osteoarthritis, surgery

Arthroscopy

SUMMARY

In this article you will learn what an arthroscopy is, why it is commonly performed and what risks it entails.

Arthroscopy is a surgical procedure that allows surgeons to view, diagnose and treat the inside of large joints.

The word arthroscopy comes from the Greek words ‘athros’ (joint) and ‘scopos’ (to look).

VIDEO SUMMARY – What is arthroscopy?

Which joints is it used on?

It is most often used to inspect knee joints as part of treatment for arthritic joint pain. Although arthroscopy of the shoulder, elbow and hip are also possible.

Even hand and ankle joints can be viewed using arthroscopy with the technology now available. This surgical procedure is widely used in rheumatic diseases such as arthritis or osteoarthritis.

How invasive is it?

Almost all arthroscopic procedures can be performed as an outpatient. Any major procedures and operations to be performed alongside arthroscopy are done under general anaesthesia. In less complicated cases, local anaesthesia is used.

In the case of knee joint arthroscopy, a tourniquet is often applied above the knee and around the thigh. This is used to temporarily interrupt local circulation in order to properly investigate the joint.

Common findings

  • Torn or degenerate meniscus or menisci (semilunar cartilage)
  • Inflammation of the joint lining (synovitis)
  • Maltracking and tilted patella (kneecap)
  • Loose fragments of cartilage or bone (loose bodies)
  • Damaged joint surface (articular cartilage)
  • Torn anterior cruciate ligament (ACL)

The Procedure

With a scalpel, the physician makes one or two incisions approximately 5 mm wide. A probe with a camera is inserted through the incision. The camera transmits an image on a monitor so that the operator can look directly into the knee joint. The great advantage of this method is that it is minimally invasive.

Small retractors, scissors, knives or other cutting instruments can be introduced via the probe into the joint. This makes it possible for the physician to treat minor damage and deformation of the joint surfaces. This can be very beneficial for patients with a progressive joint disease such as osteoarthritis.

It’s possible to minimise join abrasion by smoothing the articular surfaces and removing broken cartilage fragments from the synovial fluid (joint fluid)1. During arthroscopy, surgeons will often take a sample of synovial fluid for analysis. This fluid contains important biomarkers that can be used to identify degenerative processes or inflammation2. Results from this analysis can help to devise ongoing treatment plans.

Advantages of Arthroscopy & Joint Lavage

The biggest advantage of arthroscopy is that it’s a minimally invasive procedure. There are very few cuts required for the operation.

This helps to minimise scarring and the risk of infection. The procedure is less painful than other forms of surgery. Also patients recover much faster and can often regain full mobility of their joints.

In situations of septic arthritis (i.e. inflammation of the joint infected by bacteria) joint irrigation is very beneficial. Untreated, this can cause severe complications or even death. Septic arthritis is a life threatening condition with a high mortality rate of 11%3. As a result of joint irrigation the inflammation is eliminated and sepsis prevented4.

Risks of Arthroscopy & Joint Lavage

As with any form of surgery, arthroscopy is not a risk-free operation. Although uncommon, the following complications have been reported: excessive bleeding or swelling, skin and joint infection, blood clots, phlebitis, and technical problems with arthroscopic instruments.

Aside from the risk of injuries to the articular cartilage and ligaments, there is also a risk of infection as a result of insufficient disinfection of the surgical instrument or the patient’s skin prior to surgery. In any case, it’s important to quickly recognize the infection in order to effectively prevent further damage and movement restrictions5.

Air embolic or thrombotic phenomena in the joint can also be another health risk following arthroscopic surgery6. For operations in the shoulder area, there is a low risk of damaging the lungs7.

There are also risks with anaesthetic during and after the procedure. There is some evidence to suggest that only in rare cases can knee arthroscopy actually prevent osteoarthritis8. There is also the risk of injury to ligaments and meniscus of the knee during surgery.

Since the surgery is minimally invasive and recovery time is quick, sometimes patients put too much pressure on their joints too soon after the procedure. This can cause further damage to the articular cartilage.

Thus, surgeons recommend only gentle exercise, such as swimming, cycling or walking following surgery. These sports encourage the formation of synovial fluid, which ensures adequate lubrication of the joints. This exercise also strengthens the muscles to better support the joint and musculoskeletal system.

Benefits of joint irrigation questionable

Although cleaning the joint and eliminating any irregularities of the cartilage surfaces to improve joint function seems logical, more physicians are questioning the effectiveness of this procedure.

In 2002, Moseley and colleagues investigated the effects of joint lavage and abrasion following arthroscopy9. 180 patients either had their knee joint flushed and potential irregularities smoothed, or participated in the control. Patients in the placebo group received skin incisions and underwent a simulated débridement without insertion of the arthroscope. At no time did joint irrigation subdue pain or improve function more than the placebo control group. With similar outcomes found in a high volume of patients, statistically these results are very solid.

Authors of other studies are also critical of the effectiveness of joint irrigation. A knee arthroscopy for example, can only in the rarest cases prevent the development of osteoarthritis10. The short-term pain relief provided by rinsing the joint creates a false sense of security for the patient. As a result, the patient often overloads the joints, so the damage to the articular cartilage may increase further and valuable treatment time passes.

Possible Adverse Effects of Salt-based Solutions

Another concern is the salt-based solution used to flush the joint. The standard solution for the irrigation of articular cartilage is a saline solution which seems to cause changes in the articular cartilage. In some experimental models, it has been shown to cause inhibition of chondrocyte metabolism. This additional impairment of the already damaged cells could further harm cartilage in an arthritic joint11.

Previously, scientists showed that the use of cold salt solutions led to damage of chondrocytes and their metabolism. Thus, scientists recommend that joint irrigation solutions should always be at body temperature12.

Bibliography

  1. Richmond, J.C. ‘Surgery for osteoarthritis of the knee’, Rheum Dis Clin North Am., 2013 Feb;39(1):203-11. doi: 10.1016/j.rdc.2012.10.008. Epub 2012 Nov 9
  2. Singhal O, Kaur V, Kalhan S, Singhal MK, Gupta A, Machave Y. ‘Arthroscopic synovial biopsy in definitive diagnosis of joint diseases: An evaluation of efficacy and precision.’ Int J Appl Basic Med Res., 2012 Jul;2(2):102-6. doi: 10.4103/2229-516X.106351
  3. Kodumuri et al. , 2012. Time delay in between diagnosis and arthroscopic lavage in septic arthritis. Does it matter? Int Orthop 36 (8), 1727-31
  4. Nusem & McAlister., 2012. Arthroscopic lavage for the treatment of septic arthritis of the hip in children. Acta Orthop Belg 78 (6),730-4
  5. Bert & Bert., 2013. Management of infections after arthroscopy. Sports Med Arthrosc 21 (2),75-9; doi: 10.1097/JSA.0b013e318290cb5b
  6. Green et al., 2013. Thromboembolic complications in arthroscopic surgery. Sports Med Arthrosc 21 (2), 69-74; Pandey et al., 2013. Nonfatal air embolism falling on shoulder arthroscopy. Am J Orthop (Belle Mead NJ) 42 (6), 272-4; Struijk-Mulder et al., 2013. Deep vein thrombosis after arthroscopic anterior cruciate ligament reconstruction: a prospective cohort study of 100 patients. Arthroscopy 29 (7), 1211-6
  7. Manjuladevi et al., 2013. Postoperative airway compromise in shoulder arthroscopy: A case series. Indian J Anaesth 57 (1), 52-5
  8. Shin CS, Lee JH., ‘Arthroscopic treatment for osteoarthritic knee’, Knee Surg Relat Res. 2012 Dec;24(4):187-92. doi: 10.5792/ksrr.2012.24.4.187. Epub 2012 Nov 29
  9. Moseley et al, “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee”, N Engl J Med 2002; 347:81-88
  10. Shin & Lee., 2012. Arthroscopic treatment for osteoarthritic knee. Knee Surg Relat Res 24 (4), 187-92
  11. Gulihar et al., 2013. Effect of different irrigation fluids on human articular cartilage: an in vitro study. Arthroscopy 29 (2), 251-6
  12. Kocaoglu et al., 2011. The effect of irrigation solution at different temperatures applications on articular cartilage metabolism. Arthroscopy 27 (4), 526-31

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