Arthroscopic surgery is a procedure that allows surgeons to visualize, diagnose, and treat joint problems. The name is derived from the Greek words arthron , joint, and skopein , to look at. Arthroscopy is performed using an arthroscope, a small fiber-optic instrument that enables a close look at the inside of a joint through a small incision.
Arthroscopic surgery is used to diagnose, treat, and monitor joint injuries and diseases that affect the joints. Diagnostic arthroscopic surgery is performed when the medical history, physical exam, x rays, and bone scanning examinations, such as MRI or CT, do not provide a definitive diagnosis. Corrective arthroscopic surgery is used primarily to remove bone or cartilage or repair tendons or ligaments.
Diagnostic arthroscopic surgery is not recommended unless non-surgical treatment does not fix the problem.
Arthroscopic surgery is performed most commonly on the knees, and also on ankles, shoulders, wrists, elbows, and hips. Knee joints are large enough to allow free movement of arthroscopic instruments and therefore are ideal for the benefits of this type of examination and treatment. The technique is valued because it allows surgeons to see inside the joint through incisions as tiny as a quarter of an inch (about 1 cm) rather than the large incisions that open surgery procedures require. The accuracy of arthroscopy is said to be 100% for diagnosis compared to diagnostic imaging such as MRI. Arthroscopic surgery may be used to relieve mechanical joint problems, such as buckling, stiffness, or locking, and can preclude or delay the need for more aggressive surgery such as a joint replacement.
In arthroscopic surgery, an orthopedic surgeon uses a pencil-sized arthroscope—a fiber-optic instrument fitted with a lens, a light source, and a miniature video camera—to see inside a joint. Advanced fiber optics allow even more detail to be seen than in open surgery, often identifying problems that may have been difficult to diagnose with other methods. The arthroscope transmits highlighted images of the structures to a television monitor in the operating room . The surgeon is able to view the entire examination, getting a full view of the joint, its cartilage, and surrounding tissue. The type and extent of the injury can be determined and repair or correction can be performed if necessary. Some of the most common joint problems diagnosed and treated with arthroscopic surgery are:
- synovitis (inflamed joint lining) of the knee, shoulder, elbow, wrist, or ankle
- injuries to the shoulder, such as rotator cuff tendon tears, impingement syndrome, and dislocations
- injuries to the knee, such as meniscal (cartilage) tears, wearing down of or injury to the cartilage cushion, and anterior cruciate ligament tears with instability
- injuries to the wrist, such as carpal tunnel syndrome
- loose bodies of bone and/or cartilage in the knee, shoulder, elbow, ankle, or wrist
- joint damage caused by rheumatoid arthritis or osteoarthritis
Arthroscopic procedures are performed in a hospital or outpatient surgical facility by an orthopedic surgeon. The type of anesthesia used (local, spinal, or general) varies, as does the length of the procedure; both depend on the joint that will be operated on, the type and extent of the suspected joint injury, and/or the complexity of the anticipated repair. Arthroscopic surgery rarely takes more than an hour. Most patients who have arthroscopic surgery, whether diagnostic or corrective, are discharged within the same day; some patients, depending on the complexity of the surgery or their post-operative condition, may stay in the hospital one or two days.
Considered the most important orthopedic development in the twentieth century, arthroscopic surgery is widely used. The American Association of Orthopedic Surgeons reports that it is performed by 80% of all orthopedic surgeons. The use of arthroscopic surgery on famous athletes has been well publicized. Although arthroscopic surgery was initially only a diagnostic tool used prior to open surgery, the availability of better instruments and techniques has encouraged its use to actually treat a variety of joint problems, often avoiding more complicated surgeries with longer recovery times. New techniques under development are likely to lead to other joints being treated with arthroscopic surgery in the future. Laser technology has been introduced as a treatment option in arthroscopic surgery and other advanced technologies are being explored.
After making two small incisions about the size of a buttonhole in the skin near the joint, the surgeon injects sterile sodium chloride solution through one incision into the joint to expand it for better viewing and movement of the instruments. The surgeon will also use this access to irrigate (flood with fluid) the joint area during surgery and to suction blood and debris away from the joint. This irrigation, or "washing" part of the procedure, is believed to be of value in itself, improving joint function. The arthroscope is then inserted into the second incision. While looking at the interior of the joint on the television monitor, the surgeon can determine the extent or type of injury and, if necessary, take a biopsy specimen or repair or treat the problem. A third tiny incision may be made in order to see other parts of the joint or to insert additional instruments, such as laser or tiny scalpels, when repairs or corrections need to be made. Arthroscopic surgery can be used to remove floating bits of cartilage, to debride (clean by removing tissue or bone), and to treat minor tears and other disorders. When the procedure is finished, the arthroscope is removed and the joint is once again irrigated. The site of the incision is dressed with compression bandages (ace bandages).
Prior to arthroscopy, the patient's medical history will be reviewed and the patient will have a complete physical examination . Standard pre-operative blood and urine tests will be done as well as scans of the affected joint, such as MRI ( magnetic resonance imaging ), CT (computed tomography), and arthrogram (an x ray using dye). In some cases, an exercise regimen or muscle stimulation treatment (TENS) may be recommended to strengthen muscles around the joint prior to surgery. Surgeons may recommend pre-operative guidelines, such as:
- Discontinue aspirin and anti-inflammatory medications two weeks before surgery.
- Stop smoking to encourage post-operative healing.
- Inform the surgeon if any fever or other illness occurs, or if cuts, scratches, or bruises appear near the surgical site before the scheduled surgery.
- Do not eat, drink, or chew gum for 12 hours prior to surgery.
- Bring crutches or a walker if hip, knee, or ankle arthroscopy is being performed.
- Wear loose fitting clothing to allow for bulky dressings over the surgical site.
Immediately after the procedure, the patient will spend up to two hours in a recovery area before being discharged. Some patients may be transferred to a hospital room if the surgeon determines overnight care is necessary. The surgical site will be dressed with a compression bandage (ace bandage) or a tightly fitting stocking (support hose). An ice pack will be placed on the joint that was examined or treated by arthroscopy. This treatment may continue for up to 72 hours after surgery to keep swelling down and help prevent the formation of clots. Pain medication will be administered if needed, although most patients require little or no medicine for pain. Dressings can usually be removed on the morning after surgery and replaced by adhesive strips. The surgeon should be notified if the patient experiences any increase in pain, swelling, redness, drainage or bleeding at the site of the surgery, signs of infection (headache, muscle aches, dizziness, fever), and nausea or vomiting.
It takes several days for the puncture wounds to heal and several weeks for the joint to fully recover. Many patients can resume their daily activities, including going back to work, within a few days of the procedure. Muscle strength must be regained as soon as possible after surgery to help support the affected joint. A rehabilitation program, including physical therapy, may be suggested to speed recovery and improve the functioning of the joint. The surgeon's recommendations for recovery may include:
- Keep the surgical site and the dressings clean and dry.
- Use ice packs for up to 72 hours to reduce pain and swelling.
- Elevate the affected joint (wrist, elbow, ankle, knee) on pillows; exercise gently to encourage circulation.
- Use a knee brace or shoulder sling temporarily.
- Allow weight-bearing exercise as able.
Few complications are to be expected with arthroscopy. Those that may occur occasionally (fewer than 1% of all arthroscopies, according to the American Academy of Orthopedic Surgeons) are infection, blood clot formation, swelling or bleeding, or damage to blood vessels or nerves. Rare instrument breakage during procedures has also been reported.
Most patients undergo arthroscopic surgery as an outpatient and are home with hours or at most a day or two. Pain and complications are rare and most patients will enjoy improved mobility as they recover over a period of days, possibly with the aid of physical therapy and gentle exercise.
Some people undergoing arthroscopy may have preexisting conditions and diseases that will affect the surgical result. Recovery times will vary depending on each patient's overall condition. Certain problems may need to be treated with a combination of arthroscopic and open surgical procedures.
Alternatives to arthroscopic surgery include:
- changing activities to those less strenuous or demanding
- anti-inflammatory medications
- physical therapy and appropriate, gentle exercise such as yoga
- wearing a brace or using a walking aid
- glucosamine sulfate and chondroiten to reduce pain and stiffness
- therapeutic massage, acupuncture, or other body work
Andrews, James R. and Laura A. Timmerman. Diagnostic and Operative Arthroscopy. Philadelphia: W. B. Saunders Co., 1997.
Brillhart, Allen T., ed. Arthroscopic Laser Surgery: Clinical Applications. New York: Springer-Verlag, 1995.
Oxford Medical Publications. Oxford Textbook of Sports Medicine. New York: Oxford Medical Publications, 1994.
Wilkinson, Todd. "Pop, Crackle, Snap." Women's Sports & Fitness (April 1998): 68.
American Academy of Orthopedic Surgeons(AAOS). 6300 North River Road, Rosemont, IL 60018. (800) 346-AAOS. http://www.aaos.org .
Institute for Bone and Joint Disorders. 2222 East Highland Avenue, Phoenix, AZ 85016; 602-553-3113. http://www.ibjd.com .
American Academy of Orthopaedic Surgeons. Arthroscopy. April 15, 1998 [cited April 2003]. http://www.aaos.org .
The Arthritis Foundation. About Arthroscopic Surgery. [cited April 2003]. http://www.arthritis.org .
"Joint Irrigation for Osteoarthritis." Ivanhoe Newswire 5(2003): 20–26 [cited April 2003]. http://www.ivanhoe.com/newsalert .
"Knee Arthroscopy." The Center for Orthopaedics and Sports Medicine. April 15, 1998 [cited April 2003]. http://www.arthroscopy.com .
Lori De Milto L. Lee Culvert
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Arthroscopic surgery is performed in a hospital operating room or an outpatient surgical facility by an orthopedic surgeon.
QUESTIONS TO ASK THE DOCTOR
- Why is arthroscopy necessary for me?
- What kind of anesthesia will I have?
- How often do you perform this procedure? What results are typical?
- How much discomfort can I expect short term? Long term?
- Will physical therapy be necessary after the surgery?
- Will this procedure correct my joint problem?