Arthroscopy is a surgical procedure orthopaedic surgeons use to visualize, diagnose and treat
problems inside a joint.
The word arthroscopy comes from two Greek words, "arthro" (joint) and "skopein" (to look).
The term literally means "to look within the joint." In an arthroscopic examination, an
orthopaedic surgeon makes a small incision in the patient's skin and then inserts pencil-sized
instruments that contain a small lens and lighting system to magnify and illuminate the
structures inside the joint. Light is transmitted through fiber optics to the end of the
arthroscope that is inserted into the joint. By attaching the arthroscope to a miniature
television camera, the surgeon is able to see the interior of the joint through this very
small incision rather than a large incision needed for surgery.
The television camera attached to the arthroscope displays the image of the joint on a
television screen, allowing the surgeon to look, for example, throughout the knee-at
cartilage and ligaments, and under the kneecap. The surgeon can determine the amount or type
of injury, and then repair or correct the problem, if it is necessary.
Why is arthroscopy necessary?
Diagnosing joint injuries and disease begins with a thorough medical history, physical
examination, and usually X-rays. Additional tests such as an MRI, or CT also scan may be
needed. Through the arthroscope, a final diagnosis is made which may be more accurate than
through "open" surgery or from X-ray studies.
Disease and injuries can damage bones, cartilage, ligaments, muscles, and tendons. Some of
the most frequent conditions found during arthroscopic examinations of joints are:
Inflammation
Synovitis - inflamed lining (synovium) in knee, shoulder, elbow, wrist, or ankle.
Injury - acute and chronic
Shoulder - rotator cuff tendon tears, impingement syndrome, and recurrent dislocations
Knee - meniscal (cartilage) tears, chondromalacia (wearing or injury of cartilage
cushion), and anterior cruciate ligament tears with instability
Wrist - carpal tunnel syndrome
Loose bodies of bone and/or cartilage - knee, shoulder, elbow, ankle, or wrist
Although the inside of nearly all joints can be viewed with an arthroscope, six joints are
most frequently examined with this instrument. These include the knee, shoulder, elbow,
ankle, hip, and wrist. As advances are made by engineers in electronic technology and new
techniques are developed by orthopaedic surgeons, other joints may be treated more
frequently in the future.
How is arthroscopy performed?
Arthroscopic surgery, although much easier in terms of recovery than "open" surgery, still
requires the use of anesthetics and the special equipment in a hospital operating room or
outpatient surgical suite. You will be given a general, spinal or a local anesthetic,
depending on the joint or suspected problem.
A small incision (about the size of a buttonhole) will be made to insert the arthroscope.
Several other incisions may be made to see other parts of the joint or insert other instruments.
When indicated, corrective surgery is performed with specially-designed instruments that are
inserted into the joint through accessory incisions. Initially, arthroscopy was simply a diagnostic tool for planning standard open surgery. With development of better instrumentation and surgical techniques, many conditions can be treated arthroscopically.
For instance, most meniscal tears in the knee can be treated successfully with arthroscopic
surgery.
Some problems associated with arthritis also can be treated. Several disorders are treated
with a combination of arthroscopic and standard surgery.
- Rotator cuff procedure
- Repair or resection of torn cartilage (meniscus) from knee or shoulder
- Reconstruction of anterior cruciate ligament in knee
- Removal of inflamed lining (synovium) in knee, shoulder, elbow, wrist, ankle
- Release of carpal tunnel
- Repair of torn ligaments
- Removal of loose bone or cartilage in knee, shoulder, elbow, ankle, wrist.
After arthroscopic surgery, the small incisions will be covered with a dressing. You will be
moved from the operating room to a recovery room. Many patients need little or no pain
medications.
Before being discharged, you will be given instructions about care for your incisions, what
activities you should avoid, and which exercises you should do to aid your recovery. During
the follow-up visit, the surgeon will inspect your incisions; remove sutures, if present;
and discuss your rehabilitation program.
The amount of surgery required and recovery time will depend on the complexity of your
problem. Occasionally, during arthroscopy, the surgeon may discover that the injury or
disease cannot be treated adequately with arthroscopy alone. The extensive "open" surgery
may be performed while you are still anesthetized, or at a later date after you have
discussed the findings with your surgeon.
What are the possible complications?
Although uncommon, complications do occur occasionally during or following arthroscopy.
Infection, phlebitis (blood clots of a vein), excessive swelling or bleeding, damage to
blood vessels or nerves, and instrument breakage are the most common complications, but
occur in far less than 1 percent of all arthroscopic procedures.
What are the advantages?
Although arthroscopic surgery has received a lot of public attention because it is used to
treat well-known athletes, it is an extremely valuable tool for all orthopaedic patients and
is generally easier on the patient than "open" surgery. Most patients have their arthroscopic
surgery as outpatients and are home several hours after the surgery.
Recovery after arthroscopy
The small puncture wounds take several days to heal. The operative dressing can usually be
removed the morning after surgery and adhesive strips can be applied to cover the small
healing incisions.
Although the puncture wounds are small and pain in the joint that underwent arthroscopy is
minimal, it takes several weeks for the joint to maximally recover. A specific activity and
rehabilitation program may be suggested to speed your recover and protect future joint
function.
It is not unusual for patients to go back to work or school or resume daily activities
within a few days. Athletes and others who are in good physical condition may in some cases
return to athletic activities within a few weeks. Remember, though, that people who have
arthroscopy can have many different diagnoses and preexisting conditions, so each patient's
arthroscopic surgery is unique to that person. Recovery time will reflect that individuality.
Meniscal Injuries
What is a knee meniscus?
There are 2 menisci (plural of meniscus) in each knee. They are made of cartilage (like the
soft tip of your nose) and act as shock absorbers in the knee. Each is a C-shaped washer
between the femur (thigh bone) and the tibia (shin bone). The meniscus on the inner (medial)
side of the knee is called the medial meniscus and the one on the outer (lateral) side
of the knee is the lateral meniscus.
How does a meniscus get injured?
The meniscus can get torn. This can happen in one of 2 main ways.
One way is as part of an injury. This is one of the injuries what can happen when a
person injures his/her knee. Usually this is a twisting knee injury with the knee in a bent
or flexed position, but can happen in a variety of ways.
Another way is what happens when meniscal cartilage ages. Young meniscal cartilage is very
flexible, like young rubber. As it gets older it becomes like old rubber that has been
exposed to the air for years. It becomes hard, less flexible, more brittle and can develop
cracks in it like the cracks that develop in old rubber. These cracks in older cartilage are
called degenerative meniscal tears. These degenerative tears can occur with or without
an injury.
What are the symptoms of a meniscal injury?
They can vary greatly. Symptoms include just pain, or giving way of the knee, or catching
and locking of the knee, water on the knee, etc. Often additional tests are necessary to
determine the correct diagnosis and solve the problem and the most accurate and effective of
these is arthroscopy by an experienced arthroscopist.
What can be done about a meniscal injury?
The most effective way to deal with a meniscal injury is through arthroscopy. Arthroscopy is
not only the most accurate way of diagnosing the meniscal injury but also permits you
to deal with the meniscal tear at the same time.
Normally, if a meniscal tear is present the arthroscopist will remove the torn portion that
is causing the problem and smooth out the remaining part of the meniscus. If there are no
other problems in that knee (arthritis, ligament injuries, etc) the results of doing this
are excellent and the recuperation is just a matter of days.
What about MRI?
An MRI (magnetic resonance image) is like an x-ray but uses magnetic waves instead of x-rays
to produce the image. It allows you to see tissues as shadows of different densities. It
allows you to see tissues that x-rays cannot show and is extremely useful especially in
spines, shoulders, etc. I do not usually use MRI to deal with meniscal injuries.
The reason is simple. MRI is not totally accurate in diagnosing meniscal tears. I
have seen cases where a tear was seen on MRI which on arthroscopy turned out not to be there
and the opposite: no cartilage tear seen on MRI, but one found during arthroscopy.
The practical meaning of this is that if an MRI is done and shows a "cartilage tear" the
result is that an arthroscopy needs to be done. If however an MRI is negative, but symptoms
persist, an arthroscopy often still needs to be done because the MRI could be wrong. So the
MRI does not change what needs to be done and at a cost of about $1,000 a test it is too
expensive to do if it will not contribute usefully.
Summary
Meniscal injuries can occur either through an injury or as part of the aging process. The
symptoms are very variable from person to person. Diagnosis requires an experienced
orthopaedic surgeon and treatment usually consists of arthroscopy and can be very effective.
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