Arthroscopy

Arthroscopy, or copular speculum, is a surgical procedure classified as a diagnostic and therapeutic method. These are methods that both allow the detection of various disease states taking place within the joint, and simultaneous undertaking of appropriate surgical intervention aimed at curing the patient's discomfort.

Arthroscopy - characteristics

Arthroscopy is referred to as a "keyhole surgery" surgery, as it requires only a few small incisions to be made, through which the operator then implements the tools.

The joints in the human body are generally made of three typical elements:
• joint surface (head and acetabulum) formed by two or more bones, depending on the complexity of the joint
• joint capsule - a cellular purse that limits the joint from the outside, has a stabilizing and protective function
• joint cavity - the space inside the joint capsule, inside which the joint fluid is produced, acting as a specific "grease" and enabling the reduction of friction on joint surfaces

In addition, the additional elements that build individual joints may consist of ligaments, meniscus and articular bursa. When one of these elements fails, it may be necessary to perform arthroscopic surgery within the joint. Arthroscopy is usually performed in the knee joint, but it is not the only area that can be treated. Other large joints are also sighted: hip, shoulder, ankle, elbow, wrist, as well as smaller joints of the hands or feet.
Joint pain is one of the flagship ailments with which patients report to an orthopedy specialist. Joint problems in the form of pain, redness, swelling, and limited mobility - sudden or gradual - can be associated with different situations. They often appear in obese people, leading a sedentary lifestyle, but not only - people working physically or practicing sports are equally exposed to injury within the joint. Sudden injuries that arise, for example, when playing football, skating or skiing, riding a bicycle or lifting weights are quite common. Not taking treatment may have serious consequences in the form of permanent immobilisation of the limb, so appropriate treatment should always be taken.

Arthroscopy - benefits

The benefits of arthroscopic surgery include:
• low invasiveness of the procedure - instead of an open cut, a few small incisions are made on the • skin, which also undoubtedly brings a better cosmetic effect
• smaller in comparison to the "open" postoperative treatment - reduction of the incidence of complications even a thousand times
• lower risk of infection
• faster healing of post-operative wounds, as only punctual lesions inside the joint are left associated with obtaining access by the microtubes
• quick return of the patient to the home and improvement after surgery - the procedure does not require long-term hospitalization
• accurate treatment thanks to the possibility of visualizing the joint with the help of micro camera with high magnification.

Indications for the procedure

Among the indications for arthroscopy are:
• diagnostics unexplained in standard tests (X-ray, CT, MRI) of joint ailments
• damage to ligaments and joint tendons
• Carpal tunnel syndrome
• synovitis
• fractures inside the joint
• osteoarthritis changes
• rheumatoid arthritis and other rheumatic diseases
• the stiffness of joints deepening over time
• cancer developing within the joint
• presence of a foreign body in the pond
• chronic pain
• arthroscopy with treatment of subfold compactness
• arthroscopic reconstruction of the rotator cuff cone
• arthroscopic reconstruction of the anterior cruciate ligament
• arthroscopic reconstruction of posterior cruciate ligament
• arthroscopic treatment of shoulder instability

As for the specific indications for particular articular groups, the main indication in clinical practice is injury to the ligaments of traumatic origin. For shoulder arthroscopy - painful shoulder syndrome, damage or calcification of rotator cuff or so-called "Frozen shoulder"; elbow - tennis elbow in cases of non-responding to treatment, elbow syndrome and ulnar groove syndrome; ankle joint in case of high degree of damage - stabilization is sufficient in minor damages; hip joint - degenerative changes in the hip joints, "hip popping"; wrist - carpal tunnel syndrome or de Quervain's disease.

Contraindications for the procedure

Due to the small invasiveness of the procedure and its usually planned character there are few contraindications to its implementation, however, one can mention above all such situations as:
• presence of abscesses in the area planned for incision,
• severe general condition of the patient,
• severe coagulation disorders,
• very extensive joint damage requiring open surgery,
• a history of hypersensitivity to given anaesthetics.

Before the surgery

You should be aware that not every pain in the joints will require surgical intervention. As an exclusively diagnostic method, arthroscopy is performed only when less invasive imaging methods - ultrasound, X-ray, CT or MRI did not explain the origin of the patient's ailment. With proper qualification of the patient, each arthroscopy will be not only diagnostic, but also curative (the aim is to minimize unnecessary arthroscopic interventions - if such a procedure does not eliminate the source of ailments).
It is important to realize that the surgery alone does not guarantee a complete cure - postoperative actions of the patient are of no small importance, especially the unloading of the operated joint and compliance with medical recommendations. This will allow for proper healing.

Type of anaesthetic

Anaesthesia for arthroscopic surgery depends on the extent of the planned operation, but may be:

• general - pain, reflexes and patient awareness are eliminated during this type of anaesthesia
• wired - anaesthesia is given to interrupt the conduction in the sensory nerves, the patient has aches and reflexes, but is aware of the course of local operations (rarely).

General premedication requires proper premedication - administration of substances that will reduce anxiety and fear of surgery, inhibit the secretion of saliva and bronchial content, cause retrograde amnesia, and also enable reducing the doses required for proper anaesthesia.
In children, the procedure is always performed under general anaesthesia.

How is the procedure performed?

How does the procedure work?
Arthroscopic surgery can last from several dozen minutes to several hours, depending on the extent of the procedure, the degree of joint complexity and difficulty in performing.

Technically, you can divide such a procedure into two stages:
• diagnostic arthroscopy - during which the micro camera is introduced into the interior of the joint cavity to view the interior of the joint;
• healing arthroscopy - the time when the proper treatment is performed - eg removal of a foreign body, bone surplus, cystic and malignant changes, repair of damaged structures, excision of an overgrowth synovium, stitching of ligaments.

At the beginning, the patient undergoes proper anaesthesia. Then, 2-3 small, several millimetre incisions are made within the pond, which will allow the introduction of microsurgical instruments into its interior. There are strictly defined places for possible surgical approaches for each joint. Through one of the holes slides a guide, i.e. a small tube, which will allow the introduction of a flexible, fine micro camera of high resolution with a source of strong, cold light - arthroscope. This micro-camera is very similar to that used, for example, in gastroscopy. A tube is inserted through the second opening to allow delivery of saline solution (formerly gas) to expand the joint cavity and improve the visibility of the micrograph. The third hole is the place of introducing appropriate tools (tweezers, micros, diathermy etc.) dedicated to specific treatments inside the joint. After the therapeutic procedure, the micro camera is removed and the fluid previously applied to the joint cavity is aspirated. The holes in the tools are sewn. The treatment site is bandaged for healing, with a recommendation to change the dressing.

Time and course of convalescence

Patients after arthroscopic surgery can be released on the same day or the next day after supply and stabilization of the operated joint. However, it should be remembered that the convalescence time is determined with the physician after an individual consultation, taking into account the reason for such an operation (eg when the torn ligaments were the cause, the recovery after the procedure will last a minimum of a few weeks). It is recommended during the recovery to completely relieve the limb in the case of surgery on large joints. Sutures after the procedure are removed on the 7-10 postoperative day, during an ambulatory check-up visit.

Effects after surgery

Arthroscopy allows you to get rid of pain in the joint caused by, among others traumatic factors (rupture of tendons or ligaments), inflammatory (rheumatoid arthritis, synovitis), ongoing cancer or degenerative process. It is currently the best of minimally invasive therapeutic methods in orthopaedics - with such small interference and a small degree of complications, it is very effective in treating joint ailments of various origins. After the procedure, only small, not very visible skin scars remain, and with appropriate postoperative procedures, you can restore the efficiency of the joint and prevent permanent impairment of mobility and decrease in the quality of life of patients.

Recommendations after the procedure

As already mentioned, the surgery itself does not guarantee the return of the joint to full efficiency and the patient is equally co-responsible with the physician for ensuring appropriate conditions for healing and regeneration. In many cases, the doctor will recommend post-operative rehabilitation, allowing gradual and effective activation of the treated joint. You should often sit down, lifting the operated limb, and try to keep it in the position of extension, to prevent contracture in the joint. Avoid prolonged standing. If the patient coached a sport, it is not necessary to think about returning to sports activity earlier than after about 6 weeks, however daily home activity should be possible fully after about 2 weeks after the surgery. The doctor may order antithrombotic prophylaxis - taking small-molecule heparin in home conditions, which the patient injects himself after prior training.

How long do the effects last after the treatment last?

The effects after arthroscopy, provided that good cooperation is maintained between the doctor and the patient, and therefore compliance with the recommendations are very satisfactory and can be considered as permanent. It should be allowed to fully heal the post-operative box, then we can be sure that the risk of reoperation will be minimized. In the case of degenerative changes associated with obesity, the effect will certainly be able to enjoy longer if we decide to reduce weight.

How to avoid complications after the procedure?

To avoid complications after arthroscopy:
• avoid overloading the operated joint,
• check that there is no swelling, redness, cloudy discharge at the cut site,
• follow the recommendations for rehabilitation and postoperative antithrombotic prophylaxis,
• report to the attending physician in case of general symptoms: fever, chills, nausea and vomiting,
• use a proper diet - avoid high blood sugar levels, because it delays the healing process,
• hydrate well - drink at least 2 litters of water a day to prevent thromboembolic complications.

Possible complications after the procedure

Complications following arthroscopy may appear as after each surgical procedure, however, due to the small area of surgical access, complications are minimized to less than 0.5%. The most common complications after arthroscopic surgery include: bleeding into the joint cavity, infection of the post-operative wound, cartilage damage due to too strong manipulations inside the joint, nerve and vessel damage within the surgical access. If you notice any disturbing symptoms at a short time after the procedure, you should immediately see your doctor.

Recommended additional treatments after the procedure

Patients are advised to undertake post-operative rehabilitation with a physiotherapist. It usually takes several weeks and allows for a slow, gradual restoration of the joint to a satisfactory functionality. The physiotherapist sets up a rehabilitation plan with the patient individually.

Author: Wiktoria Feret
Literature:
Surgery - repetytorium, Wojciech Noszczyk, PZWL 2015
Manual of operational access in orthopedics and traumatology, Frederic Dubrana, ed. PZWL
Diagnostics in orthopedics, W.R. Hepp, Polish edition T. Gaździk, ed. PZWL

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