Published in "Panorama"
Arthroscopy: A Procedure of ‘minimums’
Minimum invasion, minimum blood loss, minimum pain, minimum hospitalization and minimum days off from work – yes, that’s the name of the game! That’s precisely what keyhole surgery, the extensively adopted operative procedure today, promises patients. And Arthroscopy is no different when it comes to diagnosing and treating joint problems.
Arthroscopy is an orthopaedic procedure undertaken by surgeons to visualize, diagnose and treat problems inside a joint, whether arising from injury, disease or ageing. Through a small incision made over the affected joint, a pencil-sized instrument containing a small lens and lighting system, is inserted inside the joint to reveal its status.
While almost all joints can be scoped or looked inside thus, the most common joints for which Arthroscopy is being used are the shoulder, elbow and wrists in the upper limbs and the hip, knee and ankle joints in the lower limb, explains Dr.Chandan Lala, Consultant Orthopaedic Surgeon, Zulekha Hospital, Sharjah. “The most common upper limb joint to be scoped is the shoulder joint, though overall, it is the knee joints which come in for Arthroscopic evaluations and procedures”, reveals Dr.Lala.
An Arthroscope is both, a diagnostic as well as operative tool, depending on what is revealed inside a joint and what requires to be done. The procedure is needed when there is a clinical doubt about the diagnosis and when the patient does not get relief after all conservative treatments have been tried, explains Dr.Lala. “There may be surgical procedures done initially in the open way which causes more morbidity. Such surgeries can now be done with small openings which cause less trauma for the patients, are less painful, involve minimal blood loss and quicker recovery.”
What are the joint conditions that may require an Arthroscopic procedure to be done? Dr.Lala explains, “Anything that affects the interior of the joints, would come up during an arthroscopic examination. For instance, if you consider the knee joint. The bone is covered by a layer of cartilage which acts like a tyre on the wheel of a vehicle. The cartilage can be torn in sporting injuries; it could have degenerated as a result of ageing or osteo-arthritis or from other diseases. Cartilage is a big structure covering all bone ends in a joint. So any affection or disease of the cartilage can be seen and treated with Arthroscopy. Secondly, we have two ligaments inside the knee called cruciate or cross ligaments. If they are torn, especially as happens with football, rugby and other contact sports players in particular, it can be seen and treated so that they suffer minimal trauma.”
Explaining further the areas of diagnosis and treatment with arthroscopy, within the joints, Dr.Lala says, “There is a C-shaped cartilaginous structure called the meniscus in the knee which plays an important role in weight bearing and lubricating the knee joint. This is also quite frequently torn in sportsmen. This can be diagnosed, managed, sutured, cut to shape with Arthroscopy. Then there are diseases of the joint lining, the synovium in the knee, shoulder, elbow, wrist, etc, The synovium is affected in conditions like rheumatoid arthritis.
Instruments can be attached during an Arthroscopy which can go in like shavers and do the job faster and effectively in such conditions.”
Another situation which can be dealt with Arthroscopy involves loose bodies of bones or cartilage which fall off inside a joint cavity and these can be removed with the procedure. Elaborating on this, Dr.Lala explains, “In most instances, we can arthroscopically remove these loose bodies. But at times, these loose bodies keep wandering and elude the instrument. In those situations then, we need to go for an open surgical procedure to take out the loose bodies. Also, sometimes while manouvreing the instrument in a tight corner of the joint, the instruments attached to an arthroscope may break as these are very delicate. There are magnets to pull it out but in case we are unable to pull it out thus, again we need to open in the conventional manner. But such a breakage happening is a very rare incident, possible when the performing surgeon is inexperienced.”
What does an Arthroscopy reveal that CT Scan and MRI do not show? Dr.Lala explains, “A CT Scan will only tell you the bony details; it is not so good for soft tissues. MRI has a sensitivity and specificity range which is in the range of about 95-97%. There are places, however, which give false positive results with MRI. Also, though a positive point in favour of MRI is that it is a totally non-invasive diagnostic procedure, it is not an operative one. So, an Arthroscopy which is both diagnostic and operative, is cost effective, time saving and also time loss between diagnosis and treatment is much reduced from the patient’s point of view.”
At what point is Arthroscopy advised for a patient? “When on clinical examination we suspect a problem, we’d rather the patient goes in for Arthroscopy than CT Scan or MRI”, opines Dr.Lala.
Arthroscopy, though can be done as a day-care procedure requiring surgical environment, is performed under general or spinal anesthesia. “Only when there is an absolute contra-indication to general anesthesia, do we use local anesthesia,” clarifies Dr.Lala.
What are the risks involved in an arthroscopic procedure? Any surgical procedure certainly involves a certain degree of risk, but the risk involved in Arthroscopy is minimal, ranging between 1-2%, depending on where it is done and the performing surgeon who need to be an experienced hand, assures Dr.Lala.
The risks associated with the procedure include:
Bleed at the site of the puncture through which the scope is inserted.
Bleed into the joint.
Post operative infection.
Synovial fistula, that is, continuous leak of the synovial fluid, the fluid in the joint.
Breakage of the instrument while doing the procedure.
Very, very rarely, we can have osteo-dystrophy. That is, in hyper-sensitive people, the joint can react adversely to the procedure.
Is there a possibility of damage to blood vessels or surrounding nerves while doing the procedure? Dr.Lala is candid, “While this is extremely remote, (once again as I said, these mishaps can happen only if the surgeon is inexperienced) I do not deny that it cannot happen. There are important blood vessels at the back of the joint and if you force the instrument too much at the back or you pull, for example, the knee too hard, the ligaments and nerves can get stretched. But again, if the surgeon immediately becomes aware of this, remedial measures can be taken at once to reverse the damage.”
On a very reassuring note, Dr.Lala explains, “Arthroscopy is a walk-in, walk-out procedure these days, certainly in 99% of cases. If anesthesia-wise patients are fit, this is certainly the case and few hours after the procedure has been done, patients can go home. The recovery speed and time depend on what problem has been managed by the treatment. If it’s only been a diagnostic procedure, we simply put a steri-strip at the site of incision which does not even require sutures. If a simple menisctomy has been done, the patient usually may have to take rest for about 5-7 days depending on his pain situation, how tolerant he is to it and the kind of job he does. We usually advice a week’s rest for people occupied sedentarily, about two weeks at least for manual laborers and 6 –8 weeks of rest for sports people. But all these people can walk about to do simple routine chores at home.
Is there any contra-indication to the procedure itself? “No real contra-indication for Arthroscopy unless the patient has an absolutely stiff, frozen joint,” reveals Dr.Lala. “This may happen for instance in the knee on account of some infection or rheumatoid disease where there is hardly any space in the joint for an Arthroscope to go in. There may be adhesions inside the joints due to any disease or an old injury and the joint cannot be moved and there is no space to manouvre the arthroscope.”
On the question of age barriers to the procedure, Dr.Lala ensures that there are none, except infants on whom the procedure is not done.