What is Arthroscopy?
Until recently, surgery on the inside of any joint meant making a large incision and opening the joint to do even the most minor procedure. Twenty years ago, fiber optics began changing all that and is continuing to change how we arthroscopic surgeons operate on joints in the body.
What is Arthroscopy ?
The term arthroscopy basically means to look into the joint. (Arthro means joint, and scopy means look.) So the common phrase scope the joint means to insert an arthroscope into the joint and have a look. Over the past several years, the development of very small video cameras and specialized instruments have allowed surgeons to do more than simply take a look into the joint. So now it is a surgical procedure we as Arthroscopic surgeons use to visualize, diagnose, and treat problems inside a joint.
In an arthroscopic examination, we make a small incision in the patient's skin and then insert 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, we are 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 us to look, for example, throughout the knee. This lets us see the cartilage, ligaments, and under the kneecap. We can determine the amount or type of injury and then repair or correct the problem, if it is necessary.
Why is it better ?
All surgical procedures that are done result in damage to tissues that are otherwise normal, because an incision must be made to see the problem. This is particularly bothersome for joints because to enter a joint, the joint capsule and ligaments must be cut into . For minor surgical procedures inside the joint, it is not unusual for the recovery time to be much longer. This is because the normal tissues that were cut must also heal. Also, large incisions into the joint to perform surgical procedures increase the chances for infection. Long procedures where the joint is open to the air can lead to injury to the articular cartilage (the smooth surface of all joints) because it dries the cartilage out.
Arthroscopy causes less damage to normal structures by requiring much smaller incisions through the joint capsule and ligaments around the joint. Arthroscopy also allows the joint to remain closed and reduces the risk of infection and drying out of the articular cartilage. Because of this, the healing time for most arthroscopic procedures is greatly reduced. Rehabilitation is faster, and unnecessary damage to normal structures is avoided.
Arthroscopy has also greatly expanded our understanding of problems around the joints. In many cases, conditions which were completely unknown before the invention of the arthroscope have been discovered and are now being treated very effectively with arthroscopic surgery.
What joints are being scoped ?
Diagnosing joint injuries and disease begins with a thorough medical history, physical examination, and usually X-rays. Additional tests such as magnetic resonance imaging (MRI) or computed tomography (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.
Just about every joint in the body has been scoped, but the vast majority of surgical procedures done with the arthroscope are done on the knee and the shoulder. The knee was the primary site of arthroscopic procedures in the early days of arthroscopy and continues to be a common target of the scope.
Probably the most common use of the arthroscope initially was to remove loose bodies from the knee joint or to remove a torn cartilage or torn meniscus. A loose body is a fragment of bone or cartilage that moves around inside the joint and can get caught between the two bones of the joint and cause pain. The menisci (or cartilages) of the knee are two small pieces of tissue that sit between the two bones of the knee joint and act similar to a gasket. A torn meniscus is a common problem that involves these structures and can get caught between the knee and cause pain.
Very complex surgical procedures are now done inside the knee with the aid of the arthroscope. For example, the anterior and posterior cruciate ligaments inside the knee are now almost always reconstructed without opening the knee joint. The procedure is done by using the arthroscope to help see where to drill holes in the bone and to place the ligament graft. Even fractures that involve the joint surface of the lower leg bone (the tibia) are being fixed by watching the fracture through the arthroscope while screws are inserted through small incisions in the skin--a procedure that once required a large incision into the joint.
The arthroscope is continuing to change the way we deal with shoulder surgery as well. The arthroscope is now being used to repair torn tendons around the shoulder, to reconstruct the shoulder in patients who dislocate their shoulder and have instability, and to identify problems in the shoulder that were unknown prior to shoulder arthroscopy.
Other common joints that may be treated with arthroscopy include the ankle, wrist, elbow, and hip.
What goes on during an Arthroscopy?
You will be explained what the surgery is intending to accomplish and what you can expect. You will be asked to sign a surgical consent form that describes the operation and the potential risks. It is a record that you understand the procedure. If you have any questions, now is the time to ask.
You will also need to review your other medical problems with a physician in case you have a medical problem that will require evaluation before surgery. If you have serious lung or heart problems, you may need to see your family physician to get medical clearance before the procedure.
Most arthroscopic surgical procedures are done on an outpatient basis, which means you will probably be able to go home the same day. (Some arthroscopically assisted procedures still require larger incisions to be made around the joint, and these larger procedures may require a night or two stay in the hospital.) Generally, you are asked to not eat or drink anything after midnight on the evening before surgery. If you commonly take medications in the morning, ask us whether you should take them or not.
There are many different types of anesthesia that can be done, depending on your wishes, the doctor's recommendations, and, of course, which joint is involved. In general, anesthesia may be local, regional, or general. Each of these types of anesthesia has advantages and disadvantages, but all are quite safe.
Local anesthesia involves injecting lidocaine (or a similar medication) into the joint and in the areas where the incisions are made. This is the same type of anesthesia that is typically used to sew up a laceration, for example. The benefits of this type of anesthesia are that it is relatively safe, has less effect on the rest of your body, and returns to normal quickly after the procedure. This type of anesthesia is not generally used for shoulders or hips.
Regional anesthesia is probably the most common type used for arthroscopy. It is often referred to as a block . The block is done by injecting lidocaine around the nerves that go to an extremity (in a spinal block, these are the nerves that go to the legs). The advantages to this type of anesthesia are that it does not affect the function of the lungs (a concern if you have lung problems). It does not cause as much nausea as general anesthesia, and it is relatively safer than general anesthesia. You are also awake and can watch the procedure on the TV monitor. The disadvantages are that it takes longer to take affect than going to sleep, and the recovery time may be longer even 24 hours in some cases before you can go home . So it is reserved for the longer arthroscopic procedures where the stay is 24 hours .
General anesthesia is commonly referred to as going to sleep. It is one of the commonly used option for daycare arthroscopic procedures . The advantages of general anesthesia are that you are not aware of anything that occurs during surgery and recovery is quick so that you can go home the same day . The disadvantages are that you may have a hangover with nausea and vomiting due to the drugs used, and you may have a higher risk of lung problems after surgery.
Once the anesthesia is working, the operating room nurses will prepare the equipment for arthroscopy. The surgical limb will be positioned to make it easier to do the surgery. If the procedure is going to be done on the knee, ankle, elbow, or wrist, a tourniquet may be used to stop the blood flow temporarily during the procedure. This makes it easier to see inside the joint.
When the surgery starts, 2-3 small incisions are made into the joint. These are usually about 4-5 mm . The joint is then filled with clear fluid (usually similar to the salt solution used in intravenous fluids). This expands the joint and allows the camera to work better. The fluid flows through the joint continuously to wash away blood and other material that is present during the procedure.
Once the surgery is under way, various instruments are used to perform the procedure. The camera is used to view the inside of the joint while the other instruments are used to either remove or repair the problem. If you are awake, you can watch the TV monitor and see exactly what your doctor is seeing. Still pictures or video can be taken through the arthroscope to record the condition of the joint. The Arthroscopic Surgeon performs the procedure while watching the TV monitor and guiding the instruments by what he sees on the TV. That's why arthroscopy is like a very sophisticated video game.
After arthroscopic surgery, the small incisions will be covered with a dressing. You will be moved from the operating room to a recovery room. There you will be closely monitored by the nurses until they are sure you are not having any problems from either the surgery or the anesthesia. You will probably be able to have something to drink if you are not nauseated. Normally, you will remain in the recovery room thirty to sixty minutes.Many patients need little or no pain medications.
Once you are ready to be released from the recovery room, you will probably return to the daycare room .Here you can wait until you are ready to be released to go home. You can probably have something to eat at this point and prepare to go home. You will be given some instructions at this point 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, we will inspect your incisions; remove sutures, if present; and discuss your rehabilitation program.
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 0.1 percent of all arthroscopic procedures. Infection rates are generally less after arthroscopic procedures due to smaller incisions, shorter operations, and the fact the joint is constantly being flushed out during the procedure.
What is recovery like after arthroscopy?
The small puncture wounds take several days to heal. The operative dressing can usually be removed 1-2 days 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 is usually suggested to speed your recovery 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.