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Arthroscopy

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File:Performing shoulder arthroscopy.jpg
An example of shoulder arthroscopy. The surgeon looks at a video screen which is connected to a camera that is inserted into the body, together with working instruments.

Arthroscopy (also called arthroscopic surgery) is a minimally invasive surgical procedure in which an examination and sometimes treatment of damage of the interior of a joint is performed using an arthroscope, a type of endoscope that is inserted into the joint through a small incision. Arthroscopic procedures can be performed either to evaluate or to treat many orthopaedic conditions including torn floating cartilage, torn surface cartilage, ACL reconstruction, and trimming damaged cartilage.

The advantage of arthroscopy over traditional open surgery is that the joint does not have to be opened up fully. Instead, only two small incisions are made - one for the arthroscope and one for the surgical instruments to be used in the knee cavity to fully remove the knee cap. This reduces recovery time and may increase the rate of surgical success due to less trauma to the connective tissue. It is especially useful for professional athletes, who frequently injure knee joints and require fast healing time. There is also less scarring, because of the smaller incisions. Irrigation fluid is used to distend the joint and make a surgical space. Sometimes this fluid leaks into the surrounding soft tissue causing extravasation and edema.

The surgical instruments used are smaller than traditional instruments. Surgeons view the joint area on a video monitor, and can diagnose and repair torn joint tissue, such as ligaments and menisci or cartilage

Arthroscopy is used for joints of the knee, shoulder, elbow, wrist, ankle, foot, and hip.

Knee arthroscopy

Lateral meniscus located between thigh bone (femur, above) and shin bone (tibia, below). The tibial cartilage displays a fissure (tip of teaser instrument).

Knee arthroscopy has in many cases replaced the classic arthrotomy that was performed in the past. Today knee arthroscopy is commonly performed for treating meniscus injury, reconstruction of the anterior cruciate ligament and for cartilage microfracturing. Arthroscopy can also be performed just for diagnosing and checking of the knee; however, the latter use has been mainly replaced by magnetic resonance imaging.

During an average knee arthroscopy, a small fiberoptic camera (the endoscope) is inserted into the joint through a small incision, about 4 mm (1/8 inch) long. A special fluid is used to visualize the joint parts. More incisions might be performed in order to check other parts of the knee. Then other miniature instruments are used and the surgery is performed.

Recovery after a knee arthroscopy is significantly faster as compared to arthrotomy. Most patients can return home and walk using crutches the same or the next day after the surgery. Recovery time depends on the reason that surgery was needed and the patient's physical condition. Usually a patient can fully load his leg within a couple of days and after a few weeks the joint function can fully recover. It is not uncommon for athletes who have an above average physical condition to return to normal athletic activities within a few weeks.

Arthroscopic surgeries of the knee are done for many reasons, but the usefulness of surgery for treating osteoarthritis is doubtful. A double-blind placebo-controlled study on arthroscopic surgery for osteoarthritis of the knee was published in the New England Journal of Medicine in 2002.[1] In this three-group study, 180 military veterans with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement with lavage, just arthroscopic lavage, or a sham surgery, which made superficial incisions to the skin while pretending to do the surgery. For two years after the surgeries, patients reported their pain levels and were evaluated for joint motion. Neither the patients nor the independent evaluators knew which patients had received which surgery. The study reported, "At no point did either of the intervention groups report less pain or better function than the placebo group."[2] Because there is no confirmed usefulness for these surgeries, many agencies are reconsidering paying for a surgery which seems to create risks with no benefit.[3] A 2008 study confirmed that there was no long-term benefit for chronic pain, above medication and physical therapy.[4] Since one of the main reasons for arthroscopy is to repair or trim a painful and torn or damaged meniscus, a recent study in the New England Journal of Medicine which shows that about 60% of these tears cause no pain and are found in asymptomatic subjects, may further call the rationale for this procedure into question.[5]

Spinal arthroscopy

Many invasive spine procedures involve the removal of bone, muscle, and ligaments to access and treat problematic areas. In some cases, thoracic (mid-spine) conditions requires a surgeon to access the problem area through the rib cage, dramatically lengthening recovery time.

Arthroscopic (also endoscopic) spinal procedures allow a surgeon to access and treat a variety of spinal conditions with minimal damage to surrounding tissues. Recovery times are greatly reduced due to the relatively small size of incision(s) required, and many patients are treated on an outpatient basis.[6] Recovery rates and times vary according to condition severity and the patient's overall health.

Arthroscopic procedures treat

Wrist arthroscopy

Arthroscopic view showing two of the wrist bones.

Arthroscopy of the wrist is used to investigate and treat symptoms of repetitive strain injury, fractures of the wrist and torn or damaged ligaments. It can also be used to ascertain joint damage caused by arthritis.

History

Professor Kenji Takagi in Tokyo has traditionally been credited for performing the first arthroscopic examination of the knee joint of a patient in 1919. He used a 7.3 mm cystoscope for his first arthroscopies. Recently it has been discovered that the danish physician Severin Nordentoft reported on arthroscopies of the knee joint as early as 1912 at the Proceedings of the 4lst Congress of the German Society of Surgeons at Berlin.[7] However, it is not clear if this was anatomic studies of diseased or examination of living patients.

Pioneering work in the field of arthroscopy began as early as the 1920s with the work of Eugen Bircher.[8] Bircher published several papers in the 1920s about his use of arthroscopy of the knee for diagnostic purposes.[8] After diagnosing torn tissue through arthroscopy, Bircher used open surgery to remove or repair the damaged tissue. Initially, he used an electric Jacobaeus thoracolaparoscope for his diagnostic procedures, which produced a dim view of the joint. Later, he developed a double-contrast approach to improve visibility.[9] Bircher gave up endoscopy in 1930, and his work was largely neglected for several decades.

While Bircher is often considered the inventor of arthroscopy of the knee,[10] the Japanese surgeon Masaki Watanabe, MD receives primary credit for using arthroscopy for interventional surgery.[11][12] Watanabe was inspired by the work and teaching of Dr Richard O'Connor. Later, Dr. Heshmat Shahriaree began experimenting with ways to excise fragments of menisci.[13]

The first operating arthroscope was jointly designed by these men, and they worked together to produce the first high-quality color intraarticular photography[14] The field benefited significantly from technological advances, particularly advances in flexible fiber optics during the 1970s and 1980s.

Notes

  1. ^ http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12110735 "A controlled trial of arthroscopic surgery for osteoarthritis of the knee" N Engl J Med 2002 Jul 11;347(2):81-8, Moseley JB; O'Malley K; Petersen NJ; Menke TJ; Brody BA; Kuykendall DH; Hollingsworth JC; Ashton CM; Wray NP
  2. ^ "NEJM -- A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee". Retrieved 2008-01-14.
  3. ^ "Research diversity in DeBakey awards - From the Laboratories Online Newsletter at Baylor College of Medicine (January 2003)". Retrieved 2008-01-14.
  4. ^ Kirkley A, Birmingham TB, Litchfield RB; et al. (2008). "A randomized trial of arthroscopic surgery for osteoarthritis of the knee". N. Engl. J. Med. 359 (11): 1097–107. doi:10.1056/NEJMoa0708333. PMID 18784099. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  5. ^ Martin Englund, M.D., Ph.D., Ali Guermazi, M.D., Daniel Gale, M.D., David J. Hunter, M.B.,B.S., Ph.D., Piran Aliabadi, M.D., Margaret Clancy, M.P.H., and David T. Felson, M.D., M.P.H.; et al. (2008). "Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons". N. Engl. J. Med. 359 (11): 1108–1115. doi:10.1056/NEJMoa0708333. PMID 18784100. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  6. ^ "Minimally Invasive Endoscopic Spinal Surgery". June20, 2005. Cleveland Clinic contribution to SpineUniverse.com
  7. ^ Kieser CW, Jackson R W. Severin Nordentoft: The first arthroscopist. Arthroscopy 2001, 17(5):532-5.
  8. ^ a b CH Bennett & C Chebli, 'Knee Arthroscopy'
  9. ^ Kieser CW, Jackson RW (2003). "Eugen Bircher (1882-1956) the first knee surgeon to use diagnostic arthroscopy". Arthroscopy. 19 (7): 771–6. PMID 12966386.
  10. ^ Böni T (1996). "[Knee problems from a medical history viewpoint]". Ther Umsch (in German). 53 (10): 716–23. PMID 8966679.
  11. ^ Watanabe M: History arthroscopic surgery. In Shahriaree H (first edition): O'Connor's Textbook of Arthroscopic surgery. Philadelphia, J.B. Lippincott Co., 1983.
  12. ^ Jackson RW (1987). "Memories of the early days of arthroscopy: 1965-1975. The formative years". Arthroscopy. 3 (1): 1–3. PMID 3551979.
  13. ^ Metcalf RW (1985). "A decade of arthroscopic surgery: AANA. Presidential address". Arthroscopy. 1 (4): 221–5. PMID 3913437.
  14. ^ Allen FR, Shahriaree H: Richard L. O'Connor-A Tribute. J Bone Joint 64A:315, 1982.

The Arthroscopy Journal

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